Med Surg 2 quiz questions
A patient has just returned to the postsurgical unit from post-anesthetic recovery after breast surgery for removal of a malignancy. What is the most likely major nursing diagnosis to include in this patient's immediate plan of care?
Acute pain related to tissue manipulation and incision
A nurse is planning the care of a patient with herpes zoster. What medication, if administered within the first 24 hours of the initial eruption, can arrest herpes zoster?
Acyclovir (Zovirax)
Which of the following is the medication of choice in the treatment of herpes simplex virus (HSV)?
Acyclovir (Zovirax)
A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP?
Administer stool softeners.
A client is admitted with acute osteomyelitis that developed after an open fracture of the right femur. When planning this client's care, the nurse should anticipate which measure?
Administering large doses of I.V. antibiotics as ordered
A nurse is amending a patient's plan of care in light of the fact that the patient has recently developed ascites. What should the nurse include in this patient's care plan?
Administration of diuretics as ordered
A nurse is providing an educational event to a local men's group about prostate cancer. The nurse should cite an increased risk of prostate cancer in what ethnic group?
African Americans
The nurse is educating a patient about performing testicular self-examination (TSE). The nurse informs the patient that the best time to perform the exam is when?
After a warm bath or shower
The nurse is talking with a client whowas stung by a bee and began having difficulty breathing. What serious complication from injected venom should the nurse discuss with the client?
Airway obstruction
The recovery room nurse is admitting a patient from the OR following the patient's successful splenectomy. What is the first assessment that the nurse should perform on this newly admitted patient?
Airway patency
Select the elements of assessment of a traumatic musculoskeletal injury to be included when a client is evaluated. Select all choices that are correct.
All should be included.
An older adult patient has been diagnosed with macular degeneration and the nurse is assessing him for changes in visual acuity since his last clinic visit. When assessing the patient for recent changes in visual acuity, the patient states that he sees the lines on an Amsler grid as being distorted. What is the nurse's most appropriate response?
Arrange for the patient to visit his ophthalmologist.
The nurse is providing discharge education to an adult patient who will begin a regimen of ocular medications for the treatment of glaucoma. How can the nurse best determine if the patient is able to self-administer these medications safely and effectively?
Ask the patient to demonstrate the instillation of her medications.
High doses of which of the following medications can produce bilateral tinnitus?
Aspirin
A patient with chronic kidney disease has been hospitalized and is receiving hemodialysis on a scheduled basis. The nurse should include which of the following actions in the plan of care?
Assess for a thrill or bruit over the vascular access site each shift.
The nurse is caring for a patient who has returned to the postsurgical suite after post-anesthetic recovery from a nephrectomy. The nurse's most recent hourly assessment reveals a significant drop in level of consciousness and BP as well as scant urine output over the past hour. What is the nurse's best response?
Assess the patient for signs of bleeding and inform the physician.
The nurse has implemented interventions aimed at facilitating family coping in the care of a patient with a traumatic brain injury. How can the nurse best facilitate family coping?
Assist the family in setting appropriate short-term goals.
A nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease?
Asterixis
A preceptor is discussing stroke with a new nurse on the unit. The preceptor would tell the new nurse which cardiac dysrhythmia is associated with cardiogenic embolic strokes?
Atrial Fibrillation
Which type of graft utilizes the client's own skin for wound coverage?
Autograft
A patient is scheduled for a total hip replacement and the surgeon has explained the risks of blood loss associated with orthopedic surgery. The risk of blood loss is the indication for which of the following actions?
Autologous blood donation
There are a variety of problems that can become complications after a fracture. Which of the following is described as a condition that occurs from interruption of the blood supply to the fracture fragments after which the bone tissue dies, most commonly in the femoral head?
Avascular necrosis
The nurse is planning health education for a patient who has experienced a vaginal infection. What guidelines should the nurse include in this program regarding prevention?
Avoid feminine hygiene products, such as sprays.
A patient who presents for an eye examination is diagnosed as having a visual acuity of 20/40. The patient asks the nurse what these numbers specifically mean. What is a correct response by the nurse?
"A person whose vision is 20/40 can see an object from 20 feet away that a person with 20/20 vision can see from 40 feet away."
During a routine physical examination on a 75-year-old female client, a nurse notes that the client is 5 feet, 3/8 inches (1.6 m) tall. The client states, "How is that possible? I was always 5 feet and 1/2? (1.7 m) tall." Which statement is the bestresponse by the nurse?
"After menopause, the body's bone density declines, resulting in a gradual loss of height."
A patient at high risk for breast cancer is scheduled for an incisional biopsy in the outpatient surgery department. When the nurse is providing preoperative education, the patient asks why an incisional biopsy is being done instead of just removing the mass. What would be the nurse's best response?
"An incisional biopsy is performed to confirm a diagnosis and so that special studies can be done that will help determine the best treatment."
A client who has suffered a compound fracture is preparing for discharge to home. During the teaching session, the client asks why he needs antibiotics for a broken bone. Which response by the nurse is most appropriate?
"Antibiotic therapy has been prescribed as a precaution because your bone was exposed to the environment at the time of your injury."
When preparing a client with acquired immunodeficiency syndrome (AIDS) for discharge to home, the nurse should be sure to include which instruction?
"Avoid sharing such articles as toothbrushes and razors."
The nurse is preparing to change a patient's abdominal dressing. The nurse recognizes the first step is to provide the patient with information regarding the procedure. Which of the following explanations should the nurse provide to the patient?
"During the dressing change, I will provide privacy at a time of your choosing, it should not be painful, and you can look at the incision and help with the procedure if you want to."
A client with a strong family history of coronary artery disease asks the nurse how to reduce the risk of developing the disorder. Which is the best response by the nurse?
"Exercise, keep your cholesterol in check, and manage your stress."
A 45-year-old man with diabetic nephropathy has ESKD and is starting dialysis. "What should the nurse teach the patient about hemodialysis?
"Hemodialysis is a treatment option that is usually required three times a week."
A triage nurse in the emergency department is assessing a patient who presented with complaints of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this patient's presentation?
"How many alcoholic drinks do you typically consume in a week?"
The nurse is teaching the client newly diagnosed with systemic lupus erythematous about the condition. Which statement by the client indicates teaching was effective?
"I should avoid prolonged sun exposure."
A patient develops gastrointestinal bleeding from a gastric ulcer and requires blood transfusions. The patient states to the nurse, "I am not going to have a transfusion because I don't want to get AIDS." What is the best response by the nurse?
"I understand your concern. The blood is screened very carefully for different viruses as well as HIV."
The nurse completes discharge teaching for a patient following a femoral-to-popliteal bypass graft. What response by the patient would indicate teaching was effective?
"I will call if I develop any coldness, numbness, tingling, or pain in the surgical leg."
A client scheduled for a catheter ablation procedure confides to the nurse that he is worried about having some of his heart cells destroyed. The best response by the nurse is which of the following?
"Only the specific cells causing your dysrhythmia are destroyed; your heart will function better without these cells."
The nurse is caring for a 52-year-old woman whose aunt and mother died of breast cancer. The patient states, "My doctor and I talked about Tamoxifen to help prevent breast cancer. Do you think it will work?" What would be the nurse's best response?
"Tamoxifen is known to be a highly effective protective measure."
A client with early-stage rheumatoid arthritis asks the nurse what he can do to help ease the symptoms of his disease. What would be the best response by the nurse?
"The doctor could prescribe anti-inflammatory drugs."
A 56-year-old patient has come to the clinic for his routine eye examination and is told he needs bifocals. The patient asks the nurse what change in his eyes has caused his need for bifocals. How should the nurse respond?
"There is a gradual thickening of the lens of the eye and it can limit the eye's ability for accommodation."
A female client informs the nurse that she is considering beginning sexual relations and wants to know the best way to protect herself from a sexually transmitted infection and HIV. What is the best response by the nurse?
"Using a condom (latex) and spermicidal jelly is one of the most effective ways to decrease the risk of transmission of an STI and HIV."
A nurse is providing self-care education to a patient who has been receiving treatment for acne vulgaris. What instruction should the nurse provide to the patient?
"Wash your face with water and gentle soap each morning and evening."
A clinic nurse is conducting a preoperative interview with an adult patient who will soon be scheduled to undergo cardiac surgery. What interview question most directly addresses the patient's safety?
"What prescription and nonprescription medications do you currently take?"
A client is receiving immunotherapy as part of the treatment plan for an allergic disorder. After administering the therapy, the client states, "I guess I can go home now." Which response by the nurse would be most appropriate?
"You need to stay about another half-hour so we can make sure you don't have a reaction."
The nurse is caring for a patient in the postoperative period following an abdominal hysterectomy. The patient states, "I don't want to use my pain meds because they'll make me dependent and I won't get better as fast." Which response is most important when explaining the use of pain medication?
"You will move more easily and heal more quickly with decreased pain. Dependence only occurs when it is administered for an extended period of time."
A client who has been exposed to the human immunodeficiency virus (HIV) tests negative. Which explanation by the nurse would be most appropriate?
"Your body may not have developed antibodies yet, so we need to follow up."
A client is to receive intravenous immunoglobulin (IVIG). The infusion is started at 10 a.m. The nurse would be alert for signs and symptoms of an anaphylactic reaction during which time frame?
10:30 to 11:00 a.m.
A patient with cancer of the bladder has just returned to the unit from the PACU after surgery to create an ileal conduit. The nurse is monitoring the patient's urine output hourly and notifies the physician when the hourly output is less than what?
30 mL
A client is having prostate-specific antigen (PSA) testing done. Which result would the nurse identify as abnormal?
4.6 nanograms/milliliter normal PSA levels are less than 4.0
The nurse is educating a patient about the best time to perform BSE. When does the nurse inform her is the best time after menses to perform BSE?
5-7 days
A surgical patient has just been admitted to the unit from PACU with patient-controlled analgesia (PCA). The nurse should know that the requirements for safe and effective use of PCA include what?
A clear understanding of the need to self-dose
The client has suffered a comminuted fracture. Which image best depicts this type of fracture?
A comminuted fracture (Option A) is a bone that has splintered into several fragments
The nurse is assisting the client to manage the cardiovascular risk factors of hyperlipidemia and hypertension. The client asks what kind of a diet would be best. The nurse's correct response is which of the following?
A diet low in sodium, fat, cholesterol
During a breast examination, which finding most strongly suggests that a client has breast cancer?
A fixed nodular mass with dimpling of the overlying skin
Which of the following preattack symptoms may a patient with Meniere's disease report prior to an attack?
A full feeling in the ear
The nurse is reviewing the client's admission assessment and notes that crepitus of the right knee joint was documented. The nurse recognizes that crepitus is:
A grating sound when a joint is put through range of motion
A patient is being discharged home from the ambulatory surgical center after cataract surgery. In reviewing the discharge instructions with the patient, the nurse instructs the patient to immediately call the office if the patient experiences what?
A new floater in vision
As the first priority of care, a patient with a burn injury will initially need:
A patent airway established.
The nurse coming on shift on the medical unit is taking a report on four patients. What patient does the nurse know is at the greatest risk of developing ESKD?
A patient with diabetes mellitus and poorly controlled hypertension
The nurse is planning patient teaching for a patient with ESKD who is scheduled for the creation of a fistula. The nurse would include which of the following in teaching the patient about the fistula?
A vein and an artery in your arm will be attached surgically.
A patient with a diagnosis of esophageal varices has undergone endoscopy to gauge the progression of this complication of liver disease. Following the completion of this diagnostic test, what nursing intervention should the nurse perform?
Keep patient NPO until the patient's gag reflex returns.
In assessing a scar, you notice an overgrowth of tissue. It is best described as a
Keloid
A client comes to the emergency department complaining of sudden onset of sharp, severe pain in the lumbar region that radiates around the side and toward the bladder. The client also reports nausea and vomiting and appears pale, diaphoretic, and anxious. The physician tentatively diagnoses renal calculi and orders flat-plate abdominal X-rays. Renal calculi can form anywhere in the urinary tract. What is their most common formation site?
Kidney
A nurse is preparing to administer an antiseizure medication to a client. Which of the following is an appropriate antiseizure medication?
Lamictal
A patient with a cholelithiasis has been scheduled for a laparoscopic cholecystectomy. Why is laparoscopic cholecystectomy preferred by surgeons over an open procedure?
Laparoscopic cholecystectomy poses fewer surgical risks than an open procedure.
The anesthetist is coming to the surgical admissions unit to see a patient prior to surgery scheduled for tomorrow morning. Which of the following is the priority information that the nurse should provide to the anesthetist during the visit?
Latex allergy
The nurse is performing an assessment of the patient's heart. Where would the nurse locate the apical pulse if the heart is in a normal position?
Left 5th intercostal space at the midclavicular line
The nurse is caring for a 63-year-old patient with ovarian cancer. The patient is to receive chemotherapy consisting of Taxol and Paraplatin. For what adverse effect of this treatment should the nurse monitor the patient?
Leukopenia
A nurse is reviewing the trend of a patient's scores on the Glasgow Coma Scale (GCS). This allows the nurse to gauge what aspect of the patient's status?
Level of consciousness
Which of the following enzymes aids in the digestion of fats?
Lipase
A client with acquired immunodeficiency syndrome is admitted with Pneumocystis carinii pneumonia. During a bath, the client begins to cry and says that most friends and relatives have stopped visiting and calling. What should the nurse do?
Listen and show interest as the client expresses feelings.
A 59-year-old male patient is scheduled for a hemorrhoidectomy. The OR nurse should anticipate assisting the other team members with positioning the patient in what manner?
Lithotomy position
Diagnostic testing has revealed that a patient's hepatocellular carcinoma (HCC) is limited to one lobe. The nurse should anticipate that this patient's plan of care will focus on what intervention?
Lobectomy
A patient with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate?
Loosen the patient's restrictive clothing.
The nurse is providing care to a client who has had surgery as treatment for breast cancer. The nurse would be alert for the development of which of the following?
Lymphedema
The nurse is working with a patient who is newly diagnosed with MS. What basic information should the nurse provide to the patient?
MS is a progressive demyelinating disease of the nervous system.
The most important nursing priority of treatment for a patient with an altered LOC is to:
Maintain a clear airway to ensure adequate ventilation.
A nurse is caring for a patient diagnosed with a hemorrhagic stroke. When creating this patient's plan of care, what goal should be prioritized?
Maintain and improve cerebral tissue perfusion.
The advanced practice nurse is attempting to examine the patient's ear with an otoscope. Because of impacted cerumen, the tympanic membrane cannot be visualized. The nurse irrigates the patient's ear with a solution of hydrogen peroxide and water to remove the impacted cerumen. What nursing intervention is most important to minimize nausea and vertigo during the procedure?
Maintain the irrigation fluid at a warm temperature.
A patient is being treated on the acute medical unit for acute pancreatitis. The nurse has identified a diagnosis of Ineffective Breathing Pattern Related to Pain. What intervention should the nurse perform in order to best address this diagnosis?
Maintain the patient in a semi-Fowler's position whenever possible.
Which topic is most important for the nurse to include in the teaching plan for a client newly diagnosed with Parkinson's disease?
Maintaining a safe environment
Loren Fawcett, an 18-year-old college student, arrived at your ED presenting an anaphylactic response to unknowingly ingesting nuts at a family celebration. After stabilizing Loren, you speak with her family and assuring them that she will recover. In your nursing management, what was of primary importance in Loren's care upon her admission?
Maintaining airway
A patient is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this patient's care, the nurse would expect to administer what priority medication?
Mannitol (Osmitrol)
An adult patient has been admitted to the medical unit for the treatment of acute pancreatitis. What nursing action should be included in this patient's plan of care?
Measure the patient's abdominal girth daily.
The nurse is caring for a patient who is having chest pain associated with a myocardial infarction (MI). What medication should the nurse administer intravenously to reduce pain and anxiety?
Morphine sulfate
Following a spinal cord injury a patient is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action?
Notify the neurosurgeon of the occurrence.
The nurse is caring for a patient who underwent percutaneous lithotripsy earlier in the day. What instruction should the nurse give the patient?
Notify the physician about cloudy or foul-smelling urine
A patient is 2 hours postoperative with a Foley catheter in situ. The last hourly urine output recorded for this patient was 10 mL. The tubing of the Foley is patent. What should the nurse do?
Notify the physician and continue to monitor the hourly urine output closely.
The nurse is assessing a patient with multiple sclerosis who is demonstrating involuntary, rhythmic eye movements. What term will the nurse use when documenting these eye movements?
Nystagmus
The nurse is caring for a client with right-sided heart failure who has ascites and hepatomegaly. What interventions can the nurse first provide to ensure the client has adequate nutritional intake?
Offer small, frequent feedings.
During the care of a preoperative patient, the nurse has given the patient a preoperative benzodiazepine. The patient is now requesting to void. What action should the nurse take?
Offer the patient a bedpan or urinal.
Which of the following terms refers to the surgical removal of one of the testes?
Orchiectomy
A variety of complications can occur after a leg amputation. All of the following are possibilities in the immediate postoperative period, except?
Osteomyelitis
A patient with a recent history of nephrolithiasis has presented to the ED. After determining that the patient's cardiopulmonary status is stable, what aspect of care should the nurse prioritize?
Pain management
The nurse is caring for a hospice patient who is scheduled for a surgical procedure to reduce the size of his spinal tumor in an effort to relieve his pain. The nurse should plan this patient care with the knowledge that his surgical procedure is classified as which of the following?
Palliative
The nurse is preparing a discharge teaching plan for a client who has had a prostatectomy. Which of the following would be appropriate to include?
Performing perineal exercises frequently throughout the day
The nurse is caring for a patient who has undergone supratentorial removal of a pituitary mass. What medication would the nurse expect to administer prophylactically to prevent seizures in this patient?
Phenytoin
Which nursing suggestion would be most helpful to the client with recurrent otitis externa?
Place ear plugs into the ears before swimming
A nurse is performing an admission assessment of a patient with a diagnosis of cirrhosis. What technique should the nurse use to palpate the patient's liver?
Place hand under right lower rib cage and press down lightly with the other hand.
A female patient is diagnosed with a right-sided stroke. The patient is now experiencing hemianopsia. How might the nurse help the patient manage her potential sensory and perceptional difficulties?
Place the patient's extremities where she can see them.
A patient with MS has developed dysphagia as a result of cranial nerve dysfunction. What nursing action should the nurse consequently perform?
Position the patient upright during feeding.
The nurse is caring for an 88-year-old patient who is recovering from an ileac-femoral bypass graft. The patient is day 2 postoperative and has been mentally intact, as per baseline. When the nurse assesses the patient, it is clear that he is confused and has been experiencing disturbed sleep patterns and impaired psychomotor skills. What should the nurse suspect is the problem with the patient?
Postoperative delirium
After a subarachnoid hemorrhage, the patient's laboratory results indicate a serum sodium level of less than 126 mEq/L. What is the nurse's most appropriate action?
Prepare to administer 3% NaCl by IV as ordered.
You are caring for a male patient who has had spinal anesthesia. The patient is under a physician's order to lie flat postoperatively. When the patient asks to go to the bathroom, you encourage him to adhere to the physician's order. What rationale for complying with this order should the nurse explain to the patient?
Preventing the onset of a headache
A patient is newly diagnosed with otitis externa. Which of the following should the nurse teach the patient before the patient leaves the clinic?
Proper instillation of prescribed ear drops
A patient is brought to the emergency department (ED) in a state of anaphylaxis. What is the ED nurse's priority for care?
Protect the patient's airway.
Family members of a client with traumatic brain injury are extremely distressed about their loved one. How can the nurse best assist the family to cope during this acute phase?
Provide factual information and emotional support.
A patient being treated in the hospital has been experiencing occasional urinary retention. What nursing action should the nurse take to encourage a patient who is having difficulty voiding?
Provide privacy for the patient
A hospitalized client with heart failure puts on the call light and makes the following statement: "I've become very short of breath, and I've been coughing up this pink frothy sputum." The nurse immediately suspects which of the following complications?
Pulmonary edema
The nurse is caring for a 79-year-old man who has returned to the postsurgical unit following abdominal surgery. The patient is unable to ambulate and is now refusing to wear an external pneumatic compression stocking. The nurse should explain that refusing to wear external pneumatic compression stockings increases his risk of what postsurgical complication?
Pulmonary embolism
The nurse knows that a patient who presents with the symptom of "blanching of fingers on exposure to cold" would be assessed for what rheumatic disease?
Raynaud's phenomenon
The nurse is caring for a patient on the medical-surgical unit postoperative day 5. During each patient assessment, the nurse evaluates the patient for infection. Which of the following would be most indicative of infection?
Red, warm, tender incision
A client has been diagnosed with heart failure. One of the main overall objectives of management of heart failure is which of the following?
Reduce the workload on the heart.
You are discharging a client after a cardiac catheterization. What would you include in your discharge teaching?
Report any numbness, tingling, or sharp pain in the extremity.
A nurse is caring for a patient with cirrhosis secondary to heavy alcohol use. The nurse's most recent assessment reveals subtle changes in the patient's cognition and behavior. What is the nurse's most appropriate response?
Report this finding to the primary care provider due to the possibility of hepatic encephalopathy.
A patient with chronic kidney disease is completing an exchange during peritoneal dialysis. The nurse observes that the peritoneal fluid is draining slowly and that the patient's abdomen is increasing in girth. What is the nurse's most appropriate action?
Reposition the patient to facilitate drainage.
A patient with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following is an important nursing action for this patient?
Restricting fluid intake and hydration
A nurse is assessing a patient who has been diagnosed with cholecystitis, and is experiencing localized abdominal pain. When assessing the characteristics of the patient's pain, the nurse should anticipate that it may radiate to what region?
Right shoulder
A client is brought to the emergency department by a softball team member whostates the client and another player ran into each other, and the client is having severe pain in the right shoulder. What symptoms of a fractured clavicle does the nurse recognize?
Right shoulder slopes downward and droops inward.
A patient with a sacral pressure ulcer has had a urinary catheter inserted. As a result of this new intervention, the nurse should prioritize what nursing diagnosis in the patient's plan of care?
Risk for infection related to presence of an indwelling urinary catheter
Which nursing diagnosis is most appropriate for an elderly client with osteoarthritis?
Risk for injury related to altered mobility
A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes thehighest priority?
Risk for injury related to neurologic deficit
A patient diagnosed with liver failure has jaundice. Jaundice is often first observed in which of the following areas?
Sclerae
A 40-year-old woman was diagnosed with Raynaud's phenomenon several years earlier and has sought care because of a progressive worsening of her symptoms. The patient also states that many of her skin surfaces are "stiff, like the skin is being stretched from all directions." The nurse should recognize the need for medical referral for the assessment of what health problem?
Scleroderma
The nurse is examining the area behind the patient's auricle and sees a flaky scaliness. What disorder does the nurse suspect the patient has?
Seborrheic dermatitis
What kind of otitis media is a pathogen-free fluid behind the tympanic membrane, resulting from irritation associated with respiratory allergies and enlarged adenoids?
Serous otitis media
A client has a herniated disk in the region of the third and fourth lumbar vertebrae. Which nursing assessment finding most supports this diagnosis?
Severe lower back pain
A 37-year-old male patient presents at the emergency department (ED) complaining of nausea and vomiting and severe abdominal pain. The patient's abdomen is rigid, and there is bruising to the patient's flank. The patient's wife states that he was on a drinking binge for the past 2 days. The ED nurse should assist in assessing the patient for what health problem?
Severe pancreatitis with possible peritonitis
A female patient is receiving hypothermic treatment for uncontrolled fevers related to increased intracranial pressure (ICP). Which of the following assessment finding requires immediate intervention?
Shivering
A client reports recent onset of chest pain that occurs sporadically with exertion. The client also has fatigue and mild ankle swelling, which is most pronounced at the end of the day. The nurse suspects a cardiovascular disorder. What other client complaint increases the likelihood of a cardiovascular disorder?
Shortness of breath
A patient with a diagnosis of retinal detachment has undergone a vitreoretinal procedure on an outpatient basis. What subject should the nurse prioritize during discharge education?
Signs and symptoms of increased intraocular pressure
A patient has undergone a laparoscopic cholecystectomy and is being prepared for discharge home. When providing health education, the nurse should prioritize which of the following topics?
Signs and symptoms of intra-abdominal complications
The nurse who is leading a wellness workshop has been asked about actions to reduce the risk of bladder cancer. What health promotion action most directly addresses a major risk factor for bladder cancer?
Smoking cessation
A client sustains an injury to the ligaments surrounding a joint. The nurse identifies this as which of the following?
Sprain
A nurse is caring for a patient with hepatic encephalopathy. The nurse's assessment reveals that the patient exhibits episodes of confusion, is difficult to arouse from sleep and has rigid extremities. Based on these clinical findings, the nurse should document what stage of hepatic encephalopathy?
Stage 3
A patient stepped on an acorn while walking barefoot in the backyard and developed an infection progressing to osteomyelitis. What microorganism does the nurse understand is most often the cause of the development of osteomyelitis?
Staphylococcus aureus
The registered nurse taking shift report learns that an assigned patient is blind. How should the nurse best communicate with this patient?
State her name and role immediately after entering the patient's room.
A patient with kidney stones is scheduled for extracorporeal shock wave lithotripsy (ESWL). What should the nurse include in the patient's post-procedure care?
Strain the patient's urine following the procedure.
A 42-year-old woman comes to the clinic complaining of occasional urinary incontinence when she sneezes. The clinic nurse should recognize what type of incontinence?
Stress incontinence
A client diagnosed with Huntington's disease has developed severe depression. What would be most important for the nurse to assess for?
Suicidal ideations
The ED nurse is caring for an 11-year-old brought in by ambulance after having been hit by a car. The child's parents are thought to be en route to the hospital but have not yet arrived. No other family members are present and attempts to contact the parents have been unsuccessful. The child needs emergency surgery to save her life. How should the need for informed consent be addressed?
Surgery should be done without informed consent.
A patient is exploring treatment options after being diagnosed with age-related cataracts that affect her vision. What treatment is most likely to be used in this patient's care?
Surgical intervention
The nurse is preparing health education for a patient who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education?
Take antihypertensive medication as ordered.
Which of the following should be included as part of the home care instructions for a patient with epididymitis and orchitis?
Take prescribed antibiotics.
The nurse is educating an 80-year-old patient diagnosed with HF about his medication regimen. What should the nurse to teach this patient about the use of oral diuretics?
Take the diuretic in the morning to avoid interfering with sleep.
The nurse is caring for a patient receiving hemodialysis three times weekly. The patient has had surgery to form an arteriovenous fistula. What is most important for the nurse to be aware of when providing care for this patient?
Taking a BP reading on the affected arm can damage the fistula.
When caring for the patient with acute glomerulonephritis, which of the following assessment findings should the nurse anticipate?
Tea-colored urine
The clinic nurse is preparing a plan of care for a patient with a history of stress incontinence. What role will the nurse have in implementing a behavioral therapy approach?
Teach the patient to perform pelvic floor muscle exercises
A hospitalized patient with impaired vision must get a picture in his or her mind of the hospital room and its contents in order to mobilize independently and safely. What must the nurse monitor in the patient's room?
That all furniture remains in the same position
Which of the following statements is accurate regarding care of a plaster cast?
The cast can be dented while it is damp.
A nurse is preparing a client for magnetic resonance imaging (MRI) to confirm or rule out a spinal cord lesion. During the MRI scan, which action would pose a threat to the client?
The client wears a watch and wedding band.
The nurse is teaching a patient to care for her new ocular prosthesis. What should the nurse emphasize during the patient's health education?
The need to perform thorough hand hygiene before handling the prosthesis
The nurse is performing a comprehensive health history of a patient who is in her 50s. The nurse should identify what risk factor that may increase this patient's risk for breast cancer?
The patient gave birth to her first child at age 38.
A man comes to the clinic complaining that he is having difficulty obtaining an erection. When reviewing the patient's history, what might the nurse note that contributes to erectile dysfunction?
The patient has a history of hypertension.
The OR nurse is taking the patient into the OR when the patient informs the operating nurse that his grandmother spiked a 104°F temperature in the OR and nearly died 15 years ago. What relevance does this information have regarding the patient?
The patient may be at risk for malignant hyperthermia.
A 48-year-old patient has been diagnosed with trigeminal neuralgia following recent episodes of unilateral face pain. The nurse should recognize what implication of this diagnosis?
The patient needs to be assessed for MS.
A patient who has undergone liver transplantation is ready to be discharged home. Which outcome of health education should the nurse prioritize?
The patient will take immunosuppressive agents as required.
The nurse is providing care for a patient who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the patient has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following?
The patient's activities immediately prior to the seizure.
A nurse is teaching a female client about preventing osteoporosis. Which teaching point is correct?
The recommended daily allowance of calcium may be found in a wide variety of foods.
Total parental nutrition (TPN) should be used cautiously in patients with pancreatitis due to which of the following?
They cannot tolerate high-glucose concentration.
A nurse is caring for a teenage girl who has had an anaphylactic reaction after a bee sting. The nurse is providing patient teaching prior to the patient's discharge. In the event of an anaphylactic reaction, the nurse informs the patient that she should self-administer epinephrine in what site?
Thigh
Which term describes a fungal infection of the scalp?
Tinea capitis
Which of the following superficial fungal infections begin in the skin between the toes and spreads to the soles of the feet?
Tinea pedis
An osmotic diuretic, such as mannitol, is given to the patient with increased intracranial pressure (IICP) for which of the following reasons?
To dehydrate the brain and reduce cerebral edema
A client has severe osteoarthritis in the left hip and is having surgery to replace both articular surfaces of the hip. What type of surgical procedure will the nurse prepare the client for?
Total arthroplasty
A patient who underwent a bowel resection to correct diverticula suffered irreparable nerve damage. During the case review, the team is determining if incorrect positioning may have contributed to the patient's nerve damage. What surgical position places the patient at highest risk for nerve damage?
Trendelenburg
An adult patient is in the recovery room following a nephrectomy performed for the treatment of renal cell carcinoma. The patient's vital signs and level of consciousness stabilized, but the patient then complains of severe nausea and begins to retch. What should the nurse do next?
Turn the patient completely to one side.
The nurse is providing care for a patient who has just been diagnosed with peripheral arterial occlusive disease (PAD). What assessment finding is most consistent with this diagnosis?
Unequal peripheral pulses between extremities
Which clinical finding should a nurse look for in a client with chronic renal failure?
Uremia
A patient is being discharged home after a hysterectomy. When providing discharge education for this patient, the nurse has cautioned the patient against sitting for long periods. This advice addresses the patient's risk of what surgical complication?
Venous thromboembolism
Which of the following manifestations is the most problematic for the patient diagnosed with Meniere's disease?
Vertigo
A nurse is performing a skin assessment and observes symmetrical patchy, milky white spots bilaterally. The nurse interprets these lesions as suggesting which of the following?
Vitiligo
Which of the following would the nurse expect to assess as the most common finding associated with fibromyalgia?
Widespread chronic pain
A patient is admitted to the ED complaining of severe abdominal pain, stating that he has been vomiting "coffee-ground" like emesis. The patient is diagnosed with a perforated gastric ulcer and is informed that he needs surgery. When can the patient most likely anticipate that the surgery will be scheduled?
Without delay because the bleed is emergent
An occupational health nurse is called to the floor of a factory where a worker has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to "cool the burn." How should the nurse cool the burn?
Wrap cool towels around the affected extremity intermittently.
All of the following are guidelines for avoiding hip dislocation after replacement surgery. Select the answer that is not.
You may flex at the hip to put on clothing such as pants, stockings, socks, or shoes.
One of the things a nurse has taught to a patient during preoperative teaching is to have nothing by mouth for the specified time before surgery. The patient asks the nurse why this is important. What is the most appropriate response for the patient?
You will need to have food and fluid restricted before surgery so you are not at risk for choking."
Myasthenia gravis occurs when antibodies attack which receptor sites?
acetylcholine
The nurse is caring for a client admitted with a diagnosis of septic meningitis. The nurse is aware that this infection is caused by which of the following?
bacteria
While snowboarding, a 17-year-old client fell and struck his head, resulting in a loss of consciousness. Within an hour after his arrival via squad at the ED where you practice nursing, he regained consciousness. He was admitted for 24-hour observation and was discharged without neurologic impairment. What would you expect the neurologist's diagnosis to be?
concussion
The initial sign of increasing ICP includes
decreased level of consciousness.
A client with chronic renal failure (CRF) has developed faulty red blood cell (RBC) production. The nurse should monitor this client for:
fatigue and weakness
The nurse is teaching a patient preventative measures regarding vaginal infections. The nurse should include which of the following as an important risk factor?
frequent douching
The type of fracture described as having one side of the bone broken and the other side bent would be
greenstick
Which area of the spinal column is subject to the greatest mechanical stress and degenerative changes?
lower lumbar
A nurse is developing a care plan for a client recovering from a serious thermal burn. After maintaining respirations, the nurse knows that the most important immediate goal of therapy is:
maintaining the client's fluid, electrolyte, and acid-base balance.
A nurse is educating a client who's at risk for coronary artery disease (CAD). The nurse tells the client that CAD has many risk factors. Risk factors that can be controlled or modified include:
obesity, inactivity, diet, and smoking.
The nurse teaches the patient who demonstrates herpes zoster (shingles) that
the infection results from reactivation of the chickenpox virus.
The nurse is preparing the client with a right neck mass for magnetic resonance imaging (MRI). Which question should the nurse ask? Select all that apply.
• "Are you wearing any jewelry?" • "Have you removed your hearing aid?" • "Do you have a pacemaker?"
Level of consciousness (LOC) can be assessed based on criteria in the Glasgow Coma Scale (GCS). Which of the following indicators are assessed in the GCS? Select all that apply.
• Eye opening • Verbal response • Motor response
Red bone marrow produces which of the following? Select all that apply.
• Platelets • White blood cells (WBCs) • Red blood cells (RBCs)
A nurse practitioner is examining a patient who presented at the free clinic with vulvar pruritus. For which assessment finding would the practitioner look that may indicate the patient has an infection caused by Candida albicans?
Cottage cheese-like discharge
A client presents to the clinic with complaints that he began to itch and break out in hives after taking an aspirin this morning. What medication does the nurse anticipate administering that blocks histamine receptors?
Diphenhydramine(Benadryl)
The nurse has created a plan of care for a patient who is at risk for increased ICP. The patient's care plan should specify monitoring for what early sign of increased ICP?
Disorientation and restlessness
A nurse is providing care to a female client with atopic dermatitis who has numerous lesions on the arms, neck, and legs. The client states, "My skin is so ugly. I can't imagine what people must think when they look at me. I can't look at myself sometimes." When developing the plan of care for this client, which nursing diagnosis would be most appropriate?
Disturbed body image related to appearance of visible lesions
A nursing student is writing a care plan for a newly admitted patient who has been diagnosed with a stroke. What major nursing diagnosis should most likely be included in the patient's plan of care?
Disturbed sensory perception
A patient is planning to use a negative-pressure (vacuum) device to maintain and sustain an erection. What should the nurse caution the patient about with the use of this device?
Do not leave the constricting band in place for longer than 1 hour to avoid penile injury.
A nurse is providing care to a client with Parkinson's disease. The nurse understands the the client's signs and symptoms are related to a depletion of which of the following?
Dopamine
A patient presents at the clinic with complaints of morning numbness, cramping, and stiffness in his fourth and fifth fingers. What disease process should the nurse suspect?
Dupuytren's disease
A client is suspected of having amyotrophic lateral sclerosis (ALS). To help confirm this disorder, the nurse prepares the client for various diagnostic tests. The nurse expects the physician to order:
Electromyography (EMG)
A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first?
Elevate the head of the bed.
A client is complaining of severe pain in the left great toe. What lab studies that the nurse reviews indicate that the client may have gout?
Elevated uric acid levels
The ED nurse is caring for a patient who has gone into cardiac arrest. During external defibrillation, what action should the nurse perform?
Ensure no one is touching the patient at the time shock is delivered.
The nurse is administering injected allergens for "hyposensitization," which may produce harmful systemic reactions. Prior to administering these allergens, what medication should the nurse have at the bedside?
Epinephrine
The nurse is expecting to admit a client with a diagnosis of meningitis. While preparing the client's room, which of the following would the nurse most likely have available?
Equipment to maintain infection control precautions
A 68-year-old female client who had a total hip replacement is to be discharged because her healing is almost complete. Which of the following would be most important for this client?
Exploring factors related to the client's home environment.
Bell's palsy is a disorder of which cranial nerve?
Facial (VII)
The nurse is planning the care of a patient who has been recently diagnosed with a cerebellar tumor. Due to the location of this patient's tumor, the nurse should implement measures to prevent what complication?
Falls
To assess peripheral edema, which of the following are particular areas for examination?
Feet, ankles
The nurse is admitting a 55-year-old male patient diagnosed with a retinal detachment in his left eye. While assessing this patient, what characteristic symptom would the nurse expect to find?
Flashing lights in the visual field
During a health education session, a participant has asked about the hepatitis E virus. What prevention measure should the nurse recommend for preventing infection with this virus?
Following proper hand-washing techniques
A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a patient admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray?
Fried chicken
Skin grafts are necessary for which of the following burns?
Full-thickness
A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure?
Generalized
A patient exhibiting an altered level of consciousness (LOC) due to blunt-force trauma to the head is admitted to the ED. The physician determines the patient's injury is causing increased intracranial pressure (ICP). The nurse should gauge the patient's LOC on the results of what diagnostic tool?
Glasgow Coma Scale
Which of the following actions helps the nurse to determine the quality of the skin turgor?
Grasping the skin
The nurse is assessing a client with meningitis. Which of the following signs would the nurse expect to observe?
Headache and nuchal rigidity
When planning the care of a patient with an implanted pacemaker, what assessment should the nurse prioritize?
Heart rate and rhythm
Which of the following is a primary chemical mediator of hypersensitivity?
Histamine
A patient has been diagnosed with pancreatic cancer and has been admitted for care. Following initial treatment, the nurse should be aware that the patient is most likely to require which of the following?
Hospice care
When teaching patients about the risk factors of cervical cancer, what would the nurse identify as the most important risk factor?
Human papillomavirus (HPV)
Which of the following is a degenerative neurologic disorder?
Huntington disease
An adolescent is identified as having a collection of fluid in the tunica vaginalis of his testes. The nurse knows that this adolescent will receive what medical diagnosis?
Hydrocele
The nurse is caring for a patient in acute kidney injury. Which of the following complications would most clearly warrant the administration of polystyrene sulfonate (Kayexalate)?
Hyperkalemia
Which of the following is a modifiable risk factor for coronary artery disease (CAD)?
Hyperlipidemia
The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regime, to maintain a healthy weight, and to adopt a reasonable exercise program. This advice is based on research data that shows the most important risk factor for stroke is:
Hypertension
The nurse admits a patient to the PACU with a blood pressure of 132/90 mm Hg and a pulse of 68 beats per minute. After 30 minutes, the patient's blood pressure is 94/47 mm Hg, and the pulse is 110. The nurse documents that the patient's skin is cold, moist, and pale. Of what is the patient showing signs?
Hypovolemic shock
Which of the following types of shock will a nurse observe in a client with extensive burns?
Hypovolemic shock
A patient has been diagnosed with acute pancreatitis. The nurse is addressing the diagnosis of Acute Pain Related to Pancreatitis. What pharmacologic intervention is most likely to be ordered for this patient?
IV hydromorphone (Dilaudid)
A triage nurse in the emergency department (ED) receives a phone call from a frantic father who saw his 4-year-old child tip a pot of boiling water onto her chest. The father has called an ambulance. What would the nurse in the ED receiving the call instruct the father to do?
Immerse the child in a cool bath.
The nurse is caring for a client who has just been diagnosed with sinus bradycardia. The client asks the nurse to explain what sinus bradycardia is. What would be the nurse's best explanation?
In many clients a heart rate slower than 60 beats per minute is considered to slow to maintain an adequate cardiac output.
The client is having a Weber test. During a Weber test, where should the tuning fork be placed?
In the midline of the client's skull or in the center of the forehead
A nurse is caring for a patient with liver failure and is performing an assessment in the knowledge of the patient's increased risk of bleeding. The nurse recognizes that this risk is related to the patient's inability to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function?
Inability of the liver to use vitamin K
A patient's abdominal ultrasound indicates cholelithiasis. When the nurse is reviewing the patient's laboratory studies, what finding is most closely associated with this diagnosis?
Increased bilirubin
You are the clinic nurse caring for a patient with a recent diagnosis of myasthenia gravis. The patient has begun treatment with pyridostigmine bromide (Mestinon). What change in status would most clearly suggest a therapeutic benefit of this medication?
Increased muscle strength
A patient has been successfully treated for kidney stones and is preparing for discharge. The nurse recognizes the risk of recurrence and has planned the patient's discharge education accordingly. What preventative measure should the nurse encourage the patient to adopt?
Increasing fluid intake
Development of malignant melanoma is associated with which of the following risk factors?
Individuals with a history of severe sunburn
When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority?
Ineffective airway clearance related to edema of the respiratory passages
A nurse is developing a nursing care plan for a client with peripheral arterial disease. Which of the following will be the priority nursing diagnosis?
Ineffective peripheral tissue perfusion
The nurse is creating the care plan for a 70-year-old obese patient who has been admitted to the postsurgical unit following a colon resection. This patient's age and increased body mass index mean that she is at increased risk for what complication in the postoperative period?
Infection
A patient with ESKD receives continuous ambulatory peritoneal dialysis. The nurse observes that the dialysate drainage fluid is cloudy. What is the nurse's most appropriate action?
Inform the physician and assess the patient for signs of infection.
The nurse is caring for a patient who has undergone creation of a urinary diversion. Forty-eight hours postoperatively, the nurse's assessment reveals that the stoma is a dark purplish color. What is the nurse's most appropriate response?
Inform the primary care provider that the vascular supply may be compromised.
All of the following are categories of medications used for treatment of the skin except:
Inhaled steroids
A client complains of vertigo. The nurse anticipates that the client may have a problem with which portion of the ear?
Inner ear
A client comes to the walk-in clinic complaining of a "bug in my ear." What action should be taken when there is an insect in the ear?
Instillation of mineral oil
Which of the following terms refers to leg pain that is brought on walking and caused by arterial insufficiency?
Intermittent claudication
Which of the following is a true statement regarding psoriasis?
It is characterized by patches of redness covered with silvery scales.
A client has been diagnosed with liver disease. The nurse would expect which skin variation?
Jaundice
While caring for a patient with pneumocystis pneumonia, the nurse assesses flat, purplish lesions on the back and trunk. What does the nurse suspect these lesions indicate?
Kaposi's sarcoma
The nurse has four clients that come to the clinic for healthcare. Which one of these clients has the highest risk factor for HIV infection?
A 26-year-old inmate who receives tattoos in prison
The nurse should recognize the greatest risk for the development of blindness in which of the following patients?
A 58-year-old Caucasian woman with macular degeneration
A circulating nurse provides care in a surgical department that has multiple surgeries scheduled for the day. The nurse should know to monitor which patient most closely during the intraoperative period because of the increased risk for hypothermia?
A 74-year-old woman with a low body mass index
The critical care nurse is monitoring the patient's urine output and drains following renal surgery. What should the nurse promptly report to the physician?
Absence of drain output
A patient who came to the clinic after finding a mass in her breast is scheduled for a diagnostic breast biopsy. During the nurse's admission assessment, the nurse observes that the patient is distracted and tense. What is it important for the nurse to do?
Acknowledge the fear the patient is likely experiencing.
The orthopedic surgeon has prescribed balanced skeletal traction for a patient. What advantage is conferred by balanced traction?
Balanced traction allows for greater patient movement and independence than other forms of traction.
A 48-year-old man presents to the ED complaining of severe substernal chest pain radiating down his left arm. He is admitted to the coronary care unit (CCU) with a diagnosis of myocardial infarction (MI). What nursing assessment activity is a priority on admission to the CCU?
Begin ECG monitoring.
Which of the following diagnostic tests would be utilized if a malignancy was suspected?
Biopsy
The nurse is caring for a patient who has just returned from the ERCP removal of gallstones. The nurse should monitor the patient for signs of what complications?
Bleeding and perforation
A patient with trichomoniasis comes to the walk-in clinic. In developing a care plan for this patient the nurse would know to include what as an important aspect of treating this patient?
Both partners will be treated with metronidazole (Flagyl).
A client is brought to the emergency department with symptoms of a cerebrovascular accident (CVA). The nurse would anticipate which diagnostic evaluation to be completed prior to initiation of treatment?
Brain CT scan or MRI
A client with systemic lupus erythematosus (SLE) has the classic rash of lesions on the cheeks and bridge of the nose. What term should the nurse use to describe this characteristic pattern?
Butterfly rash
As an intraoperative nurse, you are the advocate for each of the patients who receives care in the surgical setting. How can you best exemplify the principles of patient advocacy?
By maintaining each of your patients' privacy
A patient who just suffered a suspected ischemic stroke is brought to the ED by ambulance. On what should the nurse's primary assessment focus?
Cardiac and respiratory status
Which of the following complications is common for victims of electrical burns?
Cardiac dysrhythmia
Which common problem of the upper extremity results from entrapment of the median nerve at the wrist?
Carpal tunnel syndrome
A woman in her late thirties has been having unusually heavy menstrual periods combined with occasional urine and stool leakage over the last few weeks. On further enquiry, she reveals that she also has postcoital pain and bleeding. To which of the following diagnoses do you think the investigations are most likely to lead?
Cervical cancer
The nurse on the medical-surgical unit is reviewing discharge instructions with a patient who has a history of glaucoma. The nurse should anticipate the use of what medications?
Cholinergics
A 68-year-old patient is scheduled for a bilateral mastectomy. The OR nurse has come out to the holding area to meet the patient and quickly realizes that the patient is profoundly anxious. What is the most appropriate intervention for the nurse to apply?
Clearly explain any information that the patient seeks.
Which of the following actions is a quick assessment technique that the nurse might use to assess the percentage of a small or scattered burn injury?
Comparing the patient's palm with the size of the burn wound
A grating sound when a joint is put through range of motion
Compartment Syndrome
During the course of a health interview, Mrs. Young tells the nurse that she has been using a new perfume because she wants to smell good. She explains that she has had a rash on her arms and neck since she purchased and used the product. What would be an initial diagnosis for Mrs. Young?
Contact dermatitis
A middle-aged woman has sought care from her primary care provider and undergone diagnostic testing that has resulted in a diagnosis of MS. What sign or symptom is most likely to have prompted the woman to seek care?
Difficulty in coordination
The nurse is caring for a client who is displaying a third-degree AV block on the EKG monitor. The client is symptomatic due to the slow heart rate. The most appropriate nursing diagnosis for this client would be which of the following?
Decreased cardiac output
A nurse in a long-term care facility is caring for an 83-year-old woman who has a history of HF and peripheral arterial disease (PAD). At present the patient is unable to stand or ambulate. The nurse should implement measures to prevent what complication?
Deep vein thrombosis
The nurse is discharging home a patient who suffered a stroke. He has a flaccid right arm and leg and is experiencing problems with urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common patient response to a change in body image?
Depression
A 55-year-old female patient with hepatocellular carcinoma (HCC) is undergoing radiofrequency ablation. The nurse should recognize what goal of this treatment?
Destruction of the patient's liver tumor
