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Med Surg 2 Final

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4. The nurse is obtaining a history for a 23-year-old woman who is being evaluated for acute lower abdominal pain and vomiting. Which question will be most useful in determining the cause of the patient's symptoms? a. "Is it possible that you are pregnant?" b. "Can you tell me more about the pain?" c. "What type of foods do you usually eat?" d. "What is your usual elimination pattern?"

B A complete description of the pain provides clues about the cause of the problem. The usual diet and elimination patterns are less helpful in determining the reason for the patient's symptoms. Although the nurse should ask whether the patient is pregnant to determine whether the patient might have an ectopic pregnancy and before any radiology studies are done, this information is not the most useful in determining the cause of the pain. DIF: Cognitive Level: Application REF: 1015-1016 TOP: Nursing Process: Assessment

10. Which activity by the nurse will best relieve symptoms associated with ascites? A. Administering oxygen B. Elevating the head of the bed C. Monitoring serum albumin levels D. Administering IV fluids

3. A patient's complete blood count (CBC) with differential has the following values. Which value indicates to the nurse that the patient is having some type of allergic reaction? A. Total WBC 100% B. Eosinophils 11% C. Lymphocytes 38% D. Neutrophils 66%

3. The health care provider prescribes finasteride (Proscar) for a 56-year-old patient who has benign prostatic hyperplasia (BPH). When teaching the patient about the drug, the nurse informs him that a. he should change position from lying to standing slowly to avoid dizziness. b. his interest in sexual activity may decrease while he is taking the medication. c. improvement in the obstructive symptoms should occur within about 2 weeks. d. he will need to monitor his blood pressure frequently to assess for hypertension.

B A decrease in libido is a side effect of finasteride because of the androgen suppression that occurs with the drug. Although orthostatic hypotension may occur if the patient also is taking a medication for erectile dysfunction (ED), it should not occur with finasteride alone. Improvement in symptoms of obstruction takes about 6 months. The medication does not cause hypertension. DIF: Cognitive Level: Application REF: 1380 TOP: Nursing Process: Implementation

34. Which information about a patient who has just been admitted to the hospital with nausea and vomiting will require the most rapid intervention by the nurse? a. The patient has taken only sips of water. b. The patient is lethargic and difficult to arouse. c. The patient's chart indicates a recent resection of the small intestine. d. The patient has been vomiting several times a day for the last 4 days.

B A lethargic patient is at risk for aspiration, and the nurse will need to position the patient to decrease aspiration risk. The other information also is important to collect, but it does not require as quick action as the risk for aspiration. DIF: Cognitive Level: Application REF: 964 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

26. When implementing the initial plan of care for a patient admitted with acute diverticulitis, the nurse will plan to a. give stool softeners. b. administer IV fluids. c. order a diet high in fiber and fluids. d. prepare the patient for colonoscopy.

B A patient with acute diverticulitis will be NPO and given parenteral fluids. A diet high in fiber and fluids will be implemented before discharge. Bulk-forming laxatives, rather than stool softeners, are usually given, and these will be implemented later in the hospitalization. The patient with acute diverticulitis will not have a colonoscopy because of the risk for perforation and peritonitis. DIF: Cognitive Level: Application REF: 1047 TOP: Nursing Process: Planning

25. The nurse explains to a patient with a new ileostomy that after the bowel adjusts to the ileostomy, the usual drainage will be about a. 1 cup. b. 2 cups. c. 3 cups. d. 1 quart.

B After the proximal small bowel adapts to reabsorb more fluid, the average amount of ileostomy drainage is about 500 mL daily. DIF: Cognitive Level: Comprehension REF: 1042 | 1044-1045 TOP: Nursing Process: Implementation

12. A patient who has been receiving a heparin infusion and warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT). Which action will the nurse include in the plan of care? a. Use low-molecular-weight heparin (LMWH) only. b. Flush all intermittent IV lines using normal saline. c. Administer the warfarin (Coumadin) at the scheduled time. d. Teach the patient about the purpose of platelet transfusions.

B All heparin is discontinued when the 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/µl. The platelet count does not drop low enough in HIT for a platelet transfusion, and platelet transfusions increase the risk for thrombosis. DIF: Cognitive Level: Application REF: 679 | 680-681 TOP: Nursing Process: Planning

5. Two days after an exploratory laparotomy with a resection of a short segment of small bowel, a patient complains of gas pains and abdominal distention. Which nursing action is best to take at this time? a. Give a return-flow enema. b. Assist the patient to ambulate. c. Administer the ordered IV morphine sulfate. d. Insert the ordered promethazine (Phenergan) suppository.

B Ambulation will improve peristalsis and help the patient eliminate flatus and reduce gas pain. Morphine will further reduce peristalsis. A return-flow enema may decrease the patient's symptoms, but ambulation is less invasive and should be tried first. Promethazine (Phenergan) is used as an antiemetic rather than to decrease gas pains or distention. DIF: Cognitive Level: Application REF: 1016-1017 TOP: Nursing Process: Implementation

4. When caring for an alert and oriented elderly patient with a history of dehydration, the home health nurse will teach the patient to increase fluid intake a. in the late evening hours. b. if the oral mucosa feels dry. c. when the patient feels thirsty. d. as soon as changes in level of consciousness (LOC) occur.

B An alert, elderly patient will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an accurate indicator of volume depletion. Many older patients prefer to restrict fluids slightly in the evening to improve sleep quality. The patient will not be likely to notice and act appropriately when changes in LOC occur. DIF: Cognitive Level: Application REF: 308 | 311 TOP: Nursing Process: Implementation

22. A 33-year-old who has a diagnosis of fibrocystic breast changes calls the nurse in the clinic with these symptoms. Which is most important to report to the health care provider? a. There is yellow-green discharge from one of the patient's nipples. b. There is an area on the breast that is hot, pink, and tender to touch. c. The lumps are firm feeling and most are in the upper outer breast quadrants. d. The lumps are larger and more painful before the patient's menstrual period.

B An area that is hot or pink suggests an infectious process such as mastitis, which would require further assessment and treatment. The other information also will be reported, but these findings are typical in fibrocystic breasts. DIF: Cognitive Level: Application REF: 1309 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

27. Which of these actions can the nurse who is caring for a critically ill patient with multiple intravenous (IV) lines delegate to an experienced LPN? a. Administer IV antibiotics through the implantable port. b. Monitor the IV sites for redness, swelling, or tenderness. c. Remove the patient's nontunneled subclavian central venous catheter. d. Adjust the flow rate of the 0.9% normal saline in the peripheral IV line.

B An experienced LPN has the education, experience, and scope of practice to monitor IV sites for signs of infection. Administration of medications, adjustment of infusion rates, and removal of central catheters in critically ill patients require RN level education and scope of practice. DIF: Cognitive Level: Application REF: 327 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC:

32. The nurse obtains information about a hospitalized patient who is receiving chemotherapy for cancer of the colon. Which information about the patient is most indicative of a need for a change in therapy? a. Poor oral intake b. Increase in CEA c. Frequent loose stools d. Complaints of nausea

B An increase in CEA indicates that the chemotherapy is not effective for the patient's cancer and may need to be modified. The other patient findings are common adverse effects of chemotherapy. The nurse may need to address these, but they would not indicate a need for a change in therapy. DIF: Cognitive Level: Application REF: 267-268 | 281-282 TOP: Nursing Process: Assessment

20. A patient with hypertension and stage 2 chronic kidney disease (CKD) is receiving captopril (Capoten). Before administration of the medication, the nurse will check the patient's a. glucose. b. potassium. c. creatinine. d. phosphate.

B Angiotensin-converting enzyme (ACE) inhibitors are frequently used in patients with CKD because they delay the progression of the CKD, but they cause potassium retention. Therefore, careful monitoring of potassium levels is needed in patients who are at risk for hyperkalemia. The other laboratory values also would be monitored in patients with CKD but would not affect whether the captopril was given or not. DIF: Cognitive Level: Application REF: 1176 TOP: Nursing Process: Assessment

39. After receiving change-of-shift report for the following four patients with neutropenia, which patient should the nurse assess first? a. 66-year-old who has white pharyngeal lesions b. 35-year-old who has a fever of 100.8° F (38.2° C) c. 56-year-old who has frequent explosive diarrhea d. 23-year old who is complaining of severe fatigue

B 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. DIF: Cognitive Level: Application REF: 690-691 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC:

18. When preparing for an annual physical exam for a patient who is 50 years old, the nurse will plan to teach the patient about a. endoscopy. b. colonoscopy. c. computerized tomography screening. d. carcinoembryonic antigen (CEA) testing.

B At age 50, individuals with an average risk for colorectal cancer (CRC) should begin screening for CRC. Colonoscopy is the gold standard for CRC screening. The other diagnostic tests are not recommended as part of a routine annual physical exam at age 50. DIF: Cognitive Level: Application REF: 1035-1037 TOP: Nursing Process: Planning

1. A patient who is hospitalized with watery, incontinent diarrhea is diagnosed with Clostridium difficile. Which action will the nurse include in the plan of care? a. Order a diet with no dairy products for the patient. b. Place the patient in a private room with contact isolation. c. Teach the patient about why antibiotics are not being used. d. Educate the patient about proper food handling and storage.

B Because C. difficile is highly contagious, the patient should be placed in a private room and contact precautions should be used. There is no need to restrict dairy products for this type of diarrhea. Metronidazole (Flagyl) is frequently used to treat C. difficile. Improper food handling and storage do not cause C. difficile. DIF: Cognitive Level: Application REF: 1009-1010 TOP: Nursing Process: Planning MSC:

16. When performing discharge teaching for a patient who has undergone a vasectomy in the health care provider's office, the nurse instructs the patient that a. he may have temporary erectile dysfunction (ED) because of postoperative swelling. b. he should continue to use other methods of birth control for 6 weeks. c. he should not have sexual intercourse until his 6-week follow-up visit. d. he will notice a decrease in the appearance and volume of his ejaculate.

B Because it takes about 6 weeks to evacuate sperm that are distal to the vasectomy site, the patient should use contraception for 6 weeks. ED that occurs after vasectomy is psychologic in origin and not related to postoperative swelling. The patient does not need to abstain from intercourse. The appearance and volume of the ejaculate are not changed because sperm are a minor component of the ejaculate. DIF: Cognitive Level: Comprehension REF: 1398 TOP: Nursing Process: Implementation

5. A patient is admitted to the hospital with possible acute pericarditis. The nurse will plan to teach the patient about the purpose of a. electrolyte levels. b. echocardiography. c. daily blood cultures. d. cardiac catheterization.

B Echocardiograms are useful in detecting the presence of the pericardial effusions associated with pericarditis. Blood cultures are not indicated unless the patient has evidence of sepsis. Cardiac catheterization is not a diagnostic procedure for pericarditis. Electrolyte levels are not helpful in making a diagnosis of pericarditis. DIF: Cognitive Level: Application REF: 847-848 TOP: Nursing Process: Planning

35. When caring for a patient with a temporary radioactive cervical implant, which action by nursing assistive personnel (NAP) indicates that the RN should intervene? a. The NAP flushes the toilet once after emptying the patient's bedpan. b. The NAP stands by the patient's bed for 30 minutes talking with the patient. c. The NAP places the patient's bedding in the laundry container in the hallway. d. The NAP gives the patient an alcohol-containing mouthwash to use for oral care.

B Because patients with temporary implants emit radioactivity while the implants are in place, exposure to the patient is limited. Laundry and urine/feces do not have any radioactivity and do not require special precautions. Cervical radiation will not affect the oral mucosa, and alcohol-based mouthwash is not contraindicated. DIF: Cognitive Level: Application REF: 280 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation MSC:

17. When developing a teaching plan for a patient with a 42 pack-year history of cigarette smoking, it will be most important for the nurse to include information about a. computed tomography (CT) screening for lung cancer. b. options for smoking cessation. c. reasons for annual sputum cytology testing. d. erlotinib (Tarceva) therapy to prevent tumor risk.

B Because smoking is the major cause of lung cancer, the most important role for the nurse is educating patients about the benefits of and means of smoking cessation. Early screening of at-risk patients using sputum cytology, chest x-ray, or CT scanning has not been effective in reducing mortality. Erlotinib may be used in patients who have lung cancer but not to reduce risk for developing tumors. DIF: Cognitive Level: Application REF: 563 | 565 TOP: Nursing Process: Planning

25. A patient with non-Hodgkin's lymphoma develops a platelet count of 18,000/µl during chemotherapy. An appropriate nursing intervention for the patient based on this finding is to a. provide oral hygiene every 2 hours. b. check all stools for occult blood. c. check the temperature every 4 hours. d. encourage fluids to 3000 mL/day.

B 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. DIF: Cognitive Level: Application REF: 683 TOP: Nursing Process: Implementation

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

B Corticosteroid use is associated with increased risk for infection, so the nurse should report the urinary tract symptoms immediately to the health care provider. The increase in blood glucose, increased appetite, and acne also are adverse effects of corticosteroid use, but do not need diagnosis and treatment as rapidly as the probable urinary tract infection. DIF: Cognitive Level: Application REF: 1647-1649 | 1674-1675 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning

28. Which information obtained by the nurse when assessing a patient admitted with mitral valve regurgitation should be communicated to the health care provider immediately? a. The patient has 4+ peripheral edema in both legs. b. The patient has crackles audible to the lung apices. c. The patient has a palpable thrill felt over the left anterior chest. d. The patient has a loud systolic murmur all across the precordium.

B Crackles that are audible throughout the lungs indicate that the patient is experiencing severe left ventricular failure with pulmonary congestion and needs immediate interventions such as diuretics. A systolic murmur and palpable thrill would be expected in a patient with mitral regurgitation. Although 4+ peripheral edema indicates a need for a change in therapy, it does not need to be addressed urgently. DIF: Cognitive Level: Application REF: 853-854 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

3. When the nurse is evaluating the fluid balance for a patient admitted for hypovolemia associated with multiple draining wounds, the most accurate assessment to include is a. skin turgor. b. daily weight. c. presence of edema. d. hourly urine output.

B Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age. Considerable excess fluid volume may be present before fluid moves into the interstitial space and causes edema. Hourly urine outputs do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds. DIF: Cognitive Level: Application REF: 310 TOP: Nursing Process: Evaluation

38. Which of these assessment findings in a patient with a hiatal hernia who returned from a laparoscopic Nissen fundoplication 4 hours ago is most important for the nurse to address immediately? a. The patient is experiencing intermittent waves of nausea. b. The patient has absent breath sounds throughout the left lung. c. The patient has decreased bowel sounds in all four quadrants. d. The patient complains of 6/10 (0 to 10 scale) abdominal pain.

B Decreased breath sounds on one side may indicate a pneumothorax, which requires rapid diagnosis and treatment. The abdominal pain and nausea also should be addressed but they are not as high priority as the patient's respiratory status. The patient's decreased bowel sounds are expected after surgery and require ongoing monitoring but no other action. DIF: Cognitive Level: Application REF: 974-975 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

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

B Deep breathing exercises are used to decrease the risk for pulmonary complications that may occur with the reduced chest expansion that can occur with ankylosing spondylitis (AS). Patients should sleep on the back and avoid flexed positions. Prolonged standing and walking should be avoided. There is no need for frequent naps. DIF: Cognitive Level: Comprehension REF: 1661-1662 TOP: Nursing Process: Implementation

29. Which nursing action for a patient who has arrived for a scheduled hemodialysis session is most appropriate for the RN to delegate to a dialysis technician? a. Educate patient about fluid restrictions. b. Check blood pressure before starting dialysis. c. Assess for reasons for increase in predialysis weight. d. Determine the ultrafiltration rate for the hemodialysis.

B Dialysis technicians are educated in monitoring for blood pressure. Assessment, adjustment of the appropriate ultrafiltration rate, and patient teaching require the education and scope of practice of an RN. DIF: Cognitive Level: Application REF: 1185-1187 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC:

27. Which of the following assessment data obtained by the nurse when caring for a patient with thrombocytopenia should be immediately communicated to the health care provider? a. The platelet count is 52,000/µl. b. The patient is difficult to arouse. c. There are large bruises on the back. d. There are purpura on the oral mucosa.

B Difficulty in arousing the patient may indicate a cerebral hemorrhage, which is life threatening and requires immediate action. The other information should be documented and reported, but would not be unusual in a patient with thrombocytopenia. DIF: Cognitive Level: Application REF: 674 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

14. Which nursing intervention will be included in the care plan for a patient with immune thrombocytopenic purpura (ITP)? a. Assign the patient to a private room. b. Avoid intramuscular (IM) injections. c. Use rinses rather than a toothbrush for oral care. d. Restrict activity to passive and active range of motion.

B IM or subcutaneous injections should be avoided because of the risk for bleeding. A soft toothbrush can be used for oral care. There is no need to restrict activity or place the patient in a private room. DIF: Cognitive Level: Application REF: 682-683 TOP: Nursing Process: Planning MSC:

2. During assessment of the chest in a patient with pneumococcal pneumonia, the nurse would expect to find a. vesicular breath sounds. b. increased tactile fremitus. c. dry, nonproductive cough. d. hyperresonance to percussion.

B Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal pneumonia typically presents with a loose, productive cough. Adventitious breath sounds such as crackles and wheezes are typical. DIF: Cognitive Level: Application REF: 549 TOP: Nursing Process: Assessment

1. Which finding will the nurse expect when assessing a 60-year-old patient who has osteoarthritis (OA) of the left knee? a. Heberden's nodules b. Pain upon joint movement c. Redness and swelling of the knee joint d. Stiffness that increases with movement

B Initial symptoms of OA include pain with joint movement. Heberden's nodules occur on the fingers. Redness of the joint is more strongly associated with rheumatoid arthritis (RA), and stiffness in OA is worse right after the patient rests and decreases with joint movement. DIF: Cognitive Level: Comprehension REF: 1644 TOP: Nursing Process: Assessment

8. Intravenous potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take? a. Administer the KCl as a rapid IV bolus. b. Infuse the KCl at a rate of 20 mEq/hour. c. Give the KCl only through a central venous line. d. Add no more than 40 mEq/L to a liter of IV fluid.

B Intravenous KCl is administered at a maximal rate of 20 mEq/hr. Rapid IV infusion of KCl can cause cardiac arrest. Although the preferred concentration for KCl is no more than 40 mEq/L, concentrations up to 80 mEq/L may be used for some patients. KCl can cause inflammation of peripheral veins, but it can be administered by this route. DIF: Cognitive Level: Application REF: 316 TOP: Nursing Process: Implementation

16. The nurse is preparing to give the following medications to an HIV-positive patient who is hospitalized with Pneumocystis jiroveci pneumonia (PCP). Which is most important to administer at the right time? a. Nystatin (Mycostatin) tablet for vaginal candidiasis b. Oral saquinavir (Inverase) to suppress HIV infection c. Aerosolized pentamadine (NebuPent) for PCP infection d. Oral acyclovir (Zovirax) to treat systemic herpes simplex

B It is important that antiretrovirals be taken at the prescribed time every day to avoid developing drug-resistant HIV. The other medications should also be given as close as possible to the correct time, but they are not as essential to receive at the same time every day. DIF: Cognitive Level: Application REF: 252-253 TOP: Nursing Process: Implementation

11. During the admission assessment of a patient with hemolytic anemia, the nurse notes jaundice of the sclerae. The nurse will plan to check the laboratory results for a. the Schilling test. b. the bilirubin level. c. the stool occult blood test. d. the gastric analysis testing.

B Jaundice is caused by the elevation of bilirubin level associated with red blood cell (RBC) hemolysis. The other tests would not be helpful in monitoring or treating a hemolytic anemia. DIF: Cognitive Level: Application REF: 667 | 672 TOP: Nursing Process: Assessment

25. When the home health RN is planning care for a patient with a seizure disorder, which nursing action can be delegated to an LPN/LVN? a. Make referrals to appropriate community agencies. b. Place medications in the home medication organizer. c. Teach the patient and family how to manage seizures. d. Assess for use of medications that may precipitate seizures.

B LPN/LVN education includes administration of medications. The other activities require RN education and scope of practice. DIF: Cognitive Level: Application REF: 1502 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC:

25. The health care provider has prescribed the following collaborative interventions for a 49-year-old who is taking azathioprine (Imuran) for systemic lupus erythematosus. Which order will the nurse question? a. Draw anti-DNA blood titer. b. Administer varicella vaccine. c. Use naproxen (Aleve) 200 mg BID. d. Take famotidine (Pepcid) 20 mg daily.

B Live virus vaccines, such as varicella, are contraindicated in a patient taking immunosuppressive drugs. The other orders are appropriate for the patient. DIF: Cognitive Level: Application REF: 1667-1668 TOP: Nursing Process: Implementation

5. When caring for a patient with a chronic iron deficiency anemia, the nurse will assess for a. yellow-tinged sclerae. b. shiny, smooth tongue. c. numbness of the extremities. d. gum bleeding and tenderness.

B Loss of the papillae of the tongue occurs with chronic iron deficiency. Scleral jaundice is associated with hemolysis, gum bleeding and tenderness occur with thrombocytopenia or neutropenia, and extremity numbness is associated with vitamin B12 deficiency or pernicious anemia. DIF: Cognitive Level: Application REF: 652-653 TOP: Nursing Process: Assessment

12. The home health nurse notes that an elderly patient has a low serum protein level. The nurse will plan to assess for a. pallor. b. edema. c. confusion. d. restlessness.

B Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels. DIF: Cognitive Level: Application REF: 306 TOP: Nursing Process: Assessment

19. A patient with chronic kidney disease (CKD) brings all home medications to the clinic to be reviewed by the nurse. Which medication being used by the patient indicates that patient teaching is required? a. Multivitamin with iron b. Milk of magnesia 30 mL c. Calcium phosphate (PhosLo) d. Acetaminophen (Tylenol) 650 mg

B Magnesium is excreted by the kidneys, and patients with CKD should not use over-the-counter products containing magnesium. The other medications are appropriate for a patient with CKD. DIF: Cognitive Level: Application REF: 1172-1173 TOP: Nursing Process: Assessment

22. A patient who has a history of a transfusion-related acute lung injury (TRALI) is to receive a transfusion of packed red blood cells (PRBCs). Which action will the nurse take to decrease the risk for TRALI for this patient? a. Infuse the PRBCs slowly over 4 hours. b. Transfuse only leukocyte-reduced PRBCs. c. Administer the scheduled oral diuretic before the transfusion. d. Give the PRN dose of antihistamine before starting the transfusion.

B TRALI is caused by a reaction between the donor and the patient leukocytes that causes pulmonary inflammation and capillary leaking. The other actions may help prevent respiratory problems caused by circulatory overload or by allergic reactions, but they will not prevent TRALI. DIF: Cognitive Level: Application REF: 708 TOP: Nursing Process: Implementation

8. When inflating the cuff on a tracheostomy tube to the appropriate level, the best action by the nurse will be to a. check the pilot balloon after inflation to ensure that it is firm. b. use a manometer to ensure cuff pressure is at an appropriate level. c. check the amount of cuff pressure ordered by the health care provider. d. fill the balloon until minimal air leakage around the cuff is auscultated.

B Measurement of cuff pressure using a manometer to ensure that cuff pressure is 20 mm Hg or lower will avoid compression of the tracheal capillaries. A firm pilot balloon indicates that the cuff is inflated but does not assess for overinflation. A health care provider's order is not required to determine safe cuff pressure. A minimal leak technique is an alternate means for cuff inflation, but this technique does allow a small air leak around the cuff and increases the risk for aspiration. DIF: Cognitive Level: Application REF: 530 TOP: Nursing Process: Implementation

34. After obtaining the health history from a 28-year-old woman who is taking methotrexate (Rheumatrex) to treat rheumatoid arthritis, which information about the patient is most important for the nurse to report to the health care provider? a. The patient had a history of infectious mononucleosis as a teenager. b. The patient is trying to have a baby before her disease becomes more severe. c. The patient has a family history of age-related macular degeneration of the retina. d. The patient has been using large doses of vitamins and health foods to treat the RA.

B Methotrexate is teratogenic, and the patient should be taking contraceptives during methotrexate therapy. The other information will not impact the choice of methotrexate as therapy. DIF: Cognitive Level: Application REF: 1647-1649 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

3. A patient who is receiving methotrexate develops a megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of a. iron. b. folic acid. c. cobalamin (vitamin B12). d. ascorbic acid (vitamin C).

B Methotrexate use can lead to folic acid deficiency. Supplementation with oral folic acid supplements is the usual treatment. The other nutrients would not correct folic acid deficiency, although they would be used to treat other types of anemia. DIF: Cognitive Level: Application REF: 669 TOP: Nursing Process: Planning

42. The RN and nursing assistive personnel (NAP) are caring for a patient with a paralytic ileus. Which of these nursing activities is appropriate for the nurse to delegate to NAP? a. Auscultation for bowel sounds b. Applying petroleum jelly to the lips c. Irrigation of the nasogastric (NG) tube with saline d. Assessment of the nose for irritation

B NAP education and scope of practice include patient hygiene such as oral care. The other actions require education and scope of practice appropriate to the RN. DIF: Cognitive Level: Application REF: 1033-1034 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation MSC:

28. Which nursing action should the nurse delegate to nursing assistive personnel (NAP) when administering a transfusion of packed red blood cells (PRBCs) to a patient with blood loss? a. Verify the patient identification (ID) according to hospital policy. b. Obtain the temperature, blood pressure, and pulse before the transfusion. c. Double-check the product numbers on the PRBCs with the patient ID band. d. Monitor the patient for shortness of breath or chest pain during the transfusion.

B NAP education includes measurement of vital signs. The NAP would report the vital signs to the RN. The other actions require more education and a larger scope of practice and should be done by licensed nursing staff members. DIF: Cognitive Level: Application REF: 705-706 | 707 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation MSC:

15. A 22-year-old patient hospitalized with a fever and red, hot, and painful knees is suspected of having septic arthritis. Information obtained during the nursing history that indicates a risk factor for septic arthritis is that the patient a. has a parent who has reactive arthritis. b. is sexually active and has multiple partners. c. recently returned from a trip to South America. d. had several sports-related knee injuries as a teenager.

B Neisseria gonorrhoeae is the most common cause for septic arthritis in sexually active young adults. The other information does not point to any risk for septic arthritis. DIF: Cognitive Level: Comprehension REF: 1662-1664 TOP: Nursing Process: Assessment

28. When caring for a dehydrated patient with acute kidney injury who is oliguric, anemic, and hyperkalemic, which of the following prescribed actions should the nurse take first? a. Insert a urinary retention catheter. b. Place the patient on a cardiac monitor. c. Administer epoetin alfa (Epogen, Procrit). d. Give sodium polystyrene sulfonate (Kayexalate).

B Since hyperkalemia can cause fatal cardiac dysrhythmias, the initial action should be to monitor the cardiac rhythm. Kayexalate and Epogen will take time to correct the hyperkalemia and anemia. The catheter allows monitoring of the urine output, but does not correct the cause of the renal failure. DIF: Cognitive Level: Application REF: 1168 | 1175-1176 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

10. Following discharge teaching for a patient who has had a transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH), the nurse determines that additional instruction is needed when the patient says, a. "I will avoid driving until I get approval from my doctor." b. "I should call the doctor if I have any incontinence at home." c. "I will increase fiber and fluids in my diet to prevent constipation." d. "I should continue to schedule yearly appointments for prostate exams."

B Since incontinence is common for several weeks after a TURP, the patient does not need to call the health care provider if this occurs. The other patient statements indicate that the patient has a good understanding of post-TURP instructions. DIF: Cognitive Level: Application REF: 1388-1389 TOP: Nursing Process: Evaluation

35. Which of these prescribed interventions will the nurse implement first when caring for a patient who has just been diagnosed with peritonitis caused by a ruptured diverticulum? a. Administer morphine sulfate 4 mg IV. b. Infuse metronidazole (Flagyl) 500 mg IV. c. Send the patient for a computerized tomography scan. d. Insert a nasogastric (NG) tube and connect it to intermittent low suction.

B Since peritonitis can be fatal if treatment is delayed, the initial action should be to start antibiotic therapy (after any ordered cultures are obtained). The other actions can be done after antibiotic therapy is initiated. DIF: Cognitive Level: Application REF: 1021-1022 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

25. A patient with cirrhosis and esophageal varices has a new prescription for propranolol (Inderal). Which assessment finding is the best indicator that the medication has been effective? a. The apical pulse rate is 68 beats/minute. b. Stools test negative for occult blood. c. The patient denies complaints of chest pain. d. Blood pressure is less than 140/90 mm Hg.

B Since the purpose of β-blocker therapy for patients with esophageal varices is to decrease the risk for bleeding from esophageal varices, the best indicator of the effectiveness for propranolol is the lack of blood in the stools. Although propranolol is used to treat hypertension, angina, and tachycardia, the purpose for use in this patient is to decrease the risk for bleeding from esophageal varices. DIF: Cognitive Level: Application REF: 1077-1078 TOP: Nursing Process: Evaluation

17. Following a lumpectomy, a patient is scheduled for external beam radiation to the right breast. Which information should the nurse include in patient teaching? a. The radiation therapy will take a week to complete. b. Careful skin care in the radiated area will be necessary. c. Visitors are restricted until the radiation therapy is completed. d. Wigs may be used until the hair regrows after radiation therapy.

B Skin care will be needed because of the damage caused to the skin by the radiation. External beam radiation is done over a 5- to 6-week period. Hair loss does not occur with radiation therapy. Since the patient does not have radioactive implants, no visitor restrictions are necessary. DIF: Cognitive Level: Application REF: 1314 TOP: Nursing Process: Implementation

10. A patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix) has a serum potassium level of 3.2 mEq/L (3.2 mmol/L). Which action should the nurse take? a. Give both drugs as scheduled. b. Administer the spironolactone. c. Administer the furosemide and withhold the spironolactone. d. Withhold both drugs until talking with the health care provider.

B Spironolactone is a potassium-sparing diuretic and will help to increase the patient's potassium level. The nurse does not need to talk with the doctor before giving the spironolactone, although the health care provider should be notified about the low potassium value. The furosemide will further decrease the patient's potassium level and should be held until the nurse talks with the health care provider. DIF: Cognitive Level: Application REF: 1077-1078 | 1080 TOP: Nursing Process: Implementation

4. An RN is observing a nursing student who is suctioning a hospitalized patient with a tracheostomy in place. Which action by the student requires the RN to intervene? a. The student preoxygenates the patient for 1 minute before suctioning. b. The student puts on clean gloves and uses a sterile catheter to suction. c. The student inserts the catheter about 5 inches into the tracheostomy tube. d. The student applies suction for 10 seconds while withdrawing the catheter.

B Sterile gloves and a sterile catheter are used when suctioning a tracheostomy. The other student actions do not require intervention by the RN. Although the patient may not need 1 minute of preoxygenation, this would not be unsafe. Suctioning for 10 seconds is appropriate. The length of catheter that should be inserted depends on the length of the tracheostomy tube, but 5 inches would be appropriate for most adult patients. DIF: Cognitive Level: Comprehension REF: 530 TOP: Nursing Process: Implementation MSC:

19. Which of these nursing actions can the RN working in a long-term care facility delegate to an experienced LPN/LVN who is caring for a patient with a permanent tracheostomy? a. Assessing the patient's risk for aspiration b. Suctioning the tracheostomy when needed c. Educating the patient about self-care of the tracheostomy d. Determining the need for replacement of the tracheostomy tube

B Suctioning of a stable patient can be delegated to LPN/LVNs. Assessments and patient teaching should be done by the RN. DIF: Cognitive Level: Application REF: 532-534 | 542 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC:

15. When the nurse is administering a vesicant chemotherapeutic agent intravenously, an important consideration is to a. infuse the medication over a short period of time. b. stop the infusion if swelling is observed at the site. c. administer the chemotherapy through small-bore catheter. d. hold the medication unless a central venous line is available.

B Swelling at the site may indicate extravasation, and the IV should be stopped immediately. The medication generally should be given slowly to avoid irritation of the vein. The size of the catheter is not as important as administration of vesicants into a running IV line to allow dilution of the chemotherapeutic drug. These medications can be given through peripheral lines, although central vascular access devices (CVADs) are preferred. DIF: Cognitive Level: Application REF: 276 TOP: Nursing Process: Implementation

14. A patient with severe cirrhosis has an episode of bleeding esophageal varices. To detect possible complications of the bleeding episode, it is most important for the nurse to monitor a. bilirubin levels. b. ammonia levels. c. potassium levels. d. prothrombin time.

B The blood in the gastrointestinal (GI) tract will be absorbed as protein and may result in an increase in ammonia level because the liver cannot metabolize protein well. The prothrombin time, bilirubin, and potassium levels also should be monitored, but these will not be affected by the bleeding episode. DIF: Cognitive Level: Application REF: 1076-1077 TOP: Nursing Process: Assessment

37. A patient is admitted to the hospital with acute cholecystitis. Which assessment information will be most important for the nurse to report to the health care provider? a. The patient's urine is bright yellow. b. The patient's stools are clay colored. c. The patient complains of chronic heartburn. d. The patient has an increase in pain after eating.

B The clay-colored stools indicate biliary obstruction, which requires rapid intervention to resolve. The other data are not unusual for a patient with this diagnosis, although the nurse also would report the other assessment information to the health care provider. DIF: Cognitive Level: Application REF: 1096 | 1099 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

18. The nurse obtains the following assessment data in a 76-year-old patient who has influenza. Which information will be most important to communicate to the health care provider? a. Fever of 100.4° F (38° C) b. Diffuse crackles in the lungs c. Sore throat and frequent cough d. Myalgia and persistent headache

B The crackles indicate that the patient may be developing pneumonia, a common complication of influenza, which would require aggressive treatment. Myalgia, headache, mild temperature elevation, and sore throat with cough are typical symptoms of influenza and are treated with supportive care measures such as over-the-counter (OTC) pain relievers and increased fluid intake. DIF: Cognitive Level: Application REF: 524-525 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

18. A patient is seen in the health clinic with symptoms of a stooped posture, shuffling gait, and pill rolling-type tremor. The nurse will anticipate teaching the patient about a. oral corticosteroids. b. antiparkinsonian drugs. c. the purpose of electroencephalogram (EEG) testing. d. preparation for magnetic resonance imaging (MRI).

B The diagnosis of Parkinson's is made when two of the three characteristic signs of tremor, rigidity, and bradykinesia are present. The confirmation of the diagnosis is made on the basis of improvement when antiparkinsonian drugs are administered. This patient has symptoms of tremor and bradykinesia; the next anticipated step will be treatment with medications. MRI and EEG are not useful in diagnosing Parkinson's disease, and corticosteroid therapy is not used to treat it. DIF: Cognitive Level: Application REF: 1509-1510 TOP: Nursing Process: Planning

17. A patient with peptic ulcer disease associated with the presence of Helicobacter pylori is treated with triple drug therapy. The nurse will plan to teach the patient about a. sucralfate (Carafate), nystatin (Mycostatin), and bismuth (Pepto-Bismol). b. amoxicillin (Amoxil), clarithromycin (Biaxin), and omeprazole (Prilosec). c. famotidine (Pepcid), magnesium hydroxide (Mylanta), and pantoprazole (Protonix). d. metoclopramide (Reglan), bethanechol (Urecholine), and promethazine (Phenergan).

B The drugs used in triple drug therapy include a proton pump inhibitor such as omeprazole and the antibiotics amoxicillin and clarithromycin. The other combinations listed are not included in the protocol for H. pylori infection. DIF: Cognitive Level: Comprehension REF: 986 TOP: Nursing Process: Planning

19. Which action will be included in the care plan for a hospitalized patient who is neutropenic? a. Avoid any IM or subcutaneous injections. b. Check the oral temperature every 4 hours. c. Omit all fruits or vegetables from the diet. d. Place a "No Visitors" sign on the patient door.

B The earliest sign of infection in a neutropenic patient is an elevation in temperature. Although unpeeled fresh fruits and vegetables should be avoided, fruits and vegetables that are peeled or cooked are acceptable. Injections may be required for administration of medications such as filgrastim (Neupogen). The number of visitors may be limited and visitors with communicable diseases should be avoided, but a "no visitors" policy is not needed. DIF: Cognitive Level: Application REF: 693 TOP: Nursing Process: Planning

32. When the nurse is reviewing laboratory results for a patient with systemic lupus erythematosus (SLE), which result is most important to communicate to the health care provider? a. Decreased C-reactive protein (CRP) b. Elevated blood urea nitrogen (BUN) c. Positive antinuclear antibodies (ANA) d. Positive lupus erythematosus cell prep

B The elevated BUN and creatinine levels indicate possible lupus nephritis and a need for a change in therapy to avoid further renal damage. The positive lupus erythematosus (LE) cell prep and ANA would be expected in a patient with SLE. A drop in CRP shows an improvement in the inflammatory process. DIF: Cognitive Level: Application REF: 1666-1668 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

14. Which action should the nurse take first when a patient develops a nosebleed? a. Pack both nares tightly with 1/2-inch ribbon gauze. b. Pinch the lower portion of the nose for 10 minutes. c. Prepare supplies that will be needed for cauterization. d. Apply ice compresses over the patient's nose and cheeks.

B The first nursing action for epistaxis is to apply direct pressure by pinching the nostrils. Application of cold packs may decrease blood flow to the area somewhat, but will not be sufficient to stop bleeding. Cauterization or nasal packing may be needed if pressure to the nares does not stop bleeding, but these are not the first actions to take for nosebleed. DIF: Cognitive Level: Application REF: 520-521 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

6. A patient's complete blood count shows a hemoglobin of 20 g/dL and a hematocrit of 54%. Which question should the nurse ask to determine possible causes of this finding? a. "Has there been any recent weight loss?" b. "Do you have any history of lung disease?" c. "What is your intake of fruits and vegetables?" d. "Have you noticed any dark or bloody stools?"

B The hemoglobin and hematocrit results indicate polycythemia, which can be associated with chronic lung disease. The other questions will be appropriate for patients who are anemic. DIF: Cognitive Level: Application REF: 650-651 TOP: Nursing Process: Assessment

33. A homeless patient with severe anorexia and fatigue is admitted to the hospital with viral hepatitis. Which patient goal has the highest priority when the nurse is developing the plan of care? a. Increase activity level. b. Maintain adequate nutrition. c. Establish a stable home environment. d. Identify the source of exposure to hepatitis.

B The highest priority outcome is to maintain nutrition because adequate nutrition is needed for hepatocyte regeneration. Finding a home for the patient and identifying the source of the infection would be appropriate activities, but they do not have as high a priority as ensuring adequate nutrition. Although the patient's activity level will be gradually increased, rest is indicated during the acute phase of hepatitis. DIF: Cognitive Level: Application REF: 1066 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning

24. When the nurse is caring for a patient who has been admitted with a severe crushing injury after an industrial accident, which laboratory result will be most important to report to the health care provider? a. Serum creatinine level 2.1 mg/dL b. Serum potassium level 6.5 mEq/L c. White blood cell count 11,500/µL d. Blood urea nitrogen (BUN) 56 mg/dL

B The hyperkalemia associated with crushing injuries may cause cardiac arrest and should be treated immediately. The nurse also will report the other laboratory values, but abnormalities in these are not immediately life threatening. DIF: Cognitive Level: Application REF: 1167 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

5. A pregnant woman with a history of early chronic HIV infection is seen at the clinic. Which information will the nurse include when teaching the patient? a. The antiretroviral medications used to treat HIV infection are teratogenic. b. Most infants born to HIV-positive mothers are not infected with the virus. c. Since she is at an early stage of HIV infection, the infant will not contract HIV. d. It is likely that her newborn will become infected with HIV unless she uses antiretroviral drug therapy (ART).

B Only 25% of infants born to HIV-positive mothers develop HIV infection, even when the mother does not use ART during pregnancy. The percentage drops to 2% when ART is used. Perinatal transmission can occur at any stage of HIV infection (although it is less likely to occur when the viral load is lower). ART can safely be used in pregnancy, although some ART drugs should be avoided. DIF: Cognitive Level: Comprehension REF: 242 TOP: Nursing Process: Implementation

8. A patient is admitted to the hospital with a sickle cell crisis. While caring for the patient during the crisis, it is important for the nurse to a. limit the patient's intake of oral and IV fluids. b. evaluate the effectiveness of opioid analgesics. c. encourage the patient to ambulate as much as tolerated. d. teach the patient about high-protein, high-calorie foods.

B Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control. Fluid intake should be increased to reduce blood viscosity and improve perfusion. Rest is usually ordered to decrease metabolic requirements. Patients are instructed about the need for dietary folic acid, but high-protein, high-calorie diets are not emphasized. DIF: Cognitive Level: Application REF: 673-675 TOP: Nursing Process: Implementation

4. When the nurse is assessing the breasts of a 31-year-old, which finding is most indicative of a need for further evaluation? a. Bilateral nodules that are tender with palpation b. A nodule that is 1 cm in size, painless, and fixed c. A lump that increases in size before the menstrual period d. A lump that is small, mobile, and has a rubbery consistency

B Painless and fixed lumps suggest breast cancer. The other findings are more suggestive of benign processes such as fibrocystic breasts and fibroadenoma. DIF: Cognitive Level: Application REF: 1309-1310 TOP: Nursing Process: Assessment

22. When educating a patient with chronic pancreatitis about the prescribed pancrelipase (Viokase), the nurse will teach the patient to take the medication a. at bedtime. b. with every meal. c. upon arising in the morning. d. as soon as abdominal pain occurs.

B Pancreatic enzymes are used to help with digestion of nutrients and should be taken with every meal. DIF: Cognitive Level: Application REF: 1093-1094 TOP: Nursing Process: Implementation

10. When teaching a patient who has rheumatoid arthritis (RA) about how to manage activities of daily living, the nurse instructs the patient to a. stand rather than sit when performing household chores. b. avoid activities that require continuous use of the same muscles. c. strengthen small hand muscles by wringing sponges or washcloths. d. protect the knee joints by sleeping with a small pillow under the knees.

B Patients are advised to avoid repetitious movements. Sitting during household chores is recommended to decrease stress on joints. Wringing water out of sponges would increase the joint stress. Patients are encouraged to position joints in the extended position, and sleeping with a pillow behind the knees would decrease the ability of the knee to extend and also decrease knee range of motion (ROM). DIF: Cognitive Level: Application REF: 1659-1660 TOP: Nursing Process: Implementation

12. Which action will the community health nurse include when planning ways to decrease the incidence of rheumatic fever? a. Immunize susceptible groups in the community with streptococcal vaccine. b. Teach community members to seek treatment for streptococcal pharyngitis. c. Educate about the importance of monitoring temperature when infections occur. d. Provide prophylactic antibiotics to people with a family history of rheumatic fever.

B The incidence of rheumatic fever is decreased by treatment of streptococcal infections with antibiotics. Family history is not a risk factor for rheumatic fever. There is no immunization that is effective in decreasing the incidence of rheumatic fever. Education about monitoring temperature will not decrease the incidence of rheumatic fever. DIF: Cognitive Level: Application REF: 852 TOP: Nursing Process: Planning

13. A 35-year-old patient with three school-age children who has recently been diagnosed with rheumatoid arthritis (RA) tells the nurse that the inability to be involved in many family activities is causing stress at home. Which response by the nurse is most appropriate? a. "You may need to see a family therapist for some help." b. "Tell me more about the situations that are causing stress." c. "Perhaps it would be helpful for you and your family to get involved in a support group." d. "Your family may need some help to understand the impact of your rheumatoid arthritis."

B The initial action by the nurse should be further assessment. The other three responses might be appropriate based on the information the nurse obtains with further assessment. DIF: Cognitive Level: Application REF: 1660 TOP: Nursing Process: Implementation

24. After being stung by a wasp, a patient is brought to the clinic by a co-worker. Upon arrival the patient is anxious and having difficulty breathing. The first action that the nurse should take is to a. have the patient lie down. b. assess the patient's airway. c. administer high-flow oxygen. d. remove the stinger from the site.

B The initial action with any patient with difficulty breathing is to assess and maintain the airway. The other actions also are part of the emergency management protocol for anaphylaxis, but the priority is airway maintenance. DIF: Cognitive Level: Application REF: 223 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

21. The health care provider inserts a chest tube in a patient with a hemopneumothorax. When monitoring the patient after the chest tube placement, the nurse will be most concerned about a. a large air leak in the water-seal chamber. b. 400 mL of blood in the collection chamber. c. complaint of pain with each deep inspiration. d. subcutaneous emphysema at the insertion site.

B The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. A large air leak would be expected immediately after chest tube placement for pneumothorax. The pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with pneumothorax. DIF: Cognitive Level: Application REF: 572 TOP: Nursing Process: Assessment

38. The nurse is performing tuberculosis (TB) screening in a clinic that has many patients who have immigrated to the United States. Before doing a TB skin test on a patient, which question is most important for the nurse to ask? a. "Is there any family history of TB?" b. "Have you received the bacille Calmette-Guérin (BCG) vaccine for TB?" c. "How long have you lived in the United States?" d. "Do you take any over-the-counter (OTC) medications?"

B Patients who have received the BCG vaccine will have a positive Mantoux test. Another method for screening (such as a chest x-ray) will need to be used in determining whether the patient has a TB infection. The other information also may be valuable but is not as pertinent to the decision about doing TB skin testing. DIF: Cognitive Level: Application REF: 557 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

13. A couple is seen at the infertility clinic because they have not been able to conceive. When performing a focused examination to determine any possible causes for infertility, the nurse will check the man for the presence of a. hydrocele. b. varicocele. c. epididymitis. d. paraphimosis.

B Persistent varicoceles are commonly associated with infertility. Hydrocele, epididymitis, and paraphimosis are not risk factors for infertility. DIF: Cognitive Level: Comprehension REF: 1396 TOP: Nursing Process: Assessment

33. The nurse obtains this information when assessing a patient who is taking hydroxychloroquine (Plaquenil) to treat rheumatoid arthritis. Which symptom is most important to report to the health care provider? a. Abdominal cramping b. Complaint of blurry vision c. Phalangeal joint tenderness d. Blood pressure 170/84 mm Hg

B Plaquenil can cause retinopathy; the medication should be stopped. The other findings are not related to the medication, although they also will be reported. DIF: Cognitive Level: Application REF: 1647-1649 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

11. A patient diagnosed with systemic lupus erythematosus (SLE) is scheduled for plasmapheresis. The nurse plans to teach the patient that plasmapheresis will a. eliminate eosinophils and basophils from blood. b. remove antibody-antigen complexes from circulation. c. prevent foreign antibodies from damaging various body tissues. d. decrease the damage to organs caused by attacking T-lymphocytes.

B Plasmapheresis is used in SLE to remove antibodies, antibody-antigen complexes, and complement from blood. T-lymphocytes, foreign antibodies, eosinophils, and basophils do not contribute to the tissue damage in SLE. DIF: Cognitive Level: Comprehension REF: 226-227 TOP: Nursing Process: Planning

26. The nurse working in a health clinic receives calls from all these patients. Which patient should be seen by the health care provider first? a. A 44-year-old man who has perineal pain and a temperature of 100.4° F b. A 66-year-old man who has a painful erection that has lasted over 7 hours c. A 62-year-old man who has light pink urine after having a transurethral resection of the prostate (TURP) 3 days ago d. A 23-year-old man who states he had difficulty maintaining an erection last night

B Priapism can cause complications such as necrosis or hydronephrosis, and this patient should be treated immediately. The other patients do not require immediate action to prevent serious complications. DIF: Cognitive Level: Analysis REF: 1394 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Assessment

39. Which of the following nursing actions included in the plan of care for a patient with cirrhosis can the RN delegate to nursing assistive personnel? a. Assessing the patient for jaundice b. Providing oral hygiene before meals c. Palpating the abdomen for distention d. Assisting the patient in choosing the diet

B Providing oral hygiene is included in the education and scope of practice of nursing assistants. Assessments and assisting patients to choose therapeutic diets are nursing actions that require higher-level nursing education and scope of practice and would be delegated to LPNs/LVNs or RNs. DIF: Cognitive Level: Application REF: 1080-1085 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC:

7. Cardiac tamponade is suspected in a patient who has acute pericarditis. To assess for the presence of pulsus paradoxus, the nurse should a. check the electrocardiogram (ECG) for variations in rate in relation to inspiration and expiration. b. note when Korotkoff sounds are audible during both inspiration and expiration. c. auscultate for a pericardial friction rub that increases in volume during inspiration. d. subtract the diastolic blood pressure (DBP) from the systolic blood pressure (SBP).

B Pulsus paradoxus exists when there is a gap of greater than 10 mm Hg between when Korotkoff sounds can be heard during only expiration and when they can be heard throughout the respiratory cycle. The other methods described would not be useful in determining the presence of pulsus paradoxus. DIF: Cognitive Level: Comprehension REF: 847 TOP: Nursing Process: Assessment

12. A patient with Parkinson's disease has a nursing diagnosis of impaired physical mobility related to bradykinesia. Which action will the nurse include in the plan of care? a. Instruct the patient in activities that can be done while lying or sitting. b. Suggest that the patient rock from side to side to initiate leg movement. c. Have the patient take small steps in a straight line directly in front of the feet. d. Teach the patient to keep the feet in contact with the floor and slide them forward.

B Rocking the body from side to side stimulates balance and improves mobility. The patient will be encouraged to continue exercising because this will maintain functional abilities. Maintaining a wide base of support will help with balance. The patient should lift the feet and avoid a shuffling gait. DIF: Cognitive Level: Application REF: 1506-1508 | 1513-1514 TOP: Nursing Process: Planning

21. When designing a program to decrease the incidence of HIV infection in the community, the nurse will prioritize teaching about a. methods to prevent perinatal HIV transmission. b. how to prevent transmission between sexual partners. c. ways to sterilize needles used by injectable drug users. d. means to prevent transmission through blood transfusions.

B Sexual transmission is the most common way that HIV is transmitted. The nurse should also provide education about perinatal transmission, needle sterilization, and blood transfusion, but the rate of HIV infection associated with these situations is lower. DIF: Cognitive Level: Application REF: 241-242 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning

27. A patient with primary pulmonary hypertension (PPH) is receiving nifedipine (Procardia). The nurse will evaluate that the treatment is effective if a. the BP is less than 140/90 mm Hg. b. the patient reports decreased exertional dyspnea. c. the heart rate is between 60 and 100 beats/minute. d. the patient's chest x-ray indicates clear lung fields.

B Since a major symptom of PPH is exertional dyspnea, an improvement in this symptom would indicate that the medication was effective. Nifedipine will affect BP and heart rate, but these parameters would not be used to monitor effectiveness of therapy for a patient with PPH. The chest x-ray will show clear lung fields even if the therapy is not effective. DIF: Cognitive Level: Application REF: 582 TOP: Nursing Process: Evaluation

31. The following data are obtained by the nurse when assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate. Which finding is most important to report to the health care provider immediately? a. The bibasilar breath sounds are decreased. b. The patellar and triceps reflexes are absent. c. The patient has been sleeping most of the day. d. The patient reports feeling "sick to my stomach."

B The loss of the deep tendon reflexes indicates that the patient's magnesium level may be reaching toxic levels. Nausea and lethargy also are side effects associated with magnesium elevation and should be reported, but they are not as significant as the loss of deep tendon reflexes. The decreased breath sounds suggest that the patient needs to cough and deep breathe to prevent atelectasis. DIF: Cognitive Level: Application REF: 319-320 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

20. Which action can the nurse delegate to nursing assistive personnel (NAP) who help with the care of a patient admitted with tuberculosis and placed on airborne precautions? a. Teach the patient about how to use tissues to dispose of respiratory secretions. b. Stock the patient's room with all the necessary personal protective equipment. c. Interview the patient to obtain the names of family members and close contacts. d. Tell the patient's family members the reason for the use of airborne precautions.

B Since all health care workers will be educated about the various types of infection precautions used in the hospital, the NAP can safely stock the room with personal protective equipment. Obtaining contact information and patient education are higher-level skills that require RN education and scope of practice. DIF: Cognitive Level: Application REF: 240-241 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation MSC:

10. Which nursing action will the nurse include in the plan of care when admitting a patient with an exacerbation of inflammatory bowel disease (IBD)? a. Restrict oral fluid intake. b. Monitor stools for blood. c. Increase dietary fiber intake. d. Ambulate four times daily.

B Since anemia or hemorrhage may occur with IBD, stools should be assessed for the presence of blood. The other actions would not be appropriate for the patient with IBD. Because dietary fiber may increase gastrointestinal (GI) motility and exacerbate the diarrhea, severe fatigue is common with IBD exacerbations, and dehydration may occur. DIF: Cognitive Level: Application REF: 1024-1025 | 1028-1029 TOP: Nursing Process: Planning

15. When the nurse is caring for a patient who has had a total laryngectomy and radical neck dissection during the first 24 hours after surgery, what is the priority nursing action? a. Monitor for bleeding. b. Assess breath sounds. c. Clean the inner cannula every 8 hours. d. Avoid changing the tracheostomy ties.

B The most important goals posttracheotomy are to maintain the airway and ensure adequate oxygenation. Assessment of the breath sounds is the priority action. Maintenance of the tracheostomy ties, cleaning the inner cannula, and checking for bleeding also are appropriate nursing actions but are not of as high a priority. DIF: Cognitive Level: Application REF: 538-541 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

25. A patient with a history of benign prostatic hyperplasia (BPH) is admitted with acute urinary retention and an elevated blood urea nitrogen (BUN) and creatinine. Which of these prescribed therapies should the nurse implement first? a. Obtain renal ultrasound. b. Insert retention catheter. c. Infuse normal saline at 50 mL/hour. d. Draw blood for complete blood count.

B The patient's elevation in BUN is most likely associated with hydronephrosis caused by the acute urinary retention, so the insertion of a retention catheter is the first action to prevent ongoing postrenal failure for this patient. The other actions also are appropriate, but should be implemented after the retention catheter. DIF: Cognitive Level: Application REF: 1165-1167 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

21. Which action will the nurse include in the plan of care for a patient who has a central venous access device (CVAD)? a. Avoid using friction when cleaning around the CVAD insertion site. b. Use the push-pause method to flush the CVAD after giving medications. c. Obtain an order from the health care provider to change CVAD dressing. d. Have the patient turn the head toward the CAVD during injection cap changes.

B The push-pause enhances the removal of debris from the CVAD lumen and decreases the risk for clotting. To decrease infection risk, friction should be used when cleaning the CVAD insertion site. The dressing should be changed whenever it becomes damp, loose, or visibly soiled and the patient should turn away from the CVAD during cap changes. DIF: Cognitive Level: Application REF: 330-331 TOP: Nursing Process: Planning

4. When the nurse is assessing the mouth of a patient who uses smokeless tobacco for signs of oral cancer, which finding will be of most concern? a. Bleeding during tooth brushing b. Painful blisters at the border of the lips c. Red, velvety patches on the buccal mucosa d. White, curdlike plaques on the posterior tongue

C A red, velvety patch suggests erythroplasia, which has a high incidence (greater than 50%) of progression to squamous cell carcinoma. The other lesions are suggestive of acute processes (gingivitis, oral candidiasis, and herpes simplex). DIF: Cognitive Level: Comprehension REF: 968-969 TOP: Nursing Process: Assessment

14. What is the most critical assessment for a patient with a pheochromocytoma? Daily weight Breath sounds Blood pressure Abnormal girth

8. Strong opioids are most likely to cause which of the following acid-base disturbances? A. Meatbolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

8. A 64-year-old has a perineal radical prostatectomy for prostatic cancer. In the immediate postoperative period, the nurse establishes the nursing diagnosis of risk for infection related to a. urinary stasis. b. urinary incontinence. c. possible fecal contamination of the surgical wound. d. placement of a suprapubic catheter into the bladder.

C The perineal approach increases the risk for infection because the incision is located close to the anus and contamination with feces is possible. Urinary stasis and incontinence do not occur because the patient has a retention catheter in place for 1 to 2 weeks. A urethral catheter is used after the surgery. DIF: Cognitive Level: Application REF: 1388-1389 TOP: Nursing Process: Diagnosis

33. A patient in the oliguric phase of acute renal failure has a 24-hour fluid output of 150 mL emesis and 250 mL urine. The nurse plans a fluid replacement for the following day of ___ mL. a. 400 b. 800 c. 1000 d. 1400

C Usually fluid replacement should be based on the patient's measured output plus 600 mL/day for insensible losses. DIF: Cognitive Level: Application REF: 1168 OBJ: Special Questions: Alternate Item Format TOP: Nursing Process: Planning

11. A patient with Hodgkin's lymphoma who is undergoing external radiation therapy tells the nurse, "I am so tired I can hardly get out of bed in the morning." An appropriate intervention for the nurse to plan with the patient is to a. minimize activity until the treatment is completed. b. exercise vigorously when fatigue is not as noticeable. c. establish a time to take a short walk almost every day. d. consult with a psychiatrist for treatment of depression.

C Walking programs are used to keep the patient active without excessive fatigue. Vigorous exercise when the patient is less tired may lead to increased fatigue. Fatigue is expected during treatment and is not an indication of depression. Minimizing activity may lead to weakness and other complications of immobility. DIF: Cognitive Level: Application REF: 283 TOP: Nursing Process: Planning

17. A patient with hypercalcemia is being cared for on the medical unit. Nursing actions included on the care plan will include a. maintaining the patient on bed rest. b. auscultating lung sounds every 4 hours. c. monitoring for Trousseau's and Chvostek's signs. d. encouraging fluid intake up to 4000 ml every day.

D To decrease the risk for renal calculi, the patient should have an intake of 3000 to 4000 ml daily. Ambulation helps decrease the loss of calcium from bone and is encouraged in patients with hypercalcemia. Trousseau's and Chvostek's signs are monitored when there is a possibility of hypocalcemia. There is no indication that the patient needs frequent assessment of lung sounds, although these would be assessed every shift. DIF: Cognitive Level: Application REF: 317 TOP: Nursing Process: Planning

5. Which nursing action will be most effective in preventing aspiration pneumonia in patients who are at risk? a. Turn and reposition immobile patients at least every 2 hours. b. Place patients with altered consciousness in side-lying positions. c. Monitor for respiratory symptoms in patients who are immunosuppressed. d. Provide for continuous subglottic aspiration in patients receiving enteral feedings.

B The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and oxygen saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Continuous subglottic suction is recommended for intubated patients but not for all patients receiving enteral feedings. DIF: Cognitive Level: Application REF: 551 TOP: Nursing Process: Implementation

30. A patient with advanced lung cancer is admitted to the emergency department with urinary retention caused by renal calculi. Which of these laboratory values will require the most immediate action by the nurse? a. Arterial blood pH is 7.32. b. Serum calcium is 18 mEq/L. c. Serum potassium is 5.1 mEq/L. d. Arterial oxygen saturation is 91%.

B The serum calcium is well above the normal level and puts the patient at risk for cardiac dysrhythmias. The nurse should initiate cardiac monitoring and notify the health care provider. The potassium, oxygen saturation, and pH also are abnormal, and the nurse should notify the health care provider about these values as well, but they are not immediately life-threatening. DIF: Cognitive Level: Application REF: 317 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

1. A female patient's complex symptomatology over the past year has culminated in a diagnosis of systemic lupus erythematosus (SLE). Which of the patient's following statements demonstrates the need for further teaching about the disease? A. I'll try my best to stay out of the sun this summer." B. "I know that I probably have a high chance of getting arthritis." C. "I'm hoping that surgery will be an option for me in the future." D. "I understand that I'm going to be vulnerable to getting infections."

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

12. The nurse should recognize that the manifestations of Addison's disease are primarily related to the pathophysiology of renal disease. hyperthyroidism. adrenal insufficiency. increased ICP.

13. A client with end-stage kidney disease has been put on fluid restrictions. Which assessment finding indicates that the client has not adhered to this restriction? A. Blood pressure of 118/78 mm Hg B. Weight loss of 3 pounds during hospitalization C. Dyspnea and anxiety at rest D. Central venous pressure (CVP) of 6 mm Hg

19. Which statement made by the patient allows the nurse to recognize whether the patient, who is receiving brachytherapy for ovarian cancer, understands the treatment plan? A. "I may lose my hair during this treatment." B. "I must be positioned the same way during each treatment." C. "I will have a radioactive device in my body for a short time." D. "I will be placed in a semiprivate room for company."

2. A patient has been taking oral prednisone for the past several weeks after having a severe reaction to poison ivy. The nurse has explained the procedure for gradual reduction rather than sudden cessation of the drug. What is the rationale for this approach to drug administration? Prevention of hypothyroidism Prevention of diabetes insipidus Prevention of adrenal insufficiency Prevention of cardiovascular complications

2. A patient receiving high-dose chemotherapy who has bone marrow suppression has been receiving daily injections of epoetin alfa (Procrit). Which assessment finding indicates to the nurse that today's dose should be held and the health care provider notified? A. Hematocrit 28% B. Total WBC of 6200 cells/mm3 C. Blood pressure change from 130/90 mm Hg to 148/98 mm Hg D. Temperature change from 99 degrees to 100 degrees

2. A patient with aortic stenosis is admitted to the emergency department with chest pain. Which medication, if ordered by the health care provider, should the nurse question? A. Amlodipine (Norvasc) B. Aspirin C. Nitroglycerin D. Clopidogrel (Plavix)

3. A 24-year-old female patient with systemic lupus erythematosus (SLE) tells the nurse she is considering getting pregnant and wants to have a baby. Which response by the nurse is most appropriate? A. "The baby is at high risk for neonatal lupus erythematosus being diagnosed at birth." B. "Pregnancy will result in a temporary remission of your signs and symptoms." C. "Infertility can result from medications used to control your disease." D. "Autoantibodies transferred to the baby during pregnancy will cause heart defects."

3. The nurse is caring for a patient admitted with suspected hyperparathyroidism. Because of the potential effects of this disease on electrolyte balance, the nurse should assess this patient for which of the following manifestations? A. Neurologic irritability B. Declining urine output C. Lethargy and weakness D. Hyperactive bowel sounds

5. The nurse is caring for a patient after a right mastectomy with axillary lymph node dissection. Which instructions should the nurse include in the discharge instructions? "Arm exercises should not be started for 4 to 6 weeks." "Discontinue arm exercises if you have discomfort or pain." "Special massage therapy can decrease swelling in your arm." "Keep your right arm in a sling to decrease pain and swelling."

5. The surgeon was unable to spare a patient's parathyroid gland during a thyroidectomy. Which of the following assessments should the nurse prioritize when providing postoperative care for this patient? A. Assessing the patient's white blood cell levels and assessing for infection B. Monitoring the patient's hemoglobin, hematocrit, and red blood cell levels C. Monitoring the patient's serum calcium levels and assessing for signs of hypocalcemia D.Monitoring the patient's level of consciousness and assessing for acute delirium or agitation

6. The nurse coordinates postoperative care for a patient after prostate surgery. Which task is appropriate for the nurse to delegate to a licensed practical/vocational nurse (LPN/LVN)? Teach the patient how to perform Kegel exercises. Provide instructions to the patient on catheter care. Administer oxybutynin (Ditropan) for bladder spasms. Irrigate the urinary catheter to determine patency.

6. The patient is 3 weeks post-transplant from an allogeneic stem cell transplantation for acute lymphocytic leukemia. There is now some peeling of the patient's skin on the palms of the hands and the soles of the feet. Which additional assessment data supports the nurse's suspicion of possible graft-versus-host disease (GVHD)? A. The temperature is slightly below normal B. Today's platelet count is 5,000/mm3 and the WBCs are low C. The patient has had 6 to 10 watery stools daily for 3 days D. The patient's urine output is less than 800 mL in 24 hours

6. Which of the following disorder is characterized by a butterfly-shaped rash across the bridge of the nose and cheeks? A. Polymyositis B. Rheumatoid arthritis C. SLE D. Scleroderma

7. The nurse identifies which patient is at risk to develop metabolic alkalosis? A. A patient diagnosed with type 1 diabetes mellitus B. A patient with acute respiratory failure C. A patient with nasogastric suctioning D. A patient with a brain injury

7. The nurse is caring for a postoperative client who had a radical neck dissection, and the client is describing throbbing pain in the head. The nurse anticipates that the health care provider will request which medication for this client? Diphenhydramine (Benadryl) Midazolam (Versed) intravenously Morphine sulfate intravenously Oxycodone plus acetaminophen (Percocet, Tylox)

7. The nurse teaches a patient about dietary factors that are associated with prostate cancer. The nurse determines that teaching is successful if the patient selects which menu? Grilled cheese sandwich, onion rings, and hot tea Grilled steak, French fries, and vanilla shake Baked chicken, peas, apple slices, and skim milk Hamburger with cheese, pudding, and coffee

8. After receiving report, which patient should the nurse see first? A 42-year old patient with MS who has just been admitted with sepsis A 72-year old patient with Parkinson's disease who has aspiration pneumonia A 38-year old patient with myasthenia gravis who stopped taking prescribed medications A 45-year old patient with ALS who refuses enteral feedings

8. Which of the following is the most common joint affected in gout? A. Ankle B. Knee C. Metatarsophalangeal D. Tarsal area

9. Discharge teaching has been provided for a client recovering from kidney transplantation. Which information indicates that the client understands the instructions? A. "I can stop my medications when my kidney function returns to normal." B. "If my urine output is decreased, I should increase my fluids." C. "The anti-rejection medications will be taken for life." D. "I will drink 8 ounces of water with my medications."

9. When taking the blood pressure (BP) on the right arm of a patient with severe acute pancreatitis, the nurse notices carpal spasms of the patient's right hand. Which action should the nurse take next? A. Ask the patient about any arm pain. B. Retake the patient's blood pressure. C. Check the calcium level in the chart. D. Notify the health care provider immediately.

3. In caring for a client who has undergone paracentesis, which changes in the clientâ€™s status should be promptly reported to the provider? A. Increased blood pressure, increased respiratory rate B. Decreased blood pressure, increased heart rate C. Increased respiratory rate, increased apical pulse, pallor D. Tachypnea, diaphoresis, increased blood pressure

B. Decreased blood pressure, increased heart rate

2. The nurse is caring for a client with esophageal cancer who has received photodynamic therapy using porfimer sodium (Photofrin). What instructions does the nurse include in teaching the client about porfimer sodium? (Select all that apply.) Avoid sunlight for 2 weeks Cover all exposed body areas. Follow a clear liquid diet for 3 to 5 days after the procedure. Monitor for hypertension. Tissue particles may be found in the sputum.

B, C, E

6. When caring for a client with a left forearm arteriovenous fistula created for hemodialysis, which actions must the nurse take? (Select all that apply.) A. Check brachial pulses daily B. Auscultate for a bruit every 8 hours C. Teach the client to palpate for a thrill over the site. D. Elevate the arm above heart level E. Ensure that no blood pressures are taken in that arm.

B, C, E

26. The nurse implements discharge teaching for a patient following a gastroduodenostomy for treatment of a peptic ulcer. Which patient statement indicates that the teaching has been effective? a. "Persistent heartburn is expected after surgery." b. "I will try to drink liquids along with my meals." c. "Vitamin supplements may be needed to prevent problems with anemia." d. "I will need to choose foods that are low in fat and high in carbohydrate."

C Cobalamin deficiency may occur after partial gastrectomy, and the patient may need to receive cobalamin via injections or nasal spray. Foods that have moderate fat and low carbohydrate should be chosen to prevent dumping syndrome. Ingestion of liquids with meals is avoided to prevent dumping syndrome. Although peptic ulcer disease may recur, persistent heartburn is not expected after surgery and the patient should call the health care provider if this occurs. DIF: Cognitive Level: Application REF: 996-998 TOP: Nursing Process: Evaluation

4. The nurse encourages a new mother to breastfeed her infant, even for a short time, because colostrum will provide the infant with a. innate immunity. b. active immunity. c. passive immunity. d. cell-mediated immunity.

C Colostrum provides passive immunity through antibodies from the mother; these antibodies protect the infant for a few months. However, memory cells are not retained, so the protection is not permanent. Innate immunity is present at birth and occurs without exposure to an antigen. Active immunity requires that the infant manufacture antibodies after exposure to an antigen. Cell-mediated immunity is acquired through T-lymphocytes and is a form of active immunity. DIF: Cognitive Level: Comprehension REF: 216 TOP: Nursing Process: Implementation

21. When the nurse is caring for a patient with left arm lymphedema, which action will be included in the plan of care? a. Check BP on both right and left arms. b. Avoid isometric exercise on the left arm. c. Assist with application of compression dressings. d. Keep the left arm at or below the level of the heart.

C Compression of the arm assists in improving lymphatic flow toward the heart. Isometric exercises may be prescribed for lymphedema. BPs should only be done on the patient's right arm. The arm should not be placed in a dependent position. DIF: Cognitive Level: Application REF: 1323 TOP: Nursing Process: Planning

9. A patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information will the nurse include in patient teaching? a. Recommendation to drink at least 3 to 4 L daily b. Need to avoid driving or operating heavy machinery c. How to draw up and administer injections of the medication d. Use of contraceptive methods other than oral contraceptives

C Copaxone is administered by self-injection. Oral contraceptives are an appropriate choice for birth control. There is no need to avoid driving or drink large fluid volumes when taking glatiramer. DIF: Cognitive Level: Application REF: 1504-1505 TOP: Nursing Process: Implementation

9. The nurse recognizes that the goals of teaching regarding the transmission of pulmonary tuberculosis (TB) have been met when the patient with TB a. demonstrates correct use of a nebulizer. b. washes dishes and personal items after use. c. covers the mouth and nose when coughing. d. reports daily to the public health department.

C Covering the mouth and nose will help decrease airborne transmission of TB. The other actions will not be effective in decreasing the spread of TB. DIF: Cognitive Level: Application REF: 557 TOP: Nursing Process: Evaluation

28. A patient with rheumatoid arthritis refuses to take the prescribed methotrexate (Rheumatrex), telling the nurse "That drug has too many side effects. My arthritis isn't that bad yet." The most appropriate response by the nurse is a. "You have the right to refuse to take the methotrexate." b. "Methotrexate is less expensive than some of the newer drugs." c. "It is important to start methotrexate early to decrease the extent of joint damage." d. "Methotrexate is effective and has fewer side effects than some of the other drugs."

C Disease-modifying antirheumatic drugs (DMARDs) are prescribed early to prevent the joint degeneration that occurs as soon as the first year with RA. The other statements are accurate, but the most important point for the patient to understand is that it is important to start DMARDs as quickly as possible. DIF: Cognitive Level: Application REF: 1654-1655 TOP: Nursing Process: Implementation

40. Which of these nursing activities included in the care of a patient with a new colostomy should the nurse delegate to nursing assistive personnel (NAP)? a. Document the appearance of the stoma. b. Place the pouching system over the ostomy. c. Drain and measure the output from the ostomy. d. Check the skin around the ostomy for breakdown.

C Draining and measuring the output from the ostomy is included in NAP education and scope of practice. The other actions should be implemented by LPNs or RNs. DIF: Cognitive Level: Application REF: 1044 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC:

33. Which information obtained by the nurse about a patient who has been diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease is most important to communicate to the health care provider? a. The Mantoux test had an induration of only 8 mm. b. The chest-x-ray showed infiltrates in the upper lobes. c. The patient is being treated with antiretrovirals for HIV infection. d. The patient has a cough that is productive of blood-tinged mucus.

C Drug interactions can occur between the antiretrovirals used to treat HIV infection and the medications used to treat tuberculosis. The other data are expected in a patient with HIV and TB disease. DIF: Cognitive Level: Application REF: 556 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

13. After the nurse has provided patient teaching about recommended dietary choices for a patient with an acute exacerbation of inflammatory bowel disease (IBD), which diet choice by the patient indicates a need for more teaching? a. Scrambled eggs b. White toast and jam c. Oatmeal with cream d. Pancakes with syrup

C During acute exacerbations of IBD, the patient should avoid high-fiber foods such as whole grains. High-fat foods also may cause diarrhea in some patients. The other choices are low residue and would be appropriate for this patient. DIF: Cognitive Level: Application REF: 1030-1031 TOP: Nursing Process: Evaluation

32. A patient who has just been admitted with pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of severe pleuritic chest pain. Which of these prescribed medications should the nurse give first? a. guaifenesin (Robitussin) b. acetaminophen (Tylenol) c. azithromycin (Zithromax) d. codeine phosphate (Codeine)

C Early initiation of antibiotic therapy has been demonstrated to reduce mortality. The other medications also are appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy. DIF: Cognitive Level: Application REF: 549 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

2. To determine the risk for breast cancer in a 52-year-old patient who has found a small lump in her breast, which question is most pertinent for the nurse to ask? a. "Do you currently smoke cigarettes?" b. "Have you ever had any breast injuries?" c. "At what age did you start having menstrual periods?" d. "Is there any family history of fibrocystic breast changes?"

C Early menarche and late menopause are risk factors for breast cancer because of the prolonged exposure to estrogen that occurs. Cigarette smoking, breast trauma, and fibrocystic breast changes are not associated with increased breast cancer risk. DIF: Cognitive Level: Application REF: 1311 TOP: Nursing Process: Assessment

14. The long-term care nurse is evaluating the effectiveness of protein supplements on a patient who has low serum total protein level. Which of these data indicate that the patient's condition has improved? a. Hematocrit 28% b. Good skin turgor c. Absence of peripheral edema d. Blood pressure 110/72 mm Hg

C Edema is caused by low oncotic pressure in individuals with low serum protein levels; the absence of edema indicates an improvement in the patient's protein status. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status. DIF: Cognitive Level: Application REF: 306 TOP: Nursing Process: Evaluation

12. Which information will the nurse include when teaching a patient who has a diagnosis of chronic prostatitis? a. Ibuprofen (Motrin) should provide good pain control. b. Prescribed antibiotics should be taken for 7 to 10 days. c. Sexual intercourse and masturbation will help relieve symptoms. d. Cold packs should be used every 4 hours to reduce inflammation.

C Ejaculation helps drain the prostate and relieve pain. Warm baths are recommended to reduce pain. Nonsteroidal antiinflammatory drugs (NSAIDs) are frequently prescribed but usually do not offer adequate pain relief. Antibiotics for chronic prostatitis are taken for 4 to 12 weeks. DIF: Cognitive Level: Application REF: 1393 TOP: Nursing Process: Implementation

14. The nurse will plan to teach the patient with newly diagnosed achalasia that a. a liquid or blenderized diet will be necessary. b. drinking fluids with meals should be avoided. c. endoscopic procedures may be used for treatment. d. lying down and resting after meals is recommended.

C Endoscopic and laparoscopic procedures are the most effective therapy for improving symptoms caused by achalasia. Patients are advised to drink fluid with meals. Keeping the head elevated after eating will improve esophageal emptying. A semisoft diet is recommended to improve esophageal emptying. DIF: Cognitive Level: Application REF: 980-981 TOP: Nursing Process: Planning

10. When planning discharge teaching for the patient who was admitted with a sickle cell crisis, which instruction will the nurse include? a. Limit fluids to 2 to 3 quarts a day. b. Take a daily multivitamin with iron. c. Avoid exposure to crowds as much as possible. d. Drink only one or two caffeinated beverages daily.

C 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. DIF: Cognitive Level: Application REF: 673-675 TOP: Nursing Process: Planning

10. Which information about a patient with MS indicates that the nurse should consult with the health care provider before giving the prescribed dose of fampridine (Ampyra)? a. The patient has relapsing-remitting MS. b. The patient enjoys walking for relaxation. c. The patient has an increased creatinine level. d. The patient complains of pain with neck flexion.

C Fampridine should not be given to patients with impaired renal function. The other information will not impact on whether the fampridine should be administered. DIF: Cognitive Level: Application REF: 1505-1506 TOP: Nursing Process: Assessment

33. A critically ill patient develops incontinence of watery stools. What action will be best for the nurse to take to prevent complications associated with ongoing incontinence? a. Insert a rectal tube. b. Use incontinence briefs. c. Implement fecal management system. d. Assist the patient to a bedside commode or to the bathroom at frequent intervals.

C Fecal management systems are designed to contain loose stools and can be in place for as long as 4 weeks without causing damage to the rectum or anal sphincters. Rectal tubes are avoided because of possible damage to the anal sphincter and ulceration of the rectal mucosa. Incontinence briefs may be helpful but, unless they are changed frequently, are likely to increase the risk for skin breakdown. A critically ill patient will not be able to use the commode or bathroom. DIF: Cognitive Level: Application REF: 1012 TOP: Nursing Process: Implementation

35. Which parameter will be most important for the nurse to consider when titrating the IV fluid infusion rate immediately after a patient has had kidney transplantation? a. Heart rate b. Blood urea nitrogen (BUN) level c. Urine output d. Creatinine clearance

C Fluid volume is replaced based on urine output after transplant because the urine output can be as high as a liter an hour. The other data will be monitored but are not the most important determinants of fluid infusion rate. DIF: Cognitive Level: Application REF: 1192-1193 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

14. A 21-year-old woman is scheduled for percutaneous transluminal balloon valvuloplasty to treat mitral stenosis. When explaining the advantage of valvuloplasty instead of valve replacement to the patient, which information will the nurse include? a. Biologic replacement valves require the use of immunosuppressive drugs. b. Mechanical mitral valves require replacement approximately every 5 years. c. Lifelong anticoagulant therapy is needed after mechanical valve replacement. d. Ongoing cardiac care by a health care provider is unnecessary after valvuloplasty.

C Long-term anticoagulation therapy is needed after mechanical valve replacement, and this would restrict decisions about career and childbearing in this patient. Mechanical valves are durable and last longer than 5 years. All valve repair procedures are palliative, not curative, and require lifelong health care. Biologic valves do not activate the immune system, and immunosuppressive therapy is not needed. DIF: Cognitive Level: Application REF: 856-857 | 859 TOP: Nursing Process: Implementation

20. When the nurse is working in the women's health care clinic, which of these actions is appropriate to take? a. Educate a healthy 36-year-old about the need for an annual mammogram. b. Discuss the need for a clinical breast examination every year with a 22-year-old. c. Talk about magnetic resonance imaging (MRI) with a 26-year-old with a BRCA-1 mutation. d. Teach an active 70-year-old that mammography frequency can be reduced to every 3 years.

C MRI (in addition to mammography) is recommended for women who are at high risk for breast cancer. A 22-year-old patient should have a clinical breast exam every 3 years. Annual mammograms are recommended for women starting at age 40. Annual mammography is recommended for healthy older women. DIF: Cognitive Level: Application REF: 1305-1308 TOP: Nursing Process: Planning

1. After a patient has undergone a rhinoplasty, which nursing intervention will be included in the plan of care? a. Educate the patient about how to safely remove and reapply nasal packing. b. Reassure the patient that the nose will look normal when the swelling subsides. c. Instruct the patient to keep the head elevated for 48 hours to minimize swelling and pain. d. Teach the patient to use nonsteroidal anti-inflammatory drugs (NSAIDs) for pain control.

C Maintaining the head in an elevated position will decrease the amount of nasal swelling. NSAIDs increase the risk for postoperative bleeding and should not be used postoperatively. The patient would not be taught to remove or reapply nasal packing, which is usually removed by the surgeon on the day after surgery. Although return to a preinjury appearance is the goal of the surgery, it is not always possible to achieve this result. DIF: Cognitive Level: Application REF: 520 TOP: Nursing Process: Implementation

11. The complete blood count (CBC) and differential indicate that a patient is neutropenic. Which action should the nurse include in the plan of care? a. Avoid intramuscular injections. b. Encourage increased oral fluids. c. Check temperature every 4 hours. d. Increase intake of iron-rich foods.

C Neutropenic patients are at high risk for infection and sepsis and should be monitored frequently for signs of infection. The other actions would not address the patient's neutropenia. DIF: Cognitive Level: Application REF: 655 TOP: Nursing Process: Assessment

5. A patient is hospitalized for treatment of severe hemolytic anemia. An appropriate nursing action for the patient is to a. provide a diet high in vitamin K. b. place the patient on protective isolation. c. alternate periods of rest and activity. d. teach the patient how to avoid injury.

C Nursing care for patients with anemia should alternate periods of rest and activity to encourage activity without causing undue fatigue. There is no indication that the patient has a bleeding disorder, so a high vitamin K diet or teaching about how to avoid injury is not needed. Protective isolation might be used for a patient with aplastic anemia, but it is not indicated for hemolytic anemia. DIF: Cognitive Level: Application REF: 664-665 TOP: Nursing Process: Implementation

39. Which of these patients seen by the nurse in the outpatient clinic is most likely to require teaching about ways to reduce risk for osteoarthritis (OA)? a. A 56-year-old man who is a member of a construction crew b. A 24-year-old man who participates in a summer softball team c. A 49-year-old woman who works on an automotive assembly line d. A 36-year-old woman who is newly diagnosed with diabetes mellitus

C OA is more likely to occur in women as a result of estrogen reduction at menopause and in individuals whose work involves repetitive movements and lifting. Moderate exercise, such as softball, reduces risk for OA. Diabetes is not a risk factor for OA. Working on a construction crew would involve nonrepetitive work and thus would not be as risky. DIF: Cognitive Level: Application REF: 1644 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning

7. Which statement by a patient who is scheduled for a needle biopsy of the prostate indicates that the nurse's teaching about the purpose of the biopsy has been effective? a. "The biopsy will remove the cancer in my prostate gland." b. "The biopsy will determine how much longer I have to live." c. "The biopsy will help decide the treatment for my enlarged prostate." d. "The biopsy will indicate whether the cancer has spread to other organs."

C A biopsy is used to determine whether the prostate enlargement is benign or malignant and determines the type of treatment that will be needed. Biopsy does not give information about metastasis, life expectancy, or the impact of cancer on the patient's life; the three remaining statements indicate a need for patient teaching. DIF: Cognitive Level: Application REF: 270-271 TOP: Nursing Process: Evaluation

9. A patient with a large stomach tumor that is attached to the liver is scheduled to have a debulking procedure. The nurse explains that the expected outcome of this surgery is a. relief of pain by cutting sensory nerves in the stomach. b. control of the tumor growth by removal of malignant tissue. c. decrease in tumor size to improve the effects of other therapy. d. promotion of better nutrition by relieving the pressure in the stomach.

C A debulking surgery reduces the size of the tumor and makes radiation and chemotherapy more effective. Debulking surgeries do not control tumor growth. The tumor is debulked because it is attached to the liver, a vital organ (not to relieve pressure on the stomach). Debulking does not sever the sensory nerves, although pain may be lessened by the reduction in pressure on the abdominal organs. DIF: Cognitive Level: Comprehension REF: 273 TOP: Nursing Process: Implementation

24. When assessing a patient with increased extracellular fluid (ECF) osmolality, the priority assessment for the nurse to obtain is a. skin turgor. b. heart sounds. c. mental status. d. capillary refill.

C Changes in ECF osmolality lead to swelling or shrinking of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds also may be affected by ECF osmolality changes and resultant fluid shifts, these are signs that occur later and do not have as immediate an impact on patient outcomes. DIF: Cognitive Level: Application REF: 310 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

19. When obtaining a focused health history for a patient with possible testicular cancer, the nurse will ask the patient about any history of a. sexually transmitted disease (STD) infection. b. testicular trauma. c. testicular torsion. d. undescended testicles.

D Cryptorchidism is a risk factor for testicular cancer if it is not corrected before puberty. STD infection, testicular torsion, and testicular trauma are risk factors for other testicular conditions but not for testicular cancer. DIF: Cognitive Level: Comprehension REF: 1395 TOP: Nursing Process: Assessment

20. A long-term care patient who takes multiple medications develops acute gouty arthritis. The nurse will consult with the health care provider before giving the prescribed dose of a. sertraline (Zoloft). b. famotidine (Pepcid). c. oxycodone (Roxycodone). d. hydrochlorothiazide (HydroDiuril).

D Diuretic use increases uric acid levels and can precipitate gout attacks. The other medications are safe to administer. DIF: Cognitive Level: Application REF: 1666 TOP: Nursing Process: Implementation

8. Antiretroviral therapy (ART) is being considered for an HIV-infected patient who has a CD4+ cell count of 400/µl. Which factor is most important to consider when determining whether ART will be started for this patient? a. Patient social support system b. HIV genotype and phenotype c. Potential medication side effects d. Patient ability to comply with ART schedule

D Drug resistance develops quickly unless the patient takes ART medications on a stringent schedule, and this endangers both the patient and the community. The other information is also important to consider, but patients who are unable to manage and follow a complex drug treatment regimen should not be considered for ART. DIF: Cognitive Level: Application REF: 252-253 TOP: Nursing Process: Assessment

12. Which information will the nurse include when teaching a patient with newly diagnosed gastroesophageal reflux disease (GERD)? a. "Peppermint tea may be helpful in reducing your symptoms." b. "You should avoid eating between meals to reduce acid secretion." c. "Vigorous physical activities may increase the incidence of reflux." d. "It will be helpful to keep the head of your bed elevated on blocks."

D Elevating the head of the bed will reduce the incidence of reflux while the patient is sleeping. Peppermint will lower LES pressure and increase the chance for reflux. Small, frequent meals are recommended to avoid abdominal distention. There is no need to make changes in physical activities because of GERD. DIF: Cognitive Level: Application REF: 975 TOP: Nursing Process: Implementation

9. After the nurse teaches a patient with gastroesophageal reflux disease (GERD) about recommended dietary modifications, which diet choice for a snack 2 hours before bedtime indicates that the teaching has been effective? a. Chocolate pudding b. Glass of low-fat milk c. Peanut butter sandwich d. Cherry gelatin and fruit

D Gelatin and fruit are low fat and will not decrease lower esophageal sphincter (LES) pressure. Foods like chocolate are avoided because they lower LES pressure. Milk products increase gastric acid secretion. High-fat foods such as peanut butter decrease both gastric emptying and LES pressure. DIF: Cognitive Level: Application REF: 973-974 TOP: Nursing Process: Evaluation

10. In the patient who had an intraoperative hemorrhage 12 hours ago, the nurse would expect to find hematology results indicating a. a hematocrit of 45%. b. a hemoglobin of 13.2 g/dL. c. a decreased white blood cell (WBC) count. d. an elevated reticulocyte count.

D Hemorrhage causes the release of more immature RBCs from the bone marrow into the circulation. The hematocrit and hemoglobin levels are normal. The WBC count is not affected by bleeding. DIF: Cognitive Level: Comprehension REF: 644 TOP: Nursing Process: Assessment

10. A patient who has required prolonged mechanical ventilation has the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L. The nurse interprets these results as a. metabolic acidosis. b. metabolic alkalosis. c. respiratory acidosis. d. respiratory alkalosis.

D The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO3. DIF: Cognitive Level: Application REF: 323-324 TOP: Nursing Process: Assessment

11. A patient presenting with a prominent forehead, large nose, large jaw, and elongation of the facial bones is most likely to be diagnosed with acromegaly. achondroplasia. Cushing's syndrome. infantile hydrocephalus.

11. While caring for a patient with aortic stenosis, the nurse identifies pain related to decreased coronary blood flow. A priority nursing intervention for this patient would be which of the following? A. Promote rest to decrease myocardial oxygen demand. B. Teach the patient about the need for anticoagulant therapy. C. Teach the patient to use sublingual nitroglycerin for chest pain. D. Praise the head of the bed 60 degrees to decrease venous return.

23. A 45-year-old patient with acute myelogenous leukemia (AML) is considering the possibility of treatment with a hematopoietic stem cell transplant (HSCT). To assist the patient with treatment decisions, the best approach for the nurse to use is to a. emphasize the positive outcomes of a bone marrow transplant. b. discuss the need for adequate insurance to cover post-HSCT care. c. ask the patient whether there are any questions or concerns about HSCT. d. explain that a cure is not possible with any other treatment except HSCT.

C Offering the patient an opportunity to ask questions or discuss concerns about HSCT will encourage the patient to voice concerns about this treatment and also will allow the nurse to assess whether the patient needs more information about the procedure. Treatment of AML using chemotherapy is another option for the patient. It is not appropriate for the nurse to ask the patient to consider insurance needs in making this decision. DIF: Cognitive Level: Application REF: 697 TOP: Nursing Process: Implementation

14. When a patient who has had progressive chronic kidney disease (CKD) for several years is started on hemodialysis, which information about diet will the nurse include in patient teaching? a. Increased calories are needed because glucose is lost during hemodialysis. b. Unlimited fluids are allowed since retained fluid is removed during dialysis. c. More protein will be allowed because of the removal of urea and creatinine by dialysis. d. Dietary sodium and potassium are unrestricted because these levels are normalized by dialysis.

C Once 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. DIF: Cognitive Level: Application REF: 1177-1178 TOP: Nursing Process: Implementation

30. The RN observes an LPN/LVN carrying out all of the following actions while caring for a patient with stage 2 chronic kidney disease. Which action requires the RN to intervene? a. The LPN/LVN administers erythropoietin subcutaneously. b. The LPN/LVN assists the patient to ambulate in the hallway. c. The LPN/LVN gives the iron supplement and phosphate binder with lunch. d. The LPN/LVN carries a tray containing low-protein foods into the patient's room.

C Oral phosphate binders should not be given at the same time as iron because they prevent the iron from being absorbed. The phosphate binder should be given with a meal and the iron given at a different time. The other actions by the LPN/LVN are appropriate for a patient with renal insufficiency. DIF: Cognitive Level: Application REF: 1177 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation MSC:

4. Which statement by a patient who has been hospitalized for pneumonia indicates a good understanding of the discharge instructions given by the nurse? a. "I will call the doctor if I still feel tired after a week." b. "I will need to use home oxygen therapy for 3 months." c. "I will continue to do the deep breathing and coughing exercises at home." d. "I will schedule two appointments for the pneumonia and influenza vaccines."

C Patients should continue to cough and deep breathe after discharge. Fatigue for several weeks is expected. Home oxygen therapy is not needed with successful treatment of pneumonia. The pneumovax and influenza vaccines can be given at the same time. DIF: Cognitive Level: Application REF: 552 TOP: Nursing Process: Evaluation

10. When assessing an individual who has been diagnosed with early chronic HIV infection and has a normal CD4+ count, the nurse will a. check neurologic orientation. b. ask about problems with diarrhea. c. palpate the regional lymph nodes. d. examine the oral mucosa for lesions.

C Persistent generalized lymphadenopathy is common in the early stage of chronic infection. Diarrhea, oral lesions, and neurologic abnormalities would occur in the later stages of HIV infection. DIF: Cognitive Level: Application REF: 242-243 TOP: Nursing Process: Assessment

28. Which information about patient and donor tissue typing results for a patient who needs a kidney transplant is most important for the nurse to communicate to the health care provider? a. Patient is Rh positive and donor is Rh negative. b. Six antigen matches are present in HLA typing. c. Results of patient-donor cross matching are positive. d. Panel of reactive antibodies (PRA) percentage is low.

C Positive crossmatching is an absolute contraindication to kidney transplantation, since hyperacute rejection will occur after the transplant. The other information indicates that the tissue match between the patient and potential donor is acceptable. DIF: Cognitive Level: Application REF: 229 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

20. A patient who has an infusion of 50% dextrose prescribed asks the nurse why a peripherally inserted central catheter must be inserted. Which explanation by the nurse is correct? a. The prescribed infusion can be given much more rapidly when the patient has a central line. b. There is a decreased risk for infection when 50% dextrose is infused through a central line. c. The 50% dextrose is hypertonic and will be more rapidly diluted when given through a central line. d. The required blood glucose monitoring is more accurate when samples are obtained from a central line.

C Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered intravenously. Blood glucose testing is not more accurate when samples are obtained from a central line. The infection risk is higher with a central catheter than with peripheral IV lines. Hypertonic or concentrated IV solutions are not given rapidly. DIF: Cognitive Level: Application REF: 327-328 TOP: Nursing Process: Implementation

5. When teaching a patient who is scheduled for a transurethral resection of the prostate (TURP) about continuous bladder irrigation, which information will the nurse include? a. Bladder irrigation decreases the risk of postoperative bleeding. b. Hydration and urine output are maintained by bladder irrigation. c. Bladder irrigation prevents obstruction of the catheter after surgery. d. Antibiotics are infused on a continuous basis with bladder irrigation.

C The purpose of bladder irrigation is to remove clots from the bladder and to prevent obstruction of the catheter by clots. The irrigation does not decrease bleeding or improve hydration. Antibiotics are given by the IV route, not through the bladder irrigation. DIF: Cognitive Level: Comprehension REF: 1383-1385 TOP: Nursing Process: Implementation

12. The history and physical for a newly admitted patient states that the complete blood count (CBC) shows a "shift to the left." The nurse will plan to monitor the patient for a. cool extremities. b. pallor and weakness. c. elevated temperature. d. low oxygen saturation.

C The term shift to the left indicates that the number of immature polymorphonuclear neutrophils, or bands, is elevated and is a sign of severe infection. There is no indication that the patient is at risk for hypoxemia, pallor/weakness, or cool extremities. DIF: Cognitive Level: Application REF: 655 TOP: Nursing Process: Planning

22. The health care provider is considering the use of sumatriptan (Imitrex) for a patient with migraine headaches. Which information obtained by the nurse is most important to report to the health care provider? a. The patient has at least 1 to 2 cups of coffee daily. b. The patient has had migraine headaches for 30 years. c. The patient has a history of a recent acute myocardial infarction. d. The patient has been taking topiramate (Topamax) for 2 months.

C The triptans cause coronary artery vasoconstriction and should be avoided in patients with coronary artery disease. The other information will be reported to the health care provider, but none of it is an indication that sumatriptan would be an inappropriate treatment. DIF: Cognitive Level: Application REF: 1490-1492 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

32. During change-of-shift report, the nurse learns about the following four patients. Which patient requires the most rapid assessment? a. 50-year-old with chronic pancreatitis who has gnawing abdominal pain b. 48-year-old who has compensated cirrhosis and is complaining of anorexia c. 45-year-old with cirrhosis and severe ascites who has an oral temperature of 102° F (38.8° C) d. 56-year-old who is recovering from a laparoscopic cholecystectomy and has severe shoulder pain

C This patient's history and fever suggest spontaneous bacterial peritonitis, which would require rapid assessment and interventions such as antibiotic therapy. The clinical manifestations for the other patients are consistent with their diagnoses and do not indicate complications are occurring. DIF: Cognitive Level: Analysis REF: 1075-1076 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC:

24. When caring for a patient with gout and a red and painful left great toe, which nursing action will be included in the plan of care? a. Gently palpate the toe to assess swelling. b. Use pillows to keep the left foot elevated. c. Use a footboard to hold bedding away from the toe. d. Teach patient to avoid use of acetaminophen (Tylenol).

C Since any touch on the area of inflammation may increase pain, bedding should be held away from the toe and touching the toe will be avoided. Elevation of the foot will not reduce the pain, which is caused by the urate crystals. Acetaminophen can be used for pain relief. DIF: Cognitive Level: Comprehension REF: 1666 TOP: Nursing Process: Planning

36. After receiving change-of-shift report, which of these patients should the nurse assess first? a. 35-year-old who has wet desquamation associated with abdominal radiation b. 42-year-old who is sobbing after receiving a new diagnosis of ovarian cancer c. 24-year-old who is receiving neck radiation and has blood oozing from the neck d. 56-year-old who has a new pericardial friction rub after receiving chest radiation

C Since neck bleeding may indicate possible carotid artery rupture in a patient who is receiving radiation to the neck, this patient should be seen first. The diagnoses and clinical manifestations for the other patients are not immediately life threatening. DIF: Cognitive Level: Analysis REF: 295 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning MSC:

8. Before administering sodium polystyrene sulfonate (Kayexalate) to a patient with hyperkalemia, the nurse should assess the a. blood urea nitrogen (BUN) and creatinine. b. blood glucose level. c. patient's bowel sounds. d. level of consciousness (LOC).

C Sodium polystyrene sulfonate (Kayexalate) should not be given to a patient with a paralytic ileus (as indicated by absent bowel sounds) because bowel necrosis can occur. The BUN and creatinine, blood glucose, and LOC would not affect the nurse's decision to give the medication. DIF: Cognitive Level: Application REF: 1168 TOP: Nursing Process: Assessment

30. Which nursing action will be included in the plan of care for a patient who has recently been diagnosed with asymptomatic nonalcoholic fatty liver disease (NAFLD)? a. Teach symptoms of variceal bleeding. b. Discuss the need to increase caloric intake. c. Review the patient's current medication list. d. Draw blood for hepatitis serology testing.

C Some medications can increase the risk for NAFLD and these should be eliminated. NAFLD is not associated with hepatitis, weight loss is usually indicated, and variceal bleeding would not be a concern in a patient with asymptomatic NAFLD. DIF: Cognitive Level: Application REF: 1071-1072 TOP: Nursing Process: Planning

13. While the nurse is obtaining an assessment and health history from a patient, which statement by the patient will alert the nurse to a possible immunodeficiency disorder? a. "I take one baby aspirin every day to prevent stroke." b. "I usually eat eggs or meat for at least 2 meals a day." c. "I had my spleen removed many years ago after a car accident." d. "I had a chest x-ray 6 months ago when I had walking pneumonia."

C Splenectomy increases the risk for septicemia from bacterial infections. The patient's protein intake is good and should improve immune function. Daily aspirin use does not impact on immune function. A chest x-ray does not have enough radiation to suppress immune function. DIF: Cognitive Level: Application REF: 227 TOP: Nursing Process: Assessment

29. The health care provider prescribes antacids and sucralfate (Carafate) for treatment of a patient's peptic ulcer. The nurse will teach the patient to take a. antacids 30 minutes before the sucralfate. b. sucralfate at bedtime and antacids before meals. c. antacids after eating and sucralfate 30 minutes before eating. d. sucralfate and antacids together 30 minutes before each meal.

C Sucralfate is most effective when the pH is low and should not be given with or soon after antacid. Antacids are most effective when taken after eating. Administration of sucralfate 30 minutes before eating and antacids just after eating will ensure that both drugs can be most effective. The other regimens will decrease the effectiveness of the medications. DIF: Cognitive Level: Comprehension REF: 992 TOP: Nursing Process: Implementation

37. After the nurse has received change-of-shift report about the following four patients, which patient should be assessed first? a. A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes b. A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled c. A 46-year-old patient who has a deep vein thrombosis and is complaining of sudden onset shortness of breath. d. A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 100.2° F (37.8° C)

C Sudden onset shortness of breath in a patient with a deep vein thrombosis suggests a pulmonary embolism and requires immediate assessment and actions such as oxygen administration. The other patients also should be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration. DIF: Cognitive Level: Application REF: 577-578 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning

16. After a patient has had a transjugular intrahepatic portosystemic shunt (TIPS) placement, which finding indicates that the procedure has been effective? a. Lower indirect bilirubin level b. Increase in serum albumin level c. Decrease in episodes of variceal bleeding d. Improvement in alertness and orientation

C TIPS is used to lower pressure in the portal venous system and decrease the risk of bleeding from esophageal varices. Indirect bilirubin level and serum albumin levels are not affected by shunting procedures. TIPS will increase the risk for hepatic encephalopathy. DIF: Cognitive Level: Application REF: 1078-1080 TOP: Nursing Process: Evaluation

19. Ten years after seroconversion, an HIV-infected patient has a CD4+ cell count of 800/µl and an undetectable viral load. What is the priority nursing intervention at this time? a. Monitor for symptoms of AIDS. b. Teach about the effects of antiretroviral agents. c. Encourage adequate nutrition, exercise, and sleep. d. Discuss likelihood of increased opportunistic infections.

C The CD4+ level for this patient is in the normal range, indicating that the patient is the early chronic stage of infection, when the body is able to produce enough CD4+ cells to maintain a normal CD4+ count. AIDS and increased incidence of opportunistic infections typically develop when the CD4+ count is much lower than normal. Although initiation of ART is highly individual, it would not be likely that a patient with a normal CD4+ level would receive ART. DIF: Cognitive Level: Application REF: 247 | 253 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

25. Which of the following assessment data obtained by the nurse when assessing a patient with acute pericarditis should be reported immediately to the health care provider? a. Pulsus paradoxus 8 mm Hg b. Blood pressure (BP) of 166/96 c. Jugular vein distention (JVD) to the level of the jaw d. Level 6 (0 to 10 scale) chest pain with deep inspiration

C The JVD indicates that the patient may have developed cardiac tamponade and may need rapid intervention to maintain adequate cardiac output. Hypertension would not be associated with complications of pericarditis, and the BP is not high enough to indicate that there is any immediate need to call the health care provider. A pulsus paradoxus of 8 mm Hg is normal. Level 6/10 chest pain should be treated but is not unusual with pericarditis. DIF: Cognitive Level: Application REF: 847 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

23. To determine whether a patient with joint swelling and pain has systemic lupus erythematosus, which test will be most useful for the nurse to review? a. Rheumatoid factor (RF) b. Antinuclear antibody (ANA) c. Anti-Smith antibody (Anti-Sm) d. Lupus erythematosus (LE) cell prep

C The anti-Sm is antibody found almost exclusively in SLE. The other blood tests also are used in screening but are not as specific to SLE. DIF: Cognitive Level: Comprehension REF: 1667-1669 TOP: Nursing Process: Assessment

16. After teaching a patient on immunosuppressant therapy after a kidney transplant about the posttransplant drug regimen, the nurse determines that additional teaching is needed when the patient says, a. "If I develop an acute rejection episode, I will need to have other types of drugs given IV." b. "I need to be monitored closely because I have a greater chance of developing malignant tumors." c. "After a couple of years, it is likely that I will be able to stop taking the calcineurin inhibitor." d. "The drugs are given in combination because they inhibit different aspects of transplant rejection."

C The calcineurin inhibitor will need to be continued for life. The other patient statements are accurate and indicate that no further teaching is necessary about those topics. DIF: Cognitive Level: Application REF: 230-232 TOP: Nursing Process: Evaluation

4. A patient who has acute glomerulonephritis is hospitalized with acute kidney injury (AKI) and hyperkalemia. Which information will the nurse obtain to evaluate the effectiveness of the prescribed calcium gluconate IV? a. Urine output b. Calcium level c. Cardiac rhythm d. Neurologic status

C The calcium gluconate helps prevent dysrhythmias that might be caused by the hyperkalemia. The nurse will monitor the other data as well, but these will not be helpful in determining the effectiveness of the calcium gluconate. DIF: Cognitive Level: Application REF: 1168 TOP: Nursing Process: Evaluation

5. A patient with stage 2 chronic kidney disease (CKD) is scheduled for an intravenous pyelogram (IVP). Which of these orders for the patient will the nurse question? a. NPO for 6 hours before IVP procedure b. Normal saline 500 mL IV before procedure c. Ibuprofen (Advil) 400 mg PO PRN for pain d. Dulcolax suppository 4 hours before IVP procedure

C The contrast dye used in IVPs is potentially nephrotoxic, and concurrent use of other nephrotoxic medications such as the NSAIDs should be avoided. The suppository and NPO status are necessary to ensure adequate visualization during the IVP. IV fluids are used to ensure adequate hydration, which helps reduce the risk for contrast-induced renal failure. DIF: Cognitive Level: Application REF: 1169-1170 TOP: Nursing Process: Implementation

32. Two hours after a kidney transplant, the nurse obtains all of the following data when assessing the patient. Which information is most important to communicate to the health care provider? a. The urine output is 900 to 1100 mL/hr. b. The blood urea nitrogen (BUN) and creatinine levels are elevated. c. The patient's central venous pressure (CVP) is decreased. d. The patient has level 8 (on a 10-point scale) incisional pain.

C The decrease in CVP suggests hypovolemia, which must be rapidly corrected to prevent renal hypoperfusion and acute tubular necrosis. The other information is not unusual in a patient after a transplant. DIF: Cognitive Level: Application REF: 1192-1193 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

27. Which assessment information about a 62-year-old man is most important for the nurse to report to the health care provider when the patient is asking for a prescription for testosterone replacement therapy? a. The patient's symptoms have increased steadily over the last few years. b. The patient has been using sildenafil (Viagra) several times every week. c. The patient has had a gradual decrease in the force of his urinary stream. d. The patient states that he has noticed a decrease in energy level for a few years.

C The decrease in urinary stream may indicate benign prostatic hyperplasia (BPH) or prostate cancer, which are contraindications to the use of testosterone replacement therapy (TRT). The other patient data indicate that TRT may be a helpful therapy for the patient. DIF: Cognitive Level: Application REF: 1400 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

39. A patient is admitted to the emergency department with an open stab wound to the right chest. What is the first action that the nurse should take? a. Position the patient so that the right chest is dependent. b. Keep the head of the patient's bed at no more than 30 degrees elevation. c. Tape a nonporous dressing on three sides over the chest wound. d. Cover the sucking chest wound firmly with an occlusive dressing.

C The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the patient on the right side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The head of the bed should be elevated to 30 to 45 degrees to facilitate breathing. DIF: Cognitive Level: Application REF: 567 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

22. A patient receiving isoosmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result is most important to report to the health care provider? a. K+ 3.4 mEq/L (3.4 mmol/L) b. Ca+2 7.8 mg/dl (1.95 mmol/L) c. Na+ 154 mEq/L (154 mmol/L) d. PO4-3 4.8 mg/dl (1.55 mmol/L)

C The elevated serum sodium level is consistent with the patient's neurologic symptoms and indicates a need for immediate action to prevent further serious complications such as seizures. The potassium and calcium levels vary slightly from the normal but do not require any immediate action by the nurse. The phosphate level is within the normal parameters. DIF: Cognitive Level: Application REF: 311-312 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

22. When reviewing patient laboratory results, the nurse in the clinic notes elevated prostate specific antigen (PSA) levels in the following four patients. Which patient's PSA result is most important to report to the health care provider? a. A 75-year-old who uses saw palmetto to treat benign prostatic hyperplasia (BPH) b. A 38-year-old who is being treated for acute prostatitis c. A 48-year-old whose father died of metastatic prostate cancer d. A 52-year-old who goes on long bicycle rides every weekend

C The family history and elevation of PSA in the 48-year-old indicate that further evaluation of the patient for prostate cancer is needed. The elevations in PSA for the other patients are not unusual. DIF: Cognitive Level: Application REF: 1387 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Assessment

41. The nurse is caring for a patient with primary pulmonary hypertension who is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action? a. The BP is 98/56 mm Hg. b. The oxygen saturation is 94%. c. The patient's central intravenous line is disconnected. d. The international normalized ratio (INR) is prolonged.

C The half-life of this drug is 6 minutes, so the nurse will need to restart the infusion as soon as possible to prevent rapid clinical deterioration. The other data also indicate a need for ongoing monitoring or intervention, but the priority action is to reconnect the infusion. DIF: Cognitive Level: Application REF: 581 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

6. After a patient with right lower-lobe pneumonia has been treated with intravenous (IV) antibiotics for 2 days, which assessment data obtained by the nurse indicates that the treatment has been effective? a. Bronchial breath sounds are heard at the right base. b. The patient coughs up small amounts of green mucus. c. The patient's white blood cell (WBC) count is 9000/µl. d. Increased tactile fremitus is palpable over the right chest.

C The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed. DIF: Cognitive Level: Application REF: 549 TOP: Nursing Process: Evaluation

3. After discussing management of upper respiratory infections (URI) with a patient who has acute viral rhinitis, the nurse determines that additional teaching is needed when the patient says a. "I can take acetaminophen (Tylenol) to treat discomfort." b. "I will drink lots of juices and other fluids to stay hydrated." c. "I can use my nasal decongestant spray until the congestion is all gone." d. "I will watch for changes in nasal secretions or the sputum that I cough up."

C The nurse should clarify that nasal decongestant sprays should be used for no more than 3 days to prevent rebound vasodilation and congestion. The other responses indicate that the teaching has been effective. DIF: Cognitive Level: Application REF: 524 TOP: Nursing Process: Evaluation

34. A patient with cirrhosis who has been vomiting blood is admitted to the emergency department. Which action should the nurse take first? a. Insert a large-gauge IV catheter. b. Draw blood for coagulation studies. c. Check BP, heart rate, and respirations. d. Place the patient in the supine position.

C The nurse's first action should be to determine the patient's hemodynamic status by assessing vital signs. Drawing blood for coagulation studies and inserting an IV catheter also are appropriate. However, the vital signs may indicate the need for more urgent actions. Since aspiration is a concern for this patient, the nurse will need to assess the patient's vital signs and neurologic status before placing the patient in the supine position. DIF: Cognitive Level: Application REF: 1084 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

2. A 67-year-old patient tells the nurse, "I have problems with constipation now that I am older, so I use a suppository every morning." Which action should the nurse take first? a. Encourage the patient to increase oral fluid intake. b. Inform the patient that a daily bowel movement is unnecessary. c. Assess the patient about individual risk factors for constipation. d. Suggest that the patient increase dietary intake of high-fiber foods.

C The nurse's initial action should be further assessment of the patient for risk factors for constipation and for usual bowel pattern. The other actions may be appropriate but will be based on the assessment. DIF: Cognitive Level: Application REF: 1012-1013 TOP: Nursing Process: Implementation

18. A patient who has had recent cardiac surgery develops pericarditis and complains of level 6 (0 to 10 scale) chest pain with deep breathing. Which of these ordered PRN medications will be the most appropriate for the nurse to administer? a. Fentanyl 2 mg IV b. IV morphine sulfate 6 mg c. Oral ibuprofen (Motrin) 800 mg d. Oral acetaminophen (Tylenol) 650 mg

C The pain associated with pericarditis is caused by inflammation, so nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen are most effective. Opioid analgesics are usually not used for the pain associated with pericarditis. DIF: Cognitive Level: Application REF: 847-848 TOP: Nursing Process: Implementation

27. When taking the BP of a patient with severe acute pancreatitis, the nurse notices carpal spasm of the patient's hand. Which action should the nurse take next? a. Ask the patient about any arm pain. b. Retake the patient's blood pressure. c. Check the calcium level on the chart. d. Notify the health care provider immediately.

C The patient with acute pancreatitis is at risk for hypocalcemia, and the assessment data indicate a positive Trousseau's sign. The health care provider should be notified after the nurse checks the patient's calcium level. There is no indication that the patient needs to have the BP rechecked or that there is any arm pain. DIF: Cognitive Level: Application REF: 1091-1092 TOP: Nursing Process: Assessment

6. Which statement by a patient with stage 5 chronic kidney disease (CKD) indicates that the nurse's teaching about management of CKD has been effective? a. "I need to try to get more protein from dairy products." b. "I will try to increase my intake of fruits and vegetables." c. "I will measure my urinary output each day to help calculate the amount I can drink." d. "I need to take the erythropoietin to boost my immune system and help prevent infection."

C The patient with end-stage renal disease is taught to measure urine output as a means of determining an appropriate oral fluid intake. Erythropoietin is given to increase the red blood cell count and will not offer any benefit for immune function. Dairy products are restricted because of the high phosphate level. Many fruits and vegetables are high in potassium and should be restricted in the patient with CKD. DIF: Cognitive Level: Application REF: 1177-1178 TOP: Nursing Process: Evaluation

5. When the nurse is deflating the cuff of a tracheostomy tube to evaluate the patient's ability to swallow, it is important to a. clean the inner cannula of the tracheostomy tube before deflation. b. deflate the cuff during the inhalation phase of the respiratory cycle. c. suction the patient's mouth and trachea before deflation of the cuff. d. insert exactly the same volume of air into the cuff during reinflation.

C The patient's mouth and trachea should be suctioned before the cuff is deflated to prevent aspiration of oral secretions. The amount of air needed to inflate the cuff varies and is adjusted by measuring cuff pressure or using the minimal leak technique, not by measuring the volume of air removed from the cuff. The cuff is deflated during patient exhalation so that secretions will be forced into the mouth rather than aspirated. There is no need to clean the inner cannula before cuff deflation. DIF: Cognitive Level: Application REF: 534 TOP: Nursing Process: Implementation

10. External-beam radiation is planned for a patient with endometrial cancer. The nurse teaches the patient that an important measure to prevent complications from the effects of the radiation is to a. test all stools for the presence of blood. b. maintain a high-residue, high-fiber diet. c. clean the perianal area carefully after every bowel movement. d. inspect the mouth and throat daily for the appearance of thrush.

C Radiation to the abdomen will affect organs in the radiation path, such as the bowel, and cause frequent diarrhea. Careful cleaning of this area will help decrease the risk for skin breakdown and infection. Stools are likely to have occult blood from the inflammation associated with radiation, so routine testing of stools for blood is not indicated. Radiation to the abdomen will not cause stomatitis. A low-residue diet is recommended to avoid irritation of the bowel when patients receive abdominal radiation. DIF: Cognitive Level: Application REF: 284 TOP: Nursing Process: Implementation

17. A 26-year-old patient with urethritis and knee pain is diagnosed with reactive arthritis. The nurse will plan to teach the patient about the need for several months of therapy with a. anakinra (Kineret). b. etanercept (Enbrel). c. doxycycline (Vibramycin). d. methotrexate (Rheumatrex).

C Reactive arthritis associated with urethritis is usually caused by infection with Chlamydia trachomatis and requires 3 months of treatment with doxycycline. The other medications are used for chronic inflammatory problems such as rheumatoid arthritis. DIF: Cognitive Level: Application REF: 1662-1663 TOP: Nursing Process: Planning

38. Following an exploratory laparotomy and bowel resection, a patient who has a nasogastric tube to suction complains of nausea and stomach distention. The first action by the nurse should be to a. auscultate for hypotonic bowel sounds. b. notify the patient's health care provider. c. reposition the tube and check for placement. d. remove the tube and replace it with a new one.

C Repositioning the tube will frequently facilitate drainage. Because this is a common occurrence, it is not appropriate to notify the health care provider. Information about the presence or absence of bowel tones will not be helpful in improving drainage. Removing the tube and replacing it are unnecessarily traumatic to the patient. DIF: Cognitive Level: Application REF: 1016-1017 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

35. In planning care for a patient with acute severe pancreatitis, the nurse assigns the highest priority to the patient outcome of a. expressing satisfaction with pain control. b. developing no ongoing pancreatic problems. c. maintenance of normal respiratory function. d. having adequate fluid and electrolyte balance.

C Respiratory failure can occur as a complication of acute pancreatitis, and maintenance of adequate respiratory function is the priority goal. The other outcomes also would be appropriate for the patient. DIF: Cognitive Level: Application REF: 1091-1092 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning

5. A patient who has rheumatoid arthritis is seen in the outpatient clinic and the nurse notes that rheumatoid nodules are present on the patient's elbows. Which action will the nurse take? a. Draw blood for rheumatoid factor analysis. b. Teach the patient about injection of the nodule. c. Assess the nodules for skin breakdown or infection. d. Discuss the need for surgical removal of the nodule.

C Rheumatoid nodules can break down or become infected. They are not associated with changes in rheumatoid factor and injection is not needed. Rheumatoid nodules are usually not removed surgically because of a high probability of recurrence. DIF: Cognitive Level: Application REF: 1653-1654 TOP: Nursing Process: Implementation

32. When performing an admission assessment for a patient with abdominal pain, the nurse palpates the left lower quadrant and the patient complains of right lower quadrant pain. The nurse will document this as a. rebound pain. b. Cullen sign. c. Rovsing sign. d. McBurney point.

C Rovsing sign occurs when palpation of the left lower quadrant causes pain in the right lower quadrant. McBurney point, rebound pain, and Cullen sign are used to describe other aspects of the abdominal assessment. DIF: Cognitive Level: Knowledge REF: 1020 TOP: Nursing Process: Assessment

2. A recently admitted patient has a small cell carcinoma of the lung, which is causing the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse will monitor carefully for a. increased total urinary output. b. elevation of serum hematocrit. c. decreased serum sodium level. d. rapid and unexpected weight loss.

C SIADH causes water retention and a decrease in serum sodium level. Weight loss, increased urine output, and elevated serum hematocrit may be associated with excessive loss of water, but not with SIADH and water retention. DIF: Cognitive Level: Comprehension REF: 307 | 310 TOP: Nursing Process: Assessment

7. A patient is admitted with an abrupt onset of jaundice, nausea, and abnormal liver function studies. Serologic testing is negative for viral causes of hepatitis. Which question by the nurse is most appropriate? a. "Is there any history of IV drug use?" b. "Are you taking corticosteroids for any reason?" c. "Do you use any over-the-counter (OTC) drugs?" d. "Have you recently traveled to a foreign country?"

C The patient's symptoms, lack of antibodies for hepatitis, and the abrupt onset of symptoms suggest toxic hepatitis, which can be caused by commonly used OTC drugs such as acetaminophen (Tylenol). Travel to a foreign country and a history of IV drug use are risk factors for viral hepatitis. Corticosteroid use does not cause the symptoms listed. DIF: Cognitive Level: Application REF: 1070-1071 TOP: Nursing Process: Assessment

15. Which nursing action will be included in the plan of care for a patient with cirrhosis who has ascites and 4+ edema of the feet and legs? a. Restrict dietary protein intake. b. Reposition the patient every 4 hours. c. Use a pressure-relieving mattress. d. Perform passive range of motion qid.

C The pressure-relieving mattress will decrease the risk for skin breakdown for this patient. Adequate dietary protein intake is necessary in patients with ascites to improve oncotic pressure. Repositioning the patient every 4 hours will not be adequate to maintain skin integrity. Passive range of motion will not take pressure off areas like the sacrum that are vulnerable to breakdown. DIF: Cognitive Level: Application REF: 1082-1083 TOP: Nursing Process: Implementation

3. A patient with severe heart failure develops elevated blood urea nitrogen (BUN) and creatinine levels. The nurse will plan care to meet the goal of a. replacing fluid volume. b. preventing hypertension. c. maintaining cardiac output. d. diluting nephrotoxic substances.

C The primary goal of treatment for acute kidney injury (AKI) is to eliminate the cause and provide supportive care while the kidneys recover. Because this patient's heart failure is causing AKI, the care will be directed toward treatment of the heart failure. For renal failure caused by hypertension, hypovolemia, or nephrotoxins, the other responses would be correct. DIF: Cognitive Level: Application REF: 1165 TOP: Nursing Process: Planning

10. The nurse is educating a patient with cholecystitis about diet. Which of the following statements by the patient indicates a need for further teaching? A. I will eliminate all fat from my diet B. I will increase foods high in fiber C. I don't want to lose weight too rapidly D. I will eat more foods with calcium in them

10. When preparing a patient for allergy testing, the nurse provides the patient with which instruction? A. "Antihistamines should be discontinued 2 weeks before the test to avoid suppressing the test response." B. "It is okay to use your fluticasone propionate (Flonase) nasal spray before testing." C. "Aspirin in a low dose may be taken before testing." D. "You can take antihistamine nasal sprays before testing."

12. When assisting with dietary protein needs for a client on peritoneal dialysis, the nurse recommends that the client select which food? A. Eggs B. Ham C. Eggplant D. Macaroni

16. A patient recently diagnosed with human immune deficiency virus (HIV) is being treated for candidiasis. Which medication does the nurse anticipate the health care provider will prescribe for this patient? A. Fluconazole (Diflucan) B. Trimethoprim/ sulfamethoxazole (Bactrim) C. Rifampin (Rifadin) D. Acyclovir (Zovirax)

2. The nurse is teaching a patient with vitamin B12 deficiency anemia about dietary intake. Which type of food does the nurse encourage the patient to eat? A. Dairy products B. Grains C. Leafy vegetables D. Starchy vegetables

3. A client with chronic kidney disease reports chest pain. The nurse notes tachycardia and low-grade fever. Which additional assessment is warranted? A. Auscultate for pericardial friction rub. B. Assess for crackles. C. Monitor for decreased peripheral pulses. D. Determine if the client is able to ambulate

3. The nurse determines that the patient in acute adrenal insufficiency is responding favorably to treatment when the patient appears alert and oriented. the patient's urinary output has increased. pulmonary edema is reduced as evidenced by clear lung sounds. laboratory tests reveal elevations of potassium and glucose serum levels and a decrease in the sodium level.

4. A patient with a history of asthma is admitted to the clinic for allergy testing. During skin testing, the patient develops shortness of breath and stridor and becomes hypotensive. What is the most appropriate drug for the nurse to give in this situation? A. Epinephrine (Adrenaline) B. Fexofenadine (Allegra) C. Cromolyn Sodium (Nasalcrom) D. Zileuton (Zyflo)

4. The nurse is caring for a client diagnosed with esophageal cancer who is experiencing diarrhea after conventional esophageal surgery. The nurse anticipates that the health care provider will request which medication to manage diarrhea? Loperamide (Imodium) Mesalamine (Pentasa) Minocycline (Minocin) Pantoprazole (Protonix)

6. When caring for a client with hepatic encephalopathy, in which situation does the nurse question the use of neomycin (Mycifradin)? A. Kidney failure B. Refractory ascites C.Fetor hepaticus D. Paracentesis scheduled for today

7. Fibromyalgia is a common condition that A. Involves chronic fatigue, generalized muscle aching and stiffness B. Is treated by diet, exercise, and physical therapy C. Usually lasts for less than two weeks D. Is caused by a virus

9. When caring for a patient with cachexia, the nurse expects to note which symptom? A. Weight loss B. Anemia C. Bleeding tendencies D. Motor deficits

21. A patient is admitted to the hospital with acute rejection of a kidney transplant. The nurse will anticipate a. administration of immunosuppressant medications. b. insertion of an arteriovenous graft for hemodialysis. c. placement of the patient on the transplant waiting list. d. drawing blood for human leukocyte antigen (HLA) and ABO compatibility matching.

A Acute rejection is treated with the administration of additional immunosuppressant drugs such as corticosteroids. Because acute rejection is reversible, there is no indication that the patient will require another transplant, hemodialysis, or HLA/ABO testing. DIF: Cognitive Level: Application REF: 229-230 TOP: Nursing Process: Planning

28. Which assessment finding about a patient who has a serum calcium level of 7.0 mEq/L is most important for the nurse to report to the health care provider? a. The patient is experiencing laryngeal stridor. b. The patient complains of generalized fatigue. c. The patient's bowels have not moved for 4 days. d. The patient has numbness and tingling of the lips.

A Laryngeal stridor may lead to respiratory arrest and requires rapid action to correct the patient's calcium level. The other data also are consistent with hypocalcemia, but do not indicate a need for immediate action. DIF: Cognitive Level: Application REF: 318 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

16. When the nurse is taking a history for a patient who is a possible candidate for a kidney transplant, which information about the patient indicates that the patient is not an appropriate candidate for transplantation? a. The patient has metastatic lung cancer. b. The patient has poorly controlled type 1 diabetes. c. The patient has a history of chronic hepatitis C infection. d. The patient is infected with the human immunodeficiency virus.

A Disseminated malignancies are a contraindication to transplantation. The conditions of the other patients are not contraindications for kidney transplant. DIF: Cognitive Level: Comprehension REF: 1189-1190 TOP: Nursing Process: Assessment

11. Which problem for a client with cirrhosis takes priority? A. Insufficient knowledge related to the prognosis of the disease process B. Discomfort related to the progression of the disease process C. Potential for injury related to hemorrhage D. Inadequate nutrition related to an inability to tolerate usual dietary intake

C. Potential for injury related to hemorrhage

4. The nurse administers lactulose (Evalose) to a client with cirrhosis for which purpose? A. Provides enzymes necessary to digest dairy products B. Reduces portal pressure C. Promotes gastrointestinal (GI) excretion of ammonia D. Decreases GI bleeding

C. Promotes gastrointestinal (GI) excretion of ammonia

5. What teaching does the home health nurse give the family of a client with hepatitis C to prevent the spread of the infection? A. The client must not consume alcohol B. Avoid sharing the bathroom with the client C. Members of the household must not share toothbrushes D. Drink only bottled water and avoid ice

C. Members of the household must not share toothbrushes

1. A client with a history of esophageal varices has just been admitted to the emergency department after vomiting a large quantity of blood. Which action does the nurse take first? A. Obtain the charts from the previous admission B. Listen for bowel sounds in all quadrants C. Obtain pulse and blood pressure D. Ask about abdominal pain

C. Obtain pulse and blood pressure

34. A patient with pneumonia has a fever of 101.2° F (38.5° C), a nonproductive cough, and an oxygen saturation of 89%. The patient is very weak and needs assistance to get out of bed. The priority nursing diagnosis for the patient is a. hyperthermia related to infectious illness. b. impaired transfer ability related to weakness. c. ineffective airway clearance related to thick secretions. d. impaired gas exchange related to respiratory congestion.

D All these nursing diagnoses are appropriate for the patient, but the patient's oxygen saturation indicates that all body tissues are at risk for hypoxia unless the gas exchange is improved. DIF: Cognitive Level: Application REF: 552-553 OBJ: Special Questions: Prioritization TOP: Nursing Process: Diagnosis

33. Which assessment finding in a patient who had a total gastrectomy 12 hours previously is most important to report to the health care provider? a. Absent bowel sounds b. Scant nasogastric (NG) tube drainage c. Complaints of incisional pain d. Temperature 102.1° F (38.9° C)

D An elevation in temperature may indicate leakage at the anastomosis, which may require return to surgery or keeping the patient NPO. The other findings are expected in the immediate postoperative period for patients who have this surgery. DIF: Cognitive Level: Application REF: 1001 TOP: Nursing Process: Assessment

15. A patient who is seen in the outpatient clinic complains of restless legs syndrome. Which of the following over-the-counter medications that the patient is taking routinely should the nurse discuss with the patient? a. multivitamin (Stresstabs) b. acetaminophen (Tylenol) c. ibuprofen (Motrin, Advil) d. diphenhydramine (Benadryl)

D Antihistamines can aggravate restless legs syndrome. The other medications will not contribute to the restless legs syndrome. DIF: Cognitive Level: Application REF: 1516-1517 TOP: Nursing Process: Implementation

6. Which information given by a patient when the nurse is taking a health history indicates that screening for hepatitis C should be done? a. The patient eats frequent meals in fast-food restaurants. b. The patient recently traveled to an undeveloped country. c. The patient had a blood transfusion after surgery in 1998. d. The patient reports a one-time use of IV drugs 20 years ago.

D Any patient with a history of IV drug use should be tested for hepatitis C. Blood transfusions given after 1992, when an antibody test for hepatitis C became available, do not pose a risk for hepatitis C. Hepatitis C is not spread by the oral-fecal route and therefore is not caused by contaminated food or by traveling in underdeveloped countries. DIF: Cognitive Level: Application REF: 1062 TOP: Nursing Process: Assessment

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

D Aspirin interferes with the effectiveness of probenecid and should not be taken when the patient is taking probenecid. The patient's sleep pattern will not affect gout management. Drinking 3 quarts of water and eating beef only once or twice a week are appropriate for the patient with gout. DIF: Cognitive Level: Application REF: 1665 TOP: Nursing Process: Assessment

3. A patient has a tonic-clonic seizure while the nurse is in the patient's room. Which action should the nurse take? a. Insert an oral airway during the seizure to maintain a patent airway. b. Restrain the patient's arms and legs to prevent injury during the seizure. c. Avoid touching the patient to prevent further nervous system stimulation. d. Time and observe and record the details of the seizure and postictal state.

D Because diagnosis and treatment of seizures frequently are based on the description of the seizure, recording the length and details of the seizure is important. Insertion of an oral airway and restraining the patient during the seizure are contraindicated. The nurse may need to move the patient to decrease the risk of injury during the seizure. DIF: Cognitive Level: Application REF: 1501 TOP: Nursing Process: Implementation

10. A patient who recently has been experiencing frequent heartburn is seen in the clinic. The nurse will anticipate teaching the patient about a. barium swallow. b. radionuclide tests. c. endoscopy procedures. d. proton pump inhibitors.

D Because diagnostic testing for heartburn that is probably caused by gastroesophageal reflux disease (GERD) is expensive and uncomfortable, proton pump inhibitors are frequently used for a short period as the first step in the diagnosis of GERD. The other tests may be used but are not usually the first step in diagnosis. DIF: Cognitive Level: Application REF: 972-974 TOP: Nursing Process: Planning

19. A man with mild hemophilia asks the nurse, "Will my children be hemophiliacs?" Which response by the nurse is appropriate? a. "All of your children will be at risk for hemophilia." b. "Hemophilia is a multifactorial inherited condition." c. "Only your male children are at risk for hemophilia." d. "Your female children will be carriers for hemophilia."

D Because hemophilia is caused by a mutation of the X-chromosome, all female children of a man with hemophilia are carriers of the disorder and can transmit the mutated gene to their offspring. Sons of a man with hemophilia will not have the disorder. Hemophilia is caused by a genetic mutation and is not a multifactorial inherited condition. DIF: Cognitive Level: Comprehension REF: 208 TOP: Nursing Process: Implementation

40. All of the following orders are received for a patient who has vomited 1500 mL of bright red blood. Which order will the nurse implement first? a. Insert a nasogastric (NG) tube and connect to suction. b. Administer intravenous (IV) famotidine (Pepcid) 40 mg. c. Draw blood for typing and crossmatching. d. Infuse 1000 mL of lactated Ringer's solution.

D Because the patient has vomited a large amount of blood, correction of hypovolemia and prevention of hypovolemic shock are the priorities. The other actions also are important to implement quickly but are not the highest priorities. DIF: Cognitive Level: Application REF: 981-982 | 984 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

8. A client has undergone conventional esophageal surgery. The client's diet has been advanced to semi-solid, and feedings are well tolerated. The client reports experiencing diarrhea about 1 hour after each meal. What is the priority nursing intervention to help prevent further diarrhea? Ensure that the client takes adequate amounts of fluids with meals. Advance the diet to solid food and encourage eating as much as possible at meals. Give the client a dose of magnesium hydroxide (Milk of Magnesia) after each meal Encourage the client to take fluids between meals rather than with meals.

8. Which of the following individuals is at highest risk for developing testicular cancer? A 28-year-old Hispanic male with infertility caused by a varicocele A 48-year-old African American male with erectile dysfunction A 14-year-old Asian male who had surgery for testicular torsion A 30-year-old white male with a history of cryptorchidism

9. A total abdominal hysterectomy is scheduled for a 42-year-old woman with multiple uterine leiomyomas. During preoperative teaching, it is important for the nurse to inform the patient that correct use of the patient-controlled analgesia (PCA) machine will prevent postoperative pain. a retention catheter will be used to help her maintain bed rest during the first several postoperative days. she will need to take estrogen replacement therapy postoperatively to prevent symptoms of surgical menopause. leg exercises with early and frequent ambulation are necessary to prevent common complications of hysterectomy.

9. The nurse observes a patient with Parkinson's disease rocking side to side while sitting in the chair. Which action by the nurse is most appropriate? Ask if the patient is feeling either anxious or depressed Take the patient's blood pressure sitting and standing Provide the patient with diversional activities Document the activity in the patient's chart

9. The nurse obtains a health history from a 65-year-old patient with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse is most appropriate? A. "Do you have a history of a heart attack?" B. "Is there a family history of endocarditis?" C. "Have you had any recent immunizations?" D. "Have you had dental work done recently?"

19. The nurse in the outpatient clinic who notes that a patient has a decreased magnesium level should ask the patient about a. daily alcohol intake. b. intake of dietary protein. c. multivitamin/mineral use. d. use of over-the-counter (OTC) laxatives.

A Hypomagnesemia is associated with alcoholism. Protein intake would not have a significant effect on magnesium level. OTC laxatives (such as milk of magnesia) and use of multivitamin/mineral supplements would tend to increase magnesium level. DIF: Cognitive Level: Application REF: 320 TOP: Nursing Process: Assessment

15. A patient who has been treated for HIV infection for 7 years has developed fat redistribution to the trunk, with wasting of the arms, legs, and face. The nurse will anticipate teaching the patient about a. the benefits of daily exercise. b. foods that are higher in protein. c. treatment with antifungal agents. d. a change in antiretroviral therapy.

D A frequent first intervention for metabolic disorders is a change in ART. Treatment with antifungal agents would not be appropriate because there is no indication of fungal infection. Changes in diet or exercise have not proven helpful for this problem. DIF: Cognitive Level: Application REF: 255 TOP: Nursing Process: Planning

36. Which action should the nurse take first when a patient calls the clinic complaining of diarrhea of 24 hours' duration? a. Ask the patient to describe the character of the stools and any associated symptoms. b. Inform the patient that laboratory testing of blood and stool specimens will be necessary. c. Suggest that the patient drink clear liquid fluids with electrolytes, such as Gatorade or Pedialyte. d. Advise the patient to use over-the-counter loperamide (Imodium) to slow gastrointestinal (GI) motility.

A The initial response by the nurse should be further assessment of the patient. The other responses may be appropriate, depending on what is learned in the assessment. DIF: Cognitive Level: Application REF: 1008-1009 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

6. A patient found in a tonic-clonic seizure reports afterward that the seizure was preceded by numbness and tingling of the arm. The nurse knows that this finding indicates what type of seizure? a. Atonic b. Partial c. Absence d. Myoclonic

A The initial symptoms of a partial seizure involve clinical manifestations that are localized to a particular part of the body or brain. Symptoms of an absence seizure are staring and a brief loss of consciousness. In an atonic seizure, the patient loses muscle tone and (typically) falls to the ground. Myoclonic seizures are characterized by a sudden jerk of the body or extremities. DIF: Cognitive Level: Comprehension REF: 1494-1496 TOP: Nursing Process: Assessment

13. After completing discharge instructions for a patient with a total laryngectomy, the nurse determines that additional instruction is needed when the patient says, a. "I must keep the stoma covered with a loose sterile dressing at all times." b. "I can participate in most of my prior fitness activities except swimming." c. "I should wear a Medic Alert bracelet that identifies me as a neck breather." d. "I need to be sure that I have smoke and carbon monoxide detectors installed."

A The stoma may be covered with clothing or a loose dressing, but this is not essential. The other patient comments are all accurate and indicate that the teaching has been effective. DIF: Cognitive Level: Application REF: 542 TOP: Nursing Process: Evaluation

5. The nurse is reinforcing the instructions on swallowing provided by the speech-language pathologist to a client diagnosed with esophageal cancer. Which instruction to the client is the highest priority? Place food at the back of the mouth as you eat. Do not be overly concerned with tongue or lip movements. Before swallowing, tilt the head back to straighten the esophagus. Do not attempt to reach food particles that are on the lips or around the mouth.

9. A client has just been admitted to the intensive care unit after having a left lower lobectomy with a video-assisted thoracoscopic surgery. Which of these requests will the nurse implement first? Adjust oxygen flow rate to keep O2 saturation at 93% to 100%. Administer 2 g of cephalothin (Keflin) IV now. Give morphine sulfate 4 to 6 mg IV for pain. Infuse 1 unit of packed red blood cells (PRBCs) over the next 2 hours.

14. A patient diagnosed with human immune deficiency virus is concerned about getting opportunistic infections and asks the nurse how to prevent them. Which interventions does the nurse recommend to the patient? A. Clean toothbrushes once a week B. Bathe daily using an antimicrobial soap C. Eat salad at least once a day D. Wash dishes in cool water

14. When caring for a client with acute kidney injury and a temporary subclavian hemodialysis catheter, which assessment finding does the nurse report to the provider? A. Mild discomfort at the insertion site B. Temperature 100.8° F C. 1+ ankle edema D. Anorexia

15. Which medication is most effective in slowing the progression of kidney failure in a client with chronic kidney disease? A. Diltiazem (Cardizem) B. Lisinopril (Zestril) C. Clonidine (Catapres) D. Doxazosin (Cardura)

2. A patient with chronic cholecystitis reports pruritus, clay-colored stools, and voiding dark, frothy urine. Which laboratory analysis is a priority in the nurse's assessment of this patient? A. Lipase level B. Total bilirubin C. Liver function tests D. White blood cell count

2. Which instruction by the nurse will help a client with chronic kidney disease prevent renal osteodystrophy? A. Consuming a low-calcium diet B. Avoiding peas, nuts, and legumes C. Drinking cola beverages only once daily D. Increasing dairy products enriched with vitamin D

2. You are admitting a patient with complaints of abdominal pain, nausea, and vomiting. A bowel obstruction is suspected. You assess this patient for which of the following anticipated primary acid-base imbalances if the obstruction is high in the intestine? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

4. You are caring for a patient admitted with a diagnosis of COPD who has the following arterial blood gas results: pH 7.33, PaO2 47 mm Hg, PaCO2 60 mm Hg, HCO3 32 mEq/L, and O2 saturation of 92%. Which of the following is the correct interpretation of these results? A. Fully compensated respiratory alkalosis B. Partially compensated respiratory acidosis C. Normal acid-base balance with hypoxemia D. Normal acid-base balance with hypercapnia

5. A 26-year-old patient with a family history of stomach cancer asks the nurse about ways to decrease the risk for developing stomach cancer. The nurse will teach the patient to avoid A. Emotionally stressful situations B. Smoked foods such as ham and bacon. C. Foods that cause distention and bloating D. Chronic use of H2 blocking medications

5. When instructing a patient regarding a urine study for free cortisol, it is most important for the nurse to tell the patient to: Save the first voided urine in the AM. Avoid stressful situations during the collection period. Maintain a high sodium diet 3 days before collection. Complete at least 30 minutes of strenuous exercise before collecting the urine sample.

7. A patient who was admitted with myxedema coma and diagnosed with hypothyroidism is improving. Discharge is expected to occur in 2 days. Which teaching strategy is likely to result in effective patient self-management at home? A. Delay teaching until closer to discharge date. B. Provide written reminders of information taught. C. Offer multiple options for management of therapies. D. Ensure privacy for teaching by asking the family to leave.

14. Which of these does the nurse recognize as the goal of palliative surgery for the patient with cancer? A. Cure of the cancer B. Relief of symptoms or improved quality of life C. Allowing other therapies to be more effective D. Prolonging the patient's survival time

4. The nurse is caring for a patient with breast cancer who is receiving high-dose doxorubicin (Adriamycin). Which assessment is most important for the nurse to make? Assess mouth and throat. Correct Monitor cardiac rhythm. Observe for alopecia. Check visual acuity.

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

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

B No more than 4 g of acetaminophen should be taken daily to avoid liver damage. The other patient statements are correct and indicate good understanding of OA management. DIF: Cognitive Level: Application REF: 1645-1646 | 1650-1651 TOP: Nursing Process: Evaluation

12. Which information will the nurse include when teaching a patient about the transverse rectus abdominis musculocutaneous (TRAM) procedure? a. Saline-filled implants are placed under the pectoral muscles. b. Recovery from the TRAM surgery takes at least 6 to 8 weeks. c. Muscle tissue is removed from the back and used to form a breast. d. TRAM flap procedures may be done in outpatient surgery centers.

B Patients take at least 6 to 8 weeks to recover from the TRAM surgery. Tissue from the abdomen is used to reconstruct the breast. The TRAM procedure can take up to 8 hours and requires postoperative hospitalization. Saline implants are used in mammoplasty. DIF: Cognitive Level: Application REF: 1326 TOP: Nursing Process: Implementation

7. Which patient information will the nurse plan to obtain in order to determine the effectiveness of the prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD)? a. Blood pressure b. Phosphate level c. Neurologic status d. Creatinine clearance

B Calcium carbonate is prescribed to bind phosphorus and prevent mineral and bone disease in patients with CKD. The other data will not be helpful in evaluating the effectiveness of calcium carbonate. DIF: Cognitive Level: Application REF: 1176-1177 TOP: Nursing Process: Implementation

3. The nurse identifies the nursing diagnosis of decreased cardiac output related to valvular insufficiency for the patient with infective endocarditis (IE) based on the assessment finding of a. fever, chills, and diaphoresis. b. urine output less than 30 mL/hr. c. petechiae of the buccal mucosa and conjunctiva. d. increase in pulse rate of 15 beats/minute with activity.

B Decreased renal perfusion caused by inadequate cardiac output will lead to poor urine output. Petechiae, fever, chills, and diaphoresis are symptoms of IE but are not caused by decreased cardiac output. An increase in pulse rate of 15 beats/minute is normal with exercise DIF: Cognitive Level: Application REF: 845-846 TOP: Nursing Process: Diagnosis

26. A patient has systemic sclerosis manifested by CREST (calcinosis, Raynaud's phenomenon, esophageal dysfunction, sclerodactyly, telangiectasia) syndrome. Which action will the nurse include in the plan of care? a. Avoid use of capsaicin cream on hands. b. Keep patient's room warm and draft free. c. Obtain capillary blood glucose before meals. d. Assist to bathroom every 2 hours while awake.

B Keeping the room warm will decrease the incidence of Raynaud's phenomenon, one aspect of the CREST syndrome. Capsaicin cream may be used to improve circulation and decrease pain. There is no need to obtain blood glucose levels or to assist the patient to the bathroom every 2 hours. DIF: Cognitive Level: Application REF: 1672-1674 TOP: Nursing Process: Assessment

7. A patient is admitted to the hospital with idiopathic aplastic anemia. Which of these collaborative problems will the nurse include when developing the care plan? a. Potential complication: seizures b. Potential complication: infection c. Potential complication: neurogenic shock d. Potential complication: pulmonary edema

B Because the patient with aplastic anemia has pancytopenia, the patient is at risk for infection and bleeding. There is no increased risk for seizures, neurogenic shock, or pulmonary edema. DIF: Cognitive Level: Application REF: 670-671 TOP: Nursing Process: Planning

18. A routine complete blood count indicates that a patient may have myelodysplastic syndrome. At this time, the nurse will plan to teach the patient about a. packed red blood cells (PRBCs) transfusion. b. bone marrow biopsy. c. filgrastim (Neupogen) administration. d. erythropoietin (Epogen) administration.

B Bone marrow biopsy is needed to make the diagnosis and determine the specific type of myelodysplastic syndrome. The other treatments may be necessary if there is progression of the myelodysplastic syndrome, but the initial action for this asymptomatic patient will be a bone marrow biopsy. DIF: Cognitive Level: Application REF: 692-693 TOP: Nursing Process: Planning

1. The nurse is providing discharge instructions to a patient with diabetes insipidus. Which of the following instructions regarding desmopressin acetate (DDAVP) would be most appropriate? The patient can expect to experience weight loss resulting from increased diuresis. The patient should alternate nostrils during administration to prevent nasal irritation. The patient should monitor for symptoms of hypernatremia as a side effect of this drug. The patient should report any decrease in urinary elimination to the health care provider.

5. A patient is being evaluated for possible atopic dermatitis. The nurse will review the patient's laboratory values for the level of a. IgE. b. IgA. c. basophils. d. neutrophils.

A Serum IgE causes the symptoms of allergic reactions and is elevated in type 1 hypersensitivity disorders. The eosinophil level will be elevated, rather than neutrophil or basophil counts. IgA is located in body secretions and would not be tested when evaluating a patient who has symptoms of atopic dermatitis. DIF: Cognitive Level: Application REF: 217-218 | 221-222 TOP: Nursing Process: Assessment

26. Which information about a patient who was admitted 10 days previously with acute kidney injury (AKI) caused by dehydration will be most important for the nurse to report to the health care provider? a. The blood urea nitrogen (BUN) level is 67 mg/dL. b. The creatinine level is 3.0 mg/dL. c. Urine output over an 8-hour period is 2500 mL. d. The glomerular filtration rate is <30 mL/min/1.73m2.

C The high urine output indicates a need to increase fluid intake to prevent hypovolemia. The other information is typical of AKI and will not require a change in therapy. DIF: Cognitive Level: Application REF: 1167-1168 | 1170 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

8. A patient who has been newly diagnosed with leukemia is admitted to the hospital. Avoiding which potential problem takes priority in the patient's nursing care plan? A. Fluid overload (over hydration) B. Hemorrhage C. Hypoxia D. Infection

4. The nurse is providing care for a patient who has been diagnosed with Guillain-Barré syndrome. Which of the following assessments should the nurse prioritize? Pain assessment Glasgow coma scale Respiratory assessment Musculoskeletal assessment

22. The nurse will plan discharge teaching about the need for prophylactic antibiotics when having dental procedures for the patient who a. was admitted with a large acute myocardial infarction. b. is being discharged after an exacerbation of heart failure. c. has had a mitral valve replacement with a mechanical valve. d. has been treated for rheumatic fever after a streptococcal infection.

C Current American Heart Association guidelines recommend the use of prophylactic antibiotics before dental procedures for patients with prosthetic valves to prevent infective endocarditis (IE). The other patients are not at risk for IE. DIF: Cognitive Level: Application REF: 842 | 844 TOP: Nursing Process: Planning

7. The registered nurse is teaching a nursing student about the importance of observing for bone marrow suppression during chemotherapy. Select the person who displays bone marrow suppression. A. Patient with hemoglobin of 7.4 and hematocrit of 21.8 B. Patient with diarrhea and potassium level of 2.9 mEq/L C. Patient with 250,000 platelets D. Patient with 5,000 white blood cells/mm3

8. The RN working on an oncology unit has just received report on these patients. Which patient should be assessed first? A. A patient with chemotherapy-induced neutropenia who has just been admitted with an elevated temperature B. A patient with lymphoma who will need administration of an antiemetic before chemotherapy C. A patient with metastatic breast cancer who is scheduled for external beam radiation in 1 hour D. A patient with xerostomia associated with laryngeal cancer who needs oral care before breakfast

8. The nurse is caring for a trauma patient with a history of Graves' disease. Which of the following would alert the nurse to the development of thyroid storm? A. Temperature 105 degrees F B. Exophthalmos C. Hoarse voice D. Loss of deep tendon reflexes

18. When teaching a patient with renal failure about a low phosphate diet, the nurse will include information to restrict a. ingestion of dairy products. b. the amount of high-fat foods. c. the quantity of fruits and juices. d. intake of green, leafy vegetables.

A Foods high in phosphate include milk and other dairy products, so these are restricted on low-phosphate diets. Green, leafy vegetables; high-fat foods; and fruits/juices are not high in phosphate and are not restricted. DIF: Cognitive Level: Application REF: 318-319 TOP: Nursing Process: Implementation

3. A patient in the outpatient clinic is diagnosed with acute hepatitis C (HCV) infection. Which action by the nurse is appropriate? a. Schedule the patient for HCV genotype testing. b. Administer immune globulin and the HCV vaccine. c. Instruct the patient on ribavirin (Rebetol) treatment. d. Teach that the infection will resolve in a few months.

A Genotyping of HCV has an important role in managing treatment and is done before drug therapy is initiated. Since most patients with acute HCV infection convert to the chronic state, the nurse should not teach the patient that the HCV will resolve in a few months. Immune globulin or vaccine is not available for HCV. Ribavirin is used for chronic HCV infection. DIF: Cognitive Level: Application REF: 1063-1064 TOP: Nursing Process: Implementation

9. Which of these patients will the nurse working in an HIV testing and treatment clinic anticipate teaching about antiretroviral therapy (ART)? a. A patient who is currently HIV negative but has unprotected sex with multiple partners b. A patient who was infected with HIV 15 years ago and now has a CD4+ count of 840/µl c. An HIV-positive patient with a CD4+ count of 120/µl who drinks a fifth of whiskey daily d. A patient who tested positive for HIV 2 years ago and has cytomegalovirus (CMV) retinitis

D CMV retinitis is an AIDS-defining illness and indicates that the patient is appropriate for ART even though the HIV infection period is relatively short. An HIV-negative patient would not be offered ART. A patient with a CD4+ count in the normal range would not typically be started on ART. A patient who drinks alcohol heavily would be unlikely to be able to manage the complex drug regimen and would not be appropriate for ART despite the low CD4+ count. DIF: Cognitive Level: Application REF: 247 | 252-253 TOP: Nursing Process: Planning

3. A patient who is receiving chemotherapy develops a Candida albicans oral infection. The nurse will anticipate the need for a. hydrogen peroxide rinses. b. the use of antiviral agents. c. referral to a dentist for professional tooth cleaning. d. administration of nystatin (Mycostatin) oral tablets.

D Candida albicans is treated with an antifungal such as nystatin. Oral saltwater rinses may be used but will not cure the infection. Antiviral agents are used for viral infections such as herpes simplex. Referral to a dentist is indicated for gingivitis but not for Candida infection. DIF: Cognitive Level: Application REF: 968 TOP: Nursing Process: Planning

31. Which finding in a patient who is receiving interleukin-2 indicates a need for rapid action by the nurse? a. Generalized muscle aches b. Complaints of nausea and anorexia c. Oral temperature of 100.6° F (38.1° C) d. Crackles heard at the lower scapular border

D Capillary leak syndrome and acute pulmonary edema are possible toxic effects of interleukin-2; the patient may need oxygen and the nurse should rapidly notify the health care provider. The other findings are common side effects of interleukin-2. DIF: Cognitive Level: Application REF: 289-290 TOP: Nursing Process: Evaluation

24. A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. The most appropriate action by the nurse is to a. document the presence of a large air leak. b. obtain and attach a new collection device. c. notify the surgeon of a possible pneumothorax. d. take no further action with the collection device.

D Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. A new collection device is needed when the collection chamber is filled. DIF: Cognitive Level: Application REF: 572 TOP: Nursing Process: Implementation

26. To determine the effectiveness of prescribed therapies for a patient with cor pulmonale and right-sided heart failure, which assessment will the nurse make? a. Lung sounds b. Heart sounds c. Blood pressure d. Peripheral edema

D Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations of right ventricular failure such as peripheral edema, jugular vein distention, and right upper-quadrant abdominal tenderness would be expected. Abnormalities in lung sounds, blood pressure, or heart sounds are not caused by cor pulmonale. DIF: Cognitive Level: Application REF: 582 TOP: Nursing Process: Evaluation

32. The nurse has administered 3% saline to a patient with hyponatremia. Which one of these assessment data will require the most rapid response by the nurse? a. The patient's radial pulse is 105 beats/minute. b. There is sediment and blood in the patient's urine. c. The blood pressure increases from 120/80 to 142/94. d. There are crackles audible throughout both lung fields.

D Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a life-threatening adverse effect of hypertonic solutions. The increased pulse rate and blood pressure and the appearance of the urine also should be reported, but they are not as dangerous as the presence of fluid in the alveoli. DIF: Cognitive Level: Application REF: 326 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

31. A patient with Crohn's disease has megaloblastic anemia. The nurse will anticipate teaching the patient about the ongoing need for a. oral ferrous sulfate tablets. b. regular blood transfusions. c. iron dextran (Imferon) infusion. d. cobalamin (B12) nasal spray or injections.

D Crohn's disease frequently affects the ileum, where absorption of cobalamin occurs, and it must be administered regularly by nasal spray or IM to correct the anemia. Iron deficiency does not cause megaloblastic anemia. The patient may need occasional transfusions but not regularly scheduled transfusions. DIF: Cognitive Level: Application REF: 1024-1025 | 1028 TOP: Nursing Process: Planning

2. A patient is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and HIV testing is positive. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), the patient is diagnosed as having a. acute infection. b. early chronic infection. c. intermediate chronic infection. d. late chronic infection or AIDS.

D Development of PCP pneumonia meets the diagnostic criterion for AIDS. The other responses indicate an earlier stage of HIV infection than is indicated by the PCP infection. DIF: Cognitive Level: Comprehension REF: 245 TOP: Nursing Process: Assessment

12. An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen? a. Educating the patient about the long-term impact of TB on health b. Giving the patient written instructions about how to take the medications c. Teaching the patient about the high risk for infecting others unless treatment is followed d. Arranging for a daily noontime meal at a community center and giving the medication then

D Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen, and arranging a daily meal will help to ensure that the patient is available to receive the medication. The other nursing interventions may be appropriate for some patients, but are not likely to be as helpful with this patient. DIF: Cognitive Level: Application REF: 556 TOP: Nursing Process: Implementation

26. Which information about a patient who is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease is most important for the nurse to report to the health care provider? a. Shuffling gait b. Tremor at rest c. Cogwheel rigidity of limbs d. Uncontrolled head movement

D Dyskinesia is an adverse effect of the Sinemet, indicating a need for a change in medication or decrease in dose. The other findings are typical with Parkinson's disease. DIF: Cognitive Level: Application REF: 1509-1512 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning

2. A patient who has been recently diagnosed with benign prostatic hyperplasia (BPH) tells the nurse that he does not want to have a transurethral resection of the prostate (TURP) because he is afraid it might affect his ability to have intercourse. Which action should the nurse take? a. Offer reassurance that sperm production is not affected by TURP. b. Discuss alternative methods of sexual expression besides intercourse. c. Provide education about the use of medications for erectile dysfunction (ED) occurring after TURP. d. Teach that ED is not a common complication following a TURP.

D ED is not a concern with TURP, although retrograde ejaculation is likely and the nurse should discuss this with the patient. Erectile function is not usually affected by a TURP, so the patient will not need information about penile implants or reassurance that other forms of sexual expression may be used. Because the patient has not asked about fertility, reassurance about sperm production does not address his concerns. DIF: Cognitive Level: Application REF: 1383-1384 TOP: Nursing Process: Implementation

7. A 20-year-old female patient who is HIV-positive has a new prescription for efavirenz (Sustiva). Which information about the patient is most important to communicate to the prescribing physician before administering the efavirenz? a. The patient's CD4+ T cell count is 800 cells/μL. b. The patient already has etravirine (Intelence) prescribed. c. The patient states that the antiretroviral therapy (ART) frequently cause nausea. d. The patient is sexually active and does not use any contraception.

D Efavirenz can cause fetal anomalies and should not be used in patients who may be pregnant. The patient's nausea, use of another nucleoside reverse transcriptase inhibitor, and CD4+ count also should be communicated to the physician, but the most important information is that the patient may potentially be pregnant. DIF: Cognitive Level: Application REF: 247-248 TOP: Nursing Process: Implementation

36. Which nursing action is a priority when the nurse is caring for a patient with pancreatic cancer? a. Offer high-calorie, high-protein dietary choices. b. Offer psychologic support for anxiety or depression. c. Educate about the need to avoid scratching pruritic areas. d. Administer prescribed opioids to relieve pain as needed.

D Effective pain management will be necessary in order for the patient to improve nutrition, be receptive to education, or manage anxiety or depression. DIF: Cognitive Level: Application REF: 1094-1096 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning

20. Which laboratory test will the nurse use to determine whether the prescribed filgrastim (Neupogen) is effective in the treatment of a patient who is receiving chemotherapy for acute lymphocytic leukemia? a. Platelet count b. Reticulocyte count c. Total lymphocyte count d. Absolute neutrophil count

D Filgrastim increases the neutrophil count and function in neutropenic patients. Although total lymphocyte, platelet, and reticulocyte counts also are important to monitor in this patient, the absolute neutrophil count is used to evaluate the effects of filgrastim. DIF: Cognitive Level: Application REF: 691-692 TOP: Nursing Process: Evaluation

6. The nurse is assessing a patient with gastroesophageal reflux disease (GERD) who is experiencing increasing discomfort. Which patient statement indicates that additional patient education about GERD is needed? a. "I take antacids between meals and at bedtime each night." b. "I sleep with the head of the bed elevated on 4-inch blocks." c. "I quit smoking several years ago, but I still chew a lot of gum." d. "I eat small meals throughout the day and have a bedtime snack."

D GERD is exacerbated by eating late at night, and the nurse should plan to teach the patient to avoid eating at bedtime. The other patient actions are appropriate to control symptoms of GERD. DIF: Cognitive Level: Application REF: 973-974 TOP: Nursing Process: Evaluation

11. Which information will be most useful to the nurse in evaluating improvement in kidney function for a patient who is hospitalized with acute kidney injury (AKI)? a. Blood urea nitrogen (BUN) level b. Urine output c. Creatinine level d. Calculated glomerular filtration rate (GFR)

D GFR is the preferred method for evaluating kidney function. BUN levels can fluctuate based on factors such as fluid volume status. 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. DIF: Cognitive Level: Application REF: 1175-1176 TOP: Nursing Process: Evaluation

5. A patient is taking a potassium-wasting diuretic for treatment of hypertension. The nurse will teach the patient to report symptoms of adverse effects such as a. personality changes. b. frequent loose stools. c. facial muscle spasms. d. generalized weakness.

D Generalized weakness progressing to flaccidity is a manifestation of hypokalemia. Facial muscle spasms might occur with hypocalcemia. Loose stools are associated with hyperkalemia. Personality changes are not associated with electrolyte disturbances, although changes in mental status are common manifestations with sodium excess or deficit. DIF: Cognitive Level: Comprehension REF: 315 TOP: Nursing Process: Implementation MSC: NCLEX:

19. A patient with gout tells the nurse that he takes losartan (Cozaar) for control of the condition. The nurse will plan to monitor a. blood glucose. b. blood pressure. c. erythrocyte count. d. lymphocyte count.

B Losartan, an angiotensin II receptor antagonist, will lower blood pressure. It does not affect blood glucose, red blood cell count (RBC), or lymphocytes. DIF: Cognitive Level: Application REF: 1665-1666 TOP: Nursing Process: Planning

17. A 42-year-old patient who was adopted at birth is diagnosed with early Huntington's disease (HD). When teaching the patient, spouse, and children about this disorder, the nurse will provide information about the a. use of levodopa-carbidopa (Sinemet) to help reduce HD symptoms. b. need to take prophylactic antibiotics to decrease the risk for pneumonia. c. lifestyle changes such as increased exercise that delay disease progression. d. availability of genetic testing to determine the HD risk for the patient's children.

D Genetic testing is available to determine whether an asymptomatic individual has the HD gene. The patient and family should be informed of the benefits and problems associated with genetic testing. Sinemet will increase symptoms of HD given that HD involves an increase in dopamine. Antibiotic therapy will not reduce the risk for aspiration. There are no effective treatments or lifestyle changes that delay the progression of symptoms in HD. DIF: Cognitive Level: Application REF: 1517 TOP: Nursing Process: Implementation

17. A patient has a new prescription for cyclosporine after having a kidney transplant. Which information in the patient's health history has the most implications for planning patient teaching about the medication at this time? a. The patient restricts salt to treat prehypertension. b. The patient drinks 3 to 4 quarts of fluids every day. c. The patient has many concerns about the effects of cyclosporine. d. The patient has a glass of grapefruit juice every day for breakfast.

D Grapefruit juice can increase the cyclosporine to toxic levels. The patient should be taught to avoid grapefruit juice. High fluid intake will not impact cyclosporine levels or renal function. Cyclosporine may cause hypertension, and the patient's many concerns should be addressed, but these are not potentially life-threatening problems. DIF: Cognitive Level: Application REF: 230 TOP: Nursing Process: Planning

1. A patient contracts hepatitis from contaminated food. During the acute (icteric) phase of the patient's illness, the nurse would expect serologic testing to reveal a. antibody to hepatitis D (anti-HDV). b. hepatitis B surface antigen (HBsAg). c. anti-hepatitis A virus immunoglobulin G (anti-HAV IgG). d. anti-hepatitis A virus immunoglobulin M (anti-HAV IgM).

D Hepatitis A is transmitted through the oral-fecal route, and antibody to HAV IgM appears during the acute phase of hepatitis A. The patient would not have antigen for hepatitis B or antibody for hepatitis D. Anti-HAV IgG would indicate past infection and lifelong immunity. DIF: Cognitive Level: Application REF: 1060-1061 | 1064 TOP: Nursing Process: Assessment

13. A patient has a new prescription for bromocriptine (Parlodel) to control symptoms of Parkinson's disease. Which information obtained by the nurse may indicate a need for a decrease in the dose? a. The patient has a chronic dry cough. b. The patient has four loose stools in a day. c. The patient develops a deep vein thrombosis. d. The patient's blood pressure is 90/46 mm Hg.

D Hypotension is an adverse effect of bromocriptine, and the nurse should check with the health care provider before giving the medication. Diarrhea, cough, and deep vein thrombosis are not associated with bromocriptine use. DIF: Cognitive Level: Application REF: 1510 TOP: Nursing Process: Evaluation

10. Before administration of calcium carbonate (Caltrate) to a patient with chronic kidney disease (CKD), the nurse should check the laboratory value for a. creatinine. b. potassium. c. total cholesterol. d. serum phosphate.

D If serum phosphate is elevated, the calcium and phosphate can cause soft tissue calcification. The calcium carbonate should not be given until the phosphate level is lowered. Total cholesterol, creatinine, and potassium values do not affect whether calcium carbonate should be administered. DIF: Cognitive Level: Application REF: 1176 TOP: Nursing Process: Implementation

4. A patient has an enlarged prostate detected by digital rectal examination (DRE) and an elevated prostate specific antigen (PSA) level. The nurse will anticipate that the patient will need teaching about a. cystourethroscopy. b. uroflowmetry studies. c. magnetic resonance imaging (MRI). d. transrectal ultrasonography (TRUS).

D In a patient with an abnormal DRE and elevated PSA, transrectal ultrasound is used to visualize the prostate for biopsy. Uroflowmetry studies help determine the extent of urine blockage and treatment, but there is no indication that this is a problem for this patient. Cystoscopy may be used before prostatectomy but will not be done until after the TRUS and biopsy. MRI is used to determine whether prostatic cancer has metastasized but would not be ordered at this stage of the diagnostic process. DIF: Cognitive Level: Application REF: 1380 | 1387-1388 TOP: Nursing Process: Planning

30. Which of these orders will the nurse act on first for a patient who has just been admitted with probable bacterial pneumonia and sepsis? a. Administer aspirin suppository. b. Send to radiology for chest x-ray. c. Give ciprofloxacin (Cipro) 400 mg IV. d. Obtain blood cultures from two sites.

D Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic administration. The chest radiograph and aspirin administration can be done last. DIF: Cognitive Level: Application REF: 549 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

33. The nurse is caring for a patient with immune thrombocytopenic purpura (ITP) who has an order for a platelet transfusion. Which patient information indicates that the nurse should consult with the health care provider before administering platelets? a. The platelet count is 42,000/μL. b. Blood pressure (BP) is 94/56 mm Hg. c. Blood is oozing from the venipuncture site. d. Petechiae are present on the chest and back.

A Platelet transfusions are not usually indicated until the platelet count is below 10,000 to 20,000/μl unless the patient is actively bleeding, so the nurse should clarify the order with the health care provider before giving the transfusion. The other data all indicate that bleeding caused by ITP may be occurring and indicate that the platelet transfusion is appropriate. DIF: Cognitive Level: Application REF: 681 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

12. The home health nurse notes that an elderly patient has a low serum protein level. The nurse will plan to assess for a. pallor. b. edema. c. confusion. d. restlessness.

26. When caring for a clinic patient who is experiencing an allergic reaction to an unknown allergen, which nursing activity is most appropriate for the RN to delegate to an LPN/LVN? a. Perform a focused physical assessment. b. Obtain the health history from the patient. c. Teach the patient about the various diagnostic studies. d. Administer skin testing by the cutaneous scratch method.

D LPN/LVNs are educated and licensed to administer medications under the supervision of an RN. RN-level education and the scope of practice include assessment of health history, focused physical assessment, and patient teaching. DIF: Cognitive Level: Application REF: 222-223 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC:

29. After discharge teaching has been completed for a patient who has had a lung transplant, the nurse will evaluate that the teaching has been effective if the patient states a. "I will make an appointment to see the doctor every year." b. "I will not turn the home oxygen up higher than 2 L/minute." c. "I will not worry if I feel a little short of breath with exercise." d. "I will call the health care provider right away if I develop a fever."

D Low-grade fever may indicate infection or acute rejection, so the patient should notify the health care provider immediately if the temperature is elevated. Patients require frequent follow-up visits with the transplant team; annual health care provider visits would not be sufficient. Home oxygen use is not an expectation after lung transplant. Shortness of breath should be reported. DIF: Cognitive Level: Application REF: 583 TOP: Nursing Process: Evaluation

4. When a patient is diagnosed with acute hepatitis B, the nurse will plan to teach the patient about a. ways to increase exercise and activity level. b. self-administration of α-interferon (Intron A). c. side effects of nucleoside and nucleotide analogs. d. measures that will be helpful in improving appetite.

D Maintaining adequate nutritional intake is important for regeneration of hepatocytes. Interferon and antivirals may be used for chronic hepatitis B, but they are not prescribed for acute hepatitis B infection. Rest is recommended. DIF: Cognitive Level: Application REF: 1064-1065 | 1069-1070 TOP: Nursing Process: Planning

34. A patient with hemophilia calls the nurse in the hemophilia clinic to discuss all of these problems. Which problem is most important to communicate to the physician? a. Skin abrasions b. Bleeding gums c. Multiple bruises d. Dark tarry stools

D Melena is a sign of gastrointestinal bleeding and requires collaborative actions such as checking hemoglobin and hematocrit and administration of coagulation factors. The other problems indicate a need for patient teaching about how to avoid injury, but are not indicators of possible serious blood loss. DIF: Cognitive Level: Application REF: 686 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

31. Which assessment information obtained by the nurse when caring for a patient who has just had a thoracentesis is most important to communicate to the health care provider? a. BP is 150/90 mm Hg. b. Oxygen saturation is 89%. c. Pain level is 5/10 with a deep breath. d. Respiratory rate is 24 when lying flat.

B Oxygen saturation would be expected to improve after a thoracentesis. A saturation of 89% indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low oxygen saturation is the priority. DIF: Cognitive Level: Application REF: 576 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

10. The nurse is obtaining a health history from a 67-year-old patient with a 40 pack-year smoking history, complaints of hoarseness and tightness in the throat, and difficulty swallowing. Which question is most important for the nurse to ask? a. "How much alcohol do you drink in an average week?" b. "Do you have a family history of head or neck cancer?" c. "Have you had frequent streptococcal throat infections?" d. "Do you use antihistamines for upper airway congestion?"

A Prolonged alcohol use and smoking are associated with the development of laryngeal cancer, which the patient's symptoms and history suggest. Family history is not a risk factor for head or neck cancer. Frequent antihistamine use would be asked about if the nurse suspected allergic rhinitis, but the patient's symptoms are not suggestive of this diagnosis. Streptococcal throat infections also may cause these clinical manifestations, but patients also will complain of pain and fever. DIF: Cognitive Level: Application REF: 535 | 538 TOP: Nursing Process: Assessment

31. The nurse is caring for a patient with chronic hepatitis C infection who has these medications prescribed. Which medication requires further discussion with the health care provider prior to administration? a. ribavirin (Rebetol, Copegus) 600 mg PO bid b. pegylated α-interferon (PEG-Intron, Pegasys) SQ daily c. diphenhydramine (Benadryl) 25 mg PO every 4 hours PRN itching d. dimenhydrinate (Dramamine) 50 mg PO every 6 hours PRN nausea

B Pegylated α-interferon is administered weekly. The other medications are appropriate for a patient with chronic hepatitis C infection. DIF: Cognitive Level: Application REF: 1064-1066 TOP: Nursing Process: Implementation

9. Following a radical retropubic prostatectomy for prostate cancer, the patient is incontinent of urine. The nurse will plan to teach the patient a. to restrict oral fluid intake. b. pelvic floor muscle exercises. c. the use of belladonna and opium suppositories. d. how to perform intermittent self-catheterization.

B Pelvic floor muscle training (Kegel) exercises are recommended to strengthen the pelvic floor muscles and improve urinary control. Belladonna and opium suppositories are used to reduce bladder spasms after surgery. Intermittent self-catheterization may be taught before surgery if the patient has urinary retention, but it will not be useful in reducing incontinence after surgery. The patient should have a daily oral intake of 2 to 3 L. DIF: Cognitive Level: Application REF: 1388-1389 TOP: Nursing Process: Planning

28. A patient who requires daily use of a nonsteroidal anti-inflammatory drug (NSAID) for management of severe rheumatoid arthritis has recently developed melena. The nurse will anticipate teaching the patient about a. substitution of acetaminophen (Tylenol) for the NSAID. b. use of enteric-coated NSAIDs to reduce gastric irritation. c. reasons for using corticosteroids to treat the rheumatoid arthritis. d. the benefits of misoprostol (Cytotec) in protecting the gastrointestinal (GI) mucosa.

D Misoprostol, a prostaglandin analog, reduces acid secretion and incidence of upper GI bleeding associated with NSAID use. Enteric coating of NSAIDs does not reduce the risk for GI bleeding. Corticosteroids increase the risk for ulcer development and will not be substituted for NSAIDs for this patient. Acetaminophen will not be effective in treating the patient's rheumatoid arthritis. DIF: Cognitive Level: Application REF: 983-984 | 990-991 TOP: Nursing Process: Planning

13. During treatment of the patient with an acute exacerbation of polycythemia vera, a critical action by the nurse is to a. place the patient on bed rest. b. administer iron supplements. c. avoid use of aspirin products. d. monitor fluid intake and output.

D Monitoring hydration status is important during an acute exacerbation because the patient is at risk for fluid overload or underhydration. Aspirin therapy is used to decrease risk for thrombosis. The patient should be encouraged to ambulate to prevent deep vein thrombosis (DVT). Iron is contraindicated in patients with polycythemia vera. DIF: Cognitive Level: Application REF: 677 TOP: Nursing Process: Implementation

18. A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The patient tells the nurse, "I would rather have radiation than surgery." Which response by the nurse is most appropriate? a. "Are you afraid that the surgery will be very painful?" b. "Did you have bad experiences with previous surgeries?" c. "Surgery is the treatment of choice for stage I lung cancer." d. "Tell me what you know about the various treatments available."

D More assessment of the patient's concerns about surgery is indicated. An open-ended response will elicit the most information from the patient. The answer beginning, "Surgery is the treatment of choice" is accurate, but it discourages the patient from sharing concerns about surgery. The remaining two answers indicate that the nurse has jumped to conclusions about the patient's reasons for not wanting surgery. DIF: Cognitive Level: Application REF: 565 TOP: Nursing Process: Implementation

3. The nurse in the outpatient clinic is caring for a 50-year-old who smokes heavily. To reduce the patient's risk of dying from lung cancer, which action will be best for the nurse to take? a. Educate the patient about the seven warning signs of cancer. b. Plan to monitor the patient's carcinoembryonic antigen (CEA) level. c. Discuss the risks associated with cigarettes during every patient encounter. d. Teach the patient about the use of annual chest x-rays for lung cancer screening.

C Education about the risks associated with cigarette smoking is recommended at every patient encounter, since cigarette smoking is associated with multiple health problems. A tumor must be at least 0.5 cm large before it is detectable by current screening methods and may already have metastasized by that time. Oncofetal antigens such as CEA may be used to monitor therapy or detect tumor reoccurrence, but are not helpful in screening for cancer. The seven warning signs of cancer are actually associated with fairly advanced disease. DIF: Cognitive Level: Application REF: 265 | 267-269 TOP: Nursing Process: Implementation

9. A 32-year-old patient is diagnosed with early alcoholic cirrhosis. Which topic is most important to include in patient teaching? a. Need to abstain from alcohol b. Use of vitamin B supplements c. Maintenance of a nutritious diet d. Treatment with lactulose (Cephulac)

A The disease progression can be stopped or reversed by alcohol abstinence. The other interventions may be used when cirrhosis becomes more severe to decrease symptoms or complications, but the priority for this patient is to stop the progression of the disease. DIF: Cognitive Level: Application REF: 1081 | 1085 TOP: Nursing Process: Planning

28. A patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. Which information obtained by the nurse indicates that these therapies have been effective? a. Bowel sounds are present. b. Grey Turner sign resolves. c. Electrolyte levels are normal. d. Abdominal pain is decreased.

D NG suction and NPO status will decrease the release of pancreatic enzymes into the pancreas and decrease pain. Although bowel sounds may be hypotonic with acute pancreatitis, the presence of bowel sounds does not indicate that treatment with NG suction and NPO status have been effective. Electrolyte levels will be abnormal with NG suction and must be replaced by appropriate IV infusion. Although Grey Turner sign will eventually resolve, it would not be appropriate to wait for this occur to determine whether treatment was effective. DIF: Cognitive Level: Application REF: 1091 TOP: Nursing Process: Evaluation

8. Which information about a patient who has a recent history of tuberculosis (TB) indicates that the nurse can discontinue airborne isolation precautions? a. Chest x-ray shows no upper lobe infiltrates. b. TB medications have been taken for 6 months. c. Mantoux testing shows an induration of 10 mm. d. Three sputum smears for acid-fast bacilli are negative.

D Negative sputum smears indicate that M. tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route. Chest x-rays are not used to determine whether treatment has been successful. Taking medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Repeat Mantoux testing would not be done since it will not change even with effective treatment. DIF: Cognitive Level: Application REF: 557 TOP: Nursing Process: Implementation

12. The nurse will monitor a patient who is undergoing plasmapheresis for a. shortness of breath. b. high blood pressure. c. transfusion reactions. d. numbness and tingling.

D Numbness and tingling may occur as the result of the hypocalcemia caused by the citrate used to prevent coagulation. The other clinical manifestations are not associated with plasmapheresis. DIF: Cognitive Level: Application REF: 227 TOP: Nursing Process: Evaluation

34. When interviewing a patient with abdominal pain and possible irritable bowel syndrome, which question will be most important for the nurse to ask? a. "Have you been passing a lot of gas?" b. "What foods affect your bowel patterns?" c. "Do you have any abdominal distention?" d. "How long have you had abdominal pain?"

D One criterion for the diagnosis of irritable bowel syndrome (IBS) is the presence of abdominal discomfort or pain for at least 3 months. Abdominal distention, flatulence, and food intolerance also are associated with IBS, but are not diagnostic criteria. DIF: Cognitive Level: Application REF: 1017-1018 TOP: Nursing Process: Assessment

35. Which of these nursing actions should the RN working in the emergency department delegate to nursing assistive personnel who help with the care of a patient who has been admitted with nausea and vomiting? a. Auscultate the bowel sounds. b. Assess for signs of dehydration. c. Ask the patient what precipitated the nausea. d. Assist the patient with oral care after vomiting.

D Oral care is included in nursing assistive personnel education and scope of practice. The other actions are all assessments that require more education and a higher scope of nursing practice. DIF: Cognitive Level: Application REF: 965-966 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC:

11. The nurse establishes the nursing diagnosis of ineffective health maintenance related to lack of knowledge concerning long-term management of rheumatic fever when a 30-year-old recovering from rheumatic fever says, a. "I will need to have monthly antibiotic injections for 10 years or longer." b. "I will need to take aspirin or ibuprofen (Motrin) to relieve my joint pain." c. "I will call the doctor if I develop excessive fatigue or difficulty breathing." d. "I will be immune to further episodes of rheumatic fever after this infection."

D Patients with a history of rheumatic fever are more susceptible to a second episode. The other patient statements are correct and would not support the nursing diagnosis of ineffective health maintenance. DIF: Cognitive Level: Application REF: 852 TOP: Nursing Process: Diagnosis

2. A patient with acute kidney injury (AKI) has an arterial blood pH of 7.30. The nurse will assess the patient for a. vasodilation. b. poor skin turgor. c. bounding pulses. d. rapid respirations.

D Patients with metabolic acidosis caused by AKI may have Kussmaul respirations as the lungs try to regulate carbon dioxide. Bounding pulses and vasodilation are not associated with metabolic acidosis. Because the patient is likely to have fluid retention, poor skin turgor would not be a finding in AKI. DIF: Cognitive Level: Application REF: 1167 TOP: Nursing Process: Assessment

1. When teaching a 28-year-old patient about breast self-examination (BSE), the nurse will instruct the patient that a. BSE will reduce the risk of dying from breast cancer. b. BSE should be done daily while taking a bath or shower. c. annual mammograms should be scheduled in addition to BSE. d. performing BSE right after the menstrual period will improve comfort.

D Performing BSE at the end of the menstrual period will reduce the breast tenderness associated with the procedure. The evidence is not clear that BSE reduces breast cancer mortality. BSE should be done monthly. Annual mammograms are not routinely scheduled for women under age 40. DIF: Cognitive Level: Application REF: 1306-1308 TOP: Nursing Process: Implementation

38. When caring for a patient following an incisional cholecystectomy for cholelithiasis, the nurse places the highest priority on assisting the patient to a. choose low-fat foods from the menu. b. perform leg exercises hourly while awake. c. ambulate the evening of the operative day. d. turn, cough, and deep breathe every 2 hours.

D Postoperative nursing care after a cholecystectomy focuses on prevention of respiratory complications because the surgical incision is high in the abdomen and impairs coughing and deep breathing. The other nursing actions also are important to implement but are not as high a priority as ensuring adequate ventilation. DIF: Cognitive Level: Application REF: 1099-1100 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning

16. Which action by the occupational health nurse at a manufacturing plant where there is potential exposure to inhaled dust will be most helpful in reducing incidence of lung disease? a. Teach about symptoms of lung disease. b. Treat workers who inhale dust particles. c. Monitor workers for shortness of breath. d. Require the use of protective equipment.

D Prevention of lung disease requires the use of appropriate protective equipment such as masks. The other actions will help in recognition or early treatment of lung disease, but will not be effective in prevention of lung damage. DIF: Cognitive Level: Application REF: 560-561 TOP: Nursing Process: Assessment

20. A patient seen at the clinic with atopic dermatitis has a history of multiple allergies and several previous anaphylactic reactions. Which type of testing for allergens will the nurse anticipate for this patient? a. Serum IgE-level test b. Cutaneous scratch test c. Intracutaneous skin test d. Radioallergosorbent test (RAST)

D RAST is an in vitro test for hypersensitivity to specific allergens that is used when patients are likely to have anaphylactic reactions to other forms of skin testing. Cutaneous scratch testing or intracutaneous testing is more likely to cause anaphylaxis. Serum IgE level is elevated in atopic reactions but is not diagnostic for specific allergens. DIF: Cognitive Level: Application REF: 222-223 TOP: Nursing Process: Planning

18. After the nurse has completed teaching a patient who has breast cancer about the newly prescribed tamoxifen (Nolvadex), which patient statement indicates that the teaching has been effective? a. "I will expect to have leg cramps with this drug." b. "I will call the clinic if I develop any hot flashes." c. "I will be taking the medication for at least a year." d. "I will call immediately if I have any eye problems."

D Retinopathy, cataracts, and decreased visual acuity should be immediately reported because it is likely that the tamoxifen will be discontinued or decreased. Tamoxifen treatment generally lasts 5 years. Hot flashes are an expected side effect of tamoxifen. Leg cramps may be a sign of deep vein thrombosis, and the patient should immediately notify the health care provider if pain occurs. DIF: Cognitive Level: Application REF: 1316-1317 TOP: Nursing Process: Evaluation

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

D Since 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 used for many patients to decrease the number of sickle cell crises. DIF: Cognitive Level: Application REF: 672 | 674-675 TOP: Nursing Process: Evaluation

45. A patient with Crohn's disease who is taking infliximab (Remicade) calls the nurse in the outpatient clinic about all of these symptoms. Which symptom is most important to communicate to the health care provider? a. Nausea b. Joint pain c. Frequent headaches d. Elevated temperature

D Since infliximab suppresses immune function, rapid treatment of infection is essential. The other patient complaints are common side effects of the medication, but do not indicate any potentially life-threatening complications. DIF: Cognitive Level: Application REF: 1026-1027 OBJ: Special Questions: Prioritization TOP: Nursing Process: Evaluation MSC:

18. Which information about an HIV-positive patient who is taking antiretroviral medications is most important for the nurse to address when planning care? a. The patient's blood glucose level is 168 mg/dl. b. The patient complains of feeling "constantly tired." c. The patient is unable to state the side effects of the medications. d. The patient states "sometimes I miss a dose of zidovudine (AZT)."

D Since missing doses of ART can lead to drug resistance, this patient statement indicates the need for interventions such as teaching or changes in the drug scheduling. Elevated blood glucose and fatigue are common side effects of ART. The nurse should discuss medication side effects with the patient, but this is not as important as addressing the skipped doses of AZT. DIF: Cognitive Level: Application REF: 246-247 | 252-253 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning

4. A 52-year-old patient has a new diagnosis of pernicious anemia. After teaching the patient about pernicious anemia, the nurse determines that the patient understands the disorder when the patient states, a. "I need to start eating more red meat or liver." b. "I will stop having a glass of wine with dinner." c. "I will need to take a proton pump inhibitor like omeprazole (Prilosec)." d. "I would rather use the nasal spray than have to get injections of vitamin B12."

D Since pernicious anemia prevents the absorption of vitamin B12, this patient requires injections or intranasal administration of cobalamin. Alcohol use does not cause cobalamin deficiency. Proton pump inhibitors decrease the absorption of vitamin B12. Eating more foods rich in vitamin B12 is not helpful because the lack of intrinsic factor prevents absorption of the vitamin. DIF: Cognitive Level: Application REF: 669 TOP: Nursing Process: Evaluation

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

D Since spironolactone is a potassium-sparing diuretic, patients should be taught to choose low potassium foods such as apple juice rather than foods that have higher levels of potassium, such as citrus fruits. Because the patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid intake. Teach patients to avoid salt substitutes, which are high in potassium. DIF: Cognitive Level: Application REF: 314-315 TOP: Nursing Process: Implementation

19. Which nursing action will be most effective in improving oral intake for a patient with the nursing diagnosis of imbalanced nutrition: less than body requirements related to painful oral ulcers? a. Offer the patient frequent small snacks between meals. b. Assist the patient to choose favorite foods from the menu. c. Provide education about the importance of nutritional intake. d. Apply the ordered anesthetic gel to oral lesions before meals.

D Since the etiology of the patient's poor nutrition is the painful oral ulcers, the best intervention is to apply anesthetic gel to the lesions before the patient eats. The other actions might be helpful for other patients with impaired nutrition, but would not be as helpful for this patient. DIF: Cognitive Level: Application REF: 281 | 284 TOP: Nursing Process: Planning

4. A patient who is diagnosed with AIDS tells the nurse, "I have lots of thoughts about dying. Do you think I am just being morbid?" Which response by the nurse is best? a. "Thinking about dying will not improve the course of AIDS." b. "It is important to focus on the good things about your life now." c. "Do you think that taking an antidepressant might be helpful to you?" d. "Can you tell me more about the kind of thoughts that you are having?"

D More assessment of the patient's psychosocial status is needed before taking any other action. The statements, "Thinking about dying will not improve the course of AIDS" and "It is important to focus on the good things in life" discourage the patient from sharing any further information with the nurse and decrease the nurse's ability to develop a trusting relationship with the patient. Although antidepressants may be helpful, the initial action should be further assessment of the patient's feelings. DIF: Cognitive Level: Application REF: 249-251 TOP: Nursing Process: Implementation

36. A patient complains of leg cramps during hemodialysis. The nurse should first a. reposition the patient. b. massage the patient's legs. c. give acetaminophen (Tylenol). d. infuse a bolus of normal saline.

D Muscle cramps during dialysis are caused by rapid removal of sodium and water. Treatment includes infusion of normal saline. The other actions do not address the reason for the cramps. DIF: Cognitive Level: Application REF: 1186-1187 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

20. Which assessment finding in a patient with acute pancreatitis would the nurse need to report most quickly to the health care provider? a. Nausea and vomiting b. Hypotonic bowel sounds c. Abdominal tenderness and guarding d. Muscle twitching and finger numbness

D Muscle twitching and finger numbness indicate hypocalcemia, which may lead to tetany unless calcium gluconate is administered. Although the other findings also should be reported to the health care provider, they do not indicate complications that require rapid action. DIF: Cognitive Level: Application REF: 1091-1092 TOP: Nursing Process: Assessment

39. A patient who is vomiting bright red blood is admitted to the emergency department. Which assessment should the nurse perform first? a. Checking the level of consciousness b. Measuring the quantity of any emesis c. Auscultating the chest for breath sounds d. Taking the blood pressure (BP) and pulse

D The nurse is concerned about blood loss and possible hypovolemic shock in a patient with acute gastrointestinal (GI) bleeding; BP and pulse are the best indicators of these complications. The other information also is important to obtain, but BP and pulse rate are the best indicators for hypoperfusion. DIF: Cognitive Level: Application REF: 982-983 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

13. When caring for a patient with mitral valve stenosis, it is most important that the nurse assess for a. diastolic murmur. b. peripheral edema. c. right upper quadrant tenderness. d. complaints of shortness of breath.

D The pressure gradient changes in mitral stenosis lead to fluid backup into the lungs, resulting in hypoxemia and dyspnea. The other findings also may be associated with mitral valve disease, but are not indicators of possible hypoxemia. DIF: Cognitive Level: Application REF: 853 TOP: Nursing Process: Assessment

4. An elementary teacher who has just been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse, "I cannot teach anymore, it will be too upsetting if I have a seizure at work." Which response by the nurse is best? a. "You may want to contact the Epilepsy Foundation for assistance." b. "You might benefit from some psychologic counseling at this time." c. "The Department of Vocational Rehabilitation can help with work retraining." d. "Most patients with epilepsy are well controlled with antiseizure medications."

D The nurse should inform the patient that most patients with seizure disorders are controlled with medication. The other information may be necessary if the patient seizures persist after treatment with antiseizure medications is implemented. DIF: Cognitive Level: Application REF: 1497-1498 | 1501-1502 TOP: Nursing Process: Implementation

31. A patient with a recent 20-pound unintended weight loss is diagnosed with stomach cancer. Which nursing action will be included in the plan of care? a. Refer the patient for hospice services. b. Infuse IV fluids through a central line. c. Teach the patient about antiemetic therapy. d. Offer supplemental feedings between meals.

D The patient data indicate a poor nutritional state and improvement in nutrition will be helpful in improving response to therapies such as surgery, chemotherapy, or radiation. Nausea and vomiting are not common clinical manifestations of stomach cancer. There is no indication that the patient requires hospice or IV fluid infusions. DIF: Cognitive Level: Application REF: 999 | 1000-1001 TOP: Nursing Process: Planning

13. The health care provider orders an ultrasound of the spleen for a patient who has been in a car accident. Which action should the nurse take before this procedure? a. Check for any iodine allergy. b. Insert a large-bore IV catheter. c. Place the patient on NPO status. d. Assist the patient to a flat position.

D The patient is placed in a flat position before splenic ultrasound. The patient does not have to be NPO or have an IV line. No iodine-containing materials are used for ultrasound. DIF: Cognitive Level: Application REF: 658 TOP: Nursing Process: Implementation

24. A patient with leukemia is considering whether to have hematopoietic stem cell transplantation. Which information will be included in patient teaching? a. Transplant of the donated cells is painful because of the nerves in the tissue lining the bone. b. Donor bone marrow cells are transplanted through an incision into the sternum or hip bone. c. The transplant procedure takes place in a sterile operating room to minimize the risk for infection. d. Hospitalization will be required for several weeks after the hematopoietic stem cell transplant (HSCT).

D The patient requires strict protective isolation to prevent infection for 2 to 4 weeks after HSCT while waiting for the transplanted marrow to start producing cells. The transplanted cells are infused through an IV line, so the transplant is not painful, nor is an operating room or incision required. DIF: Cognitive Level: Comprehension REF: 291-292 TOP: Nursing Process: Planning

20. A patient admitted with acute dyspnea is diagnosed with dilated cardiomyopathy. Which information will the nurse include when teaching the patient about management of this disorder? a. Elevating the legs above the heart will help relieve angina. b. No more than two alcoholic drinks daily are recommended. c. Careful compliance with diet and medications will prevent heart failure. d. Notify the doctor about any symptoms of heart failure such as shortness of breath.

D The patient should be instructed to notify the health care provider about any worsening of heart failure symptoms. Because dilated cardiomyopathy does not respond well to therapy, even patients with good compliance with therapy may have recurrent episodes of heart failure. The patient is instructed to avoid alcoholic beverages. Elevation of the legs above the heart will worsen symptoms (although this approach is appropriate for a patient with hypertrophic cardiomyopathy). DIF: Cognitive Level: Application REF: 863 TOP: Nursing Process: Planning

18. A patient receiving head and neck radiation has ulcerations over the oral mucosa and tongue and thick, ropey saliva. The nurse will teach the patient to a. remove food debris from the teeth and oral mucosa with a stiff toothbrush. b. use cotton-tipped applicators dipped in hydrogen peroxide to clean the teeth. c. gargle and rinse the mouth several times a day with an antiseptic mouthwash. d. rinse the mouth before and after each meal and at bedtime with a saline solution.

D The patient should rinse the mouth with a saline solution frequently. A soft toothbrush is used for oral care. Hydrogen peroxide may damage tissues. Antiseptic mouthwashes may irritate the oral mucosa and are not recommended. DIF: Cognitive Level: Application REF: 284 TOP: Nursing Process: Implementation

24. A patient with a peptic ulcer who has a nasogastric (NG) tube develops sudden, severe upper abdominal pain, diaphoresis, and a very firm abdomen. Which action should the nurse take next? a. Irrigate the NG tube. b. Obtain the vital signs. c. Listen for bowel sounds. d. Give the ordered antacid.

B The patient's symptoms suggest acute perforation, and the nurse should assess for signs of hypovolemic shock. Irrigation of the NG tube, administration of antacids, or both would be contraindicated because any material in the stomach will increase the spillage into the peritoneal cavity. The nurse should assess the bowel sounds, but this is not the first action that should be taken. DIF: Cognitive Level: Application REF: 989-990 | 992-993 TOP: Nursing Process: Implementation

3. A 21-year-old woman is scheduled for percutaneous transluminal balloon valvuloplasty to treat mitral stenosis. When explaining the advantage of valvuloplasty instead of valve replacement to the patient, which information will the nurse include? A. Biologic replacement valves require the use of immunosuppressive drugs B. Mechanical mitral valves require replacement approximately every 5 years C. Lifelong anticoagulant therapy is needed after mechanical valve replacement D. Ongoing cardiac care by a health care provider is unnecessary after valvuloplasty

3. A client with an inoperable esophageal tumor is receiving swallowing therapy. Which task does the home health nurse delegate to an experienced home health aide? Teaching family members how to determine whether the client is obtaining adequate nutrition Assessing lung sounds for possible aspiration when the client is swallowing clear liquids Reminding the client to use the chin-tuck technique each time the client attempts to swallow Instructing family members about symptoms that may indicate a need to call the provider

4. An IV hydrocortisone infusion is started before a patient is taken to surgery for a bilateral adrenalectomy. The nurse explains to the patient that this is done to prevent sodium and water retention after surgery. prevent clots from forming in the legs during recovery from surgery. provide substances to respond to stress after removal of the adrenal glands stimulate the inflammatory response to promote wound healing.

4. Which of the following is a nursing priority in the care of a patient with a diagnosis of hypothyroidism? A. Providing a dark, low-stimulation environment B. Closely monitoring the patient's intake and output C. Patient teaching related to levothyroxine (Synthroid) D. Patient teaching related to radioactive iodine therapy

6. A patient who has blunt abdominal trauma after an automobile accident is complaining of severe pain. A peritoneal lavage returns brown drainage with fecal material. Which action will the nurse plan to take next? a. Auscultate the bowel sounds. b. Prepare the patient for surgery. c. Check the patient's oral temperature. d. Obtain information about the accident.

B Return of brown drainage and fecal material suggests perforation of the bowel and the need for immediate surgery. Auscultation of bowel sounds, checking the temperature, and obtaining information about the accident are appropriate actions, but the priority is to prepare to send the patient for emergency surgery. DIF: Cognitive Level: Application REF: 1018-1019 TOP: Nursing Process: Planning

5. A patient with an acid-base imbalance has an altered potassium level. The nurse recognizes that the potassium level is altered because A. Potassium is returned to extracellular fluid when metabolic acidosis is corrected. B. Hyperkalemia causes an alkalosis that results in potassium being shifted into the cells. C. Acidosis causes hydrogen ions in the blood to be exchanged for potassium from the cells. D. In alkalosis, potassium is shifted into extracellular fluid to bind excessive bicarbonate.

5. Assessment findings reveal that a patient admitted to the hospital has a contact type I hypersensitivity to latex. Which preventive nursing intervention is best in planning care for this patient? A. Report the need for desensitization therapy B. Convey the need for pharmacologic therapy to the provider C. Communicate the need for avoidance therapy to the health care team D. Discuss symptomatic therapy with the health care provider

5. The nurse cares for a patient taking prednisone (Deltasone) and acyclovir (Zovirax) for Bell's palsy. It is most important for the nurse to follow up on which patient statement? "I can take both medications with food and milk." "chances of a full recovery are good if I take the medications." "I will need to take these medications for 2-3 months." "I can take acetaminophen with the prescribed medications."

6. During change-of-shift report, the nurse learns about the following four patients. Which patient requires assessment first? A. 40-year-old with chronic pancreatitis who has gnawing abdominal pain B. 58-year-old who has compensated cirrhosis and is complaining of anorexia C. 55-year-old with cirrhosis and ascites who has an oral temperature of 102° F (38.8°) D. 36-year-old recovering from a laparoscopic cholecystectomy who has severe shoulder pain

6. The nurse teaches a patient who has migraine headaches about sumatriptan (Imitrex). Which statement by the patient requires an intervention by the nurse? "this drug could cause birth defects." "the injection might feel like a bee sting." "this medicine will prevent migraine headaches." "I can take another dose if the first does not work."

6. Which of the following assessment parameters is of highest priority when caring for a patient undergoing a water deprivation test? Serum glucose Arterial blood gases Patient weight Patient temperature

8. The nurse is assessing a client with a cardiac infection. Which symptoms support the diagnosis of infective endocarditis instead of pericarditis or rheumatic carditis? A. Friction rub auscultated at the left lower sternal border B.Pain aggravated by breathing, coughing, and swallowing C. Splinter hemorrhages D. Thickening of endocardium

44. After receiving change-of-shift report, which of the following patients should the nurse assess first? a. A patient whose new ileostomy has drained 800 mL over the previous 8 hours b. A patient with familial adenomatous polyposis who has occult blood in the stool c. A patient with ulcerative colitis who has had six liquid stools in the previous 4 hours d. A patient who has abdominal distention and an apical heart rate of 136 beats/minute

D The patient's abdominal distention and tachycardia suggest hypovolemic shock caused by problems such as peritonitis or intestinal obstruction, which will require rapid intervention. The other patients also should be assessed as quickly as possible, but the data do not indicate any life-threatening complications associated with their diagnoses. DIF: Cognitive Level: Analysis REF: 1031-1034 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning MSC:

29. A patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 30 minutes after the transfusion is started. After stopping the transfusion, what is the first action that the nurse should take? a. Draw blood for a new crossmatch. b. Send a urine specimen to the laboratory. c. Give the PRN diphenhydramine (Benadryl). d. Administer the PRN acetaminophen (Tylenol).

D 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 (Benadryl) is used for allergic reactions. This type of reaction does not indicate incorrect crossmatching. DIF: Cognitive Level: Application REF: 708 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

23. When assessing a 24-year-old patient who has just arrived after an automobile accident, the emergency department nurse notes that the breath sounds are absent on the right side. The nurse will anticipate the need for a. emergency pericardiocentesis. b. stabilization of the chest wall with tape. c. administration of an inhaled bronchodilator. d. insertion of a chest tube with a chest drainage system.

D The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patient's clinical manifestations are not consistent with these problems. DIF: Cognitive Level: Application REF: 567 TOP: Nursing Process: Planning

43. A hospitalized patient who has been taking antibiotics for several days develops watery diarrhea. Which action should the nurse take first? a. Notify the health care provider. b. Obtain a stool specimen for analysis. c. Provide education about handwashing. d. Place the patient on contact precautions.

D The patient's history and new onset diarrhea suggest a C. difficile infection, which requires implementation of contact precautions to prevent spread of the infection to other patients. The other actions also are appropriate but can be accomplished after contact precautions are implemented. DIF: Cognitive Level: Application REF: 1008-1010 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:

26. A postoperative patient who is receiving nasogastric suction is complaining of anxiety and incisional pain. The patient's respiratory rate is 32 breaths/minute and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first? a. Discontinue the nasogastric suctions for a few hours. b. Notify the health care provider about the ABG results. c. Teach the patient about the need to take slow, deep breaths. d. Give the patient the PRN morphine sulfate 4 mg intravenously.

D The patient's respiratory alkalosis is caused by the increased respiratory rate associated with pain and anxiety. The nurse's first action should be to medicate the patient for pain. Although the nasogastric suction may contribute to the alkalosis, it is not appropriate to discontinue the tube when the patient needs gastric suction. The health care provider may be notified about the ABGs but is likely to instruct the nurse to medicate for pain. The patient will not be able to take slow, deep breaths when experiencing pain. DIF: Cognitive Level: Application REF: 322-323 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

22. A patient with systemic lupus erythematosus (SLE) who has a facial rash and alopecia tells the nurse, "I hate the way I look! I never go anywhere except here to the health clinic." An appropriate nursing diagnosis for the patient is a. activity intolerance related to fatigue and inactivity. b. impaired social interaction related to lack of social skills. c. impaired skin integrity related to itching and skin sloughing. d. social isolation related to embarrassment about the effects of SLE.

D The patient's statement about not going anywhere because of hating the way he or she looks supports the diagnosis of social isolation because of embarrassment about the effects of the SLE. Activity intolerance is a possible problem for patients with SLE, but the information about this patient does not support this as a diagnosis. The rash with SLE is nonpruritic. There is no evidence of lack of social skills for this patient. DIF: Cognitive Level: Application REF: 1670-1672 TOP: Nursing Process: Diagnosis

30. Fifteen minutes after a transfusion of packed red blood cells is started, a patient complains of back pain and dyspnea. The pulse rate is 124. The nurse's first action should be to a. administer oxygen therapy at a high flow rate. b. obtain a urine specimen to send to the laboratory. c. notify the health care provider about the symptoms. d. disconnect the transfusion and infuse normal saline.

D The patient's 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. DIF: Cognitive Level: Application REF: 708 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

8. A patient with recurring heartburn receives a new prescription for esomeprazole (Nexium). In teaching the patient about this medication, the nurse explains that this drug a. neutralizes stomach acid and provides relief of symptoms in a few minutes. b. reduces the reflux of gastric acid by increasing the rate of gastric emptying. c. coats and protects the lining of the stomach and esophagus from gastric acid. d. treats gastroesophageal reflux disease by decreasing stomach acid production.

D The proton pump inhibitors decrease the rate of gastric acid secretion. Promotility drugs such as metoclopramide (Reglan) increase the rate of gastric emptying. Cryoprotective medications such as sucralfate (Carafate) protect the stomach. Antacids neutralize stomach acid and work rapidly. DIF: Cognitive Level: Comprehension REF: 973-974 TOP: Nursing Process: Implementation

24. Which assessment finding in a patient who is hospitalized with infective endocarditis (IE) is most important to communicate to the health care provider? a. Generalized muscle aching b. Sudden onset left flank pain c. Janeway's lesions on the palms d. Temperature 100.5° F (38.1° C)

B Sudden onset of flank pain indicates possible embolization to the kidney and may require diagnostic testing such as a renal arteriogram and interventions to improve renal perfusion. The other findings are typically found in IE but do not require any new interventions. DIF: Cognitive Level: Application REF: 842-844 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

19. A patient seen at the health clinic with a severe migraine headache tells the nurse about having four similar headaches in the last 3 months. Which initial action should the nurse take? a. Refer the patient for stress counseling. b. Ask the patient to keep a headache diary. c. Suggest the use of muscle-relaxation techniques. d. Teach about the effectiveness of the triptan drugs.

B The initial nursing action should be further assessment of the precipitating causes of the headaches, quality, and location of pain, etc. Stress reduction, muscle relaxation, and the triptan drugs may be helpful, but more assessment is needed first. DIF: Cognitive Level: Application REF: 1492-1493 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

8. The nurse has identified a nursing diagnosis of acute pain related to inflammatory process for a patient with acute pericarditis. The most appropriate intervention by the nurse for this problem is to a. force fluids to 3000 mL/day to decrease fever and inflammation. b. teach the patient to take deep, slow respirations to control the pain. c. remind the patient to ask for the opioid pain medication every 4 hours. d. position the patient in Fowler's position, leaning forward on the overbed table.

D Sitting upright and leaning forward frequently will decrease the pain associated with pericarditis. Forcing fluids will not decrease the inflammation or pain. Taking deep respirations tends to increase pericardial pain. Opioids are not very effective at controlling pain caused by acute inflammatory conditions and are usually ordered PRN. The patient would receive scheduled doses of a nonsteroidal anti-inflammatory drug (NSAID). DIF: Cognitive Level: Application REF: 848-849 TOP: Nursing Process: Implementation

16. After a patient is diagnosed with lobular carcinoma in situ (LCIS), the nurse will anticipate that patient teaching may be needed about a. lumpectomy. b. lymphatic mapping. c. MammaPrint testing. d. tamoxifen (Nolvadex).

D Tamoxifen is used as a chemopreventive therapy in some patients with LCIS. The other diagnostic tests and therapies are not needed because LCIS does not usually require treatment. DIF: Cognitive Level: Application REF: 1312-1313 TOP: Nursing Process: Planning

1. To determine the severity of the symptoms for a patient with benign prostatic hyperplasia (BPH) the nurse will ask the patient about a. blood in the urine. b. lower back or hip pain. c. erectile dysfunction (ED). d. strength of the urinary stream.

D The American Urological Association (AUA) Symptom Index for a patient with BPH asks questions about the force and frequency of urination, nocturia, etc. Blood in the urine, ED, and back or hip pain are not typical symptoms of BPH. DIF: Cognitive Level: Application REF: 1377-1379 TOP: Nursing Process: Assessment

8. When evaluating the red cell indices of a patient, the nurse knows that a low mean corpuscular volume (MCV) indicates a. hypochromic red blood cells (RBCs). b. inadequate numbers of RBCs. c. low hemoglobin in the RBCs. d. small size of the RBCs

D The MCV is low when the RBCs are smaller than normal. Inadequate numbers of RBCs are an indication of anemia. Low levels of hemoglobin in the RBCs and hypochromic RBCs result in a low mean corpuscular hemoglobin (MCH). DIF: Cognitive Level: Comprehension REF: 655 TOP: Nursing Process: Assessment

2. A patient is receiving intravesical bladder chemotherapy. The nurse will monitor for a. nausea. b. alopecia. c. mucositis. d. hematuria.

D The adverse effects of intravesical chemotherapy are confined to the bladder. The other adverse effects are associated with systemic chemotherapy. DIF: Cognitive Level: Application REF: 276-277 TOP: Nursing Process: Evaluation

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

D The joints should be maintained in an extended position to avoid contractures, so patients should use a small, flat pillow for sleeping. The other information is appropriate for a patient with RA and indicates that teaching has been effective. DIF: Cognitive Level: Application REF: 1657 | 1659-1660 TOP: Nursing Process: Evaluation

33. Which information noted by the nurse reviewing the laboratory results of a patient who is receiving chemotherapy is most important to report to the health care provider? a. Hematocrit of 30% b. Platelets of 95,000/µl c. Hemoglobin of 10 g/L d. WBC count of 1700/µl

D The low WBC count places the patient at risk for severe infection and is an indication that the chemotherapy dose may need to be lower or that white blood cell (WBC) growth factors such as filgrastim (Neupogen) are needed. The other laboratory data do not indicate any immediate life-threatening adverse effects of the chemotherapy. DIF: Cognitive Level: Application REF: 280 | 282 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

8. A patient with cirrhosis has 4+ pitting edema of the feet and legs. The data indicate that it is most important for the nurse to monitor the patient's a. hemoglobin. b. temperature. c. activity level. d. albumin level.

D The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of edema. The other parameters also should be monitored, but they are not directly associated with the patient's current symptoms. DIF: Cognitive Level: Application REF: 1075 | 1077 TOP: Nursing Process: Assessment

2. When teaching the patient with allergic rhinitis about management of the condition, the nurse explains that a. over-the-counter (OTC) antihistamines cause sedation, so prescription antihistamines are usually ordered. b. corticosteroid nasal sprays will reduce inflammation, but systemic effects limit their use. c. use of oral antihistamines for a few weeks before the allergy season may prevent reactions. d. identification and avoidance of environmental triggers are the best way to avoid symptoms.

D The most important intervention is to assist the patient in identifying and avoiding potential allergens. Intranasal corticosteroids (not oral antihistamines) should be started several weeks before the allergy season. Corticosteroid nasal sprays have minimal systemic absorption. Nonsedating antihistamines are available OTC. DIF: Cognitive Level: Application REF: 521-523 TOP: Nursing Process: Implementation

1. The teaching plan for a patient with acute sinusitis will need to include which of the following interventions (select all that apply)? a. Taking a hot shower will increase sinus drainage and decrease pain. b. Over-the-counter (OTC) antihistamines can be used to relieve congestion and inflammation. c. Saline nasal spray can be made at home and used to wash out secretions. d. Blowing the nose forcefully should be avoided to decrease nosebleed risk. e. You will be more comfortable if you keep your head in an upright position.

A, B, C, E The steam and heat from a shower will help thin secretions and improve drainage. Antihistamines can be used. Patients can use either OTC sterile saline solutions or home-prepared saline solutions to thin and remove secretions. Maintaining an upright posture decreases sinus pressure and the resulting pain. Blowing the nose after a hot shower or using the saline spray is recommended to expel secretions. DIF: Cognitive Level: Analysis REF: 526-527 OBJ: Special Questions: Alternate Item Format TOP: Nursing Process: Implementation

1. The nurse at the clinic is interviewing a 61-year-old woman who is 5 feet, 3 inches tall and weighs 125 pounds (57 kg). The patient has not seen a health care provider for 20 years. She walks 5 miles most days and has a glass of wine 2 or 3 times a week. Which topics will the nurse plan to include in patient teaching about cancer screening and decreasing cancer risk (select all that apply)? a. Pap testing b. Tobacco use c. Sunscreen use d. Mammography e. Colorectal screening

A, C, D, E The patient's age, gender, and history indicate a need for screening and/or teaching about colorectal cancer, mammography, Pap smears, and sunscreen. The patient does not use excessive alcohol or tobacco, she is physically active, and her body weight is healthy. DIF: Cognitive Level: Analysis REF: 269-270 | eTable 16-3 OBJ: Special Questions: Alternate Item Format TOP: Nursing Process: Planning

8. The nurse is teaching a postmenopausal patient with stage III breast cancer about the expected outcomes of her cancer treatment. Which patient statement indicates that the teaching has been effective? a. "After cancer has not recurred for 5 years, it is considered cured." b. "The cancer will be cured if the entire tumor is surgically removed." c. "Cancer is never considered cured, but the tumor can be controlled with surgery, chemotherapy, and radiation." d. "I will need to have follow-up examinations for many years after I have treatment before I can be considered cured."

D The risk of recurrence varies by the type of cancer. For breast cancer in postmenopausal women the patient needs at least 20 disease-free years to be considered cured. Some cancers are considered cured after a shorter time span, or after surgery, but stage III breast cancer will require additional therapies and ongoing follow-up. DIF: Cognitive Level: Application REF: 271-272 TOP: Nursing Process: Evaluation

13. Which statement by a 52-year-old patient newly diagnosed with stage I breast cancer indicates to the nurse that patient teaching may be needed? a. "There are several options available for treating the cancer." b. "I will probably need radiation to the breast after having the surgery." c. "I can probably have reconstructive surgery at the same time as a mastectomy." d. "Mastectomy will be the best choice to decrease the chance of cancer recurrence."

D The survival rates with lumpectomy and radiation or modified radical mastectomy are comparable. The other patient statements indicate a good understanding of stage I breast cancer treatment. DIF: Cognitive Level: Application REF: 1314-1316 TOP: Nursing Process: Assessment

26. A patient who was admitted with acute bleeding from esophageal varices asks the nurse the purpose for the ordered ranitidine (Zantac). Which response by the nurse is most appropriate? a. The medication will reduce the risk for aspiration. b. The medication will decrease nausea and anorexia. c. The medication will inhibit the development of gastric ulcers. d. The medication will prevent irritation to the esophageal varices.

D The therapeutic action of H2 receptor blockers in patients with esophageal varices is to prevent irritation and bleeding from the varices caused by reflux of acid gastric contents. Although ranitidine does decrease the risk for peptic ulcers, reduce nausea, and help prevent aspiration pneumonia, these are not the primary purpose for H2 receptor blockade in this patient. DIF: Cognitive Level: Application REF: 1080 TOP: Nursing Process: Implementation

21. A 64-year-old with acute myelogenous leukemia (AML) who has induction therapy prescribed asks the nurse whether the planned chemotherapy will be worth undergoing. Which response by the nurse is appropriate? a. "If you do not want to have chemotherapy, there are other options for treatment such as stem cell transplantation." b. "The decision about chemotherapy is one that you and the doctor need to make rather than asking what I would do." c. "You don't need to make a decision about treatment right now since leukemias in adults tend to progress quite slowly." d. "The side effects of the chemotherapy are difficult, but AML frequently does go into remission with chemotherapy."

D This response uses therapeutic communication by addressing the patient's question and giving accurate information. The other responses either give inaccurate information or fail to address the patient's question, which will discourage the patient from asking the nurse for information. DIF: Cognitive Level: Application REF: 696 | 697-698 TOP: Nursing Process: Implementation

4. The health care provider performs a bone marrow aspiration from the left posterior iliac crest on a patient with pancytopenia. Following the procedure, the nurse should a. elevate the head of the bed to 45 degrees. b. apply a sterile Band-Aid at the aspiration site. c. use half-inch sterile gauze to pack the wound. d. have the patient lie on the left side for an hour.

D To decrease the risk for bleeding, the patient should lie on the left side for 30 to 60 minutes. The wound after bone marrow biopsy is small and will not be packed with gauze. A pressure dressing is used to cover the aspiration site. There is no indication that the head needs to be elevated for this patient. DIF: Cognitive Level: Application REF: 658 TOP: Nursing Process: Implementation

24. Which of these prescribed interventions will the nurse implement first for a hospitalized patient who is experiencing continuous tonic-clonic seizures? a. Give phenytoin (Dilantin) 100 mg IV. b. Monitor level of consciousness (LOC). c. Obtain computed tomography (CT) scan. d. Administer lorazepam (Ativan) 4 mg IV.

D To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure medications such as the benzodiazepines. A CT scan is appropriate, but prevention of any seizure activity during the CT scan is necessary. Phenytoin also will be administered, but it is not rapidly acting. Patients who are experiencing tonic-clonic seizures are nonresponsive, although the nurse should assess LOC after the seizure. DIF: Cognitive Level: Application REF: 1498 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

14. A patient with metastatic cancer of the colon experiences severe vomiting following each administration of chemotherapy. An important nursing intervention for the patient is to a. teach about the importance of nutrition during treatment. b. have the patient eat large meals when nausea is not present. c. offer dry crackers and carbonated fluids during chemotherapy. d. administer prescribed antiemetics 1 hour before the treatments.

D Treatment with antiemetics before chemotherapy may help prevent nausea. Although nausea may lead to poor nutrition, there is no indication that the patient needs instruction about nutrition. The patient should eat small, frequent meals. Offering food and beverages during chemotherapy is likely to cause nausea. DIF: Cognitive Level: Application REF: 283 TOP: Nursing Process: Implementation

15. A patient who is nauseated and vomiting up blood-streaked fluid is admitted to the hospital with acute gastritis. To determine possible risk factors for gastritis, the nurse will ask the patient about a. the amount of fat in the diet. b. history of recent weight gain or loss. c. any family history of gastric problems. d. use of nonsteroidal anti-inflammatory drugs (NSAIDs).

D Use of an NSAID is associated with damage to the gastric mucosa, which can result in acute gastritis. Family history, recent weight gain or loss, and fatty foods are not risk factors for acute gastritis. DIF: Cognitive Level: Comprehension REF: 985-986 TOP: Nursing Process: Assessment

15. While caring for a patient with mitral valve prolapse (MVP) without valvular regurgitation, the nurse determines that discharge teaching has been effective when the patient states that it will be necessary to a. plan to take antibiotics before any dental appointments. b. limit physical activity to avoid stressing the heart valves. c. take 1 aspirin a day to prevent embolization from the valve. d. avoid use of over-the-counter (OTC) medications that contain stimulant drugs.

D Use of stimulant medications should be avoided by patients with MVP since these may exacerbate symptoms. Daily aspirin and restricted physical activity are not needed by patients with mild MVP. Antibiotic prophylaxis is needed for patients with MVP with regurgitation but will not be necessary for this patient. DIF: Cognitive Level: Application REF: 854-855 TOP: Nursing Process: Evaluation

11. A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, "How will I talk after the surgery?" The best response by the nurse is, a. "You will breathe through a permanent opening in your neck, but you will not be able to communicate orally." b. "You won't be able to talk right after surgery, but you will be able to speak again after the tracheostomy tube is removed." c. "You won't be able to speak as you used to, but there are artificial voice devices that will give you the ability to speak normally." d. "You will have a permanent opening into your neck, and you will need to have rehabilitation for some type of voice restoration."

D Voice rehabilitation is planned after a total laryngectomy, and a variety of assistive devices are available to restore communication. Although the ability to communicate orally is changed, it would not be appropriate to tell a patient that this ability would be lost. Artificial voice devices do not permit normal-sounding speech. In a total laryngectomy, the vocal cords are removed, so normal speech is impossible. DIF: Cognitive Level: Application REF: 541 TOP: Nursing Process: Implementation

21. A new order for IV gentamicin (Garamycin) 60 mg BID is received for a patient with diabetes who has pneumonia. When evaluating for adverse effects of the medication, the nurse will plan to monitor the patient's a. urine osmolality. b. serum potassium. c. blood glucose level. d. blood urea nitrogen (BUN) and creatinine.

D When a patient at risk for chronic kidney disease (CKD) receives a nephrotoxic medication, it is important to monitor renal function with BUN and creatinine levels. The other laboratory values would not be useful in determining the effect of the gentamicin. DIF: Cognitive Level: Application REF: 1165 | 1166 TOP: Nursing Process: Evaluation

7. When caring for a patient who is receiving heparin, the nurse will monitor a. prothrombin time (PT). b. fibrin degradation products (FDP). c. international normalized ratio (INR). d. activated partial thromboplastin time (aPTT).

D aPTT testing is used to determine whether heparin is at a therapeutic level. FDP is useful in diagnosis of problems such as disseminated intravascular coagulation (DIC). PT and INR are most commonly used to test for therapeutic levels of warfarin (Coumadin). DIF: Cognitive Level: Comprehension REF: 656 TOP: Nursing Process: Assessment

8. The pathology report for a 42-year-old who has had a modified radical mastectomy identifies the tumor as an estrogen-receptor positive adenocarcinoma. The nurse will plan on teaching the patient about a. estradiol (Estrace). b. raloxifene (Evista). c. tamoxifen (Nolvadex). d. trastuzumab (Herceptin).

C Tamoxifen is used for estrogen-dependent breast tumors in premenopausal women. Raloxifene is used to prevent breast cancer, but it is not used postmastectomy to treat breast cancer. Estradiol will increase the growth of estrogen-dependent tumors. Trastuzumab is used to treat tumors that have the HER-2 receptor. DIF: Cognitive Level: Application REF: 1318-1319 TOP: Nursing Process: Planning

25. A patient with renal failure who has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion is somnolent and has decreased deep tendon reflexes. Which action should the nurse take first? a. Notify the patient's health care provider. b. Withhold the next scheduled dose of Maalox. c. Review the magnesium level on the patient's chart. d. Check the chart for the most recent potassium level.

C The patient has a history and symptoms consistent with hypermagnesemia; the nurse should check the chart for a recent serum magnesium level. Notification of the health care provider will be done after the nurse knows the magnesium level. The Maalox should be held, but more immediate action is needed to correct the patient's decreased deep tendon reflexes (DTRs) and somnolence. Monitoring of potassium levels also is important for patients with renal failure, but the patient's current symptoms are not consistent with hyperkalemia. DIF: Cognitive Level: Application REF: 319-320 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

13. Which of the following findings would alarm the nurse when caring for a patient receiving chemotherapy who has a platelet count of 17,000/mm3? A. Increasing shortness of breath B. Diminished bilateral breath sounds C. Change in mental status D. Weight gain of 4 pounds in 1 day

10. Which assessment finding represents a positive response to erythropoietin (Epogen, Procrit) therapy? A. Hematocrit of 26.7% B. Potassium within normal range C. Absence of spontaneous fractures D. Less fatigue

11. A patient presents with complaints of fatigue, shortness of breath on exertion, and a yellowing of the skin. Laboratory data indicates anemia along with an increase in bilirubin levels. Which of the following would the nurse expect the patient to be diagnosed with? A. Hemolytic anemia B. Sickle cell anemia C. Idiopathic thrombocytopenia purpura D. Pernicious anemia

11. When caring for a client with oral cancer who has developed stomatitis as a complication of radiation and chemotherapy, which action does the nurse delegate to the home health aide? Provide oral care using disposable foam swabs. Inspect the oral mucosa for evidence of oral candidiasis. Instruct the client on how to use nystatin (Mycostatin) oral rinses. Assist the client in making appropriate dietary choices.

11. Which action should the nurse take when assessing a patient with trigeminal neuralgia? Have the patient clench the jaws Inspect the oral mucosa and teeth Palpate the face to compare skin temperature bilaterally Identify trigger zones by lightly touching the affected side

10. When planning care for a patient hospitalized with a streptococcal infective endocarditis (IE), which intervention is a priority for the nurse to include? A. Monitor labs for streptococcal antibodies B. Arrange for placement of a long-term IV catheter. C. Teach the importance of completing all oral antibiotics. D. Encourage the patient to begin regular aerobic exercise.

17. A patient with von Willebrand disease is admitted to the hospital for minor knee surgery. The nurse will review the coagulation survey to check the a. platelet count. b. bleeding time. c. thrombin time. d. prothrombin time.

B The bleeding time is affected by von Willebrand disease. Platelet count, prothrombin time, and thrombin time are normal in von Willebrand disease. DIF: Cognitive Level: Comprehension REF: 685 TOP: Nursing Process: Assessment

1. While assisting a client during peritoneal dialysis, the nurse observes the drainage stop after 200 mL of peritoneal effluent drains into the bag. What action should the nurse implement first? A. Instruct the client to deep-breathe and cough. B. Document the effluent as output. C. Turn the client to the opposite side. D. Re-position the catheter.

10. A round face, preauricular fat, hyperpigmentation, and a "buffalo hump" in the posterior cervical area are associated with acromegaly. achondroplasia. Cushing syndrome. infantile hydrocephalus.

11. Which intervention will be most helpful for the patient with mucositis? A. Administering a biological response modifier B. Encouraging oral care with commercial mouthwash C. Providing oral care with a disposable mouth swab D. Maintaining NPO until the lesions resolve

20. The nurse is conducting a health assessment interview with a patient diagnosed with human immune deficiency virus (HIV). Which statement by the patient does the nurse immediately address? A. When I injected heroin, I was exposed to HIV." B. "I don't understand how the antiretroviral drugs work." C. "I remember to take my antiretroviral drugs almost every day." D. "My sex drive is weaker than it used to be since I started taking my antiretroviral medications."

2. A health care worker believes that he may have been exposed to hepatitis A. Which intervention is the highest priority to prevent him from developing the disease? A. Requesting vaccination for hepatitis A B. Using a needleless system in daily work C. Getting the three-part hepatitis B vaccine D. Requesting an injection of immunoglobulin

D. Requesting an injection of immunoglobulin

4. A patient with multiple myeloma reports bone pain that is unrelieved by analgesics. How does the nurse respond to this patient'€™s problem? A. "Ask your doctor to prescribe more medication." B. "It is too soon for additional medication to be given." C. "I'll turn on some soothing classical music for you." D. "Would you like to try some relaxation techniques?"

9. When providing discharge teaching to a client with cirrhosis, it is essential for the nurse to emphasize avoidance of which of these? A. Vitamin K-containing products B. Potassium-sparing diuretics C. Nonabsorbable antibiotics D. Nonsteroidal anti-inflammatory drugs (NSAIDs)

1. Which patient is more likely to develop gallstones? A. 45-year-old Caucasian female with a family history of gallstones B. 55-year-old African-American male with a history of diabetes mellitus C. 62-year-old Hispanic/Latino female with a history of irritable bowel syndrome D. 60-year-old obese, American-Indian female with a history of diabetes mellitus

10. A 68-year-old patient hospitalized with a new diagnosis of Guillain-Barré syndrome has numbness and weakness of both feet. The nurse will anticipate teaching the patient about Intubation and mechanical ventilation Administration of corticosteroid drugs Insertion of a NG feeding tube Infusion of immunoglobulin (Sandoglobulin)

10. A client has had a radical neck dissection with a permanent tracheostomy for treatment of oral cancer. In what order should the following orders for postoperative nutritional care be implemented? Monitor weight, teach swallowing exercises, assess aspiration risk, provide nasogastric nutrition. Teach swallowing exercises, assess aspiration risk, monitor weight, provide nasogastric nutrition. Assess aspiration risk, teach swallowing exercises, provide nasogastric nutrition, monitor weight. Provide nasogastric nutrition, assess aspiration risk, monitor weight, teach swallowing exercises.

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

11. When caring for a client who receives peritoneal dialysis (PD), which finding does the nurse report to the provider immediately? A. Pulse oximetry reading of 95% B. Sinus bradycardia, rate of 58 beats/min C. Blood pressure of 148/90 mm Hg D. Temperature of 101.2° F (38.4° C)

12. A client with oral cancer is depressed over the diagnosis and tells the nurse of plans to have a radical neck dissection. What is the nurse's best reaction? Listen to the client and then explain that it is normal to feel depressed about the diagnosis. Explain the grieving process and listen to what the client has to say. Suggest that the client talk with friends and family and seek their support. Listen to the client's concerns and feelings, and then suggest that the client join a community group of cancer survivors.

12. The nurse asks a client with liver disease to raise the arms to shoulder level and dorsiflex the hands. A few moments later, the hand begins to flap upward and downward. How does the nurse correctly document this in the medical record? A. Positive Babinski sign B. Hyperreflexia C. Kehr's sign D. Asterixis

13. A client with oral carcinoma has a priority problem of risk for airway blockage related to obstruction by the tumor. At the beginning of the shift, which action will the nurse take first? Suction the client's oral secretions to clear the airway. Place the client on humidified oxygen per nasal cannula. Assist the client to an upright position to facilitate breathing. Assess the respiratory effort and quantities and types of oral secretions.

18. A patient with an acquired immune deficiency is seen in the clinic for re-evaluation of the immune system's response to prescribed medication. Which test result does the nurse convey to the health care provider? A. Therapeutic highly active antiretroviral therapy (HAART) level B. Positive human immune deficiency virus (HIV), enzyme-linked immunosorbent assay (ELISA), Western blot C. Positive Papanicolaou (Pap) test D. Improved CD4+ T-cell count and reduced viral load

18. The nurse is reviewing the medical record of a patient who is prescribed a decongestant. The nurse plans to contact the patient's health care provider if the patient has which condition? A. Cataracts B. Crohn's Disease C. Diabetes mellitus D. Hypertension

15. Which laboratory information will the nurse monitor to detect heparin-induced thrombocytopenia (HIT) in a patient who is receiving a continuous heparin infusion? a. Prothrombin time b. Erythrocyte count c. Fibrinogen degradation products d. Activated partial thromboplastin time

D Platelet aggregation in HIT causes neutralization of heparin, so that the activated partial thromboplastin time will be shorter and more heparin will be needed to maintain therapeutic levels. The other data will not be affected by HIT. DIF: Cognitive Level: Application REF: 679 TOP: Nursing Process: Assessment

14. A patient with HIV infection has developed Mycobacterium avium complex infection. An appropriate outcome for the patient is that the patient will a. be free from injury. b. receive immunizations. c. have adequate oxygenation. d. maintain intact perineal skin.

D The major manifestation of M. avium infection is loose, watery stools, which would increase the risk for perineal skin breakdown. The other outcomes would be appropriate for other complications (pneumonia, dementia, influenza, etc.) associated with HIV infection. DIF: Cognitive Level: Application REF: 245 TOP: Nursing Process: Planning

19. Which action should the nurse take first when caring for a patient who has been admitted for lumpectomy and axillary lymph node dissection? a. Teach the patient how to deep breathe and cough. b. Discuss options for postoperative pain management. c. Explain the postdischarge care of the axillary drains. d. Ask the patient to describe what she knows about the surgery.

D Before teaching, the nurse should assess the patient's current knowledge level. The other teaching also may be appropriate, depending on the assessment findings. DIF: Cognitive Level: Application REF: 1320-1323 TOP: Nursing Process: Implementation

41. The nurse who is interviewing a 40-year-old obtains information about the following patient problems. Which information is most important to communicate to the health care provider? a. The patient had an appendectomy at age 17. b. The patient smokes a pack/day of cigarettes. c. The patient has a history of frequent constipation. d. The patient has recently noticed blood in the stools.

D Blood in the stools is a possible clinical manifestation of colorectal cancer and requires further testing by the health care provider. The other patient information also will be communicated to the health care provider, but does not indicate an urgent need for further testing or intervention. DIF: Cognitive Level: Application REF: 1035-1036 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

15. Which action by a patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD? a. The patient slows the inflow rate when experiencing pain. b. The patient leaves the catheter exit site without a dressing. c. The patient plans 30 to 60 minutes for a dialysate exchange. d. The patient cleans the catheter while taking a bath every day.

D Patients are encouraged to take showers rather than baths to avoid infections at the catheter insertion side. The other patient actions indicate good understanding of peritoneal dialysis. DIF: Cognitive Level: Application REF: 1182-1183 TOP: Nursing Process: Evaluation

37. A patient is admitted to the emergency department with severe abdominal pain with rebound tenderness. The vital signs include temperature 101° F (38.3° C), pulse 130, respirations 34, and blood pressure (BP) 84/50. Which of the following interventions should the nurse implement first? a. Administer IV ketorolac (Toradol) 15 mg. b. Draw blood for a complete blood count (CBC). c. Obtain a computed tomography (CT) scan of the abdomen. d. Infuse 1000 mL of lactated Ringer's solution over 30 minutes.

D The priority for this patient is to treat the patient's hypovolemic shock with fluid infusion. The other actions should be implemented after starting the fluid infusion. DIF: Cognitive Level: Application REF: 1016 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

2. Which menu choice indicates that the patient understands the nurse's teaching about best 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

A 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. DIF: Cognitive Level: Application REF: 666 TOP: Nursing Process: Evaluation

13. A patient has just arrived on the postoperative unit after having a laparoscopic esophagectomy for treatment of esophageal cancer. Which nursing action should be included in the postoperative plan of care? a. Elevate the head of the bed to at least 30 degrees. b. Reposition the nasogastric (NG) tube if drainage stops or decreases. c. Notify the doctor immediately about bloody NG drainage. d. Start oral fluids when the patient has active bowel sounds.

A Elevation of the head of the bed decreases the risk for reflux and aspiration of gastric secretions. The NG tube should not be repositioned without consulting with the health care provider. Bloody NG drainage is expected for the first 8 to 12 hours. A swallowing study is needed before oral fluids are started. DIF: Cognitive Level: Application REF: 979 TOP: Nursing Process: Planning

19. When caring for the patient with infective endocarditis of the tricuspid valve, the nurse will plan to monitor the patient for a. dyspnea. b. flank pain. c. hemiparesis. d. splenomegaly.

A Embolization from the tricuspid valve would cause symptoms of pulmonary embolus. Flank pain, hemiparesis, and splenomegaly would be associated with embolization from the left-sided valves. DIF: Cognitive Level: Application REF: 842-843 TOP: Nursing Process: Planning

19. A patient is hospitalized with vomiting of "coffee-ground" emesis. The nurse will anticipate preparing the patient for a. endoscopy. b. angiography. c. gastric analysis testing. d. barium contrast studies.

A Endoscopy is the primary tool for visualization and diagnosis of upper gastrointestinal (GI) bleeding. Angiography is used only when endoscopy cannot be done because it is more invasive and has more possible complications. Gastric analysis testing may help with determining the cause of gastric irritation, but it is not used for acute GI bleeding. Barium studies are helpful in determining the presence of gastric lesions, but not whether the lesions are actively bleeding. DIF: Cognitive Level: Application REF: 982 TOP: Nursing Process: Planning

9. While examining the lymph nodes during physical assessment, the nurse would be most concerned about a. a 2-cm nontender supraclavicular node. b. a 1-cm mobile and nontender axillary node. c. an inability to palpate any superficial lymph nodes. d. firm inguinal nodes in a patient with an infected foot.

A Enlarged and nontender nodes are most suggestive of malignancy such as lymphoma. Firm nodes are an expected finding in an area of infection. The superficial lymph nodes are usually not palpable in adults, but if they are palpable, they are normally 0.5 to 1 cm and nontender. DIF: Cognitive Level: Application REF: 649-650 | 651 TOP: Nursing Process: Assessment

3. A patient with a small immobile breast lump is advised to have a fine needle aspiration (FNA) biopsy. The nurse explains that an advantage to this procedure is that a. FNA is done in the outpatient clinic, and results are available in 1 to 2 days. b. only a small incision is needed, resulting in minimal breast pain and scarring. c. if the biopsy results are negative, no further diagnostic testing will be needed. d. FNA is guided by a mammogram, ensuring that cells are taken from the lesion.

A FNA is done in outpatient settings and results are available in 24 to 48 hours. No incision is needed. FNA may be guided by ultrasound, but not by mammogram. Since the immobility of the breast lump suggests cancer, further testing will be done if the FNA is negative. DIF: Cognitive Level: Application REF: 1308 TOP: Nursing Process: Implementation

29. A patient with an exacerbation of rheumatoid arthritis (RA) is taking prednisone (Deltasone) 40 mg daily. Which of these assessment data obtained by the nurse indicate that the patient is experiencing a side effect of the medication? a. The patient's blood glucose is 165 mg/dL. b. The patient has no improvement in symptoms. c. The patient has experienced a recent 5-pound weight loss. d. The patient's erythrocyte sedimentation rate (ESR) has increased.

A Hyperglycemia is a side effect of prednisone. Corticosteroids increase appetite and lead to weight gain. An elevated ESR and no improvement in symptoms would indicate that the prednisone was not effective but would not be side effects of the medication. DIF: Cognitive Level: Application REF: 1647-1649 TOP: Nursing Process: Evaluation

13. A patient is receiving 3% NaCl solution for correction of hyponatremia. During administration of the solution, the most important assessment for the nurse to monitor is a. lung sounds. b. urinary output. c. peripheral pulses. d. peripheral edema.

A Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are the most serious of the symptoms of fluid excess listed. Bounding peripheral pulses, peripheral edema, or changes in urine output also are important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation. DIF: Cognitive Level: Application REF: 327 TOP: Nursing Process: Assessment

16. A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.1 mEq/L. Of the following medications that the patient has been taking at home, the nurse will be most concerned about a. oral digoxin (Lanoxin) 0.25 mg daily. b. ibuprofen (Motrin) 400 mg every 6 hours. c. metoprolol (Lopressor) 12.5 mg orally daily. d. lantus insulin 24 U subcutaneously every evening.

A Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse also will need to do more assessment regarding the other medications, but there is not as much concern with the potassium level. DIF: Cognitive Level: Application REF: 315 TOP: Nursing Process: Assessment

22. Interleukin-2 (IL-2) is used as adjuvant therapy for a patient with metastatic renal cell carcinoma. The nurse teaches the patient that the purpose of therapy with this agent is to a. enhance the patient's immunologic response to tumor cells. b. stimulate malignant cells in the resting phase to enter mitosis. c. prevent the bone marrow depression caused by chemotherapy. d. protect normal cells from the harmful effects of chemotherapy.

A IL-2 enhances the ability of the patient's own immune response to suppress tumor cells. IL-2 does not protect normal cells from damage caused by chemotherapy, stimulate malignant cells to enter mitosis, or prevent bone marrow depression. DIF: Cognitive Level: Comprehension REF: 288-289 TOP: Nursing Process: Implementation

25. Twelve hours after undergoing a gastroduodenostomy (Billroth I), a patient complains of increasing abdominal pain. The patient has absent bowel sounds and 200 mL of bright red nasogastric (NG) drainage in the last hour. The most appropriate action by the nurse at this time is to a. notify the surgeon. b. irrigate the NG tube. c. administer the prescribed morphine. d. continue to monitor the NG drainage.

A Increased pain and 200 mL of bright red NG drainage 12 hours after surgery indicate possible postoperative hemorrhage, and immediate actions such as blood transfusion and/or return to surgery are needed. Because the NG is draining, there is no indication that irrigation is needed. The patient may need morphine, but this is not the highest priority action. Continuing to monitor the NG drainage is not an adequate response. DIF: Cognitive Level: Application REF: 996 | 997-998 TOP: Nursing Process: Implementation

6. After the nurse has finished teaching a patient about taking oral ferrous sulfate, which patient statement indicates that additional instruction is needed? a. "I will call the doctor if my stools start to turn black." b. "I will take a stool softener if I feel constipated occasionally." c. "I should take the iron with orange juice about an hour before eating." d. "I should increase my fluid and fiber intake while I am taking the iron tablets."

A It is normal for the stools to appear black when a patient is taking iron and the patient should not call the doctor about this. The other patient statements are correct. DIF: Cognitive Level: Application REF: 666-667 TOP: Nursing Process: Evaluation

22. A patient experiences a steering wheel injury as a result of an automobile accident. During the initial assessment, the emergency department nurse would be most concerned about a. paradoxic chest movement. b. the complaint of chest wall pain. c. a heart rate of 110 beats/minute. d. a large bruised area on the chest.

A Paradoxic chest movement indicates that the patient may have flail chest, which can severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange. DIF: Cognitive Level: Application REF: 567 | 569 TOP: Nursing Process: Assessment

1. The nurse is called to the patient's room by the patient's spouse when the patient experiences a seizure. Upon finding the patient in a clonic reaction, the nurse should Turn the patient to the side Start oxygen by mask at 6 L/min Restrain the patient's arms and legs to prevent injury Record the time sequence of the patient's movements and responses as they occur

10. Which intervention is most important for the nurse to teach the patient with polycythemia vera to prevent injury as a result of the increased bleeding tendency? A. Use a soft-bristled toothbrush B. Drink at least 3 liters of liquids per day C. Wear gloves in socks outdoors in cool weather D. Exercise slowly and only on the advice of your physician

14. A client who has undergone surgery and radiation therapy to treat oral cancer reports persistent dry mouth. What will the nurse teach this client about managing this symptom? Use saliva substitutes, especially when eating dry foods. This condition is common but is temporary. Use lozenges and hard candies to prevent dry mouth. This indicates a complication of therapy.

15. A patient is receiving highly active antiretroviral therapy (HAART). Which statement by the Patient indicates a need for further teaching by the nurse? A. "With this treatment, I probably cannot spread this virus to others." B. "This treatment does not kill the virus." C. "This medication prevents the virus from replicating in the body." D. "Research has shown the effectiveness of this therapy if I do not forget to take any doses."

19. In discharging a patient diagnosed with acquired immune deficiency syndrome (AIDS), which statement by the nurse uses a nonjudgmental approach in discussing sexual practices and behaviors? A."Have you had sex with men or women or both?" B. "I hope you use condoms to protect your partners." C. ``You must tell me all of your partnersâ€™ names, so I can let them know about possibly having AIDS." D. "You must tell me if you have a history of any sexually transmitted diseases because the public health department needs to know."

2. The nurse identifies which patient as being the most at risk for the development of breast cancer? A 72-year-old female with a personal history of colon cancer A 59-year-old female who has inherited the APC gene A 43-year-old female who is obese and leads a sedentary lifestyle A 25-year-old female with fibrocystic breast disease

3. The nurse is teaching a patient about induction therapy for acute leukemia. Which patient statement indicates a need for additional education? A. "After this therapy, I will not need to have any more." B. "I will need to avoid people with a cold or flu." C. "I will probably lose my hair during this therapy." D. "The goal of this therapy is to put me in remission."

3. You are caring for a patient admitted with an exacerbation of asthma. After several treatments, the ABG results are pH 7.40, PaCO2 40 mm Hg, HCO3 24 mEq/L, PaO2 92 mm Hg, O2 saturation 99%. You interpret these results as which of the following? A. Within normal limits B. Slight metabolic acidosis C. Slight respiratory acidosis D. Slight respiratory alkalosis

4. A patient diagnosed with fibromyalgia syndrome (FMS) reports difficulty sleeping at night. Which suggestion should the nurse give to the patient? A. "Melatonin is a hormone that is often used in supplements to improve sleep. It may also ease fibromyalgia pain." B. "Diphenhydramine (Benadryl) is a nonprescription sleep aid that is effective and does not cause tolerance." C. "Drinking a glass of red wine 30 minutes before bedtime will reduce anxiety and help you fall asleep." D. "Evening primrose oil is an herbal supplement that can be used as a sleep aid and to relieve anxiety."

4. The nurse is planning care for a 48-year-old woman with acute severe pancreatitis. The highest priority patient outcome is A. Maintaining normal respiratory function. B. Expressing satisfaction with pain control. C. Developing no ongoing pancreatic disease. D. Having adequate fluid and electrolyte balance.

7. After receiving change-of-shift report about these four clients, which client should the nurse assess first? A. A 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset frequent premature ventricular contractions B. A 55-year-old admitted with pulmonary edema who received furosemide (Lasix) and whose current O2 saturation is 94% C. A 68-year-old with pericarditis who is reporting sharp, stabbing chest pain when taking deep breaths D. A 79-year-old admitted for possible rejection of a heart transplant who has a heart rate of 95 beats/min

7. The nurse is providing discharge instructions to a patient with diabetes insipidus. Which of the following instructions regarding DDAVP would be most appropriate? The patient should alternate nostrils during administration to prevent nasal irritation. The patient can expect to experience weight loss secondary to increased diuresis. The patient should monitor for symptoms of hypernatremia as a side effect of this drug. The patient should report any decrease in urinary elimination to the health care provider.

24. A 22-year-old man tells the nurse at the health clinic that he has recently had some problems with erectile dysfunction. When assessing for possible etiologic factors, which question should the nurse ask first? a. "Are you using any recreational drugs or drinking a lot of alcohol?" b. "Have you been experiencing an unusual amount of anxiety or stress?" c. "Do you have any history of an erection that lasted for 6 hours or more?" d. "Do you have any chronic cardiovascular or peripheral vascular disease?"

A A common etiologic factor for erectile dysfunction (ED) in younger men is use of recreational drugs or alcohol. Stress, priapism, and cardiovascular illness also contribute to ED, but they are not common etiologic factors in younger men. DIF: Cognitive Level: Application REF: 1398 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

18. A pregnant patient with a family history of cystic fibrosis (CF) asks for information about genetic testing. The most appropriate action by the nurse is to a. refer the patient to a qualified genetic counselor. b. ask the patient why genetic testing is important to her. c. remind the patient that genetic testing has many social implications. d. tell the patient that cystic fibrosis is an autosomal-recessive disorder.

A A genetic counselor is best qualified to address the multiple issues involved in genetic testing for a patient who is considering having children. Although genetic testing does have social implications, a pregnant patient will be better served by a genetic counselor who will have more expertise in this area. CF is an autosomal-recessive disorder, but the patient might not understand the implications of this statement. Asking why the patient feels genetic testing is important may imply to the patient that the nurse is questioning her value system regarding issues such as abortion. DIF: Cognitive Level: Application REF: 209 TOP: Nursing Process: Implementation

24. Which nursing action will be included in the plan of care for a patient admitted with multiple myeloma? a. Monitor fluid intake and output. b. Administer calcium supplements. c. Assess lymph nodes for enlargement. d. Limit weight-bearing and ambulation.

A A high fluid intake and urine output helps prevent the complications of kidney stones caused by hypercalcemia and renal failure caused by deposition of Bence-Jones protein in the renal tubules. Weight bearing and ambulation are encouraged to help bone retain calcium. Lymph nodes are not enlarged with multiple myeloma. Calcium supplements will further increase the patient's calcium level and are not used. DIF: Cognitive Level: Application REF: 704 TOP: Nursing Process: Planning

14. When a patient is scheduled for stereotactic core biopsy of the breast, which information will the nurse include in patient education? a. A local anesthetic will be given before the biopsy specimen is obtained. b. You will need to lie flat on your back and lie very still during the biopsy. c. A thin needle will be inserted into the lump and aspirated to remove tissue. d. You should not have anything to eat or drink for 6 hours before the procedure.

A A local anesthetic is given before stereotactic biopsy. NPO status is not needed because no sedative drugs are given. The patient is placed in the prone position. A biopsy gun is used to obtain the specimens. DIF: Cognitive Level: Application REF: 1308 TOP: Nursing Process: Implementation

46. A patient with a gunshot wound to the abdomen undergoes surgery, and a colostomy is formed as illustrated. Which information will be included in patient teaching? a. This type of colostomy is usually temporary. b. Soft, formed stool can be expected as drainage. c. Stool will be expelled from both ostomy stomas. d. Irrigations can regulate drainage from the stomas.

A A loop, or double-barrel stoma, is usually temporary. Stool will be expelled from the proximal stoma only. The stool from the transverse colon will be liquid and regulation through irrigations will not be possible. DIF: Cognitive Level: Application REF: 1040-1041 | 1042 | 1044-1045 TOP: Nursing Process: Implementation

16. A patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care? a. Assist with active range of motion. b. Observe for agitation and paranoia. c. Give muscle relaxants as needed to reduce spasms. d. Use simple words and phrases to explain procedures.

A ALS causes progressive muscle weakness, but assisting the patient to perform active ROM will help to maintain strength as long as possible. Psychotic symptoms such as agitation and paranoia are not associated with ALS. Cognitive function is not affected by ALS, and the patient's ability to understand procedures will not be impaired. Muscle relaxants will further increase muscle weakness and depress respirations. DIF: Cognitive Level: Application REF: 1516-1517 TOP: Nursing Process: Planning

12. A patient needing vascular access for hemodialysis asks the nurse what the differences are between an arteriovenous (AV) fistula and a graft. The nurse explains that one advantage of the fistula is that it a. is much less likely to clot. b. increases patient mobility. c. can accommodate larger needles. d. can be used sooner after surgery.

A AV fistulas are much less likely to clot than grafts, although it takes longer for them to mature to the point where they can be used for dialysis. The choice of an AV fistula or a graft does not have an impact on needle size or patient mobility. DIF: Cognitive Level: Comprehension REF: 1184-1185 TOP: Nursing Process: Implementation

30. A patient calls the clinic and tells the nurse about a new onset of severe and frequent, diarrhea. The nurse anticipates that the patient will need to a. collect a stool specimen. b. prepare for colonoscopy. c. schedule a barium enema. d. have blood cultures drawn.

A Acute diarrhea is usually caused by an infectious process and stool specimens are obtained for culture and examined for parasites or white blood cells. There is no indication that the patient needs a colonoscopy, blood cultures, or a barium enema. DIF: Cognitive Level: Application REF: 1007-1008 TOP: Nursing Process: Planning

30. A hospitalized 24-year-old patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first? a. Start the ordered PRN oxygen at 6 L/min. b. Put a moist hot pack on the patient's neck. c. Give the ordered PRN acetaminophen (Tylenol). d. Notify the patient's health care provider immediately.

A Acute treatment for cluster headache is administration of 100% oxygen at 6 to 8 L/min. If the patient obtains relief with the oxygen, there is no immediate need to notify the health care provider. Cluster headaches last only 60 to 90 minutes, so oral pain medications have minimal effect. Hot packs are helpful for tension headaches but are not as likely to reduce pain associated with a cluster headache. DIF: Cognitive Level: Application REF: 1492-1493 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

23. After providing discharge instructions to a patient following a laparoscopic cholecystectomy, the nurse recognizes that teaching has been effective when the patient states, a. "I can remove the bandages on my incisions tomorrow and take a shower." b. "I can expect some yellow-green drainage from the incision for a few days." c. "I should plan to limit my activities and not return to work for 4 to 6 weeks." d. "I will always need to maintain a low-fat diet since I no longer have a gallbladder."

A After a laparoscopic cholecystectomy, the patient will have Band-Aids in place over the incisions. Patients are discharged the same (or next) day and have few restrictions on activities of daily living. Drainage from the incisions would be abnormal, and the patient should be instructed to call the health care provider if this occurs. A low-fat diet may be recommended for a few weeks after surgery but will not be a life-long requirement. DIF: Cognitive Level: Application REF: 1100 TOP: Nursing Process: Evaluation

1. A patient who has vague symptoms of fatigue and headaches is found to have a positive enzyme immunoassay (EIA) for human immunodeficiency virus (HIV) antibodies. In discussing the test results with the patient, the nurse informs the patient that a. the EIA test will need to be repeated to verify the results. b. a viral culture will be done to determine the progress of the disease. c. it will probably be 10 or more years before the patient develops acquired immunodeficiency syndrome (AIDS). d. the Western blot test will be done to determine whether AIDS has developed.

A After an initial positive EIA test, the EIA is repeated before more specific testing such as the Western blot is done. Viral cultures are not part of HIV testing. Because the nurse does not know how recently the patient was infected, it is not appropriate to predict the time frame for AIDS development. The Western blot tests for HIV antibodies, not for AIDS. DIF: Cognitive Level: Application REF: 246 TOP: Nursing Process: Implementation

21. When obtaining a health history from a patient with acute pancreatitis, the nurse asks the patient specifically about a history of a. alcohol use. b. diabetes mellitus. c. high-protein diet. d. cigarette smoking.

A Alcohol use is one of the most common risk factors for pancreatitis in the United States. Cigarette smoking, diabetes, and high-protein diets are not risk factors. DIF: Cognitive Level: Comprehension REF: 1088-1089 TOP: Nursing Process: Assessment

29. A patient with tumor lysis syndrome (TLS) is taking allopurinol (Xyloprim). Which laboratory value should the nurse monitor to determine the effectiveness of the medication? a. Uric acid level b. Serum potassium c. Serum phosphate d. Blood urea nitrogen

A Allopurinol is used to decrease uric acid levels. BUN, potassium, and phosphate levels are also increased in TLS but are not affected by allopurinol therapy. DIF: Cognitive Level: Application REF: 295 TOP: Nursing Process: Evaluation

13. A patient undergoing external radiation has developed a dry desquamation of the skin in the treatment area. Which patient statement indicates that the nurse's teaching about management of the skin reaction has been effective? a. "I can buy some aloe vera gel to use on the area." b. "I will expose the treatment area to a sun lamp daily." c. "I can use ice packs to relieve itching in the treatment area." d. "I will scrub the area with warm water to remove the scales."

A Aloe vera gel and cream may be used on the radiated skin area. Ice and sunlamps may injure the skin. Treatment areas should be cleaned gently to avoid further injury. DIF: Cognitive Level: Application REF: 285 TOP: Nursing Process: Evaluation

9. A patient hospitalized with an acute exacerbation of ulcerative colitis is having 14 to 16 bloody stools a day and crampy abdominal pain associated with the diarrhea. The nurse will plan to a. place the patient on NPO status. b. administer IV metoclopramide (Reglan). c. teach the patient about total colectomy surgery. d. administer cobalamin (vitamin B12) injections.

A An initial therapy for an acute exacerbation of inflammatory bowel disease (IBD) is to rest the bowel by making the patient NPO. Cobalamin (vitamin B12) is absorbed in the ileum, which is not affected by ulcerative colitis. Although total colectomy is needed for some patients, there is no indication that this patient is a candidate. Metoclopramide increases peristalsis and will worsen symptoms. DIF: Cognitive Level: Application REF: 1022-1025 TOP: Nursing Process: Planning

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

A Anakinra is administered by subcutaneous injection. GI bleeding is not a side effect of this medication. Because the medication is injected, instructions to take it with 8 oz of fluid would not be appropriate. The patient is likely to be concurrently taking aspirin or NSAIDs, and these should not be discontinued. DIF: Cognitive Level: Application REF: 1647-1649 | 1655-1656 TOP: Nursing Process: Implementation

17. The nurse is caring for a patient who had kidney transplantation several years ago. Which assessment finding may indicate that the patient is experiencing adverse effects to the prescribed corticosteroid? a. Joint pain b. Tachycardia c. Postural hypotension d. Increase in creatinine level

A Aseptic necrosis of the weight-bearing joints can occur when patients take corticosteroids over a prolonged period. Increased creatinine level, orthostatic dizziness, and tachycardia are not caused by corticosteroid use. DIF: Cognitive Level: Application REF: 1193-1194 TOP: Nursing Process: Evaluation

28. After the nurse has completed teaching a patient with newly diagnosed celiac disease, which breakfast choice by the patient indicates good understanding of the information? a. Corn tortilla with eggs b. Bagel with cream cheese c. Oatmeal with non-fat milk d. Whole wheat toast with butter

A Avoidance of gluten-containing foods is the only treatment for celiac disease. Corn does not contain gluten, while oatmeal and wheat do. DIF: Cognitive Level: Application REF: 1050 | 1051-1052 TOP: Nursing Process: Evaluation

27. After teaching a patient diagnosed with progressive systemic sclerosis about health maintenance activities, the nurse determines that additional instruction is needed when the patient says, a. "I should lie down for an hour after meals." b. "Paraffin baths can be used to help my hands." c. "Lotions will help if I rub them in for a long time." d. "I should perform range-of-motion exercises daily."

A Because of the esophageal scarring, patients should sit up for 2 hours after eating. The other patient statements are correct and indicate that the teaching has been effective. DIF: Cognitive Level: Application REF: 1674 TOP: Nursing Process: Evaluation

8. Which nursing action will be included in the plan of care for a patient with bowel irregularity and a new diagnosis of irritable bowel syndrome (IBS)? a. Encourage the patient to express feelings and ask questions about IBS. b. Suggest that the patient increase the intake of milk and other dairy products. c. Educate the patient about the use of alosetron (Lotronex) to reduce symptoms. d. Teach the patient to avoid using nonsteroidal anti-inflammatory drugs (NSAIDs).

A Because psychologic and emotional factors can affect the symptoms for IBS, encouraging the patient to discuss emotions and ask questions is an important intervention. Alosetron has serious side effects and is used only for female patients who have not responded to other therapies. Although yogurt may be beneficial, milk is avoided because lactose intolerance can contribute to symptoms in some patients. NSAIDs can be used by patients with IBS. DIF: Cognitive Level: Application REF: 1017-1018 TOP: Nursing Process: Implementation

25. A 53-year-old man tells the nurse he has been having increasing problems with erectile dysfunction (ED) for several years but is now interested in using Viagra (sildenafil). Which action should the nurse take first? a. Ask the patient about any prescription drugs he is taking. b. Tell the patient that Viagra does not always work for ED. c. Discuss the common adverse effects of erectogenic drugs. d. Assure the patient that ED is commonly associated with aging.

A Because some medications can cause ED and patients using nitrates should not take Viagra, the nurse should first assess for prescription drug use. The nurse may want to teach the patient about realistic expectations and adverse effects of Viagra therapy, but this should not be the first action. Although ED does increase with aging, it may be secondary to medication use or cardiovascular disease in a 53-year-old. DIF: Cognitive Level: Application REF: 1399 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

36. The health care provider prescribes the following therapies for a patient who has been admitted with dehydration and hypotension after 3 days of nausea and vomiting. Which order will the nurse implement first? a. Infuse normal saline at 250 mL/hr. b. Administer IV ondansetron (Zofran). c. Provide oral care with moistened swabs. d. Insert a 16-gauge nasogastric (NG) tube.

A Because the patient has severe dehydration, rehydration with IV fluids is the priority. The other orders should be accomplished as quickly as possible after the IV fluids are initiated. DIF: Cognitive Level: Application REF: 964-965 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

9. A postoperative patient who has been receiving nasogastric suction for 3 days has a serum sodium level of 125 mEq/L (125 mmol/L). Which of these prescribed therapies that the patient has been receiving should the nurse question? a. Infuse 5% dextrose in water at 125 ml/hr. b. Administer IV morphine sulfate 4 mg every 2 hours PRN. c. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea. d. Administer 3% saline if serum sodium drops to less than 128 mEq/L.

A Because the patient's gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringer's solution would usually be ordered for this patient. The other orders are appropriate for a postoperative patient with gastric suction. DIF: Cognitive Level: Application REF: 311-313 | 326 TOP: Nursing Process: Planning

6. When reviewing the chart for a patient with cervical cancer, the nurse notes that the cancer is staged as Tis, N0, M0. The nurse will teach the patient that a. the cancer is localized to the cervix. b. the cancer cells are well-differentiated. c. further testing is needed to determine the spread of the cancer. d. it is difficult to determine the original site of the cervical cancer.

A Cancer in situ indicates that the cancer is localized to the cervix and is not invasive at this time. Cell differentiation is not indicated by clinical staging. Because the cancer is in situ, the origin is the cervix. Further testing is not indicated given that the cancer has not spread. DIF: Cognitive Level: Comprehension REF: 268-269 TOP: Nursing Process: Implementation

26. Which assessment information obtained by the nurse for a patient with aortic stenosis would be most important to report to the health care provider? a. The patient complains of chest pain associated with ambulation. b. A loud systolic murmur is audible along the right sternal border. c. A thrill is palpable at the 2nd intercostal space, right sternal border. d. The point of maximum impulse (PMI) is at the left midclavicular line.

A Chest pain occurring with aortic stenosis is caused by cardiac ischemia, and reporting this information would be a priority. A systolic murmur and thrill are expected in a patient with aortic stenosis. A PMI at the left midclavicular line is normal. DIF: Cognitive Level: Application REF: 853 | 855 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

12. A 24-year-old woman who uses injectable illegal drugs asks the nurse about preventing AIDS. The nurse informs the patient that the best way to reduce the risk of HIV infection from drug use is to a. participate in a needle-exchange program. b. clean drug injection equipment before use. c. ask those who share equipment to be tested for HIV. d. avoid sexual intercourse when using injectable drugs.

A Participation in needle-exchange programs has been shown to control the rate of HIV infection. Cleaning drug equipment before use also reduces risk, but it might not be consistently practiced by individuals in withdrawal. HIV antibodies do not appear for several weeks to months after exposure, so testing drug users would not be very effective in reducing risk for HIV exposure. It is difficult to make appropriate decisions about sexual activity when under the influence of drugs. DIF: Cognitive Level: Application REF: 252 TOP: Nursing Process: Implementation

31. Which newly admitted patient should the nurse assign as a roommate for a patient who has aplastic anemia? a. A patient with severe heart failure b. A patient who has viral pneumonia c. A patient who has right leg cellulitis d. A patient with multiple abdominal drains

A 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. DIF: Cognitive Level: Application REF: 670-671 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Implementation MSC:

18. A patient who has had several episodes of bloody diarrhea is admitted to the emergency department. Which action should the nurse anticipate taking? a. Obtain a stool specimen for culture. b. Administer antidiarrheal medications. c. Teach about adverse effects of nonsteroidal anti-inflammatory drugs (NSAIDs). d. Provide education about antibiotic therapy.

A Patients with bloody diarrhea should have a stool culture for E. coli O157:H7. NSAIDs may cause occult blood in the stools, but not diarrhea. Antidiarrheal medications usually are avoided for possible infectious diarrhea to avoid prolonging the infection. Antibiotic therapy in the treatment of infectious diarrhea is controversial because it may precipitate kidney complications. DIF: Cognitive Level: Application REF: 1001-1002 TOP: Nursing Process: Planning

6. To assess the patient with pericarditis for the presence of a pericardial friction rub, the nurse should a. auscultate with the stethoscope diaphragm at the lower left sternal border. b. listen for a rumbling, low-pitched, systolic sound over the left anterior chest. c. feel the precordial area with the palm of the hand to detect vibration with cardiac contraction. d. ask the patient to stop breathing during auscultation to distinguish the sound from a pleural friction rub.

A Pericardial friction rubs are heard best with the diaphragm at the lower left sternal border. Because dyspnea is one clinical manifestation of pericarditis, the nurse should time the friction rub with the pulse rather than ask the patient to stop breathing during auscultation. Friction rubs are not typically low pitched or rumbling and are not confined to systole. Rubs are not assessed by palpation. DIF: Cognitive Level: Comprehension REF: 847 TOP: Nursing Process: Assessment

5. Which action will the nurse take when evaluating a patient who is taking phenytoin (Dilantin) for adverse effects of the medication? a. Inspect the oral mucosa. b. Listen to the lung sounds. c. Auscultate the bowel tones. d. Check pupil reaction to light.

A Phenytoin can cause gingival hyperplasia, but does not affect bowel tones, lung sounds, or pupil reaction to light. DIF: Cognitive Level: Application REF: 1498 TOP: Nursing Process: Evaluation

35. The nurse observes nursing assistive personnel (NAP) doing all the following activities when caring for a patient with right lower lobe pneumonia. The nurse will need to intervene when NAP a. lower the head of the patient's bed to 10 degrees. b. splint the patient's chest during coughing. c. help the patient to ambulate to the bathroom. d. assist the patient to a bedside chair for meals.

A Positioning the patient with the head of the bed lowered will decrease ventilation. The other actions are appropriate for a patient with pneumonia. DIF: Cognitive Level: Application REF: 552-553 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation MSC:

6. When the nurse is caring for a patient whose HIV status in unknown, which of these patient exposures is most likely to require postexposure prophylaxis? a. Needle stick with a needle and syringe used to draw blood b. Splash into the eyes when emptying a bedpan containing stool c. Contamination of open skin lesions with patient vaginal secretions d. Needle stick injury with a suture needle during a surgical procedure

A Puncture wounds are the most common means for workplace transmission of blood-borne diseases, and a needle with a hollow bore that had been contaminated with the patient's blood would be a high-risk situation. The other situations described would be much less likely to result in transmission of the virus. DIF: Cognitive Level: Application REF: 242 | 252 TOP: Nursing Process: Implementation MSC:

16. Cobalamin injections have been prescribed for a patient with chronic atrophic gastritis. The nurse determines that teaching regarding the injections has been effective when the patient states, a. "The cobalamin injections will prevent me from becoming anemic." b. "These injections will increase the hydrochloric acid in my stomach." c. "These injections will decrease my risk for developing stomach cancer." d. "The cobalamin injections need to be taken until my inflamed stomach heals."

A Cobalamin supplementation prevents the development of pernicious anemia. The incidence of stomach cancer is higher in patients with chronic gastritis, but cobalamin does not reduce the risk for stomach cancer. Chronic gastritis may cause achlorhydria, but cobalamin does not correct this. The loss of intrinsic factor secretion with chronic gastritis is permanent, and the patient will need lifelong supplementation with cobalamin. DIF: Cognitive Level: Application REF: 986-987 TOP: Nursing Process: Evaluation

18. A patient with an acute attack of gout is treated with colchicine. The nurse determines that the drug is effective upon finding a. relief of joint pain. b. increased urine output. c. elevated serum uric acid. d. decreased white blood cells (WBC).

A Colchicine produces pain relief in 24 to 48 hours by decreasing inflammation. The recommended increase in fluid intake of 2 to 3 L/day would increase urine output but would not indicate the effectiveness of colchicine. Elevated uric acid levels would result in increased symptoms. The WBC count might decrease with decreased inflammation, but this would not be as useful in determining the effectiveness of colchicine as a decrease in pain. DIF: Cognitive Level: Comprehension REF: 1665 TOP: Nursing Process: Evaluation

3. A patient with bacterial pneumonia has rhonchi and thick sputum. Which action will the nurse use to promote airway clearance? a. Assist the patient to splint the chest when coughing. b. Educate the patient about the need for fluid restrictions. c. Encourage the patient to wear the nasal oxygen cannula. d. Instruct the patient on the pursed lip breathing technique.

A Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal oxygen will improve gas exchange, but will not improve airway clearance. Pursed lip breathing is used to improve gas exchange in patients with COPD, but will not improve airway clearance. DIF: Cognitive Level: Application REF: 552-553 TOP: Nursing Process: Implementation

2. Which assessment finding about a patient who has been using naproxen (Naprosyn) for 3 weeks to treat osteoarthritis is most important for the nurse to report to the health care provider? a. The patient has dark colored stools. b. The patient's pain has not improved. c. The patient is using capsaicin cream (Zostrix). d. The patient has gained 3 pounds over 3 weeks.

A Dark colored stools may indicate that the patient is experiencing gastrointestinal bleeding caused by the naproxen. The information about the patient's ongoing pain and weight gain also will be reported and may indicate a need for a different treatment and/or counseling about avoiding weight gain, but these are not as large a concern as the possibility of gastrointestinal bleeding. Use of capsaicin cream with oral medications is appropriate. DIF: Cognitive Level: Application REF: 1646 | 1650 TOP: Nursing Process: Assessment

1. The nurse obtains a health history from a patient with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse is most appropriate? a. "Have you been to the dentist lately?" b. "Do you have a history of a heart attack?" c. "Is there a family history of endocarditis?" d. "Have you had any recent immunizations?"

A Dental procedures place the patient with a prosthetic mitral valve at risk for infective endocarditis (IE). Myocardial infarction (MI), immunizations, and a family history of endocarditis are not risk factors for IE. DIF: Cognitive Level: Application REF: 844 | 845-846 TOP: Nursing Process: Assessment

25. When the nurse is caring for a patient with breast cancer who is receiving chemotherapy with doxorubicin (Adriamycin) and cyclophosphamide (Cytoxan), which assessment finding is most important to communicate to the health care provider? a. The patient's apical pulse is irregular. b. The patient has complaints of fatigue. c. The patient eats only 15% of food on meal tray. d. The patient's white blood cell (WBC) count is 5000/mm3.

A Doxorubicin can cause cardiac toxicity; the dysrhythmia should be reported because it may indicate a need for a change in therapy. Anorexia, fatigue, and a low-normal WBC count are expected effects of chemotherapy. DIF: Cognitive Level: Application REF: 1318 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

8. A 28-year-old woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. Which response by the nurse is accurate? a. "MS symptoms may be worse after the pregnancy." b. "Women with MS frequently have premature labor." c. "Symptoms of MS are likely to become worse during pregnancy." d. "MS is associated with a slightly increased risk for congenital defects."

A During the postpartum period, women with MS are at greater risk for exacerbation of symptoms. There is no increased risk for congenital defects in infants born of mothers with MS. Symptoms of MS may improve during pregnancy. Onset of labor is not affected by MS. DIF: Cognitive Level: Comprehension REF: 1503-1504 TOP: Nursing Process: Implementation

9. While obtaining an admission health history from a patient with possible rheumatic fever, which question will be most pertinent to ask? a. "Have you had a recent sore throat?" b. "Are you using any illegal IV drugs?" c. "Do you have any family history of congenital heart disease?" d. "Can you recall having any chest injuries in the last few weeks?"

A Rheumatic fever occurs as a result of an abnormal immune response to a streptococcal infection. Although illicit intravenous (IV) drug use should be discussed with the patient before discharge, it is not a risk factor for rheumatic fever and would not be as pertinent when admitting the patient. Family history is not a risk factor for rheumatic fever. Chest injury would cause musculoskeletal chest pain rather than rheumatic fever. DIF: Cognitive Level: Application REF: 850 TOP: Nursing Process: Assessment

2. While obtaining a health history from a patient with numerous petechiae on the skin, the nurse asks the patient specifically about the patient's use of a. salicylates. b. contraceptives. c. antiseizure drugs. d. antihypertensives.

A Salicylates interfere with platelet function and can lead to petechiae and ecchymoses. Antiseizure drugs may cause anemia, but not bleeding. Oral contraceptives increase clotting risk. Antihypertensives do not commonly cause problems with decreased clotting. DIF: Cognitive Level: Comprehension REF: 649 TOP: Nursing Process: Assessment

9. The nurse has instructed a patient who is receiving hemodialysis about appropriate dietary choices. Which menu choice by the patient indicates that the teaching has been successful? a. Scrambled eggs, English muffin, and apple juice b. Oatmeal with cream, half a banana, and herbal tea c. Split-pea soup, whole-wheat toast, and nonfat milk d. Cheese sandwich, tomato soup, and cranberry juice

A Scrambled eggs would provide high-quality protein, and apple juice is low in potassium. Cheese is high in salt and phosphate, and tomato soup would be high in potassium. Split-pea soup is high in potassium, and dairy products are high in phosphate. Bananas are high in potassium, and the cream would be high in phosphate. DIF: Cognitive Level: Application REF: 1177-1178 TOP: Nursing Process: Evaluation

21. Which statement by a 24-year-old woman with systemic lupus erythematosus (SLE) indicates that the patient has understood the nurse's teaching about management of the condition? a. "I will use a sunscreen whenever I am outside." b. "I will try to keep exercising even if I am tired." c. "I should take birth control pills to keep from getting pregnant." d. "I should not take aspirin or nonsteroidal anti-inflammatory drugs."

A Severe skin reactions can occur in patients with SLE who are exposed to the sum. Patients should avoid fatigue by balancing exercise with rest periods as needed. Oral contraceptives can exacerbate lupus. Aspirin and nonsteroidal anti-inflammatory drugs are used to treat the musculoskeletal manifestations of SLE. DIF: Cognitive Level: Application REF: 1666 | 1669-1672 TOP: Nursing Process: Evaluation

7. The nurse discusses the prevention and management of allergic reactions with a beekeeper who has developed a hypersensitivity to bee stings. The nurse identifies a need for additional teaching when the patient states, a. "I will plan to take oral antihistamines daily before going to work." b. "I will get a prescription for epinephrine and learn to self-inject it." c. "I should wear a Medic Alert bracelet indicating my allergy to bee stings." d. "I am going to need job retraining so that I can work in a different occupation."

A Since the patient is at risk for bee stings and the severity of allergic reactions tends to increase with added exposure to allergen, taking oral antihistamines will not adequately control the patient's hypersensitivity reaction. The other patient statements indicate a good understanding of management of the problem. DIF: Cognitive Level: Application REF: 223 TOP: Nursing Process: Evaluation

32. When counseling a patient with a family history of stomach cancer about ways to decrease risk for developing stomach cancer, the nurse will teach the patient to avoid a. smoked foods such as bacon and ham. b. foods that cause abdominal distention. c. chronic use of H2 blocking medications. d. emotionally or physically stressful situations.

A Smoked foods such as bacon, ham, and smoked sausage increase the risk for stomach cancer. Use of H2 blockers, stressful situations, and abdominal distention are not associated with an increased incidence of stomach cancer. DIF: Cognitive Level: Comprehension REF: 998-999 TOP: Nursing Process: Implementation

1. When doing discharge teaching for a patient who has had an emergency splenectomy following an automobile accident, the nurse will teach the patient about the increased risk for a. infection. b. lymphedema. c. chronic anemia. d. prolonged bleeding.

A Splenectomy increases the risk for infection, especially with gram-positive bacteria. The risks for lymphedema, bleeding, and anemia are not increased after splenectomy. DIF: Cognitive Level: Application REF: 647 TOP: Nursing Process: Implementation

11. After the nurse has finished teaching a patient with ulcerative colitis about sulfasalazine (Azulfidine), which patient statement indicates that the teaching has been effective? a. "I will need to use a sunscreen when I am outdoors." b. "I will need to avoid contact with people who are sick." c. "The medication will need to be tapered if I need surgery." d. "The medication will prevent infections that cause the diarrhea."

A Sulfasalazine may cause photosensitivity in some patients. It is not used to treat infections. Sulfasalazine does not reduce immune function. Unlike corticosteroids, tapering of sulfasalazine is not needed. DIF: Cognitive Level: Application REF: 1026-1027 TOP: Nursing Process: Evaluation

11. When helping a patient with rheumatoid arthritis (RA) plan a daily routine, the nurse informs the patient that it is most helpful to start the day with a. a warm bath followed by a short rest. b. a short routine of isometric exercises. c. active range-of-motion (ROM) exercises. d. stretching exercises to relieve joint stiffness.

A Taking a warm shower or bath is recommended to relieve joint stiffness, which is worse in the morning. Isometric exercises would place stress on joints and would not be recommended. Stretching and ROM should be done later in the day, when joint stiffness is decreased. DIF: Cognitive Level: Application REF: 1656-1657 | 1659-1660 TOP: Nursing Process: Planning

11. A patient with multiple sclerosis (MS) has urinary retention caused by a flaccid bladder. Which action will the nurse plan to take? a. Teach the patient how to use the Credé method. b. Decrease the patient's fluid intake in the evening. c. Suggest the use of incontinence briefs for nighttime use only. d. Assist the patient to the commode every 2 hours during the day.

A The Credé method can be used to improve bladder emptying. Decreasing fluid intake will not improve bladder emptying and may increase risk for urinary tract infection (UTI) and dehydration. The use of incontinence briefs and frequent toileting will not improve bladder emptying. DIF: Cognitive Level: Application REF: 1507-1508 TOP: Nursing Process: Planning

24. Which data obtained by the nurse during the assessment of a patient with cirrhosis will be of most concern? a. The patient's hands flap back and forth when the arms are extended. b. The patient has ascites and a 2-kg weight gain from the previous day. c. The patient's skin has multiple spider-shaped blood vessels on the abdomen. d. The patient complains of right upper-quadrant pain with abdominal palpation.

A The asterixis indicates that the patient has hepatic encephalopathy, and hepatic coma may occur. The spider angiomas and right upper quadrant abdominal pain are not unusual for the patient with cirrhosis and do not require a change in treatment. The ascites and weight gain do indicate the need for treatment but not as urgently as the changes in neurologic status. DIF: Cognitive Level: Application REF: 1072-1074 | 1075-1077 TOP: Nursing Process: Assessment

21. The health care provider orders intravenous (IV) ranitidine (Zantac) for a patient with gastrointestinal (GI) bleeding caused by peptic ulcer disease. When teaching the patient about the effect of the medication, which information will the nurse include? a. "Ranitidine decreases secretion of gastric acid." b. "Ranitidine neutralizes the acid in the stomach." c. "Ranitidine constricts the blood vessels in the stomach and decreases bleeding." d. "Ranitidine covers the ulcer with a protective material that promotes healing."

A Ranitidine is a histamine-2 (H2) receptor blocker, which decreases the secretion of gastric acid. The response beginning, "Ranitidine constricts the blood vessels" describes the effect of vasopressin. The response beginning "Ranitidine neutralizes the acid" describes the effect of antacids. And the response beginning "Ranitidine covers the ulcer" describes the action of sucralfate (Carafate). DIF: Cognitive Level: Comprehension REF: 965 | 983 TOP: Nursing Process: Implementation

16. While caring for a patient with aortic stenosis, the nurse establishes a nursing diagnosis of acute pain related to decreased coronary blood flow. An appropriate intervention by the nurse is to a. promote rest to decrease myocardial oxygen demand. b. educate the patient about the need for anticoagulant therapy. c. teach the patient to use sublingual nitroglycerin for chest pain. d. elevate the head of the bed 60 degrees to decrease venous return.

A Rest is recommended to balance myocardial oxygen supply and demand and to decrease chest pain. The patient with aortic stenosis requires higher preload to maintain cardiac output, so nitroglycerin and measures to decrease venous return are contraindicated. Anticoagulation is not recommended unless the patient has atrial fibrillation. DIF: Cognitive Level: Application REF: 855 TOP: Nursing Process: Implementation

23. During examination of a 67-year-old man, the nurse notes bilateral enlargement of the breasts. Which action should the nurse take first? a. Question the patient about any medications being currently used. b. Teach the patient about how to palpate the breast tissue for lumps. c. Refer the patient for mammography and biopsy of the breast tissue. d. Explain that this is a temporary condition due to hormonal changes.

A The first action should be further assessment. Since gynecomastia is a possible side effect of drug therapy, asking about the current drug regimen is appropriate. The other actions may be needed, depending on the data that are obtained with further assessment. DIF: Cognitive Level: Application REF: 1310-1311 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

13. Which nursing action will be included in the plan of care for a patient who is being treated for bleeding esophageal varices with balloon tamponade? a. Monitor the patient for shortness of breath. b. Encourage the patient to cough every 4 hours. c. Deflate the gastric balloon every 8 to 12 hours. d. Verify the position of the balloon every 6 hours.

A The most common complication of balloon tamponade is aspiration pneumonia. In addition, if the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway. Coughing increases the pressure on the varices and increases the risk for bleeding. Balloon position is verified after insertion and does not require further verification. The esophageal balloon is deflated every 8 to 12 hours to avoid necrosis, but if the gastric balloon is deflated, the esophageal balloon may occlude the airway. DIF: Cognitive Level: Application REF: 1082-1083 | 1084 TOP: Nursing Process: Implementation

14. A staff nurse has a tuberculosis (TB) skin test of 16-mm induration. A chest radiograph is negative, and the nurse has no symptoms of TB. The occupational health nurse will plan on teaching the staff nurse about the a. use and side effects of isoniazid (INH). b. standard four-drug therapy for TB. c. need for annual repeat TB skin testing. d. bacille Calmette-Guérin (BCG) vaccine.

A The nurse is considered to have a latent TB infection and should be treated with INH daily for 6 to 9 months. The four-drug therapy would be appropriate if the nurse had active TB. TB skin testing is not done for individuals who have already had a positive skin test. BCG vaccine is not used in the United States and would not be helpful for this individual, who already has a TB infection. DIF: Cognitive Level: Application REF: 556-557 TOP: Nursing Process: Planning

15. A patient has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. The nurse interprets these results as a. metabolic acidosis. b. metabolic alkalosis. c. respiratory acidosis. d. respiratory alkalosis.

A The pH and HCO3 indicate that the patient has a metabolic acidosis. The ABGs are inconsistent with the other responses. DIF: Cognitive Level: Application REF: 323-324 TOP: Nursing Process: Assessment

36. A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142, BP reading of 100/60, and respirations of 42. The nurse's first action should be to a. elevate the head of the bed to 45 to 60 degrees. b. administer the ordered pain medication. c. notify the patient's health care provider. d. offer emotional support and reassurance.

A The patient has symptoms consistent with a pulmonary embolism. Elevating the head of the bed will improve ventilation and gas exchange. The other actions can be accomplished after the head is elevated (and oxygen is started). DIF: Cognitive Level: Application REF: 580 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

27. A patient recovering from a gastrojejunostomy (Billroth II) for treatment of a duodenal ulcer develops dizziness, weakness, and palpitations about 20 minutes after eating. To avoid recurrence of these symptoms, the nurse teaches the patient to a. lie down for about 30 minutes after eating. b. choose foods that are high in carbohydrates. c. increase the amount of fluid intake with meals. d. drink sugared fluids or eat candy after each meal.

A The patient is experiencing symptoms of dumping syndrome, which may be reduced by lying down after eating. Increasing fluid intake and choosing high carbohydrate foods will increase the risk for dumping syndrome. Having a sweet drink or hard candy will correct the hypoglycemia that is associated with dumping syndrome but will not prevent dumping syndrome. DIF: Cognitive Level: Application REF: 996-998 TOP: Nursing Process: Implementation

12. Which information obtained by the nurse about a patient with colon cancer who is scheduled for external radiation therapy to the abdomen indicates a need for patient teaching? a. The patient swims a mile 5 days a week. b. The patient has a history of dental caries. c. The patient eats frequently during the day. d. The patient showers with Dove soap daily.

A The patient is instructed to avoid swimming in salt water or chlorinated pools during the treatment period. The patient does not need to change the habits of eating frequently or showering with a mild soap. A history of dental caries will not impact the patient who is scheduled for abdominal radiation. DIF: Cognitive Level: Application REF: 284-285 TOP: Nursing Process: Assessment

19. An hour after a thoracotomy, a patient complains of incisional pain at a level 7 out of 10 and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action is best for the nurse to take next? a. Administer the prescribed PRN morphine. b. Assist the patient to deep breathe and cough. c. Milk the chest tube gently to remove any clots. d. Tape the area around the insertion site of the chest tube.

A The patient is unlikely to take deep breaths or cough until the pain level is lower. A chest tube output of 100 mL is not unusual in the first hour after thoracotomy and would not require milking of the chest tube. An air leak is expected in the initial postoperative period after thoracotomy. DIF: Cognitive Level: Application REF: 573-574 TOP: Nursing Process: Implementation

30. Which information will be best for the nurse to include when teaching a patient with peptic ulcer disease (PUD) about dietary management of the disease? a. "Avoid foods that cause pain after you eat them." b. "High-protein foods are least likely to cause pain." c. "You will need to remain on a bland diet indefinitely." d. "You should avoid eating many raw fruits and vegetables."

A The best information is that each individual should choose foods that are not associated with postprandial discomfort. Raw fruits and vegetables may irritate the gastric mucosa, but chewing well seems to decrease this and some patients may tolerate these well. High-protein foods help to neutralize acid, but they also stimulate hydrochloric (HCl) acid secretion and may increase discomfort for some patients. Bland diets may be recommended during an acute exacerbation of PUD, but there is little scientific evidence to support their use. DIF: Cognitive Level: Application REF: 992 TOP: Nursing Process: Implementation

1. The nurse obtains all of the following assessment data about a patient with deficient fluid volume caused by a massive burn injury. Which of the following assessment data will be of greatest concern? a. The blood pressure is 90/40 mm Hg. b. Urine output is 30 ml over the last hour. c. Oral fluid intake is 100 ml for the last 8 hours. d. There is prolonged skin tenting over the sternum.

A The blood pressure indicates that the patient may be developing hypovolemic shock as a result of fluid loss. This will require immediate intervention to prevent the complications associated with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all indicate the need for increasing the patient's fluid intake but not as urgently as the hypotension. DIF: Cognitive Level: Application REF: 310 TOP: Nursing Process: Assessment

11. The nurse is reviewing the chart for a patient who is scheduled for an annual physical exam. Which information will be most important in determining whether the patient needs HIV testing? a. Patient age b. Patient lifestyle c. Patient symptoms d. Patient sexual orientation

A The current CDC policy is to offer routine testing for HIV to all individuals age 13 to 64. Although lifestyle, symptoms, and sexual orientation may suggest increased risk for HIV infection, the goal is to test all individuals in this age range. DIF: Cognitive Level: Application REF: 252 TOP: Nursing Process: Planning

17. To evaluate the effectiveness of ART, the nurse will schedule the patient for a. viral load testing. b. enzyme immunoassay. c. rapid HIV antibody testing. d. immunofluorescence assay.

A The effectiveness of ART is measured by the decrease in the amount of virus detectable in the blood. The other tests are used to detect HIV antibodies, which remain positive even with effective ART. DIF: Cognitive Level: Application REF: 246-247 TOP: Nursing Process: Planning

23. The nurse witnesses a patient with a seizure disorder as the patient suddenly jerks the arms and legs, falls to the floor, and regains consciousness immediately. It will be most important for the nurse to a. assess the patient for a possible head injury. b. give the scheduled dose of divalproex (Depakote). c. document the timing and description of the seizure. d. notify the patient's health care provider about the seizure.

A The patient who has had a myoclonic seizure and fall is at risk for head injury and should be evaluated and treated for this possible complication first. Documentation of the seizure, notification of the seizure, and administration of antiseizure medications also are appropriate actions, but the initial action should be assessment for injury. DIF: Cognitive Level: Application REF: 1494-1495 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

6. A patient with symptomatic benign prostatic hyperplasia (BPH) is scheduled for photovaporization of the prostate (PVP) at an outpatient surgical center. The nurse will plan to teach the patient a. how to care for an indwelling urinary catheter. b. that the urine will appear bloody for several days. c. about complications associated with urethral stenting. d. that symptom improvement will occur in 2 to 3 weeks.

A The patient will have an indwelling catheter for 24 to 48 hours and will need teaching about catheter care. There is minimal bleeding with this procedure. Symptom improvement is almost immediate after PVP. Stent placement is not included in the procedure. DIF: Cognitive Level: Application REF: 1381-1382 TOP: Nursing Process: Planning

23. In a patient with acute kidney injury (AKI) who requires hemodialysis, a temporary vascular access is obtained by placing a catheter in the left femoral vein. Which intervention will be included in the plan of care? a. Place the patient on bed rest. b. Start continuous pulse oximetry. c. Discontinue the retention catheter. d. Restrict the patient's oral protein intake.

A The patient with a femoral vein catheter must be on bed rest to prevent trauma to the vein. Protein intake is likely to be increased when the patient is receiving dialysis. The retention catheter is likely to remain in place because accurate measurement of output will be needed. There is no indication that the patient needs continuous pulse oximetry. DIF: Cognitive Level: Application REF: 1185-1186 TOP: Nursing Process: Planning

38. All of these patients call the outpatient clinic and ask to make an appointment as soon as possible. Which patient should the nurse schedule to be seen first? a. 19-year-old with no previous health problems who has a nontender lump in the axilla b. 46-year-old with sickle cell anemia who says "that my eyes always look sort of yellow" c. 21-year-old with hemophilia who wants to learn how to self-administer factor VII replacement d. 50-year-old with early-stage chronic lymphocytic leukemia who has complaints of chronic fatigue

A The patient's age and presence of a nontender axillary lump suggest possible lymphoma, which needs rapid diagnosis and treatment. The other patients have questions about treatment or symptoms that are consistent with their diagnosis but do not need to be seen urgently. DIF: Cognitive Level: Analysis REF: 698-699 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Implementation MSC:

17. Which of these patients in the respiratory disease clinic should the nurse assess first? a. A 23-year-old, complaining of a sore throat, who has a "hot potato" voice b. A 34-year-old who has a "scratchy throat" and a positive rapid strep antigen test c. A 55-year-old who is receiving radiation for throat cancer and has severe fatigue d. A 72-year-old with a history of a total laryngectomy whose stoma is red and inflamed

A The patient's clinical manifestation of a "hot potato" voice suggests a possible peritonsillar abscess that could lead to an airway obstruction requiring rapid assessment and potential treatment. The other patients do not have diagnoses or symptoms that indicate any life-threatening problems. DIF: Cognitive Level: Analysis REF: 528 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

27. A few days after an acute myocardial infarction (MI), a patient complains of stabbing chest pain that increases with deep breathing. Which action will the nurse take first? a. Auscultate the heart sounds. b. Check the patient's oral temperature. c. Notify the patient's health care provider. d. Give the ordered acetaminophen (Tylenol).

A The patient's clinical manifestations and history are consistent with pericarditis, and the first action by the nurse should be to listen for a pericardial friction rub. Checking the temperature, giving acetaminophen (Tylenol), and notifying the health care provider also are appropriate actions but would not be done before listening for a rub. DIF: Cognitive Level: Application REF: 846-847 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

14. A patient who received a bone marrow transplant for treatment of leukemia develops a skin rash 10 days after the transplant. The nurse recognizes this reaction as an indication that the a. donor T cells are attacking the patient's skin cells. b. patient's antibodies are rejecting the donor bone marrow. c. patient is experiencing a delayed hypersensitivity reaction. d. patient will need treatment to prevent hyperacute rejection.

A The patient's history and symptoms indicate that the patient is experiencing graft-versus-host disease, in which the donated T cells attack the patient's tissues. The history and symptoms are not consistent with rejection or delayed hypersensitivity. DIF: Cognitive Level: Comprehension REF: 232 TOP: Nursing Process: Evaluation

10. A patient with rheumatic fever has subcutaneous nodules, erythema marginatum, and polyarthritis. An appropriate nursing diagnosis based on these findings is a. activity intolerance related to arthralgia. b. risk for infection related to open skin lesions. c. chronic pain related to permanent joint fixation. d. risk for impaired skin integrity related to pruritus.

A The patient's joint pain will lead to difficulty with activity. The skin lesions seen in rheumatic fever are not open or pruritic. Although acute joint pain will be a problem for this patient, joint inflammation is a temporary clinical manifestation of rheumatic fever and is not associated with permanent joint changes. DIF: Cognitive Level: Application REF: 850-853 TOP: Nursing Process: Diagnosis

35. A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which action is most important for the nurse to take? a. Notify the patient's physician. b. Avoid unnecessary venipunctures. c. Apply sterile dressings to the sites. d. Give prescribed proton-pump inhibitors.

A The patient's new onset of bleeding and diagnosis of sepsis suggest that disseminated intravascular coagulation (DIC) may have developed, which will require collaborative actions such as diagnostic testing, blood product administration, and heparin administration. The other actions also are appropriate, but the most important action should be to notify the physician so that DIC treatment can be initiated rapidly. DIF: Cognitive Level: Application REF: 687-689 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

42. A patient who was admitted the previous day with pneumonia complains of a sharp pain "whenever I take a deep breath." Which action will the nurse take next? a. Listen to the patient's lungs. b. Administer the PRN morphine. c. Have the patient cough forcefully. d. Notify the patient's health care provider.

A The patient's statement indicates that pleurisy or a pleural effusion may have developed and the nurse will need to listen for a pleural friction rub and/or decreased breath sounds. Assessment should occur before administration of pain medications. The patient is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provider. DIF: Cognitive Level: Application REF: 576 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

17. A 46-year-old man who has erectile dysfunction (ED) tells the nurse that he decided to seek treatment because his wife "is losing patience with the situation." The most appropriate nursing diagnosis for the patient is a. ineffective role performance related to effects of ED. b. anxiety related to inability to have sexual intercourse. c. situational low self-esteem related to decrease in sexual activity. d. ineffective sexuality patterns related to frequency of intercourse.

A The patient's statement indicates that the relationship with his wife is his primary concern. Although anxiety, low self-esteem, and ineffective sexuality patterns also may be concerns, the patient information suggests that addressing the role performance problem will lead to the best outcome for this patient. DIF: Cognitive Level: Application REF: 1399-1400 TOP: Nursing Process: Diagnosis

13. When caring for a patient with a left arm arteriovenous fistula, which action will the nurse include in the plan of care to maintain the patency of the fistula? a. Check the fistula site for a bruit and thrill. b. Assess the rate and quality of the left radial pulse. c. Compare blood pressures in the left and right arms. d. Irrigate the fistula site with saline every 8 to 12 hours.

A The presence of a thrill and bruit indicates adequate blood flow through the fistula. Pulse rate and quality are not good indicators of fistula patency. Blood pressures should never be obtained on the arm with a fistula. Irrigation of the fistula might damage the fistula, and typically only dialysis staff would access the fistula. DIF: Cognitive Level: Comprehension REF: 1184-1185 TOP: Nursing Process: Planning

6. A 62-year-old patient who is having an annual check-up tells the nurse, "I don't understand why I need to have so many cancer screening tests now. I feel just fine!" The nurse will plan to teach the patient about the a. consequences of aging on cell-mediated immunity. b. decrease in antibody production associated with aging. c. impact of poor nutrition on immune function in older people. d. incidence of cancer-stimulating infections in older individuals.

A The primary impact of aging on immune function is on the activity of T cells, which are responsible for tumor immunity. Antibody function is not impacted as much by aging and does not protect against malignancy. Poor nutrition does contribute to decreased immunity, but there is no evidence that it is a contributing factor for this patient. Although some types of cancer are associated with specific infections, this patient does not have an active infection. DIF: Cognitive Level: Application REF: 217 TOP: Nursing Process: Planning

1. When caring for a patient who has just been diagnosed with early chronic HIV infection, which prophylactic measures will the nurse anticipate being included in the plan of care (select all that apply)? a. Hepatitis B vaccine b. Pneumococcal vaccine c. Influenza virus vaccine d. Trimethoprim-sulfamethoxazole e. Varicella zoster immune globulin

A, B, C Prevention of other infections is an important intervention in patients who are HIV positive, and these vaccines are recommended as soon as the HIV infection is diagnosed. Antibiotics and immune globulin are used to prevent and treat infections that occur later in the course of the disease, when the CD4 count has dropped or when infection has occurred. DIF: Cognitive Level: Application REF: 247-248 OBJ: Special Questions: Alternate Item Format TOP: Nursing Process: Implementation

8. Which of the following findings indicate probable addisonian crisis? (Select all that apply) Back pain Abdominal pain Sudden weakness Temperature of 101º F Increased blood pressure

A, B, C, D

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

A, B, C, E

1. During assessment of the patient with fibromyalgia syndrome (FMS), the nurse would expect the patient to report (select all that apply)? a. sleep disturbances. b. multiple tender points. c. cardiac palpitations and dizziness. d. multijoint pain with inflammation and swelling. e. widespread bilateral, burning musculoskeletal pain.

A, B, C, E These symptoms are commonly described by patients with FMS. Cardiac involvement and joint inflammation are not typical of FMS. DIF: Cognitive Level: Comprehension REF: 1676-1678 OBJ: Special Questions: Alternate Item Format TOP: Nursing Process: Assessment

4. Which clients are at risk for acute kidney injury (AKI)? (Select all that apply.) A. Football player in preseason practice B. Client who underwent contrast dye radiology C. Accident victim recovering from severe hemorrhage D. Accountant with diabetes E. Client in the ICU on a high dose of antibiotics F. Client recovering from gastrointestinal influenza

A, B, C, E, F

1. The nurse is observing a co-worker who is caring for a client with a nasogastric tube following esophageal surgery. Which actions by the co-worker require the nurse to intervene? (Select all that apply Checking tube placement every 12 hours Keeping the bed flat Placing the client upright when taking sips of water Providing mouth care every 8 hours Securing the tube

A, B, D

13. A patient with Parkinson's disease is admitted to the hospital for treatment of pneumonia. Which nursing interventions will be included in the plan of care (select all that apply)? Used an elevated toilet seat Cut patient's food into small pieces Provide high-protein foods at each meal Place an armchair at the patient's table Observe for sudden exacerbation of symptoms

A, B, D

2. A patient with Parkinson's disease is admitted to the hospital for treatment of an acute infection. Which nursing interventions will be included in the plan of care (select all that apply)? a. Use an elevated toilet seat. b. Cut patient's food into small pieces. c. Provide high protein foods at each meal. d. Place an arm chair at the patient's bedside. e. Observe for sudden exacerbation of symptoms.

A, B, D Since the patient with Parkinson's has difficulty chewing, food should be cut into small pieces. An armchair should be used when the patient is seated so that the patient can use the arms to assist with getting up from the chair. An elevated toilet seat will facilitate getting on and off the toilet. High protein foods will decrease the effectiveness of L-dopa. Parkinson's is a steadily progressive disease without acute exacerbations. DIF: Cognitive Level: Application REF: 1511-1512 | 1513-1514 OBJ: Special Questions: Alternate Item Format TOP: Nursing Process: Planning

1. After an unimmunized individual is exposed to hepatitis B through a needle-stick injury, which actions will the nurse plan to take (select all that apply)? a. Administer hepatitis B vaccine. b. Test for antibodies to hepatitis B. c. Teach about α-interferon therapy. d. Give hepatitis B immune globulin. e. Educate about oral antiviral therapy.

A, B, D The recommendations for hepatitis B exposure include both vaccination and immune globulin administration. In addition, baseline testing for hepatitis B antibodies will be needed. Interferon and oral antivirals are not used for hepatitis B prophylaxis. DIF: Cognitive Level: Application REF: 1069 OBJ: Special Questions: Alternate Item Format TOP: Nursing Process: Planning MSC:

1. The nurse notes new onset confusion in an 89-year-old patient in a long-term care facility. The patient is normally alert and oriented. In which order should the nurse take the following actions? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. Obtain the oxygen saturation. b. Check the patient's pulse rate. c. Document the change in status. d. Notify the health care provider.

A, B, D, C Assessment for physiologic causes of new onset confusion such as pneumonia, infection, or perfusion problems should be the first action by the nurse. Airway and oxygenation should be assessd first. 1. While being prepared for a biopsy of a lump in the right breast, the patient asks the nurse about the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct? a. "Benign tumors do not cause damage to other tissues." b. "Benign tumors are likely to recur in the same location." c. "Malignant tumors may spread to other tissues or organs." d. "Malignant cells reproduce more rapidly than normal cells." ANS: C The major difference between benign and malignant tumors is that malignant tumors invade adjacent tissues and spread to distant tissues and benign tumors never metastasize. The other statements are inaccurate. Both types of tumors may cause damage to adjacent tissues. Malignant cells do not reproduce more rapidly than normal cells. Benign tumors do not usually recur. DIF: Cognitive Level: Comprehension REF: 263 TOP: Nursing Process: Implementation

9. The nurse is teaching a patient with newly diagnosed anemia about conserving energy. What does the nurse tell the patient? Select all that apply A. "Allow others to perform your care during periods of extreme fatigue." B. "Drink small quantities of protein shakes and nutritional supplements daily." C. "Perform a complete bath daily to reduce your chance of getting an infection." D. "Provide yourself with four to six small, easy-to-eat meals daily." E. "Perform your care activities in groups to conserve your energy." F. "Stop activity when shortness of breath or palpitations are present."

A, B, D, F

12. When caring for a patient with iron deficiency anemia, the nurse would include which of the following as part of the education? A. "Eating lean red meats can help increase your iron." B. "You may experience dark stools with iron supplements." C. "The best thing to do is to take the iron supplements with milk." D. "You should take your iron with meals for the best absorption." E. "Taking your iron with Vitamin C can help increase the amount your body takes in."

A, B, E

7. While managing care for a client with chronic kidney disease, which actions does the registered nurse (RN) plan to delegate to unlicensed assistive personnel (UAP)? (Select all that apply.) A. Obtain the client's pre-hemodialysis weight. B. Check the arteriovenous (AV) fistula for a thrill and bruit. C. Document the amount the client drinks throughout the shift. D. Auscultate the client's lung sounds every 4 hours. E. Explain the components of a low-sodium diet.

A, C

12. A 27-year-old patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient's assigned room (select all that apply)? Side-rail pads Tongue blade Oxygen mask Suction tubing Urinary catheter Nasogastric tube

A, C, D

5. A patient is diagnosed with mitral stenosis and new-onset atrial fibrillation. Which interventions could the nurse delegate to nursing assistive personnel (NAP) (select all that apply)? A. Obtain and record daily weight B. Determine apical-radial pulse rate C. Observe for overt signs of bleeding D. Obtain and record vital signs, including pulse oximetry E. Teach the patient how to purchase a Medic Alert bracelet

A, C, D

5. The nurse assists a client with acute kidney injury (AKI) to modify the diet in which ways? (Select all that apply.) A. Restricted protein B. Liberal sodium C. Restricted fluids D. Low potassium E. Low fat

A, C, D

1. When preparing to admit a patient who has been treated for status epilepticus in the emergency department, which equipment should the nurse have available in the room (select all that apply)? a. Siderail pads b. Tongue blade c. Oxygen mask d. Suction tubing e. Nasogastric tube

A, C, D The patient is at risk for further seizures, and oxygen and suctioning may be needed after any seizures to clear the airway and maximize oxygenation. The bed's side rails should be padded to minimize the risk for patient injury during a seizure. Insertion of a nasogastric (NG) tube is not indicated because the airway problem is not caused by vomiting or abdominal distention. Use of tongue blades during a seizure is contraindicated. DIF: Cognitive Level: Application REF: 1500-1501 OBJ: Special Questions: Alternate Item Format TOP: Nursing Process: Planning

16. Which potential side effects should be included in the teaching plan for a patient undergoing radiation therapy for neck cancer? Select all that apply. A. Fatigue B. Changes in color of hair C. Change in taste D. Changes in skin of the neck E. Difficulty swallowing

A, C, D, E

17. Which signs or symptoms should the nurse report immediately because they indicate thrombocytopenia secondary to cancer chemotherapy? Select all that apply A. Bruises B. Fever C. Petechiae D. Epistaxis E. Pallor

A, C, D, E

9. Which of the following should a patient with Addison's disease carry at all times? (Select all that apply) Dexamethasone An injectable diuretic agent The physician's phone number The patient's medication schedule Documentation of the patient's diagnosis

A, C, D, E

6. The nurse has received in report that the patient receiving chemotherapy has severe neutropenia. Which of the following does the nurse plan to implement? Select all that apply A. Assess for fever B. Observe for bleeding C. Administer pegfilgrastim (Neulasta) D. Do not permit fresh flowers or plants in the room E. Do not allow 16 year old son to visit F. Teach the patient to omit raw fruits and vegetables from his diet

A, C, D, F

7. When caring for a client with portal hypertension, the nurse assesses for which potential complications? Select all that apply A. Esophageal varices B. Hematuria C. Fever D. Ascites E. Hemorrhoids

A, D, E

1. A patient who is receiving an IV antibiotic develops wheezes and dyspnea. In which order should the nurse implement these prescribed actions? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. Discontinue the antibiotic infusion. b. Give diphenhydramine (Benadryl) IV. c. Inject epinephrine (Adrenalin) IM or IV. d. Prepare an infusion of dopamine (Intropin). e. Start 100 % oxygen using a nonrebreather mask.

A, E, C, B, D The nurse should initially discontinue the antibiotic, since it is the likely cause of the allergic reaction. Next, oxygen delivery should be maximized, followed by treatment of bronchoconstriction with epinephrine administered IM or IV. Diphenhydramine will work more slowly than epinephrine, but will help prevent progression of the reaction. Since the patient currently does not have evidence of hypotension, the dopamine infusion can be prepared last. DIF: Cognitive Level: Application REF: 223 OBJ: Special Questions: Alternate Item Format, Prioritization TOP: Nursing Process: Implementation

1. The nurse is caring for a patient taking levothyroxine (Synthroid). What is most important for the nurse to assess? A. Decreased appetite and constipation B. Chest pain and heart palpitations C. Weight gains or weight loss D. Muscle weakness and fatigue

1. The nurse teaches a 43-year-old patient about screening for early detection of breast cancer. Which statement by the patient requires an intervention by the nurse? "A breast examination should be done right after my menstrual period." "Self-breast examination is a reliable way to detect breast cancer early." "I should plan to have a mammogram every year." "I will see my doctor every year for a breast examination."

1. What should the nurse include in health teaching to prevent rheumatic fever? A. Antibiotic therapy before dental surgery for individuals with rheumatoid arthritis B. Prompt recognition and treatment of streptococcal pharyngitis C. Completion of 4 to 6 weeks of antibiotic therapy for infective endocarditis D. Avoidance of respiratory infections in children born with heart defects

10. A 78-year old patient presents with complaints of depression and confusion. Which of the following endocrine disturbances does the nurse expect the patient to be screened for? A. Hyperthyroidism B. Hypothyroidism C. Hyperparathyroidism D. Hypoparathyroidism

12. A patient hospitalized with polymyositis has joint pain; erythematous facial rash; eyelid edema; and a weak, hoarse voice. The safety priority for the patient is addressing the A. Acute pain B. Risk for aspiration C. Disturbed visual perception D. Risk for impaired skin integrity

12. After receiving report on the following patients, which patient should the nurse assess first? A. Patient with rheumatic fever who has a sharp chest pain with a deep breath B. Patient with acute aortic regurgitation whose blood pressure is 86/54 mm Hg C. Patient with infective endocarditis who has a murmur and splinter hemorrhages D. Patient with dilated cardiomyopathy who has bilateral crackles at the lung bases

13. A patient diagnosed with human immune deficiency virus is prescribed zidovudine (Retrovir), efavirenz (Sustiva), lamivudine (Epivir), and enfuvirtide (Fuzeon). The patient asks the nurse what will happen if the prescriptions are not refilled on time, or if a few doses of one of the medications are missed. What is the nurse's best response? A. "This will not make any difference in the viral load." B. "Blood concentrations will be decreased, which will lead to increased viral replication." C. "If only one dose of medication is missed, this will not make a difference." D. " This will cause an increase in opportunistic infections."

13. During the assessment of a 45-year-old man with Cushing's syndrome, a nurse should note the most consistent assessment finding of jaundice. hypertension. memory recall without deficit. appropriate height and weight.

15. Which patient problem does the nurse set as the priority for the patient experiencing chemotherapy-induced peripheral neuropathy? A. Potential for lack of understanding related to side effects of chemotherapy B. Risk for Injury related to sensory and motor deficits C. Potential for ineffective coping strategies related to loss of motor control D. Altered sexual function related to erectile dysfunction

17. A patient who is human immune deficiency virus positive is experiencing anorexia and diarrhea. Which nursing actions does the nurse delegate to a nursing assistant? A. Collaborate with the patient to select foods that are higher in calories B. Provide oral care to the patient before meals to enhance appetite C. Assess the perianal area every 8 hours to assess for signs of skin breakdown D. Discuss the need to avoid foods that are spicy or irritating

7. The nurse provides information to the caregiver of a patient with epilepsy who has tonic-clonic seizures. Which statement, if made by the caregiver, requires further teaching? Objects should not be placed in the mouth during a seizure I should call 911 if breathing stops during the seizure It is normal for a person to be sleepy after a seizure The jerking movements may last for 30-40 seconds

8. When providing dietary teaching to a client with hepatitis, what practice does the nurse recommend? A. Having a large meal earlier in the morning B. Consuming increased carbohydrates and moderate protein C. Restricting fluids to 1500 mL/day D. Limiting alcoholic beverages to once weekly

9. What is the significance of deep, rapid breathing (Kussmaul respirations) in metabolic acidosis? A. It indicates that anxiety, with rapid breathing, is a cause of respiratory acidosis. B. It indicates the excessive carbon dioxide is exhaled to compensate for metabolic acidosis. C. It indicates that diabetic ketoacidosis is the cause of the metabolic acidosis. D. It indicates that more oxygen is necessary to compensate for respiratory acidosis.

9. When caring for a woman receiving radioactive iodine therapy for Graves' disease, the nurse knows that additional education is needed when the patient states: A. I need to avoid pregnancy while I'm receiving this treatment. B. I should notice that my symptoms are gone within a week. C. I will be sure to wash my bed linens separately from the rest of the family. D. I may experience dry mouth or irritation in my mouth as a side effect.

4. Which clinical finding would most likely indicate decreased cardiac output in a patient with aortic valve regurgitation? A. Reduction in peripheral edema and weight B. Carotid venous distention and new-onset atrial fibrillation C. Significant pulsus paradoxus and diminished peripheral pulses D. Shortness of breath on minimal exertion and a diastolic murmur

1. Vasopressin (Pitressin) 0.2 units/min infusion is prescribed for a patient with acute arterial gastrointestinal (GI) bleeding. The vasopressin label states vasopressin 20 units/50 mL normal saline. How many mL/min will the nurse infuse? ____________________

0.5 There are 0.4 units/1 mL. An infusion of 0.5 mL/min will result in the patient receiving 0.2 mL/min as prescribed. DIF: Cognitive Level: Application REF: 982-983 OBJ: Special Questions: Alternate Item Format TOP: Nursing Process: Implementation

5. A patient is undergoing diagnostic testing for symptoms of polyarthralgia, fatigue, and hair loss. Laboratory results include the presence of anti-DNA, antinuclear antibodies, and anti-Smith in the blood. The nurse recognizes that these findings are most likely to be related to A. Systemic sclerosis B. Rheumatoid arthritis C. Chronic fatigue syndrome D. Systemic lupus erythematosus

6. A client is being discharged after a minimally invasive esophagectomy. Which teaching point does the nurse consider to be of the highest priority during the predischarge teaching session? Instruct the client to eat three meals daily. Emphasize the importance of lying down after meals. Encourage the client to ask his or her health care provider for antidepressant medication. Report the presence of fever and a swollen, painful neck incision.

15. When caring for a patient who has a new diagnosis of Crohn's disease after having frequent diarrhea and a weight loss of 10 pounds (4.5 kg) over 2 months, the nurse will plan to teach the patient about a. medication use. b. fluid restriction. c. enteral nutrition. d. activity restrictions.

A Medications are used to induce and maintain remission in patients with inflammatory bowel disease (IBD). Decreased activity level is indicated only if the patient has severe fatigue and weakness. Fluids are needed to prevent dehydration. There is no advantage to enteral feedings. DIF: Cognitive Level: Application REF: 1025-1027 TOP: Nursing Process: Planning

14. When teaching a patient with myasthenia gravis (MG) about management of the disease, the nurse advises the patient to a. perform physically demanding activities in the morning. b. anticipate the need for weekly plasmapheresis treatments. c. do frequent weight-bearing exercise to prevent muscle atrophy. d. protect the extremities from injury due to poor sensory perception.

A Muscles are generally strongest in the morning, and activities involving muscle activity should be scheduled then. Plasmapheresis is not routinely scheduled but is used for myasthenia crisis or for situations in which corticosteroid therapy should be discontinued. There is no decrease in sensation with MG, and muscle atrophy does not occur because muscles are used during part of the day. DIF: Cognitive Level: Application REF: 1512-1514 TOP: Nursing Process: Implementation

2. During the assessment of a patient with infective endocarditis (IE), the nurse would expect to find a. a new regurgitant murmur. b. a pruritic rash on the trunk. c. involuntary muscle movement. d. substernal chest pain and pressure.

A New regurgitant murmurs occur in IE because vegetation on the valves prevents valve closure. Substernal chest discomfort, rashes, and involuntary muscle movement are clinical manifestations of other cardiac disorders such as angina and rheumatic fever. DIF: Cognitive Level: Comprehension REF: 842-843 TOP: Nursing Process: Assessment

11. When teaching the patient who is receiving standard multidrug therapy for tuberculosis (TB) about possible toxic effects of the antitubercular medications, the nurse will give instructions to notify the health care provider if the patient develops a. yellow-tinged skin. b. changes in hearing. c. orange-colored sputum. d. thickening of the fingernails.

A Noninfectious hepatitis is a toxic effect of isoniazid (INH), rifampin, and pyrazinamide, and patients who develop hepatotoxicity will need to use other medications. Changes in hearing and nail thickening are not expected with the four medications used for initial TB drug therapy. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider. DIF: Cognitive Level: Application REF: 555 | 556 TOP: Nursing Process: Implementation

20. The nurse is caring for a hospitalized 82-year-old patient who has nasal packing in place to treat a nosebleed. Which of the following assessment findings will require the most immediate action by the nurse? a. The oxygen saturation is 89%. b. The nose appears red and swollen. c. The patient's temperature is 100.1° F (37.8° C). d. The patient complains of level 7 (0 to 10 scale) pain.

A Older patients with nasal packing are at risk of aspiration or airway obstruction. An O2 saturation of 89% should alert the nurse to assess further for these complications. The other assessment data also indicate a need for nursing action but not as immediately as the fall in O2 saturation. DIF: Cognitive Level: Application REF: 520 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

10. Which information will the nurse include in the patient teaching plan for a patient who is receiving rifampin (Rifadin) for treatment of tuberculosis? a. "Your urine, sweat, and tears will be orange colored." b. "Read a newspaper daily to check for changes in vision." c. "Take vitamin B6 daily to prevent peripheral nerve damage." d. "Call the health care provider if you notice any hearing loss."

A Orange-colored body secretions are a side effect of rifampin. The other adverse effects are associated with other antituberculosis medications. DIF: Cognitive Level: Application REF: 555 TOP: Nursing Process: Planning

20. When caring for a patient who has been diagnosed with orchitis, the nurse will plan to provide teaching about a. pain management. b. emergency surgical repair. c. aspiration of fluid from the scrotal sac. d. application of warm packs to the scrotum.

A Orchitis is very painful and effective pain management will be needed. The other therapies will not be used to treat orchitis. DIF: Cognitive Level: Application REF: 1395 TOP: Nursing Process: Planning

16. A patient with an uncuffed tracheostomy tube coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first? a. Insert the obturator and attempt to reinsert the tracheostomy tube. b. Position the patient in an upright position with the neck extended. c. Assess the patient's oxygen saturation and notify the health care provider. d. Ventilate the patient with a manual bag until the health care provider arrives.

A The first action should be to attempt to reinsert the tracheostomy tube to maintain the patient's airway. Assessing the patient's oxygenation is an important action, but it is not the most appropriate first action in this situation. Covering the stoma with a dressing and manually ventilating the patient may be an appropriate action if the nurse is unable to reinsert the tracheostomy tube. The patient should be placed in a semi-Fowler's position if reinsertion of the tracheostomy tube is not successful. DIF: Cognitive Level: Application REF: 531 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

13. After 2 months of tuberculosis (TB) treatment with a standard four-drug regimen, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next? a. Ask the patient whether medications have been taken as directed. b. Discuss the need to use some different medications to treat the TB. c. Schedule the patient for directly observed therapy three times weekly. d. Educate about using a 2-drug regimen for the last 4 months of treatment.

A The first action should be to determine whether the patient has been compliant with drug therapy because negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. Depending on whether the patient has been compliant or not, different medications or directly observed therapy may be indicated. A two-drug regimen will be used only if the sputum smears are negative for AFB. DIF: Cognitive Level: Application REF: 556-557 TOP: Nursing Process: Implementation

21. A patient tells the nurse about using acetaminophen (Tylenol) several times every day for recurrent bilateral headaches. Which action will the nurse plan to take first? a. Discuss the need to stop taking the acetaminophen. b. Suggest the use of biofeedback for headache control. c. Teach the patient about magnetic resonance imaging (MRI). d. Describe the use of botulism toxin (BOTOX) for headaches.

A The headache description suggests that the patient is experiencing medication overuse headache. The initial action will be withdrawal of the medication. The other actions may be needed if headaches persist. DIF: Cognitive Level: Application REF: 1492-1493 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning

15. A 32-year-old man who is being admitted for a unilateral orchiectomy for testicular cancer does not talk to his wife and speaks to the nurse only to answer the admission questions. Which action is best for the nurse to take? a. Ask the patient if he has any questions or concerns about the diagnosis and treatment. b. Document the patient's lack of communication on the chart and continue preoperative care. c. Assure the patient's wife that concerns about sexual function are common with this diagnosis. d. Teach the patient and the wife that impotence is rarely a problem after unilateral orchiectomy.

A The initial action by the nurse should be assessment for any anxiety or questions about the surgery or postoperative care. The nurse should address the patient, not the spouse, when discussing the diagnosis and any possible concerns. Without further assessment of patient concerns, the nurse should not offer education about complications after orchiectomy. Documentation of the patient's lack of interaction is not an adequate nursing action in this situation. DIF: Cognitive Level: Application REF: 1397 TOP: Nursing Process: Implementation

16. A patient with type A hemophilia has been admitted to the hospital with severe pain and swelling in the right knee. During the initial care of the patient, the nurse should a. immobilize the knee. b. apply heat to the joint. c. assist the patient with light weight bearing. d. perform passive range of motion to the knee.

A The initial action should be total rest of the knee to minimize bleeding. Ice packs are used to decrease bleeding. Range of motion (ROM) and weight-bearing exercise are contraindicated initially, but after the bleeding stops, ROM and physical therapy are started. DIF: Cognitive Level: Application REF: 686 TOP: Nursing Process: Implementation

39. A patient is brought to the emergency department with a knife impaled in the abdomen following a domestic fight. During the initial assessment of the patient, the nurse should a. assess the BP and pulse. b. remove the knife to assess the wound. c. determine the presence of Rovsing sign. d. insert a urinary catheter and assess for hematuria.

A The initial assessment is focused on determining whether the patient has hypovolemic shock. The knife should not be removed until the patient is in surgery, where bleeding can be controlled. Rovsing sign is assessed in the patient with suspected appendicitis. A patient with a knife in place will be taken to surgery and assessed for bladder trauma there. DIF: Cognitive Level: Application REF: 1019-1020 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

24. After teaching a patient to irrigate a new colostomy, the nurse will determine that the teaching has been effective if the patient a. hangs the irrigating container about 18 inches above the stoma. b. stops the irrigation and removes the irrigating cone if cramping occurs. c. inserts the irrigation tubing no further than 4 to 6 inches into the stoma. d. fills the irrigating container with 1000 to 2000 mL of lukewarm tap water.

A The irrigating container should be hung 18 to 24 inches above the stoma. If cramping occurs, the irrigation should be temporarily stopped and the cone left in place. Five hundred to 1000 mL of water should be used for irrigation. An irrigation cone, rather than tubing, should be inserted into the stoma; 4 to 6 inches would be too far for safe insertion. DIF: Cognitive Level: Application REF: 1045 TOP: Nursing Process: Evaluation

36. A patient who had arthroscopic surgery of the left knee 5 days ago is admitted with a red, swollen, and hot knee. Which assessment finding by the nurse should be reported to the health care provider immediately? a. The blood pressure is 88/46 mm Hg. b. The white blood cell count is 14,200/µL. c. The patient is taking ibuprofen (Motrin). d. The patient says the knee is very painful.

A The low blood pressure suggests that the patient may be developing septicemia as a complication of septic arthritis. Immediate blood cultures and initiation of antibiotic therapy are indicated. The other information is typical of septic arthritis and also should be reported to the health care provider, but it does not indicate any immediately life-threatening problems. DIF: Cognitive Level: Application REF: 1662-1664 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

23. A patient with a bleeding duodenal ulcer has a nasogastric (NG) tube in place, and the health care provider orders 30 mL of aluminum hydroxide/magnesium hydroxide (Maalox) to be instilled through the tube every hour. To evaluate the effectiveness of this treatment, the nurse a. periodically aspirates and tests gastric pH. b. monitors arterial blood gas values on a daily basis. c. checks each stool for the presence of occult blood. d. measures the amount of residual stomach contents hourly.

A The purpose for antacids is to increase gastric pH. Checking gastric pH is the most direct way of evaluating the effectiveness of the medication. Arterial blood gases may change slightly, but this does not directly reflect the effect of antacids on gastric pH. Because the patient has upper gastrointestinal (GI) bleeding, occult blood in the stools will appear even after the acute bleeding has stopped. The amount of residual stomach contents is not a reflection of resolution of bleeding or of gastric pH. DIF: Cognitive Level: Application REF: 973 TOP: Nursing Process: Evaluation

12. A patient who has advanced cirrhosis is receiving lactulose (Cephulac). Which finding by the nurse indicates that the medication is effective? a. The patient is alert and oriented. b. The patient denies nausea or anorexia. c. The patient's bilirubin level decreases. d. The patient has at least one stool daily.

A The purpose for lactulose in the patient with cirrhosis is to lower ammonia levels and prevent encephalopathy. Although lactulose may be used to treat constipation, that is not the purpose for this patient. Lactulose will not decrease nausea and vomiting or lower bilirubin levels. DIF: Cognitive Level: Application REF: 1078-1079 TOP: Nursing Process: Evaluation

11. The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take? a. Notify the patient's health care provider. b. Give the prescribed PRN lorazepam (Ativan). c. Start the prescribed PRN oxygen at 2 to 4 L/min. d. Encourage the patient to take deep, slow breaths.

A The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the need for actions such as administration of sodium bicarbonate, which will require a prescription by the health care provider. Oxygen therapy is not indicated because there is no indication that the increased respiratory rate is related to hypoxemia. The respiratory pattern is compensatory, and the patient will not be able to slow the respiratory rate. Ativan administration will slow the respiratory rate and increase the level of acidosis. DIF: Cognitive Level: Application REF: 323 TOP: Nursing Process: Implementation

22. During the initial postoperative assessment of a patient's stoma formed from a transverse colostomy, the nurse finds it to be deep pink with moderate edema and a small amount of bleeding. The nurse should a. document the stoma assessment. b. monitor the stoma every 30 minutes. c. notify the surgeon about the stoma appearance. d. place an ice pack on the stoma to reduce swelling.

A The stoma appearance indicates good circulation to the stoma. There is no indication that surgical intervention is needed or that frequent stoma monitoring is required. Swelling of the stoma is normal for 2 to 3 weeks after surgery, and an ice pack is not needed. DIF: Cognitive Level: Application REF: 1041-1042 TOP: Nursing Process: Implementation

14. Which information will the nurse plan to include when teaching a 19-year-old to perform testicular self-examination? a. Testicular self-examination should be done in a warm area. b. The only structure normally felt in the scrotal sac is the testis. c. Testicular self-examination should be done at least every week. d. Call the health care provider if one testis is larger than the other.

A The testes will hang lower in the scrotum when the temperature is warm (e.g., during a shower), and it will be easier to palpate. The epididymis is also normally palpable in the scrotum. One testis is normally larger. The patient should perform testicular self-examination monthly. DIF: Cognitive Level: Comprehension REF: 1397 TOP: Nursing Process: Planning

3. The nurse who is reviewing laboratory data for an 86-year-old patient will be most concerned about a. a white blood cell (WBC) count of 3500/μL. b. a hematocrit of 37%. c. a platelet count of 400,000/μL. d. a hemoglobin of 11.8 g/dL.

A The total WBC count is not usually affected by aging, and the low WBC here would indicate that the patient's immune function may be compromised. The platelet count is normal. The slight decrease in hemoglobin and hematocrit are not unusual for an older patient. DIF: Cognitive Level: Application REF: 648 TOP: Nursing Process: Assessment

1. Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which information best supports this diagnosis? a. Weak, nonproductive cough effort b. Large amounts of greenish sputum c. Respiratory rate of 28 breaths/minute d. Resting pulse oximetry (SpO2) of 85%

A The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern. DIF: Cognitive Level: Application REF: 551-552 TOP: Nursing Process: Diagnosis

5. When combination therapy of α-interferon and ribavirin (Rebetol) is being used to treat chronic hepatitis C, the nurse will plan to monitor for a. leukopenia. b. hypokalemia. c. polycythemia. d. hypoglycemia.

A Therapy with ribavirin and α-interferon may cause leukopenia. The other problems are not associated with this drug therapy. DIF: Cognitive Level: Application REF: 1066 TOP: Nursing Process: Planning

6. A client who recently had a heart valve replacement is taking warfarin (Coumadin) as prescribed. What health teaching will the nurse include before the client is discharged? A. "Take your pulse every day and call your doctor if it is below 60." B. "Weigh yourself every day in the morning using the same scale." C. "Purchase a home kit to monitor your blood pressure every day." D. "Avoid foods that are high in vitamin K, such as kale and spinach."

20. A 40-year-old divorced mother of four school-age children is hospitalized with metastatic ovarian cancer. The nurse finds the patient crying, and she tells the nurse that she does not know what will happen to her children when she dies. The most appropriate response by the nurse is a. "Why don't we talk about the options you have for the care of your children?" b. "Perhaps your ex-husband will take the children when you can't care for them." c. "For now you need to concentrate on getting well, not worry about your children." d. "Many patients with cancer live for a long time, so there is time to plan for your children."

A This response expresses the nurse's willingness to listen and recognizes the patient's concern. The responses beginning "Many patients with cancer live for a long time" and "For now you need to concentrate on getting well" close off discussion of the topic and indicate that the nurse is uncomfortable with the topic. In addition, the patient with metastatic ovarian cancer may not have a long time to plan. Although it is possible that the patient's ex-husband will take the children, more assessment information is needed before making plans. DIF: Cognitive Level: Application REF: 270 | 297 TOP: Nursing Process: Implementation

7. When caring for a patient admitted with hyponatremia, which actions will the nurse anticipate taking? a. Restrict patient's oral free water intake. b. Avoid use of electrolyte-containing drinks. c. Infuse a solution of 5% dextrose in 0.45% saline. d. Administer vasopressin (antidiuretic hormone, [ADH]).

A To help improve serum sodium levels, water intake is restricted. Electrolyte-containing beverages will improve the patient's sodium level. Administration of vasopressin or hypotonic IV solutions will decrease the serum sodium level further. DIF: Cognitive Level: Application REF: 313 | 326 TOP: Nursing Process: Planning

5. To decrease the risk for cancers of the tongue and buccal mucosa, which information will the nurse include when teaching a patient who is seen for an annual physical exam in the outpatient clinic? a. Avoid use of cigarettes and smokeless tobacco. b. Use sunscreen when outside even on cloudy days. c. Complete antibiotics used to treat throat infections. d. Use antivirals to treat herpes simplex virus (HSV) infections.

A Tobacco use greatly increases the risk for oral cancer. Acute throat infections do not increase risk for oral cancer, although chronic irritation of the oral mucosa does increase risk. Sun exposure does not increase the risk for cancers of the buccal mucosa. Human papillomavirus (HPV) infection is associated with increased risk, but HSV infection is not a risk factor for oral cancer. DIF: Cognitive Level: Comprehension REF: 968-969 TOP: Nursing Process: Assessment

23. Which of these prescriptions written by the health care provider for a patient admitted with infective endocarditis (IE) and a fever should the nurse implement first? a. Order blood cultures drawn from two sites. b. Give acetaminophen (Tylenol) PRN for fever. c. Administer ceftriaxone (Rocephin) 1 g IV. d. Obtain a transesophageal echocardiogram.

A Treatment of the IE with antibiotics should be started as quickly as possible, but it is essential to obtain blood cultures before initiating antibiotic therapy to obtain accurate sensitivity results. The echocardiogram and Tylenol administration also should be implemented rapidly, but the blood cultures (and then administration of the antibiotic) have the highest priority. DIF: Cognitive Level: Application REF: 843-845 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

15. A student nurse prepares a list of teaching topics for a patient with a new diagnosis of breast cancer. Which topic indicates that the student needs more education about breast cancer diagnostic testing? a. CA 15-3 level testing b. HER-2 receptor testing c. Estrogen receptor testing d. Oncotype DX assay testing

A Tumor markers such as CA 15-3 are used to monitor response to treatment for breast cancer, not to detect or diagnose breast cancer. The other tests are likely to be used for additional diagnostic testing in a patient with breast cancer. DIF: Cognitive Level: Application REF: 1312-1314 TOP: Nursing Process: Planning MSC:

34. When caring for a patient who is pancytopenic, which action by nursing assistive personnel (NAP) indicates a need for the RN to intervene? a. The NAP assists the patient to use dental floss after eating. b. The NAP adds baking soda to the patient's saline oral rinses. c. The NAP puts fluoride toothpaste on the patient's toothbrush. d. The NAP has the patient rinse after meals with a saline solution.

A Use of dental floss is avoided in patients with pancytopenia because of the risk for infection and bleeding. The other actions are appropriate for oral care of a pancytopenic patient. DIF: Cognitive Level: Application REF: eTable 16-5 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation MSC:

3. In counseling a couple in which the man has an autosomal recessive disorder, and the woman has no gene for the disorder, the nurse uses Punnett squares to show the couple that the probability of their having a child with the disorder is a. 0%. b. 25%. c. 50%. d. 75%.

A When one parent has no gene for an autosomal recessive disorder, the children will not display the characteristics of the disorder. However, the children will be carriers of the autosomal recessive disorder. DIF: Cognitive Level: Application REF: 210 TOP: Nursing Process: Implementation

4. When caring for a patient who has osteoarthritis, the nurse will anticipate the need to teach the patient about which of these medications? a. Adalimumab (Humira) b. Prednisone (Deltasone) c. Capsaicin cream (Zostrix) d. Sulfasalazine (Azulfidine)

C Capsaicin cream blocks the transmission of pain impulses and is helpful for some patients in treating OA. The other medications would be used for patients with RA. DIF: Cognitive Level: Application REF: 1646 | 1650 TOP: Nursing Process: Planning

9. A patient with laryngeal cancer has received teaching about radiation therapy. Which statement by the patient indicates that the teaching has been effective? a. "I will need to buy a water bottle to carry with me." b. "I should not use any lotions on my neck and throat." c. "Until the radiation is complete, I may have diarrhea." d. "Alcohol-based mouthwashes will help clean oral ulcers."

A Xerostomia can be partially alleviated by drinking fluids at frequent intervals. Radiation will damage tissues at the site being radiated but should not affect the abdominal organs, so loose stools are not a usual complication of head and neck radiation therapy. Frequent oral rinsing with non-alcohol-based rinses is recommended. Prescribed lotions and sunscreen may be used on irradiated skin, although they should not be used just before the radiation therapy. DIF: Cognitive Level: Application REF: 538 TOP: Nursing Process: Evaluation

6. A patient has the following arterial blood gas (ABG) results: pH 7.48, PaO2 86 mm Hg, PaCO2 44 mm Hg, HCO3 29 mEq/L. When assessing the patient, the nurse would expect the patient to experience A. Warm, flushed skin. B. Respiratory rate of 36. C. Blood pressure of 94/52. D. Hypertonic muscles with cramping.

6. When assessing a patient who is returned to the surgical unit following a thyroidectomy, the nurse would be most concerned if the patient A. Complains of thirst. B. States her throat is sore. C. Holds her head when she moves in bed. D. Makes harsh, vibratory sounds when she breathes.

7. A patient who is receiving a blood transfusion suddenly exclaims to the nurse, "I don'€™t feel right!" What does the nurse do next? A. Call the rapid response team B. Obtain vital signs and continue to monitor C. Slow the infusion rate of the transfusion D. Stop the transfusion.

7. Which assessment finding is of most concern for a 46-year-old woman with acute pancreatitis? A. Absent bowel sounds B. Abdominal tenderness C. Left upper quadrant pain D. Palpable abdominal mass

18. A patient with benign prostatic hyperplasia (BPH) with mild obstruction tells the nurse, "My symptoms have gotten a lot worse this week." Which response by the nurse is most appropriate? a. "I will talk to the doctor about ordering a prostate specific antigen (PSA) test." b. "Have you been taking any over-the-counter (OTC) medications recently?" c. "Have you talked to the doctor about surgical procedures such as transurethral resection of the prostate (TURP)?" d. "The prostate gland changes slightly in size from day to day, and this may be making your symptoms worse."

B Because the patient's increase in symptoms has occurred abruptly, the nurse should ask about OTC medications that might cause contraction of the smooth muscle in the prostate and worsen obstruction. The prostate gland does not vary in size from day to day. A TURP may be needed, but more assessment about possible reasons for the sudden symptom change is a more appropriate first response by the nurse. PSA testing is done to differentiate BPH from prostatic cancer. DIF: Cognitive Level: Application REF: 1383 TOP: Nursing Process: Assessment

14. A confused patient with pancytopenia of unknown origin is scheduled for the following diagnostic tests. The nurse should contact the patient's family member to sign a consent form before the a. ABO blood typing. b. bone marrow biopsy. c. abdominal ultrasound. d. complete blood count (CBC).

B Bone marrow biopsy is a minor surgical procedure that requires the patient or guardian to sign a surgical consent form. The other procedures do not require a signed consent by the patient or family. DIF: Cognitive Level: Application REF: 658 TOP: Nursing Process: Implementation

20. Before undergoing a colon resection for cancer of the colon, a patient has an elevated carcinoembryonic antigen (CEA) test. The nurse explains that the test is used to a. confirm the diagnosis of colon cancer. b. monitor the tumor status after surgery. c. identify the extent of cancer spread or metastasis. d. determine the need for postoperative chemotherapy.

B CEA is used to monitor for cancer recurrence after surgery. CEA levels do not help determine whether there is metastasis of the cancer. Confirmation of the diagnosis is made on the basis of biopsy. Chemotherapy use is based on factors other than CEA. DIF: Cognitive Level: Comprehension REF: 1036-1037 TOP: Nursing Process: Implementation

2. A patient seen in the outpatient clinic has an immune deficiency involving the T-lymphocytes. The nurse should teach the patient about the need for more frequent screening for a. allergies. b. malignancy. c. antibody deficiency. d. autoimmune disorders.

B Cell-mediated immunity is responsible for the recognition and destruction of cancer cells. Allergic reactions, autoimmune disorders, and antibody deficiencies are mediated primarily by humoral immunity. DIF: Cognitive Level: Application REF: 214 TOP: Nursing Process: Implementation

2. A patient who has been NPO during treatment for nausea and vomiting caused by gastric irritation is to start oral intake. Which of these should the nurse offer to the patient? a. A glass of orange juice b. A dish of lemon gelatin c. A cup of coffee with cream d. A bowl of hot chicken broth

B Clear liquids are usually the first foods started after a patient has been nauseated. Acidic foods such as orange juice, very hot foods, and coffee are poorly tolerated when patients have been nauseated. DIF: Cognitive Level: Application REF: 965 | 966-967 TOP: Nursing Process: Implementation

31. The nurse is assessing a patient who is receiving peritoneal dialysis with 2 L inflows. Which information should be reported immediately to the health care provider? a. The patient has an outflow volume of 1800 mL. b. The patient's peritoneal effluent appears cloudy. c. The patient has abdominal pain during the inflow phase. d. The patient complains of feeling bloated after the inflow.

B Cloudy appearing peritoneal effluent is a sign of peritonitis and should be reported immediately so that treatment with antibiotics can be started. The other problems can be addressed through nursing interventions such as slowing the inflow and repositioning the patient. DIF: Cognitive Level: Application REF: 1183-1184 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

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

B Cold application is helpful in reducing pain during periods of exacerbation of RA. Because the joint pain is chronic, patients are instructed to exercise even when joints are painful. ROM exercises are intended to strengthen joints as well as improve flexibility, so passive ROM alone is not sufficient. Recreational exercise is encouraged but is not a replacement for ROM exercises. DIF: Cognitive Level: Application REF: 1660 TOP: Nursing Process: Implementation

11. Leuprolide (Lupron) is prescribed for a patient with cancer of the prostate. In teaching the patient about this drug, the nurse informs the patient that side effects may include a. dizziness. b. hot flashes. c. urinary incontinence. d. increased infection risk.

B Hot flashes may occur with decreased testosterone production. Dizziness may occur with the α-blockers used for benign prostatic hyperplasia (BPH). Urinary incontinence may occur after prostate surgery, but it is not an expected medication side effect. Risk for infection is increased in patients receiving chemotherapy. DIF: Cognitive Level: Comprehension REF: 1390 TOP: Nursing Process: Implementation

14. A patient who has had a total proctocolectomy and permanent ileostomy tells the nurse, "I cannot bear to even look at the stoma. I do not think I can manage all these changes." Which is the best action by the nurse? a. Develop a detailed written plan for ostomy care for the patient. b. Ask the patient more about the concerns with stoma management. c. Reassure the patient that care for the ileostomy will become easier. d. Postpone any patient teaching until the patient adjusts to the ileostomy.

B Encouraging the patient to share concerns assists in helping the patient adjust to the body changes. Acknowledgment of the patient's feelings and concerns is important rather than offering false reassurance. Because the patient indicates that the feelings about the ostomy are the reason for the difficulty with the many changes, development of a detailed ostomy care plan will not improve the patient's ability to manage the ostomy. Although detailed ostomy teaching may be postponed, the nurse should offer teaching about some aspects of living with an ostomy. DIF: Cognitive Level: Application REF: 1042 | 1044-1046 TOP: Nursing Process: Implementation

11. To evaluate the effectiveness of treatment for a patient who has hepatic encephalopathy, which action should the nurse take? a. Request that the patient stand on one foot. b. Ask the patient to extend both arms to the front. c. Instruct the patient to perform the Valsalva maneuver. d. Have the patient walk a few steps with the eyes closed.

B Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic encephalopathy. The other tests also might be done as part of the neurologic assessment but would not be diagnostic for hepatic encephalopathy. DIF: Cognitive Level: Application REF: 1076-1077 TOP: Nursing Process: Assessment

22. The family member of a patient who has suffered massive abdominal trauma in an automobile accident asks the nurse why the patient is receiving famotidine (Pepcid). The nurse will explain that the medication will a. prevent aspiration of gastric contents. b. inhibit the development of stress ulcers. c. lower the chance for H. pylori infection. d. decrease the risk for nausea and vomiting.

B Famotidine is administered to prevent the development of physiologic stress ulcers, which are associated with a major physiologic insult such as massive trauma. Famotidine does not decrease nausea or vomiting, prevent aspiration, or prevent H. pylori infection. DIF: Cognitive Level: Application REF: 981 TOP: Nursing Process: Implementation

23. The home health nurse is caring for a patient who has been receiving interferon therapy for treatment of cancer. Which statement by the patient may indicate a need for a change in treatment? a. "I have frequent muscle aches and pains." b. "I rarely have the energy to get out of bed." c. "I experience chills after I inject the interferon." d. "I take acetaminophen (Tylenol) every 4 hours."

B Fatigue can be a dose-limiting toxicity for use of biologic therapies. Flulike symptoms, such as muscle aches and chills, are common side effects with interferon use. Patients are advised to use Tylenol every 4 hours. DIF: Cognitive Level: Application REF: 288-290 TOP: Nursing Process: Assessment

16. A patient with Crohn's disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, fecal-smelling urine. The nurse will teach the patient a. to clean the perianal area carefully after any stools. b. about fistula formation between the bowel and bladder. c. to empty the bladder before and after sexual intercourse. d. about the effects of corticosteroid use on immune function.

B Fistulas between the bowel and bladder occur in Crohn's disease and can lead to UTI. There is no information indicating that the patient's risk for UTI is caused by poor cleaning or not voiding before and after intercourse. Steroid use may increase the risk for infection, but the characteristics of the patient's urine indicate that a fistula has occurred. DIF: Cognitive Level: Application REF: 1023-1024 TOP: Nursing Process: Implementation

28. A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the RN caring for the patient indicates that the nurse should take action? a. The patient ambulates several times a day in the room. b. The patient's visitors bring in some fresh peaches from home. c. The patient cleans with a warm washcloth after having a stool. d. The patient uses soap and shampoo to shower every other day.

B Fresh, thinned-skin fruits are not permitted in a neutropenic diet because of the risk of bacteria being present. The patient should ambulate in the room rather than the hospital hallway to avoid exposure to other patients or visitors. Because overuse of soap can dry the skin and increase infection risk, showering every other day is acceptable. Careful cleaning after having a bowel movement will help to prevent skin breakdown and infection. DIF: Cognitive Level: Application REF: eTable 16-5 TOP: Nursing Process: Evaluation

7. A patient at the clinic who has metastatic breast cancer has a new prescription for trastuzumab (Herceptin). The nurse will plan to a. have the patient schedule frequent eye examinations. b. instruct the patient to call if she notices ankle swelling. c. remind the patient that hot flashes may occur with the medication. d. teach the patient about the need to monitor serum electrolyte levels.

B Herceptin can lead to ventricular dysfunction, so the patient is taught to self-monitor for symptoms of heart failure. There is no need to monitor serum electrolyte levels. Hot flashes or changes in visual acuity may occur with tamoxifen, but not with trastuzumab. DIF: Cognitive Level: Application REF: 1319-1320 TOP: Nursing Process: Planning

23. A patient who has ulcerative colitis has a proctocolectomy and ileostomy. Which information will the nurse include in patient teaching? a. Restrict fluid intake to prevent constant liquid drainage from the stoma. b. Use care when eating high-fiber foods to avoid obstruction of the ileum. c. Irrigate the ileostomy daily to avoid having to wear a drainage appliance. d. Change the pouch every day to prevent leakage of contents onto the skin.

B High-fiber foods are introduced gradually and should be well chewed to avoid obstruction of the ileostomy. Patients with ileostomies lose the absorption of water in the colon and need to take in increased amounts of fluid. The pouch should be drained frequently but is changed every 5 to 7 days. The drainage from an ileostomy is liquid and continuous, so control by irrigation is not possible. DIF: Cognitive Level: Application REF: 1042 | 1044-1045 TOP: Nursing Process: Implementation

20. A patient with newly diagnosed lung cancer tells the nurse, "I think I am going to die pretty soon." Which response by the nurse is best? a. "Would you like to talk to the hospital chaplain about your feelings?" b. "Can you tell me what it is that makes you think you will die so soon?" c. "Are you afraid that the treatment for your cancer will not be effective?" d. "Do you think that taking an antidepressant medication would be helpful?"

B The nurse's initial response should be to collect more assessment data about the patient's statement. The answer beginning "Can you tell me what it is" is the most open-ended question and will offer the best opportunity for obtaining more data. The answer beginning, "Are you afraid" implies that the patient thinks that the cancer will be immediately fatal, although the patient's statement may not be related to the cancer diagnosis. The remaining two answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate. DIF: Cognitive Level: Application REF: 565 TOP: Nursing Process: Implementation

21. A patient with benign prostatic hyperplasia (BPH) is admitted to the hospital with urinary retention and new onset elevations in the blood urea nitrogen (BUN) and creatinine. Which of these prescribed therapies should the nurse implement first? a. Schedule an abdominal computed tomography (CT) scan. b. Insert a urinary retention catheter. c. Draw blood for a complete blood count. d. Infuse normal saline at 50 mL/hr.

B The patient data indicate that the patient may have acute renal failure caused by the BPH. The initial therapy will be to insert a catheter. The other actions also are appropriate, but they can be implemented after the acute urinary retention is resolved. DIF: Cognitive Level: Application REF: 1378-1379 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

16. A chemotherapeutic agent known to cause alopecia is prescribed for a patient. To maintain the patient's self-esteem, the nurse plans to a. suggest that the patient limit social contacts until regrowth of the hair occurs. b. encourage the patient to purchase a wig or hat and wear it once hair loss begins. c. have the patient wash the hair gently with a mild shampoo to minimize hair loss. d. inform the patient that the hair will grow back once the chemotherapy is complete.

B The patient is taught to anticipate hair loss and to be prepared with wigs, scarves, or hats. Limiting social contacts is not appropriate at a time when the patient is likely to need a good social support system. The damage occurs at the hair follicle and will occur regardless of gentle washing or use of a mild shampoo. The information that the hair will grow back is not immediately helpful in maintaining the patient's self-esteem. DIF: Cognitive Level: Application REF: 281 | 286 TOP: Nursing Process: Planning

10. After the nurse completes discharge teaching for a patient who has had a left modified radical mastectomy and lymph node dissection, which statement by the patient indicates that teaching has been successful? a. "I will need to use my right arm and to rest the left one." b. "I will avoid reaching over the stove with my left hand." c. "I will keep my left arm in a sling until the incision is healed." d. "I will stop the left arm exercises if moving the arm is painful."

B The patient should avoid any activity that might injure the left arm, such as reaching over a burner. If the left arm exercises are painful, analgesics should be used and the exercises continued in order to restore strength and range of motion. The left arm should be elevated at or above heart level and should be used to improve range of motion and function. DIF: Cognitive Level: Application REF: 1320-1323 TOP: Nursing Process: Evaluation

11. A patient has a saline breast implant inserted in the outpatient surgery area. Which instruction will the nurse include in the discharge teaching? a. Take aspirin every 4 hours to reduce inflammation. b. Check wound drains for excessive blood or any foul odor. c. Wear a loose-fitting bra to decrease irritation of the sutures. d. Resume normal activities 2 to 3 days after the mammoplasty.

B The patient should be taught drain care because the drains will be in place for 2 or 3 days after surgery. Normal activities can be resumed after 2 to 3 weeks. A bra that provides good support is typically ordered. Aspirin will decrease coagulation and is typically not given after surgery. DIF: Cognitive Level: Application REF: 1326-1327 TOP: Nursing Process: Implementation

15. A patient seeks medical care after sharing needles for heroin injection with a friend who has hepatitis B. To provide immediate protection from infection, the nurse expects to administer a. corticosteroids. b. gamma globulin. c. hepatitis B vaccine. d. fresh frozen plasma.

B The patient should first receive antibodies for hepatitis B from injection of gamma globulin. The hepatitis B vaccination series should be started to provide active immunity. Fresh frozen plasma and corticosteroids will not be effective in preventing hepatitis B in the patient. DIF: Cognitive Level: Application REF: 211-212 TOP: Nursing Process: Planning

36. A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature 102° F (38.9° C), and severe back pain. Which of these physician orders will the nurse implement first? a. Administer morphine sulfate 4 mg IV. b. Infuse normal saline 500 mL over 30 minutes. c. Draw blood for complete blood count and coagulation studies. d. Give acetaminophen (Tylenol) 650 mg for temperature 102° F or higher.

B 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 also are appropriate and should be rapidly implemented, but improving perfusion is the priority for this patient. DIF: Cognitive Level: Application REF: 688 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

1. After the insertion of an arteriovenous graft (AVG) in the right forearm, a patient complains of pain and coldness of the right fingers. Which action should the nurse take? a. Elevate the patient's arm above the level of the heart. b. Report the patient's symptoms to the health care provider. c. Remind the patient about the need to take a daily low-dose aspirin tablet. d. Educate the patient about the normal vascular response after AVG insertion.

B The patient's complaints suggest the development of distal ischemia (steal syndrome) and may require revision of the AVG. Elevation of the arm above the heart will decrease perfusion. Pain and coolness are not normal after AVG insertion. Aspirin therapy is not used to maintain grafts. DIF: Cognitive Level: Application REF: 1184-1185 TOP: Nursing Process: Implementation

23. A patient who has been hospitalized for 2 days has been receiving normal saline IV at 100 ml/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding by the nurse is the priority to report to the health care provider? a. Serum sodium level of 138 mEq/L (138 mmol/L) b. Gradually decreasing level of consciousness (LOC) c. Oral temperature of 100.1° F with bibasilar lung crackles d. Weight gain of 2 pounds (1 kg) above the admission weight

B The patient's history and change in LOC could be indicative of several fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information will be ordered by the health care provider to determine the cause of the change in LOC and the appropriate interventions. The weight gain, elevated temperature, crackles, and serum sodium level also will be reported, but do not indicate a need for rapid action to avoid complications. DIF: Cognitive Level: Application REF: 309-315 | 323 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

29. Following a thymectomy, a patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient complains of nausea and severe abdominal cramps. Which action should the nurse take first? a. Auscultate the patient's bowel sounds. b. Notify the patient's health care provider. c. Administer the prescribed PRN antiemetic drug. d. Give the scheduled dose of prednisone (Deltasone).

B The patient's history and symptoms indicate a possible cholinergic crisis. The health care provider should be notified immediately, and it is likely that atropine will be prescribed. The other actions will be appropriate if the patient is not experiencing a cholinergic crisis. DIF: Cognitive Level: Application REF: 1514-1515 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

20. A hospitalized patient complains of a moderate bilateral headache that radiates from the base of the skull. Which of these prescribed PRN medications should the nurse administer initially? a. lorazepam (Ativan) b. acetaminophen (Tylenol) c. morphine sulfate (Roxanol) d. butalbital and aspirin (Fiorinal)

B The patient's symptoms are consistent with a tension headache, and initial therapy usually involves a nonopioid analgesic such as acetaminophen, sometimes combined with a sedative or muscle relaxant. Lorazepam may be used in conjunction with acetaminophen but would not be appropriate as the initial monotherapy. Morphine sulfate and butalbital and aspirin would be more appropriate for a headache that did not respond to a nonopioid analgesic. DIF: Cognitive Level: Application REF: 1490 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

29. Following a thyroidectomy, a patient complains of "a tingling feeling around my mouth." The nurse will immediately check for a. an elevated serum potassium level. b. the presence of Chvostek's sign. c. a decreased thyroid hormone level. d. bleeding on the patient's dressing.

B The patient's symptoms indicate possible hypocalcemia, which can occur secondary to parathyroid injury/removal during thyroidectomy. There is no indication of a need to check the potassium level, the thyroid hormone level, or for bleeding. DIF: Cognitive Level: Application REF: 318 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

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

B The patient's vocal weakness and hoarseness indicate weakness of the pharyngeal muscles and a high risk for aspiration. The other nursing diagnoses also are appropriate but are not as high a priority as the maintenance of the patient's airway. DIF: Cognitive Level: Application REF: 1674-1675 OBJ: Special Questions: Prioritization TOP: Nursing Process: Diagnosis

2. The nurse determines that administration of hepatitis B vaccine to a patient has been effective when a specimen of the patient's blood reveals a. HBsAg. b. anti-HBs. c. anti-HBc IgG. d. anti-HBc IgM.

B The presence of surface antibody to HBV (anti-HBs) is a marker of a positive response to the vaccine. The other laboratory values indicate current infection with HBV. DIF: Cognitive Level: Analysis REF: 1061-1062 | 1064 TOP: Nursing Process: Evaluation

6. A patient with stage II breast cancer tells the nurse, "I need to decide about what type of surgery to have, but I feel so overwhelmed that I cannot make any decisions yet! What do you think I should do?" Which response by the nurse is best? a. "I would have a lumpectomy, but you need to decide what is best for you." b. "Tell me what you understand about the surgical options that are available." c. "It would not be appropriate for me to make the decision about your health." d. "There is no need to make a decision rapidly; you have time to think about this."

B This response indicates the nurse's willingness to assist the patient with the decision-making process without imposing the nurse's values or opinions. Response B indicates that the nurse is not willing to help the patient with the decision about treatment. Because treatment decisions for breast cancer do need to be made relatively quickly, response C is not accurate. Since the nurse's values and situation are not the same as the patient's, imposing the nurse's opinions during this emotionally vulnerable time is not appropriate. DIF: Cognitive Level: Application REF: 1320 TOP: Nursing Process: Implementation

4. After the nurse has finished teaching a patient who is scheduled to receive external beam radiation for abdominal cancer about appropriate diet, which dietary selection by the patient indicates that the teaching has been effective? a. Fresh fruit salad b. Roasted chicken c. Whole wheat toast d. Cream of potato soup

B To minimize the diarrhea that is commonly associated with bowel radiation, the patient should avoid foods high in roughage, such as fruits and whole grains. Lactose-intolerance may develop secondary to radiation, so dairy products also should be avoided. DIF: Cognitive Level: Application REF: 283 TOP: Nursing Process: Evaluation

4. When planning care for a patient hospitalized with a streptococcal infective endocarditis (IE), which intervention will the nurse include? a. Monitor labs for streptococcal antibodies. b. Arrange for insertion of a long-term IV catheter. c. Encourage the patient to get regular aerobic exercise. d. Teach the importance of completing all oral antibiotics.

B Treatment for IE involves 4 to 6 weeks of IV antibiotic therapy in order to eradicate the bacteria, which will require a long-term IV catheter such as a peripherally inserted central catheter (PICC) line. Rest periods and limiting physical activity to a moderate level are recommended during the treatment for IE. Oral antibiotics are not effective in eradicating the infective bacteria that cause IE. Blood cultures, rather than antibody levels, are used to monitor the effectiveness of antibiotic therapy. DIF: Cognitive Level: Application REF: 844-845 TOP: Nursing Process: Planning

7. When obtaining a health history and physical assessment for a patient with possible multiple sclerosis (MS), the nurse should a. assess for the presence of chest pain. b. inquire about any urinary tract problems. c. inspect the skin for rashes or discoloration. d. question the patient about any increase in libido.

B Urinary tract problems with incontinence or retention are common symptoms of MS. Chest pain and skin rashes are not symptoms of MS. A decrease in libido is common with MS. DIF: Cognitive Level: Application REF: 1503-1504 TOP: Nursing Process: Assessment

28. A patient with a pleural effusion is scheduled for a thoracentesis. Before the procedure, the nurse will plan to a. start a peripheral intravenous line to administer the necessary sedative drugs. b. position the patient sitting upright on the edge of the bed and leaning forward. c. remove the water pitcher and remind the patient not to eat or drink anything for 6 hours. d. instruct the patient about the importance of incentive spirometer use after the procedure.

B When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and can more easily be located and removed. The lung will expand after the effusion is removed; incentive spirometry is not needed to assure alveolar expansion. The patient does not usually require sedation for the procedure, and there are no restrictions on oral intake because the patient is not sedated or unconscious. DIF: Cognitive Level: Application REF: 576 TOP: Nursing Process: Planning

8. A 67-year-old male patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. Which information obtained by the nurse indicates that these therapies have been effective? A. Bowel sounds are present. B. Grey Turner sign resolves. C. Electrolyte levels are normal. D. Abdominal pain is decreased.

2. The nurse is reviewing the charts for five patients who are scheduled for their yearly physical examinations in October. Which of the following patients will require the inactivated influenza vaccination (select all that apply)? a. A 56-year-old patient who is allergic to eggs b. A 36-year-old female patient who is pregnant c. A 42-year-old patient who has a 15 pack-year smoking history d. A 30-year-old patient who takes corticosteroids for rheumatoid arthritis e. A 24-year-old patient who has allergies to penicillin and the cephalosporins

B, D Current guidelines suggest that healthy individuals between 6 months and age 49 receive intranasal immunization with live, attenuated influenza vaccine. Individuals who are pregnant, have chronic medical conditions, or are immunocompromised should receive inactivated vaccine. The corticosteroid use by the 30-year-old increases the risk for infection. Individuals with egg allergies should not receive inactivated flu vaccine because it is made using eggs. DIF: Cognitive Level: Application REF: 524 | 525 OBJ: Special Questions: Alternate Item Format TOP: Nursing Process: Planning

1. The nurse enters the room of a patient who has just returned from surgery for a total laryngectomy and radical neck dissection and notes the following problems. In which order should the nurse address the problems? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. The nasogastric (NG) tube is disconnected from suction and clamped off. b. The patient is in a side-lying position with the head of the bed flat. c. The Hemovac in the neck incision contains 200 mL of bloody drainage. d. The patient is coughing blood-tinged secretions from the tracheostomy.

B, D, C, A The patient should first be placed in a semi-Fowler's position to maintain the airway and reduce incisional swelling. The blood-tinged secretions may obstruct the airway, so suctioning is the next appropriate action. Then the Hemovac should be drained because the 200 mL of drainage will decrease the amount of suction in the Hemovac and could lead to incisional swelling and poor healing. Finally, the NG tube should be reconnected to suction to prevent gastric dilation, nausea, and vomiting. DIF: Cognitive Level: Analysis REF: 532-534 | 538-539 OBJ: Special Questions: Alternate Item Format, Prioritization TOP: Nursing Process: Implementation

8. Which signs and symptoms indicate rejection of a transplanted kidney? (Select all that apply.) A. BUN 21 mg/dL, creatinine 0.9 mg/dL B. Crackles in the lung fields C. Temperature of 98.8 D. Blood pressure of 164/98 mm Hg E. 3+ edema of the lower extremities

B, D, E

5. What are the typical clinical manifestations of anemia? Select all that apply A. Decreased breath sounds B. Dyspnea on exertion C. Elevated temperature D. Fatigue E. Pallor F. Tachycardia

B, D, E, F

15. When caring for a patient who is hospitalized with active tuberculosis (TB), the nurse observes a family member who is visiting the patient. The nurse will need to intervene if the family member a. washes the hands before entering the patient's room. b. hands the patient a tissue from the box at the bedside. c. puts on a surgical face mask before visiting the patient. d. brings food from a "fast-food" restaurant to the patient.

C A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the patient's room because the HEPA mask can filter out 100% of small airborne particles. Hand washing before visiting the patient is not necessary, but there is no reason for the nurse to stop the family member from doing this. Because anorexia and weight loss are frequent problems in patients with TB, bringing food from outside the hospital is appropriate. The family member should wash the hands after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue. DIF: Cognitive Level: Application REF: 557 TOP: Nursing Process: Implementation

40. The nurse notes that a patient has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which action should the nurse take first? a. Assist the patient to sit up at the bedside. b. Splint the patient's chest during coughing. c. Medicate the patient with the prescribed morphine. d. Have the patient use the prescribed incentive spirometer.

C A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain (which increases with deep breathing and coughing). The first action by the nurse should be to medicate the patient to minimize incisional pain. The other actions are all appropriate ways to improve airway clearance but should be done after the morphine is given. DIF: Cognitive Level: Application REF: 574 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

32. All of the following patients are waiting to be admitted by the emergency department nurse. Which one requires the most rapid assessment and care by the nurse? a. The patient with hemochromatosis who is complaining of abdominal pain b. The patient with thrombocytopenia who has oozing after having a tooth extracted c. The patient with chemotherapy-induced neutropenia who has a temperature of 100.8° F d. The patient with a history of sickle cell anemia who has had nausea and diarrhea for 24 hours

C A neutropenic patient with a fever is assumed to have an infection and is at risk for rapidly developing sepsis. Rapid assessment, cultures, and initiation of antibiotic therapy are needed. The other patients also require rapid assessment and care but not as urgently as the neutropenic patient. DIF: Cognitive Level: Analysis REF: 691-692 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC:

18. Which data obtained when assessing a patient who had a kidney transplant 8 years ago and who is receiving the immunosuppressants tacrolimus (Prograf), cyclosporine (Sandimmune), and prednisone (Deltasone) will be of most concern to the nurse? a. The blood glucose is 144 mg/dL. b. The patient's blood pressure is 150/92. c. There is a nontender lump in the axilla. d. The patient has a round, moonlike face.

C A nontender lump suggests a malignancy such as a lymphoma, which could occur as a result of chronic immunosuppressive therapy. The elevated glucose, moon face, and hypertension are possible side effects of the prednisone and should be addressed, but they are not as great a concern as the possibility of a malignancy. DIF: Cognitive Level: Application REF: 1193-1194 TOP: Nursing Process: Assessment

21. The nurse is taking a health history from a 24-year-old patient with hypertrophic cardiomyopathy (HC). Which information obtained by the nurse is most relevant? a. The patient reports using cocaine once at age 16. b. The patient has a history of a recent upper respiratory infection. c. The patient's 29-year-old brother has had a sudden cardiac arrest. d. The patient has a family history of coronary artery disease (CAD).

C About half of all cases of HC have a genetic basis, and it is the most common cause of sudden cardiac death in otherwise healthy young people; the information about the patient's brother will be helpful in planning care (such as an automatic implantable cardioverter-defibrillator [AICD]) for the patient and in counseling other family members. The patient should be counseled against use of stimulant drugs, but the one-time use indicates that the patient is not at current risk for cocaine use. Viral infections and CAD are risk factors for dilated cardiomyopathy, but not for HC. DIF: Cognitive Level: Application REF: 861-862 TOP: Nursing Process: Assessment

6. When caring for a patient with a new diagnosis of rheumatoid arthritis, which action will the nurse include in the plan of care? a. Instruct the patient to purchase a soft mattress. b. Teach patient to use lukewarm water when bathing. c. Suggest that the patient take a nap in the afternoon. d. Suggest exercise with light weights several times daily.

C Adequate rest helps decrease the fatigue and pain that are associated with rheumatoid arthritis. Patients are taught to avoid stressing joints, to use warm baths to relieve stiffness, and to use a firm mattress. DIF: Cognitive Level: Application REF: 1656-1657 | 1659-1660 TOP: Nursing Process: Planning

3. After having a positive rapid-antibody test for HIV, a patient is anxious and does not appear to hear what the nurse is saying. At this time, it is most important that the nurse a. teach the patient about the medications available for treatment. b. inform the patient how to protect sexual and needle-sharing partners. c. remind the patient about the need to return for retesting to verify the results. d. ask the patient to notify individuals who have had risky contact with the patient.

C After an initial positive antibody test, the next step is retesting to confirm the results. A patient who is anxious is not likely to be able to take in new information or be willing to disclose information about HIV status of other individuals. DIF: Cognitive Level: Application REF: 246 TOP: Nursing Process: Implementation

8. Which instruction will be included when teaching a patient with possible allergies about intradermal skin testing? a. "Do not eat anything for about 6 hours before the testing." b. "Take an oral antihistamine about an hour before the testing." c. "Plan to wait in the clinic for 20 to 30 minutes after the testing." d. "Reaction to the testing will take about 48 to 72 hours to occur."

C Allergic reactions usually occur within minutes after injection of an allergen, and the patient will be monitored for at least 20 minutes for anaphylactic reactions after the testing. Medications that might modify the response, such as antihistamines, should be avoided before allergy testing. There is no reason to be NPO for skin testing. Results with intradermal testing occur within minutes. DIF: Cognitive Level: Application REF: 222-223 TOP: Nursing Process: Implementation

1. A patient whose mother has been diagnosed with BRCA gene-related breast cancer asks the nurse, "Do you think I should be tested for the gene?" Which response by the nurse is most appropriate? a. "In most cases, breast cancer is not caused by the BRCA gene." b. "It depends on how you will feel if the test is positive for the BRCA gene." c. "There are many things to consider before deciding to have genetic testing." d. "You should decide first whether you are willing to have a double mastectomy."

C Although presymptomatic testing for genetic disorders allows patients to take action (such as mastectomy) to prevent the development of some genetically caused disorders, patients also need to consider that test results in their medical file may impact insurance, employability, etc. Telling a patient that a decision about mastectomy should be made before testing implies that the nurse has made a judgment about what the patient should do if the test is positive. Although the patient may need to think about her reaction if the test is positive, other issues (e.g., insurance) also should be considered. Although most breast cancers are not related to BRCA gene alterations, the patient with the gene alteration has a markedly increased risk for breast cancer. DIF: Cognitive Level: Application REF: 209-210 TOP: Nursing Process: Implementation

19. Which of these laboratory test results will be most important for the nurse to monitor when evaluating the effects of therapy for a patient who has acute pancreatitis? a. Calcium b. Bilirubin c. Amylase d. Potassium

C Amylase is elevated in acute pancreatitis. Although changes in the other values may occur, they would not be as useful in evaluating whether the prescribed therapies have been effective. DIF: Cognitive Level: Application REF: 1090 TOP: Nursing Process: Evaluation

7. A 51-year-old man is scheduled for an annual physical exam at the outpatient clinic. The nurse will plan to teach the patient about the purpose of a. urinalysis collection. b. uroflowmetry studies. c. prostate specific antigen (PSA) testing. d. transrectal ultrasound scanning (TRUS).

C An annual digital rectal exam (DRE) and PSA are recommended starting at age 50 for men who have an average risk for prostate cancer. Urinalysis and uroflowmetry studies are done if patients have symptoms of urinary tract infection or changes in the urinary stream. TRUS may be ordered if the DRE or PSA are abnormal. DIF: Cognitive Level: Application REF: 1380 TOP: Nursing Process: Planning

27. To determine whether a patient's angioedema has responded to prescribed therapies, which action should the nurse take first? a. Ask about any clear nasal discharge. b. Obtain blood pressure and heart rate. c. Check for swelling of the lips and tongue. d. Assess extremities for wheal and flare lesions.

C Angioedema is characterized by swelling of the eyelids, lips, and tongue. Wheal and flare lesions; clear nasal drainage; and hypotension and tachycardia are characteristic of other allergic reactions. DIF: Cognitive Level: Application REF: 220 OBJ: Special Questions: Prioritization TOP: Nursing Process: Evaluation

17. During postoperative teaching with a patient who had a mitral valve replacement with a mechanical valve, the nurse instructs the patient regarding the a. use of daily aspirin for anticoagulation. b. correct method for taking the radial pulse. c. need for frequent laboratory blood testing. d. possibility of valve replacement in 7 to 10 years.

C Anticoagulation with warfarin (Coumadin) is needed for a patient with mechanical valves to prevent clotting on the valve; this will require frequent international normalized ratio (INR) testing. Daily aspirin use will not be effective in reducing risk for clots on the valve. Mechanical valves are durable and would last longer than 7 to 10 years. Monitoring of the radial pulse is not necessary after valve replacement. DIF: Cognitive Level: Application REF: 857 | 859 TOP: Nursing Process: Implementation

25. Immediately after the nurse administers an intracutaneous injection of an allergen on the forearm, a patient complains of itching at the site and of weakness and dizziness. The nurse should first a. remind the patient to remain calm. b. administer subcutaneous epinephrine. c. apply a tourniquet above the injection site. d. rub a local anti-inflammatory cream on the site.

C Application of a tourniquet will decrease systemic circulation of the allergen and should be the first reaction. A local anti-inflammatory cream may be applied to the site of a cutaneous test if the itching persists. Epinephrine will be needed if the allergic reaction progresses to anaphylaxis. The nurse should assist the patient to remain calm, but this is not an adequate initial nursing action. DIF: Cognitive Level: Application REF: 223 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

6. The nurse is caring for a spontaneously breathing patient who has a tracheostomy. To determine that the patient can protect the airway when eating without having the tracheostomy cuff inflated, the nurse will deflate the cuff and a. ask the patient to say a few sentences. b. monitor for signs of respiratory distress. c. have the patient drink a small amount of grape juice and observe for coughing. d. auscultate the lungs for crackles after having the patient take a few sips of water.

C Assessing the ability of the patient to drink a colored fluid, such as grape juice, will provide evidence that the patient will not aspirate. Even if the patient is able to talk, aspiration may occur. Because the patient is already breathing spontaneously, deflating the cuff would not cause respiratory distress. Crackles are not present immediately after aspiration, since the inflammatory process takes time to occur. DIF: Cognitive Level: Application REF: 534 TOP: Nursing Process: Implementation

7. When admitting a patient with a stroke who is unconscious and unresponsive to stimuli, the nurse learns from the patient's family that the patient has a history of gastroesophageal reflux disease (GERD). The nurse will plan to do frequent assessments of the patient's a. apical pulse. b. bowel sounds. c. breath sounds. d. abdominal girth.

C Because GERD may cause aspiration, the unconscious patient is at risk for developing aspiration pneumonia. Bowel sounds, abdominal girth, and apical pulse will not be affected by the patient's stroke or GERD and do not require more frequent monitoring than the routine. DIF: Cognitive Level: Application REF: 972-973 TOP: Nursing Process: Assessment

9. Prednisone (Deltasone) is prescribed for a patient with an acute exacerbation of rheumatoid arthritis. Which laboratory result will the nurse monitor to determine whether the medication has been effective? a. Blood glucose test b. Liver function tests c. C-reactive protein level d. Serum electrolyte levels

C C-reactive protein is a marker for inflammation, and a decrease would indicate that the corticosteroid therapy was effective. Blood glucose and serum electrolyte levels also will be monitored to check for side effects of prednisone. Liver function is not routinely monitored for patients receiving steroids. DIF: Cognitive Level: Application REF: 1653-1655 TOP: Nursing Process: Evaluation

5. A 51-year-old woman at menopause is considering the use of hormone replacement therapy (HRT) but is concerned about the risk of breast cancer. Which information will the nurse include when discussing HRT with the patient? a. HRT does not appear to increase the risk for breast cancer unless there are other risk factors. b. HRT is a safe therapy for menopausal symptoms if there is no family history of BRCA genes. c. She and her health care provider must weigh the benefits of HRT against the possible risks of breast cancer. d. Alternative therapies with herbs and natural drugs are as effective as estrogen in relieving menopausal symptoms.

C Because HRT has been linked to increased risk for breast cancer, the patient and provider must determine whether or not to use HRT. Breast cancer incidence is increased in women using HRT, independent of other risk factors. HRT increases the risk for both non-BRCA-associated cancer and BRCA-related cancers. Alternative therapies can be used but are not consistent in relieving menopausal symptoms. DIF: Cognitive Level: Application REF: 1311 TOP: Nursing Process: Implementation

28. When the nurse is assessing a patient with myasthenia gravis, which action will be most important to take? a. Check pupillary size. b. Monitor grip strength. c. Observe respiratory effort. d. Assess level of consciousness.

C Because respiratory insufficiency may be life threatening, it will be most important to monitor respiratory function. The other data also will be assessed but are not as critical. DIF: Cognitive Level: Application REF: 1512-1514 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

7. A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action will be included in the plan of care? a. Leave the tracheostomy inner cannula inserted at all times. b. Place the decannulation cap in the tube before cuff deflation. c. Assess the ability to swallow before using the fenestrated tube. d. Inflate the tracheostomy cuff during use of the fenestrated tube.

C Because the cuff is deflated when using a fenestrated tube, the patient's risk for aspiration should be assessed before changing to a fenestrated tracheostomy tube. The decannulation cap is never inserted before cuff deflation because to do so would obstruct the patient's airway. The cuff is deflated and the inner cannula removed to allow air to flow across the patient's vocal cords when using a fenestrated tube. DIF: Cognitive Level: Application REF: 529 | 535 TOP: Nursing Process: Planning

1. A patient with deep partial-thickness burns experiences severe pain associated with nausea during dressing changes. Which action will be most useful in decreasing the patient's nausea? a. The patient NPO for 2 hours before and after dressing changes. b. Avoid performing dressing changes close to the patient's mealtimes. c. Administer the prescribed morphine sulfate before dressing changes. d. Give the ordered prochlorperazine (Compazine) before dressing changes.

C Because the patient's nausea is associated with severe pain, it is likely that it is precipitated by stress and pain. The best treatment will be to provide adequate pain medication before dressing changes. The nurse should avoid doing painful procedures close to mealtimes, but nausea/vomiting that occur at other times also should be addressed. Keeping the patient NPO does not address the reason for the nausea and vomiting and will have an adverse effect on the patient's nutrition. Administration of antiemetics is not the best choice for a patient with nausea caused by pain. DIF: Cognitive Level: Application REF: 963-964 TOP: Nursing Process: Implementation

21. Which nursing action is most important to include in the plan of care for a patient who had an abdominal-perineal resection the previous day? a. Teach about a low-residue diet. b. Monitor output from the stoma. c. Assess the perineal drainage and incision. d. Encourage acceptance of the colostomy stoma.

C Because the perineal wound is at high risk for infection, the initial care is focused on assessment and care of this wound. Teaching about diet is best done closer to discharge from the hospital. There will be very little drainage into the colostomy until peristalsis returns. The patient will be encouraged to assist with the colostomy, but this is not the highest priority in the immediate postoperative period. DIF: Cognitive Level: Application REF: 1039 TOP: Nursing Process: Planning

9. A patient who receives weekly immunotherapy at a clinic missed the previous appointment. When the patient comes for the next injection, the nurse should a. schedule an additional dose that week. b. administer the usual dosage of the allergen. c. consult with the health care provider about giving a lower allergen dose. d. re-evaluate the patient's sensitivity to the allergen with a repeat skin test.

C Because there is an increased risk for adverse reactions after a patient misses a scheduled dose of allergen, the nurse should check with the health care provider before administration of the injection. A skin test is used to identify the allergen and would not be used at this time. An additional dose for the week may increase the risk for a reaction. DIF: Cognitive Level: Application REF: 224 TOP: Nursing Process: Implementation

35. When the nurse is reviewing laboratory data for a patient who is taking methotrexate (Rheumatrex) to treat rheumatoid arthritis, which information is most important to communicate to the health care provider? a. The blood glucose is 75 mg/dL. b. The rheumatoid factor is positive. c. The white blood cell (WBC) count is 1500/μL. d. The erythrocyte sedimentation rate is elevated.

C Bone marrow suppression is a possible side effect of methotrexate, and the patient's low WBC count places the patient at high risk for infection. The elevated erythrocyte sedimentation rate and positive rheumatoid factor are expected in rheumatoid arthritis. The blood glucose is normal. DIF: Cognitive Level: Application REF: 1647-1649 OBJ: Special Questions: Prioritization TOP: Nursing Process: Evaluation

29. Which instructions will the nurse include in discharge teaching for a patient who has had a hemorrhoidectomy at an outpatient surgical center? a. Maintain a low-residue diet until the surgical area is healed. b. Use ice packs on the perianal area to relieve pain and swelling. c. Take prescribed pain medications before a bowel movement is expected. d. Delay having a bowel movement for several days until healing has occurred.

C Bowel movements may be very painful, and patients may avoid defecation unless pain medication is taken before the bowel movement. Delay of bowel movements is likely to lead to constipation. A high-residue diet will increase stool bulk and prevent constipation. Sitz baths are used to relieve pain and keep the surgical area clean. DIF: Cognitive Level: Application REF: 1053 TOP: Nursing Process: Implementation

21. A patient who has severe pain associated with terminal liver cancer is being cared for at home by family members. Which finding by the nurse indicates that teaching regarding pain management has been effective? a. The patient agrees to take the medications by the IV route in order to improve analgesic effectiveness. b. The patient uses the ordered opioid pain medication whenever the pain is greater than 5 (0 to 10 scale). c. The patient takes opioids around the clock on a regular schedule and uses additional doses when breakthrough pain occurs. d. The patient states that nonopioid analgesics may be used when the maximal dose of the opioid is reached without adequate pain relief.

C For chronic cancer pain, analgesics should be taken on a scheduled basis, with additional doses as needed for breakthrough pain. Taking the medications only when pain reaches a certain level does not provide effective pain control. Although nonopioid analgesics also may be used, there is no maximum dose of opioid. Opioids are given until pain control is achieved. The IV route is not more effective than the oral route, and the oral route is preferred. DIF: Cognitive Level: Application REF: 295-296 TOP: Nursing Process: Evaluation

25. When providing preoperative instruction for a patient scheduled for a left pneumonectomy for cancer of the lung, the nurse informs the patient that the postoperative care includes a. positioning on the right side. b. bed rest for the first 24 hours. c. frequent use of an incentive spirometer. d. chest tubes to water-seal chest drainage.

C Frequent deep breathing and coughing are needed after chest surgery to prevent atelectasis. To promote gas exchange, patients after pneumonectomy are positioned on the surgical side. Chest tubes are not usually used after pneumonectomy because the affected side is allowed to fill with fluid. Early mobilization decreases the risk for postoperative complications such as pneumonia and deep vein thrombosis. DIF: Cognitive Level: Application REF: 573 TOP: Nursing Process: Planning

22. Which of the following information obtained by the nurse who is caring for a patient with end-stage renal disease (ESRD) indicates the nurse should consult with the health care provider before giving the prescribed epoetin alfa (Procrit)? a. Creatinine 1.2 mg/dL b. Oxygen saturation 89% c. Hemoglobin level 13 g/dL d. Blood pressure 98/56 mm Hg

C High hemoglobin levels are associated with a higher rate of thromboembolic events and increased risk of death from serious cardiovascular events (heart attack, heart failure, stroke) when EPO is administered to a target hemoglobin of >12 g/dL. Hemoglobin levels higher than 12 g/dL indicate a need for a decrease in epoetin alfa dose. The other information also will be reported to the health care provider, but will not affect whether the medication is administered. DIF: Cognitive Level: Application REF: 1176-1177 TOP: Nursing Process: Assessment

12. A patient who had a total laryngectomy has a nursing diagnosis of hopelessness related to loss of control of personal care. Which information obtained by the nurse is the best indicator that the problem identified in this nursing diagnosis is resolving? a. The patient lets the spouse provide tracheostomy care. b. The patient allows the nurse to suction the tracheostomy. c. The patient asks how to clean the tracheostomy stoma and tube. d. The patient uses a communication board to request "No Visitors."

C Independently caring for the laryngectomy tube indicates that the patient has regained control of personal care and hopelessness is at least partially resolved. Letting the nurse and spouse provide care and requesting no visitors may indicate that the patient is still experiencing hopelessness. DIF: Cognitive Level: Application REF: 539-540 | 542 TOP: Nursing Process: Evaluation

18. When assessing a patient who had a liver transplant a week previously, the nurse obtains the following data. Which finding is most important to communicate to the health care provider? a. Dry lips and oral mucosa b. Crackles at both lung bases c. Temperature 100.8° F (38.2° C) d. No bowel movement for 4 days

C Infection risk is high in the first few months after liver transplant and fever is frequently the only sign of infection. The other patient data indicate the need for further assessment or nursing actions, but do not indicate a need for urgent action. DIF: Cognitive Level: Application REF: 1088 TOP: Nursing Process: Implementation

30. When assessing the need for psychologic support after the patient has been diagnosed with stage I cancer of the colon, which question by the nurse will provide the most information? a. "How long ago were you diagnosed with this cancer?" b. "Do you have any concerns about body image changes?" c. "Can you tell me what has been helpful to you in the past when coping with stressful events?" d. "Are you familiar with the stages of emotional adjustment to a diagnosis like cancer of the colon?"

C Information about how the patient has coped with past stressful situations helps the nurse determine usual coping mechanisms and their effectiveness. The length of time since the diagnosis will not provide much information about the patient's need for support. The patient's knowledge of typical stages in adjustment to a critical diagnosis does not provide insight into patient needs for assistance. Since surgical interventions for stage I cancer of the colon may not cause any body image changes, this question is not appropriate at this time. DIF: Cognitive Level: Application REF: 296 TOP: Nursing Process: Assessment

1. After teaching a patient about management of migraine headaches, the nurse determines that the teaching has been effective when the patient says, a. "I will take the (Topamax) as soon as any headaches start." b. "I should avoid taking aspirin and sumatriptan (Imitrex) at the same time." c. "I will try to lie down someplace dark and quiet when the headaches begin." d. "A glass of wine might help me relax and prevent headaches from developing."

C It is recommended that the patient with a migraine rest in a dark, quiet area. Topiramate (Topamax) is used to prevent migraines and must be taken for several months to determine effectiveness. Aspirin or other nonsteroidal anti-inflammatory medications can be taken with the triptans. Alcohol may precipitate migraine headaches. DIF: Cognitive Level: Application REF: 1490-1494 TOP: Nursing Process: Evaluation

24. Which of the following nursing interventions for the patient who has had right-sided breast-conservation surgery and an axillary lymph node dissection is appropriate to delegate to an LPN/LVN? a. Teaching the patient how to avoid injury to the right arm b. Assessing the patient's range of motion for the right arm c. Administering an analgesic 30 minutes before the scheduled arm exercises d. Evaluating the patient's understanding of discharge instructions about drain care

C LPN/LVN education and scope of practice include administration and evaluation of the effects of analgesics. Assessment, teaching, and evaluation of a patient's understanding of instructions are more complex tasks that are more appropriate to RN level education and scope of practice. DIF: Cognitive Level: Application REF: 1320-1324 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC:

9. A patient returns to the surgical unit following a right modified radical mastectomy with dissection of axillary lymph nodes. Which nursing action should be included in the plan of care? a. Insist that the patient examine the surgical incision when the dressings are removed. b. Teach the patient to use the ordered patient-controlled analgesia (PCA) every 10 minutes. c. Post a sign at the bedside warning against blood pressures or venipunctures in the right arm. d. Obtain a permanent breast prosthesis for the patient before she is discharged from the hospital.

C The patient is at risk for lymphedema and infection if blood pressures or venipuncture are done on the right arm. The patient is taught to use the PCA as needed for pain control rather than at a set time. The nurse allows the patient to examine the incision and participate in care when the patient feels ready. Permanent breast prostheses are usually obtained about 6 weeks after surgery. DIF: Cognitive Level: Application REF: 1320-1323 TOP: Nursing Process: Planning

5. During a routine health examination, a 30-year-old patient tells the nurse about a family history of colon cancer. Which action should the nurse take next? a. Educate the patient about the need for a colonoscopy at age 50. b. Teach the patient how to do home testing for fecal occult blood. c. Obtain more information from the patient about the family history. d. Schedule a sigmoidoscopy to provide baseline data about the patient.

C The patient may be at increased risk for colon cancer, but the nurse's first action should be further assessment. The other actions may be appropriate, depending on the information that is obtained from the patient with further questioning. DIF: Cognitive Level: Application REF: eTable 16-3 TOP: Nursing Process: Implementation

26. A 22-year-old with acute myelogenous leukemia who is receiving outpatient chemotherapy develops an absolute neutrophil count of 900/µl. Which action by the nurse in the outpatient clinic is most appropriate? a. Discuss the need for hospital admission to treat the neutropenia. b. Plan to discontinue the chemotherapy until the neutropenia resolves. c. Teach the patient how to administer filgrastim (Neupogen) injections at home. d. Obtain a high-efficiency particulate air (HEPA) filter for the patient for home use.

C The patient may be taught to self-administer filgrastim injections. Although chemotherapy may be stopped with severe neutropenia (neutrophil count less than 500/µl), 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. DIF: Cognitive Level: Application REF: 690 | 693 TOP: Nursing Process: Implementation

17. The health care provider plans a paracentesis for a patient with ascites caused by liver cancer. To prepare the patient for the procedure, the nurse a. places the patient on NPO status. b. assists the patient to lie flat in bed. c. asks the patient to empty the bladder. d. positions the patient on the right side.

C The patient should empty the bladder to decrease the risk of bladder perforation during the procedure. The patient would be positioned in Fowler's position and would not be able to lie flat without compromising breathing. Since no sedation is required for paracentesis, the patient does not need to be NPO. DIF: Cognitive Level: Application REF: 1081 | 1083-1084 TOP: Nursing Process: Implementation

27. While teaching a patient who has a new diagnosis of acute leukemia about the complications associated with chemotherapy, the patient is restless and is looking away, never making eye contact. After the teaching, the patient asks the nurse to repeat all of the information. Based on this assessment, which nursing diagnosis is most likely for the patient? a. Risk for ineffective adherence to treatment related to denial of need for chemotherapy b. Acute confusion related to infiltration of leukemia cells into the central nervous system c. Risk for ineffective health maintenance related to anxiety about new leukemia diagnosis d. Knowledge deficit: chemotherapy related to a lack of interest in learning about treatment

C The patient who has a new cancer diagnosis is likely to have high anxiety, which may impact learning and require that the nurse repeat and reinforce information. The patient's history of a recent diagnosis suggests that infiltration of the leukemia is not a likely cause of the confusion. The patient asks for the information to be repeated, indicating that lack of interest in learning and denial are not etiologic factors. DIF: Cognitive Level: Application REF: 270 TOP: Nursing Process: Diagnosis

26. A patient with cancer has a nursing diagnosis of imbalanced nutrition: less than body requirements related to altered taste sensation. Which nursing action is most appropriate? a. Add strained baby meats to foods such as casseroles. b. Teach the patient about foods that are high in nutrition. c. Avoid giving the patient foods that are strongly disliked. d. Put extra spice in the foods that are served to the patient.

C The patient will eat more if disliked foods are avoided and foods that the patient likes are included instead. Additional spice is not usually an effective way to enhance taste. Adding baby meats to foods will increase calorie and protein levels, but does not address the issue of taste. The patient's poor intake is not caused by a lack of information about nutrition. DIF: Cognitive Level: Application REF: 293 TOP: Nursing Process: Implementation

10. While obtaining a health history from the patient who works as a laboratory technician, the nurse learns that the patient has a history of allergic rhinitis, asthma, and multiple food allergies. It is important that the nurse a. encourage the patient to carry an epinephrine kit in case a type IV allergic reaction to latex develops. b. advise the patient to use oil-based hand creams to decrease contact with natural proteins in latex gloves. c. document the patient's allergy history and be alert for any clinical manifestations of a type I latex allergy. d. recommend that the patient use vinyl gloves instead of latex gloves in preventing blood-borne pathogen contact.

C The patient's allergy history and occupation indicate a risk for development of latex allergy, and the nurse should be prepared to manage any symptoms that occur. Epinephrine is not an appropriate treatment for contact dermatitis that is caused by a type IV allergic reaction to latex. Oil-based creams will increase the exposure to latex from latex gloves. Vinyl gloves are appropriate to use when exposure to body fluids is unlikely. DIF: Cognitive Level: Application REF: 224-225 TOP: Nursing Process: Implementation

7. A patient is admitted to the hospital for evaluation of right lower quadrant abdominal pain with nausea and vomiting. Which action should the nurse take? a. Check for rebound tenderness. b. Assist the patient to cough and deep breathe. c. Apply an ice pack to the right lower quadrant. d. Encourage the patient to take sips of clear liquids.

C The patient's clinical manifestations are consistent with appendicitis, and application of an ice pack will decrease inflammation at the area. The patient should be NPO in case immediate surgery is needed. Checking for rebound tenderness frequently is unnecessary and uncomfortable for the patient. The patient will need to know how to cough and deep breathe postoperatively, but coughing will increase pain at this time. DIF: Cognitive Level: Application REF: 1020-1021 TOP: Nursing Process: Implementation

1. A patient with anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patient's laboratory findings to include a. normal red blood cell (RBC) indices. b. a hematocrit (Hct) of 38%. c. a hemoglobin (Hb) of 8.6 g/dL (86 g/L). d. an RBC count of 4,500,000/μL.

C The patient's clinical manifestations indicate moderate anemia, which is consistent with an Hb of 6 to 10 g/dL. The other values are all within the range of normal. DIF: Cognitive Level: Comprehension REF: 662 | 663 TOP: Nursing Process: Assessment

16. While working at a summer camp, the nurse notices a circular lesion with a red border and clear center on the arm of a patient who is in the camp clinic complaining of chills and muscle aches. Which action should the nurse take next? a. Palpate the abdomen. b. Auscultate the heart sounds. c. Ask the patient about recent outdoor activities. d. Question the patient about immunization history.

C The patient's clinical manifestations suggest possible Lyme disease. A history of recent outdoor activities such as hikes will help confirm the diagnosis. The patient's symptoms do not suggest cardiac or abdominal problems or lack of immunization. DIF: Cognitive Level: Application REF: 1663-1664 TOP: Nursing Process: Assessment

34. During hemodialysis, a patient complains of nausea and dizziness. Which action should the nurse take first? a. Slow down the rate of dialysis. b. Obtain blood to check the blood urea nitrogen (BUN) level. c. Check the patient's blood pressure. d. Give prescribed PRN antiemetic drugs.

C The patient's complaints of nausea and dizziness suggest hypotension, so the initial action should be to check the BP. The other actions also may be appropriate, based on the blood pressure obtained. DIF: Cognitive Level: Application REF: 1186-1187 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

7. A home health patient with rheumatoid arthritis (RA) complains to the nurse about having chronically dry eyes. Which action by the nurse is most appropriate? a. Reassure the patient that dry eyes are a common problem with RA. b. Teach the patient more about adverse affects of the RA medications. c. Suggest that the patient start using over-the-counter (OTC) artificial tears. d. Ask the health care provider about lowering the methotrexate (Rheumatrex) dose.

C The patient's dry eyes are consistent with Sjögren's syndrome, a common extraarticular manifestation of RA. Symptomatic therapy such as OTC eye drops is recommended. Dry eyes are not a side effect of methotrexate. Although dry eyes are common in RA, it is more helpful to offer a suggestion to relieve these symptoms than to offer reassurance. The dry eyes are not caused by RA treatment, but by the disease itself. DIF: Cognitive Level: Application REF: 1676 TOP: Nursing Process: Implementation

37. After receiving change-of-shift report, which patient should the nurse assess first? a. A patient who was admitted yesterday with gastrointestinal (GI) bleeding and has melena b. A patient who is crying after receiving a diagnosis of esophageal cancer c. A patient with esophageal varices who has a blood pressure of 96/54 mm Hg d. A patient with nausea who has a dose of metoclopramide (Reglan) scheduled

C The patient's history and blood pressure indicate possible hemodynamic instability caused by GI bleeding. The data about the other patients do not indicate acutely life-threatening complications. DIF: Cognitive Level: Application REF: 980-982 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC:

41. A patient with acute gastrointestinal (GI) bleeding is receiving normal saline IV at a rate of 500 mL/hr. Which assessment finding obtained by the nurse is most important to communicate immediately to the health care provider? a. The patient's blood pressure (BP) has increased to 142/94 mm Hg. b. The nasogastric (NG) suction is returning coffee-ground material. c. The patient's lungs have crackles audible to the midline. d. The bowel sounds are very hyperactive in all four quadrants.

C The patient's lung sounds indicate that pulmonary edema may be developing as a result of the rapid infusion of IV fluid and that the fluid infusion rate should be slowed. The return of coffee-ground material in an NG tube is expected for a patient with upper GI bleeding. The BP is slightly elevated but would not be an indication to contact the health care provider immediately. Hyperactive bowel sounds are common when a patient has GI bleeding. DIF: Cognitive Level: Application REF: 984 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

11. A 62-year-old patient who has been diagnosed with esophageal cancer tells the nurse, "I know that my chances are not very good, but I do not feel ready to die yet." Which response by the nurse is most appropriate? a. "You may have quite a few years still left to live." b. "Thinking about dying will only make you feel worse." c. "Having this new diagnosis must be very hard for you." d. "It is important that you be realistic about your prognosis."

C This response is open-ended and will encourage the patient to further discuss feelings of anxiety or sadness about the diagnosis. Patients with esophageal cancer have only a low survival rate, so the response "You may have quite a few years still left to live" is misleading. The response beginning, "Thinking about dying" indicates that the nurse is not open to discussing the patient's fears of dying. And the response beginning, "It is important that you be realistic," discourages the patient from feeling hopeful, which is important to patients with any life-threatening diagnosis. DIF: Cognitive Level: Application REF: 977-979 TOP: Nursing Process: Implementation

7. The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action will the nurse take? a. Repeat the tuberculin skin testing. b. Teach about the reason for the blood tests. c. Obtain consecutive sputum specimens from the patient for 3 days. d. Instruct the patient to expectorate three specimens as soon as possible.

C Three consecutive sputum specimens are obtained on different days for bacteriologic testing for M. tuberculosis. The patient should not provide all the specimens at once. Blood cultures are not used for tuberculosis testing. Once skin testing is positive, it is not repeated. DIF: Cognitive Level: Application REF: 555 TOP: Nursing Process: Implementation

22. When the nurse is admitting a patient who has acute rejection of an organ transplant, which of these already admitted patients will be the most appropriate roommate? a. A patient who has viral pneumonia b. A patient with second degree burns c. A patient who is recovering from an anaphylactic reaction to a bee sting d. A patient with graft-versus-host disease after a recent bone marrow transplant

C Treatment for a patient with acute rejection includes administration of additional immunosuppressants, and the patient should not be exposed to increased risk for infection as would occur from patients with viral pneumonia, graft-versus-host disease, and burns. There is no increased exposure to infection from a patient with anaphylaxis. DIF: Cognitive Level: Application REF: 230 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning MSC:

2. When a patient is experiencing a cluster headache, the nurse will plan to assess for a. nuchal rigidity. b. projectile vomiting. c. unilateral eyelid swelling. d. throbbing, bilateral facial pain.

C Unilateral eye edema, tearing, and ptosis are characteristic of cluster headaches. Nuchal rigidity suggests meningeal irritation, such as occurs with meningitis. Although nausea and vomiting may occur with migraine headaches, projectile vomiting is more consistent with increases in intracranial pressure (ICP). Unilateral sharp, stabbing pain, rather than throbbing pain, is characteristic of cluster headaches. DIF: Cognitive Level: Comprehension REF: 1490 TOP: Nursing Process: Assessment

20. A 22-year-old patient with Escherichia coli O157:H7 food poisoning is admitted to the hospital with bloody diarrhea and dehydration. All of the following orders are received. Which order will the nurse question? a. Infuse lactated Ringer's solution at 250 mL/hr. b. Monitor blood urea nitrogen and creatinine daily. c. Administer loperamide (Imodium) after each stool. d. Provide a clear liquid diet and progress diet as tolerated.

C Use of antidiarrheal agents is avoided with this type of food poisoning. The other orders are appropriate. DIF: Cognitive Level: Application REF: 1001-1002 TOP: Nursing Process: Implementation

12. A patient who has an exacerbation of ulcerative colitis is having 15 to 20 stools daily and has excoriated perianal skin. Which patient behavior indicates that teaching regarding maintenance of skin integrity has been effective? a. The patient uses incontinence briefs to contain loose stools. b. The patient asks for antidiarrheal medication after each stool. c. The patient uses witch hazel compresses to decrease anal irritation. d. The patient cleans the perianal area with soap and water after each stool.

C Witch hazel compresses are suggested to reduce anal irritation and discomfort. Incontinence briefs may trap diarrhea and increase the incidence of skin breakdown. Antidiarrheal medications are not given 15 to 20 times a day. The perianal area should be washed with plain water after each stool. DIF: Cognitive Level: Application REF: 1029 TOP: Nursing Process: Evaluation

25. The nurse teaches a patient with cancer of the liver about high-protein, high-calorie diet choices. Which snack choice by the patient indicates that the teaching has been effective? a. Orange sherbet b. Fresh fruit salad c. Strawberry yogurt d. Cream cheese bagel

C Yogurt has high biologic value because of the protein and fat content. Fruit salad does not have high amounts of protein or fat. Orange sherbet is lower in fat and protein than yogurt. Cream cheese is low in protein. DIF: Cognitive Level: Application REF: 293 TOP: Nursing Process: Evaluation

3. Interferon β-1b (Betaseron) has been prescribed for a young woman who has been diagnosed with relapsing-remitting multiple sclerosis. The nurse determines that additional teaching about the drug is needed when the patient says, "I will need to rotate injection sites with each dose I inject." "I should report any depression or suicidal thoughts that develop." "I should avoid direct sunlight and use sunscreen and protective clothing when out of doors." "because this drug is a corticosteroid, I should reduce my sodium intake to prevent edema."

3. The nurse performs a breast examination on a female patient. Which clinical manifestation, if assessed by the nurse, indicates that further evaluation for breast cancer is needed? Bilateral pendulous breasts Palpable lump that is freely movable and tender Breast is warm to touch, indurated, and painful Irregular, nonmobile, nontender lump with induration

1. A patient has the following arterial blood gas results: pH 7.52; PaCO2 30 mm Hg; HCO3- 24 mEq/L. The nurse determines that these results indicate A. metabolic acidosis. B. metabolic alkalosis. C. respiratory acidosis. D. respiratory alkalosis

1. A patient in the allergy clinic develops all of these clinical manifestations after receiving an intradermal injection of an allergen. Which symptom requires the most immediate action by the nurse? A. Anxiety B. Utricaria C. Pruritis D. Stridor

1. A patient with thrombocytopenia is being discharged. What information does the nurse incorporate into the teaching plan for this patient? A. "Avoid large crowds." B. "Drink at least 2 liters of fluid per day." C. "Elevate your lower extremities when sitting." D. "Use a soft-bristled toothbrush."

12. Which nursing action is most appropriate for the nurse working in an allergy clinic to delegate to a nursing assistant? A. Plan the schedule for desensitization therapy for a patient with allergies B. Monitor the patient who has just received skin testing for signs of Anaphylaxis C. Educate the patient with a latex allergy about other substances with cross-sensitivity to latex D. Remind the patient to stay at the clinic for 30 minutes after receiving intradermal allergy testing

13. The RN is caring for a client with end-stage liver disease that has resulted in ascites. Which action does the RN delegate to unlicensed assistive personnel (UAP)? A. Assessing skin integrity and abdominal distention B. Drawing blood from a central venous line for electrolyte studies C. Evaluating laboratory study results for the presence of hypokalemia D. Placing the client in a semi-Fowlers position

13. The nurse is teaching a patient with scleroderma about different exercises to prevent complications. The nurse knows that teaching as been effective when the patient states A. "This will help built muscle strength." B. "I need to do this to improve my cardiac health." C. "Exercises will prevent my joints from becoming arthritic." D. "The exercises will help prevent skin retraction and promote vascularization."

14. Which statement by a client with cirrhosis indicates that further instruction is needed about the disease? A. "Cirrhosis is a chronic disease that has scarred my liver." B. "The scars on my liver create problems with blood circulation." C. "Because of the scars on my liver, blood clotting and blood pressure are affected." D. "My liver is scarred, but the cells can regenerate themselves and repair the damage."

2. The nurse admits a patient with advanced Parkinson's disease at the outpatient clinic with a cough and fever. During assessment of the patient, the nurse would expect to find Slurred speech, visual disturbances, and ataxia Muscle atrophy, spasticity, and speech difficulties Muscle weakness, double vision, and reports of fatigue Drooling, stooped posture, tremors, and a propulsive gait

2. The nurse is caring for a patient after a parathyroidectomy related to hyperparathyroidism. The nurse should administer intravenous calcium gluconate if the patient exhibits which clinical manifestations? A. Decreased muscle tone and muscle weakness B. Shortened QT interval on the electrocardiogram C. Tingling of the hands and around the mouth D. Muscle spasms or laryngospasms

2. The nurse teaches a patient with gouty arthritis about food that may be consumed on a low-purine diet. Which food item, if selected by the patient, would indicate an understanding of the instructions? A. Chicken B. Salmon C. Liver D. Eggs

3. In the care of a patient with acute pancreatitis, which assessment parameter requires immediate nursing intervention? A. Heart rate of 105 beats/min B.Serum glucose of 136 mg/dL C. Blood pressure of 102/76 mm Hg D. Respiratory rate of 28 breaths/min

19. During preoperative preparation for a patient scheduled for an abdominal-perineal resection, the nurse will a. give IV antibiotics starting 24 hours before surgery to reduce the number of bowel bacteria. b. teach the patient that activities such as sitting at the bedside will be started the first postoperative day. c. instruct the patient that another surgery in 8 to 12 weeks will be used to create an ileal-anal reservoir. d. administer polyethylene glycol lavage solution (GoLYTELY) to ensure that the bowel is empty before the surgery.

D A bowel-cleansing agent is used to empty the bowel before surgery to reduce the risk for infection. Oral antibiotics (rather than IV antibiotics) are given to reduce colonic and rectal bacteria. Sitting is contraindicated after an abdominal-perineal resection. A permanent colostomy is created with this surgery. DIF: Cognitive Level: Application REF: 1036-1038 TOP: Nursing Process: Implementation

3. In teaching a patient who has chronic constipation about the use of psyllium (Metamucil), which information will the nurse include? a. Absorption of fat-soluble vitamins may be reduced by fiber-containing laxatives. b. Dietary sources of fiber should be eliminated to prevent excessive gas formation. c. Use of this type of laxative to prevent constipation does not cause adverse effects. d. Large amounts of fluid should be taken to prevent impaction or bowel obstruction.

D A high fluid intake is needed when patients are using bulk-forming laxatives to avoid worsening constipation. Although bulk-forming laxatives are generally safe, the nurse should emphasize the possibility of constipation or obstipation if inadequate fluid intake occurs. Although increased gas formation is likely to occur with increased dietary fiber, the patient should gradually increase dietary fiber and eventually may not need the psyllium. Fat-soluble vitamin absorption is blocked by stool softeners and lubricants, not by bulk-forming laxatives. DIF: Cognitive Level: Application REF: 1012-1014 TOP: Nursing Process: Implementation

29. Which information about a patient who is receiving immunotherapy and has just received an allergen injection is most important to communicate to the health care provider? a. The patient's IgG level is increased. b. The injection site is red and swollen. c. The patient's allergy symptoms have not improved. d. There is a 3-cm wheal at the site of the allergen injection.

D A local reaction larger than quarter size may indicate that a decrease in the allergen dose is needed. An increase in IgG indicates that the therapy is effective. Redness and swelling at the site are not unusual. Because immunotherapy usually takes 1 to 2 years to achieve an effect, an improvement in the patient's symptoms is not expected after a few months. DIF: Cognitive Level: Application REF: 224 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

29. When the nurse is caring for a patient with acute pancreatitis, which assessment finding is of most concern? a. Absent bowel sounds b. Abdominal tenderness c. Left upper quadrant pain d. Palpable abdominal mass

D A palpable abdominal mass may indicate the presence of a pancreatic abscess, which will require rapid surgical drainage to prevent sepsis. Absent bowel sounds, abdominal tenderness, and left upper quadrant pain are common in acute pancreatitis and do not require rapid action to prevent further complications. DIF: Cognitive Level: Application REF: 1089-1090 TOP: Nursing Process: Assessment

27. Which patient education will the nurse provide before discharge for a patient who has had a herniorrhaphy to repair an incarcerated inguinal hernia? a. Encourage the patient to cough. b. Provide sitz baths several times daily. c. Avoid use of acetaminophen (Tylenol) for pain. d. Apply a scrotal support and ice to reduce swelling.

D A scrotal support and ice are used to reduce edema and pain. Coughing will increase pressure on the incision. Sitz baths will not relieve pain and would not be of use after this surgery. Acetaminophen can be used for postoperative pain. DIF: Cognitive Level: Application REF: 1049-1050 TOP: Nursing Process: Implementation

17. A patient has a large bowel obstruction that occurred as a result of diverticulosis. When assessing the patient, the nurse will plan to monitor for a. referred back pain. b. metabolic alkalosis. c. projectile vomiting. d. abdominal distention.

D Abdominal distention is seen in lower intestinal obstruction. Metabolic alkalosis is common in high intestinal obstruction because of the loss of HCl acid from vomiting. Referred back pain is not a common clinical manifestation of intestinal obstruction. Bile-colored vomit is associated with higher intestinal obstruction. DIF: Cognitive Level: Application REF: 1031-1033 TOP: Nursing Process: Assessment

37. Which of the following nursing actions included in the care plan for a patient with neutropenia is appropriate for the RN to delegate to an LPN/LVN who is assisting with patient care? a. Assessing the patient for signs and symptoms of infection b. Teaching the patient the purpose of neutropenic precautions c. Developing a discharge teaching plan for the patient and family d. Administering the ordered subcutaneous filgrastim (Neupogen) injection

D Administration of medications is included in LPN/LVN education and scope of practice. Patient education, assessment, and developing the plan of care require RN level education and scope of practice. DIF: Cognitive Level: Application REF: 690 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation MSC:

23. After a transurethral resection of the prostate (TURP), a patient with continuous bladder irrigation complains of painful bladder spasms. The nurse observes a decrease in urine output and clots in the urine. Which action should the nurse take first? a. Increase the flow rate of the bladder irrigation. b. Administer the prescribed IV morphine sulfate. c. Give the patient the prescribed belladonna and opium suppository. d. Manually instill and then withdraw 50 mL of saline into the catheter.

D The assessment suggests that obstruction by a clot is causing the bladder spasms, and the nurse's first action should be to irrigate the catheter manually and to try to remove the clots. IV morphine will not decrease the spasm, although pain may be reduced. Increasing the flow rate of the irrigation will further distend the bladder and may increase spasms. The belladonna and opium suppository will decrease bladder spasms but will not remove the obstructing blood clot. DIF: Cognitive Level: Application REF: 1383-1384 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

13. Which nursing action will be most useful in assisting a 21-year-old college student to adhere to a newly prescribed antiretroviral therapy (ART) regimen? a. Give the patient detailed information about possible medication side effects. b. Remind the patient of the importance of taking the medications as scheduled. c. Encourage the patient to join a support group for students who are HIV positive. d. Check the patient's class schedule to help decide when the ART should be taken.

D The best approach to improve adherence is to learn about important activities in the patient's life and adjust the ART around those activities. The other actions also are useful, but they will not improve adherence as much as individualizing the ART to the patient's schedule. DIF: Cognitive Level: Application REF: 253 TOP: Nursing Process: Planning

27. A patient with Parkinson's disease has decreased tongue mobility and an inability to move the facial muscles. Which nursing diagnosis is of highest priority? a. Activity intolerance b. Self-care deficit: toileting c. Ineffective self-health management d. Imbalanced nutrition: less than body requirements

D The data about the patient indicate that poor nutrition will be a concern because of decreased swallowing. The other diagnoses also may be appropriate for a patient with Parkinson's disease, but the data do not indicate they are current problems for this patient. DIF: Cognitive Level: Application REF: 1511 OBJ: Special Questions: Prioritization TOP: Nursing Process: Diagnosis

17. A patient with ovarian cancer is distressed because her husband rarely visits and tells the nurse, "He just doesn't care." The husband indicates to the nurse that "I never know what to say to help her." An appropriate nursing diagnosis is a. compromised family coping related to disruption in lifestyle. b. impaired home maintenance related to perceived role changes. c. risk for caregiver role strain related to burdens of caregiving responsibilities. d. dysfunctional family processes related to effect of illness on family members.

D The data indicate that this diagnosis is most appropriate because poor communication among the family members is affecting family processes. No data suggest a change in lifestyle or its role as an etiology. The data do not support impairment in home maintenance or a burden caused by caregiving responsibilities. DIF: Cognitive Level: Application REF: 296 TOP: Nursing Process: Diagnosis

15. When reviewing the complete blood count (CBC) for a patient admitted with abdominal pain, which information will be most important for the nurse to communicate to the health care provider? a. Monocytes 4% b. Hemoglobin 11.6 g/dL c. Platelet count 145,000/µL d. White blood cells (WBCs) 13,500/µL

D The elevation in WBCs indicates that an abdominal infection may be the cause of the patient's pain and that further diagnostic testing is needed. The monocytes are at a normal level. The slight decreases in hemoglobin and platelet count also would be reported but would not require any immediate action. DIF: Cognitive Level: Application REF: 653-656 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

27. After noting lengthening QRS intervals in a patient with acute kidney injury (AKI), which action should the nurse take first? a. Document the QRS interval. b. Notify the patient's health care provider. c. Look at the patient's current blood urea nitrogen (BUN) and creatinine levels. d. Check the chart for the most recent blood potassium level.

D The increasing QRS interval is suggestive of hyperkalemia, so the nurse should check the most recent potassium and then notify the patient's health care provider. The BUN and creatinine will be elevated in a patient with AKI, but they would not directly affect the electrocardiogram (ECG). Documentation of the QRS interval also is appropriate, but interventions to decrease the potassium level are needed to prevent life-threatening bradycardia. DIF: Cognitive Level: Application REF: 1167 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

23. For early detection of an anaphylactic reaction in a patient who has received allergen testing using the cutaneous scratch method, which action should the nurse take first? a. Check blood pressure and pulse rate. b. Auscultate the lung sounds bilaterally. c. Monitor pupil size and reaction to light. d. Assess the arm at the site of the skin testing.

D The initial symptoms of anaphylaxis are itching and edema at the site of the exposure. Hypotension, tachycardia, dilated pupils, and wheezes occur later. Rapid administration of epinephrine when excessive itching or swelling at the skin site is observed can prevent the progression to anaphylaxis. DIF: Cognitive Level: Application REF: 218 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

Med Surg 2 Final

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Chapter 1

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