Med Surg 4
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)?
Administer hepatitis B vaccine. Test for antibodies to hepatitis B. Give hepatitis B immune globulin.
A patient who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, "I feel obsessed with morbid thoughts about dying." Which response by the nurse is appropriate?
"Can you tell me more about the thoughts that you are having?"
A patient who uses injectable illegal drugs asks the nurse about preventing acquired immunodeficiency syndrome (AIDS). Which response by the nurse is best?
"Consider participating in a needle-exchange program." Participation in needle-exchange programs has been shown to decrease and control the rate of HIV infection.
Which patient statement to the nurse is most consistent with the diagnosis of venous insufficiency?
"I can't get my shoes on at the end of the day." Because the edema associated with venous insufficiency increases when the patient has been standing, shoes will feel tighter at the end of the day.
The nurse has started discharge teaching for a patient who is to continue warfarin (Coumadin) after hospitalization for venous thromboembolism (VTE). The nurse determines that additional teaching is needed when the patient says which of the following?
"I should reduce the amount of green, leafy vegetables that I eat." Patients taking warfarin are taught to follow a consistent diet with regard to foods that are high in vitamin K, such as green, leafy vegetables
Which statement made by a patient with coronary artery disease after the nurse has completed teaching about the therapeutic lifestyle changes (TLC) diet indicates that further teaching is needed?
"I will miss being able to eat peanut butter sandwiches." Although only 30% of the daily calories should come from fats, most of the fat in the TLC diet should come from monounsaturated fats such as are found in nuts, olive oil, and canola oil. The patient can include peanut butter sandwiches as part of the TLC diet. One glass of wine is okay with TLC diet.
Which instructions should the nurse include in a teaching plan for an older patient newly diagnosed with peripheral artery disease (PAD)?
"It is very important that you stop smoking cigarettes." Smoking cessation is essential for slowing the progression of PAD to critical limb ischemia and reducing the risk of myocardial infarction and death.
While working in the outpatient clinic, the nurse notes that a patient has a history of intermittent claudication. Which statement by the patient would support this information?
"My legs cramp when I walk more than a block." Cramping that is precipitated by a consistent level of exercise is descriptive of intermittent claudication.
A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4+ T-cell count of less than 200 cells/L. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct?
"The patient has developed acquired immunodeficiency syndrome (AIDS)."
Chronic venous disease
-dilated superficial veins. -swollen, dry, scaly ankles. -serosanguineous drainage from the ulcer.
Which blood pressure (BP) finding by the nurse indicates that no changes in therapy are needed for a 48-yr-old patient with newly diagnosed hypertension?
128/76 mm Hg The 8th Joint National Committee's recommended goal for antihypertensive therapy for a 30- to 59-yr-old patient with hypertension is a BP below 140/90 mm Hg.
The nurse on the intermediate care unit received change-of-shift report on four patients with hypertension. Which patient should the nurse assess first?
48-yr-old with a blood pressure of 160/92 mm Hg who reports chest pain The patient with chest pain may be experiencing acute myocardial infarction and rapid assessment and intervention are needed.
After receiving change of shift report, which patient admitted to the emergency department should the nurse assess first?
A 50-yr-old patient who is complaining of sudden sharp and severe upper back pain The patient's presentation of sudden sharp and severe upper back pain is consistent with dissecting thoracic aneurysm, which will require the most rapid intervention.
During change-of-shift report, the nurse learns about the following four patients. Which patient requires assessment first?
A 55-yr-old patient with cirrhosis and ascites who has an oral temperature of 102° F (38.8° C) This patient's history and fever suggest possible spontaneous bacterial peritonitis, which would require rapid assessment and interventions such as antibiotic therapy.
Which information about a patient population would be most useful to help the nurse plan for human immunodeficiency virus (HIV) testing needs?
Age The current Centers for Disease Control and Prevention policy is to offer routine testing for HIV to all individuals age 13 to 64 years.
Which focused data will the nurse monitor in relation to the 4+ pitting edema assessed in a patient with cirrhosis?
Albumin level The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of edema.
The nurse plans a presentation for community members about how to decrease the risk for antibiotic-resistant infections. Which information will the nurse include in the teaching plan (select all that apply)?
Antibiotics may sometimes be prescribed to prevent infection. Continue taking antibiotics until all of the prescription is gone. Hand washing is effective in preventing many viral and bacterial infections.
Which topic should the nurse include in patient teaching for a patient with a venous stasis ulcer on the left lower leg?
Application of elastic compression stockings Compression of the leg is essential to healing of venous stasis ulcers
Which actions could the nurse delegate to unlicensed assistive personnel (UAP) who are providing care for a patient who is at risk for venous thromboembolism?
Apply sequential compression device whenever the patient is in bed. UAP training includes the use of equipment that requires minimal nursing judgment, such as sequential compression devices.
Which action should the nurse take when giving the initial dose of oral labetalol to a patient with hypertension?
Ask the patient to request assistance before getting out of bed. Labetalol decreases sympathetic nervous system activity by blocking both - and -adrenergic receptors, leading to vasodilation and a decrease in heart rate, which can cause severe orthostatic hypotension.
A patient born in 1955 had hepatitis A infection 1 year ago. According to Centers for Disease Control and Prevention (CDC) guidelines, which action should the nurse include in care when the patient is seen for a routine annual physical examination?
Ask whether the patient has been screened for hepatitis C. Current CDC guidelines indicate that all patients who were born between 1945 and 1965 should be screened for hepatitis C because many individuals who are positive have not been diagnosed.
Which topic is most important to include in patient teaching for a 41-yr-old patient diagnosed with early alcoholic cirrhosis?
Avoiding alcohol ingestion The disease progression can be stopped or reversed by alcohol abstinence.
The nurse is caring for a patient with a descending aortic dissection. Which assessment finding is most important to report to the health care provider?
Blood pressure of 138/88 mm Hg The blood pressure is typically kept at less than 120 mm Hg systolic to minimize extension of the dissection. The nurse will need to notify the health care provider so that -blockers or other antihypertensive drugs can be prescribed.
The nurse is developing a discharge teaching plan for a patient diagnosed with thromboangiitis obliterans (Buerger's disease). Which expected outcome has the highest priority for this patient?
Cessation of all tobacco use Absolute cessation of nicotine use is needed to reduce the risk for amputation in patients with Buerger's disease.
An older patient with a history of an abdominal aortic aneurysm arrives at the emergency department (ED) with severe back pain and absent pedal pulses. Which action should the nurse take first?
Check the blood pressure. Because the patient appears to be experiencing aortic dissection, the nurse's first action should be to determine the hemodynamic status by assessing blood pressure.
Which nursing action should the nurse take first to assist a patient with newly diagnosed stage 1 hypertension in making needed dietary changes?
Collect a detailed diet history. The initial nursing action should be assessment of the patient's baseline dietary intake through a thorough diet history.
A young adult female patient who is human immunodeficiency virus (HIV) positive has a new prescription for efavirenz (Sustiva). Which information is most important to include in the medication teaching plan?
Continue to use contraception while taking this medication. To prevent harm, it is most critical to inform patients that efavirenz can cause fetal anomalies and should not be used in patients who may be or may become pregnant.
Which of these patients who have arrived at the human immunodeficiency virus (HIV) clinic should the nurse assess first?
Patient who has had 10 liquid stools in the last 24 hours The nurse should assess the patient for dehydration and hypovolemia.
To improve the physical activity level for a mildly obese 71-yr-old patient, which action should the nurse plan to take?
Determine what kind of physical activities the patient usually enjoys. Because patients are more likely to continue physical activities that they already enjoy, the nurse will plan to ask the patient about preferred activities. The goal for older adults is 30 minutes of moderate activity on most days. Older adults should plan for a longer warm-up period. Benefits of exercises, such as improved activity tolerance, should be emphasized rather than aiming for significant weight loss in older mildly obese adults.
After reviewing information shown in the accompanying figure from the medical records of a 43-yr-old patient, which risk factor modification for coronary artery disease should the nurse include in patient teaching?
Dietary changes to improve lipid levels
A patient treated for human immunodeficiency virus (HIV) infection for 6 years has developed fat redistribution to the trunk with wasting of the arms, legs, and face. What recommendation will the nurse give to the patient?
Discuss a change in antiretroviral therapy. A frequent first intervention for metabolic disorders is a change in antiretroviral therapy (ART).
A 46-yr-old service-counter worker undergoes sclerotherapy for treatment of superficial varicose veins at an outpatient center. Which instructions should the nurse provide to the patient before discharge?
Elastic compression stockings should be applied before getting out of bed. Elastic compression stockings are applied with the legs elevated to reduce pressure in the lower legs. Walking is recommended to prevent recurrent varicosities.
Eight years after seroconversion, a human immunodeficiency virus (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?
Encourage adequate nutrition, exercise, and sleep. The CD4+ level for this patient is in the normal range, indicating that the patient is the stage of asymptomatic chronic infection when the body is able to produce enough CD4+ cells to maintain a normal CD4+ count. Maintaining healthy lifestyle behaviors is an important goal in this stage.
The nurse palpates enlarged cervical lymph nodes on a patient diagnosed with acute human immunodeficiency virus (HIV) infection. Which action would be appropriate for the nurse to take?
Explain to the patient that this is an expected finding. Persistent generalized lymphadenopathy is common in the early stages of HIV infection.
Which finding indicates to the nurse that a patient's transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective?
Fewer episodes of bleeding varices TIPS is used to lower pressure in the portal venous system and decrease the risk of bleeding from esophageal varices.
A patient who has recently started taking pravastatin (Pravachol) and niacin reports several symptoms to the nurse. Which information is most important to communicate to the health care provider?
Generalized muscle aches and pains Muscle aches and pains may indicate myopathy and rhabdomyolysis, which have caused acute kidney injury and death in some patients who have taken the statin medications. These symptoms indicate that the pravastatin may need to be discontinued.
A patient with hyperlipidemia has a new order for colesevelam (Welchol). Which nursing action is appropriate when scheduling this medication?
Give the patient's other medications 2 hours after colesevelam. The bile acid sequestrants interfere with the absorption of many other drugs and giving other medications at the same time should be avoided. Taking an aspirin concurrently with the colesevelam may increase the incidence of gastrointestinal side effects such as heartburn. For maximum effect, colesevelam should be administered with meals.
Which nursing intervention for a patient who had an open repair of an abdominal aortic aneurysm 2 days previously is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?
Help the patient to use a pillow to splint while coughing. Assisting a patient who has already been taught how to cough is part of routine postoperative care and within the education and scope of practice for UAP.
The nurse is caring for a patient infected with human immunodeficiency virus (HIV) who has just been diagnosed with asymptomatic chronic HIV infection. Which prophylactic measures will the nurse include in the plan of care (select all that apply)?
Hepatitis B vaccine Pneumococcal vaccine Influenza virus vaccine Asymptomatic chronic HIV infection is a stage between acute HIV infection and a diagnosis of symptomatic chronic HIV infection. Although called asymptomatic, symptoms (e.g., fatigue, headache, low-grade fever, night sweats) often occur. 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.
Which information is most important for the nurse to include when teaching a patient with newly diagnosed hypertension?
Hypertension is usually asymptomatic until target organ damage occurs. Hypertension is usually asymptomatic until target organ damage has occurred.
The nurse who works in the vascular clinic has several patients with venous insufficiency scheduled today. Which patient should the nurse assign to an experienced licensed practical/vocational nurse (LPN/LVN)?
Patient who needs wound care for a chronic venous stasis ulcer on the right lower leg. LPN education and scope of practice includes wound care.
A patient is being evaluated for postthrombotic syndrome. Which assessment will the nurse perform?
Inspect for presence of lipodermatosclerosis. Clinical signs of postthrombotic syndrome include lipodermatosclerosis. In this situation, the skin on the lower leg becomes scarred, and the leg becomes tapered like an "inverted bottle."
Which goal has the highest priority in the plan of care for a 26-yr-old patient who is homeless who was admitted with viral hepatitis who has severe anorexia and fatigue?
Maintain adequate nutrition. The highest priority outcome is to maintain nutrition because adequate nutrition is needed for hepatocyte regeneration.
The nurse will most likely prepare a medication teaching plan about antiretroviral therapy (ART) for which patient?
Patient who tested positive for HIV 2 years ago and now has cytomegalovirus (CMV) retinitis 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 older adult with chronic human immunodeficiency virus (HIV) infection who takes medications for coronary artery disease and hypertension has chosen to begin early antiretroviral therapy (ART). Which information will the nurse include in patient teaching?
Many drugs interact with antiretroviral medications. The nurse will teach the patient about potential interactions between antiretrovirals and the medications that the patient is using for chronic health problems.
When caring for a patient on the first postoperative day after an abdominal aortic aneurysm repair, which assessment finding is most important for the nurse to communicate to the health care provider?
Maroon-colored liquid stool Loose, bloody (maroon colored) stools at this time may indicate intestinal ischemia or infarction and should be reported immediately because the patient may need an emergency bowel resection.
A pregnant woman with asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, "I am very nervous about making my baby sick." Which information will the nurse include when teaching the patient?
Most infants born to HIV-positive mothers are not infected with the virus.
Which patient exposure by the nurse is most likely to require postexposure prophylaxis when the patient's human immunodeficiency virus (HIV) status is unknown?
Needle stick with a needle and syringe used for a venipuncture
The nurse is caring for a patient with critical limb ischemia who has just arrived on the nursing unit after having percutaneous transluminal balloon angioplasty. Which action should the nurse perform first?
Obtain vital signs. Bleeding is a possible complication after catheterization of the femoral artery, so the nurse's first action should be to assess for changes in vital signs that might indicate hemorrhage. The
The nurse prepares to administer the following medications to a hospitalized patient with human immunodeficiency (HIV). Which medication is most important to administer at the scheduled time?
Oral saquinavir (Invirase) It is important that antiretrovirals be taken at the prescribed time every day to avoid developing drug-resistant HIV.
A patient who is human immunodeficiency virus (HIV)-infected has a CD4+ cell count of 400/µL. Which factor is most important for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient?
Patient's ability to follow a complex medication regimen Drug resistance develops quickly unless the patient takes ART medications on a strict, regular schedule. In addition, drug resistance endangers both the patient and community.
A patient with chronic hepatitis C infection has several medications prescribed. Which medication requires further discussion with the health care provider before administration?
Pegylated -interferon (PEG-Intron, Pegasys) 1.5 mcg/kg PO daily Pegylated -interferon is administered subcutaneously, not orally.
A patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care?
Place the patient on a pressure-relief mattress. 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.
A 36-yr-old female patient is receiving treatment for chronic hepatitis C with pegylated interferon (PEG-Intron, Pegasys), ribavirin (Rebetol), and telaprevir (Incivek). Which finding is important to communicate to the health care provider to suggest a change in therapy?
Positive urine pregnancy test Because ribavirin is teratogenic, the medication will need to be discontinued immediately.
A patient informed of a positive rapid antibody test result for human immunodeficiency virus (HIV) is anxious and does not appear to hear what the nurse is saying. What action by the nurse is most important at this time?
Remind the patient about the need to return for retesting to verify the results.
When caring for a patient with acute coronary syndrome who has returned to the coronary care unit after having angioplasty with stent placement, the nurse obtains the following assessment data. Which data indicate the need for immediate action by the nurse?
Report of severe chest pain. The patient's chest pain indicates that restenosis of the coronary artery may be occurring and requires immediate actions, such as administration of oxygen and nitroglycerin, by the nurse.
Which action will be included in the care for a patient who has recently been diagnosed with asymptomatic nonalcoholic fatty liver disease (NAFLD)?
Review the patient's current medication list. Some medications can increase the risk for NAFLD, and they should be eliminated.
Which action will the nurse include in the plan of care for a patient who has been diagnosed with chronic hepatitis B?
Schedule for liver cancer screening every 6 months. Patients with chronic hepatitis are at higher risk for development of liver cancer and should be screened for liver cancer every 6 to 12 months.
A patient in the outpatient clinic is diagnosed with acute hepatitis C (HCV) infection. Which action by the nurse is appropriate?
Schedule the patient for HCV genotype testing. Genotyping of HCV has an important role in managing treatment and is done before drug therapy is initiated.
The nurse is reviewing the laboratory test results for a patient who has recently been diagnosed with hypertension. Which result is most important to communicate to the health care provider?
Serum creatinine of 2.8 mg/dL The elevated serum creatinine indicates renal damage caused by the hypertension. Normal value is 0.6-1.6 mg/dL
Which assessment finding for a patient who is receiving IV furosemide (Lasix) to treat stage 2 hypertension is most important to report to the health care provider?
Serum potassium level of 3.0 mEq/L Hypokalemia is a frequent adverse effect of the loop diuretics and can cause life-threatening dysrhythmias. The health care provider should be notified of the potassium level immediately and administration of potassium supplements initiated
A patient in the outpatient clinic has a new diagnosis of peripheral artery disease (PAD). Which group of drugs will the nurse plan to include when teaching about PAD management?
Statins Research indicates that statin use by patients with PAD improves multiple outcomes.
The registered nurse (RN) caring for an HIV-positive patient admitted with tuberculosis can delegate which action to unlicensed assistive personnel (UAP)?
Stock the patient's room with the necessary personal protective equipment. A patient diagnosed with tuberculosis would be placed on airborne precautions. Because all health care workers are taught about the various types of infection precautions used in the hospital, the UAP can safely stock the room with personal protective equipment. Obtaining contact information and patient teaching are higher-level skills that require RN education and scope of practice.
An older patient has been diagnosed with possible white coat hypertension. Which planned action by the nurse best addresses the suspected cause of the hypertension?
Teach the patient how to self-monitor and record BPs at home.
A patient who is 2 days post femoral popliteal bypass graft to the right leg is being cared for on the vascular unit. Which action by a licensed practical/vocational nurse (LPN/LVN) caring for the patient requires the registered nurse (RN) to intervene?
The LPN/LVN has the patient to sit in a chair for 2 hours. The patient should avoid sitting for long periods because of the increased stress on the suture line caused by leg edema and because of the risk for venous thromboembolism (VTE
Which action by a new nurse who is giving fondaparinux (Arixtra) to a patient with a lower leg venous thromboembolism (VTE) indicates that more education about the drug is needed?
The nurse ejects the air bubble from the syringe before giving the drug. The air bubble is not ejected before giving fondaparinux to avoid loss of drug.
The nurse is assessing a patient who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider?
The patient cannot move the left arm and leg when asked to do so.
After the nurse teaches the patient with stage 1 hypertension about diet modifications that should be implemented, which diet choice indicates that the teaching has been most effective?
The patient drinks low-fat milk with each meal. For the prevention of hypertension, the Dietary Approaches to Stop Hypertension (DASH) recommendations include increasing the intake of calcium-rich foods.
When discussing risk factor modification for a patient who has a 5-cm abdominal aortic aneurysm, the nurse will focus teaching on which patient risk factor?
Uncontrolled hypertension Male gender, Turner Syndrome, and Abdominal trauma contribute to the patient's risk, but only hypertension can potentially be modified to decrease the patient's risk for further expansion of the aneurysm.
Which action will be included in the plan of care when the nurse is caring for a patient who is receiving nicardipine (Cardene) to treat a hypertensive emergency?
Use an automated noninvasive blood pressure machine to obtain frequent measurements. Frequent monitoring of BP is needed when the patient is receiving rapid-acting IV antihypertensive medications. This can be most easily accomplished with an automated BP machine or arterial line.
To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review?
Viral load testing The effectiveness of ART is measured by the decrease in the amount of virus detectable in the blood.
To detect possible complications in a patient with severe cirrhosis who has bleeding esophageal varices, it is most important for the nurse to monitor
ammonia levels. The protein in the blood in the gastrointestinal tract will be absorbed and may result in an increase in the ammonia level because the liver cannot metabolize protein very well.
The nurse evaluates that administration of hepatitis B vaccine to a healthy patient has been effective when the patient's blood specimen reveals
anti-HBs. The presence of surface antibody to HBV (anti-HBs) is a marker of a positive response to the vaccine.
A young adult contracts hepatitis from contaminated food. During the acute (icteric) phase of the patient's illness, the nurse would expect serologic testing to reveal
anti-hepatitis A virus immunoglobulin M (anti-HAV IgM). Hepatitis A is transmitted through the oral-fecal route, and antibody to HAV IgM appears during the acute phase of hepatitis A. Anti-HAV IgG would indicate past infection and lifelong immunity.
A patient has a 6-cm thoracic aortic aneurysm that was discovered during routine chest x-ray. When obtaining an admission history from the patient, it will be most important for the nurse to ask about
trouble swallowing. Difficulty swallowing may occur with a thoracic aneurysm because of pressure on the esophagus.
A 56-yr-old patient who has no previous history of hypertension or other health problems suddenly develops a blood pressure (BP) of 198/110 mm Hg. After reconfirming the BP, it is appropriate for the nurse to tell the patient that
diagnosis, treatment, and ongoing monitoring will be needed. A sudden increase in BP in a patient older than age 50 years with no previous hypertension history or risk factors indicates that the hypertension may be secondary to some other problem. The BP will need treatment and ongoing monitoring.
When developing a teaching plan for a 61-yr-old patient with multiple risk factors for coronary artery disease (CAD), the nurse should focus primarily on the
elevated low-density lipoprotein (LDL) level.
The charge nurse observes a new registered nurse (RN) doing discharge teaching for a patient with hypertension who has a new prescription for enalapril (Vasotec). The charge nurse will need to intervene if the new RN tells the patient to
increase the dietary intake of high-potassium foods. The ACE inhibitors cause retention of potassium by the kidney, so hyperkalemia is a possible adverse effect.
An older patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the right leg. The nurse should notify the health care provider and immediately
keep the patient in bed in the supine position. The patient's history and clinical manifestations are consistent with acute arterial occlusion, and resting the leg will decrease the O2 demand of the tissues and minimize ischemic damage until circulation can be restored.
The nurse administering -interferon and ribavirin (Rebetol) to a patient with chronic hepatitis C will plan to monitor for
leukopenia.
The nurse will plan to teach the patient diagnosed with acute hepatitis B about
measures for improving the appetite. Maintaining adequate nutritional intake is important for regeneration of hepatocytes.
A patient at the clinic says, "I always walk after dinner, but lately my leg cramps and hurts after just a few minutes of starting. The pain goes away after I stop walking, though." The nurse should
palpate for the presence of dorsalis pedis and posterior tibial pulses. The nurse should assess for other clinical manifestations of peripheral arterial disease in a patient who describes intermittent claudication.
The nurse performing an assessment of a patient who has chronic peripheral artery disease (PAD) of the legs and an ulcer on the right second toe would expect to find
prolonged capillary refill in all the toes. Capillary refill is prolonged in PAD because of the slower and decreased blood flow to the periphery.
Propranolol (Inderal) is prescribed for a patient diagnosed with hypertension. The nurse should consult with the health care provider before giving this drug when the patient reveals a history of
reactive airway disease. Nonselective -blockers block 1- and 2-adrenergic receptors and can cause bronchospasm, especially in patients with a history of asthma. -Blockers will have no effect on the patient's peptic ulcer disease or alcohol use. -Blocker therapy is recommended after MI.
Several hours after a patient had an open surgical repair of an abdominal aortic aneurysm, the UAP reports to the nurse that urinary output for the past 2 hours has been 45 mL. The nurse notifies the health care provider and anticipates an order for a(n)
serum creatinine level. The decreased urine output suggests decreased renal perfusion and monitoring of renal function is needed.
A serum potassium level of 3.2 mEq/L (3.2 mmol/L) is reported for a patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix) due. Which action should the nurse take?
Administer the spironolactone. Spironolactone is a potassium-sparing diuretic and will help increase the patient's potassium level.
Which action should the nurse take to evaluate treatment effectiveness for a patient who has hepatic encephalopathy?
Ask the patient to extend both arms forward. Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic encephalopathy.
During change-of-shift report, the nurse obtains the following information about a hypertensive patient who received the first dose of nadolol (Corgard) during the previous shift. Which information indicates that the patient needs immediate intervention?
The patient has developed wheezes throughout the lung fields. The most urgent concern for this patient is the wheezes, which indicate that bronchospasm (a common adverse effect of the noncardioselective -blockers) is occurring. The nurse should immediately obtain an O2 saturation measurement, apply supplemental O2, and notify the health care provider.
The nurse has just finished teaching a hypertensive patient about the newly prescribed drug, ramipril (Altace). Which patient statement indicates that more teaching is needed?
"I can expect some swelling around my lips and face." Angioedema occurring with angiotensin-converting enzyme (ACE) inhibitor therapy is an indication that the ACE inhibitor should be discontinued. The patient should be taught that if any swelling of the face or oral mucosa occurs, the health care provider should be immediately notified because this could be life threatening
A patient has just been diagnosed with hypertension and has been started on captopril . Which information is most important to include when teaching the patient about this drug?
Change position slowly to help prevent dizziness and falls. The angiotensin-converting enzyme (ACE) inhibitors frequently cause orthostatic hypotension, and patients should be taught to change position slowly to allow the vascular system time to compensate for the position change. Increasing fluid intake may counteract the effect of the drug, and the patient is taught to use gum or hard candy to relieve dry mouth. The BP should be taken in the nondominant arm by newly diagnosed patients in the morning, before taking the drug, and in the evening. Because ACE inhibitors cause potassium retention, increased intake of high-potassium foods is inappropriate.
Which nursing action will be most useful in assisting a college student to adhere to a newly prescribed antiretroviral therapy (ART) regimen?
Check the patient's class schedule to help decide when the drugs should be taken
Which assessment finding for a patient who has been admitted with a right calf venous thromboembolism (VTE) requires immediate action by the nurse?
New onset shortness of breath New onset dyspnea suggests a pulmonary embolus, which will require rapid actions such as O2 administration and notification of the health care provider.
The nurse obtains the following information from a patient newly diagnosed with prehypertension. Which finding is most important to address with the patient?
No regular physical exercise The recommendations for preventing hypertension include exercising aerobically for 30 minutes most days of the week.
The nurse is caring for a patient immediately after repair of an abdominal aortic aneurysm. On assessment, the patient has absent popliteal, posterior tibial, and dorsalis pedis pulses. The legs are cool and mottled. Which action should the nurse take first?
Notify the surgeon and anesthesiologist. Lower extremity pulses may be absent for a short time after surgery because of vasospasm and hypothermia. Decreased or absent pulses together with a cool and mottled extremity may indicate embolization or graft occlusion. These findings should be reported to the surgeon immediately because this is an emergency situation. Because pulses are marked before surgery, the nurse would know whether pulses were present before surgery before notifying the health care providers about the absent pulses.
To prepare a patient with ascites for paracentesis, the nurse
asks the patient to empty the bladder. 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. Because no sedation is required for paracentesis, the patient does not need to be NPO.
A young adult patient tells the health care provider about experiencing cold, numb fingers when running during the winter, and Raynaud's phenomenon is suspected. The nurse will anticipate teaching the patient about tests for
autoimmune disorders. Secondary Raynaud's phenomenon may occur in conjunction with autoimmune diseases such as rheumatoid arthritis.
A patient with a venous thromboembolism (VTE) is started on enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why two medications are necessary. Which response by the nurse is most accurate?
"Enoxaparin will work right away, but warfarin takes several days to begin preventing clots." Low molecular weight heparin (LMWH) is used because of the immediate effect on coagulation and discontinued once the international normalized ratio (INR) value indicates that the warfarin has reached a therapeutic level.
A patient with a history of hypertension treated with a diuretic and an angiotensin-converting enzyme (ACE) inhibitor arrives in the emergency department complaining of a severe headache and nausea and has a blood pressure (BP) of 238/118 mm Hg. Which question should the nurse ask to follow up on these findings?
"Have you consistently taken your medications?" Sudden withdrawal of antihypertensive medications can cause rebound hypertension and hypertensive crisis.
A patient with hypertension who has just started taking atenolol (Tenormin) returns to the health clinic after 2 weeks for a follow-up visit. The blood pressure (BP) is unchanged from the previous visit. Which action should the nurse take first?
Ask the patient if the medication is being taken as prescribed. Because nonadherence with antihypertensive therapy is common, the nurse's initial action should be to determine whether the patient is taking the atenolol as prescribed.
A patient has been admitted with acute liver failure. Which assessment data are most important for the nurse to communicate to the health care provider?
Asterixis and lethargy The patient's findings of asterixis and lethargy are consistent with grade 2 hepatic encephalopathy. Patients with acute liver failure can deteriorate rapidly from grade 1 or 2 to grade 3 or 4 hepatic encephalopathy and need early transfer to a transplant center.
A patient is being treated for bleeding esophageal varices with balloon tamponade. Which nursing action will be included in the plan of care?
Monitor the patient for shortness of breath. 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. Balloons may be deflated briefly every 8 to 12 hours to avoid tissue necrosis, but if only the gastric balloon is deflated, the esophageal balloon may occlude the airway. Balloons are not deflated for nausea.
The nurse is admitting a patient newly diagnosed with peripheral artery disease. Which admission order should the nurse question?
Omeprazole drug therapy Because the antiplatelet effect of clopidogrel is reduced when it is used with omeprazole, the nurse should clarify this order with the health care provider.
The health care provider has prescribed bed rest with the feet elevated for a patient admitted to the hospital with venous thromboembolism. Which action by the nurse to elevate the patient's feet is best?
One pillow is placed under the thighs and two pillows are placed under the lower legs. The purpose of elevating the feet is to enhance venous flow from the feet to the right atrium, which is best accomplished by placing two pillows under the feet and one under the thighs.
Which finding indicates to the nurse that lactulose is effective for an older adult who has advanced cirrhosis?
The patient is alert and oriented. The purpose of 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.
The nurse is caring for a patient who is human immunodeficiency virus (HIV) positive and taking antiretroviral therapy (ART). Which information is most important for the nurse to address when planning care?
The patient reports missing some doses of zidovudine (AZT). Because 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.
Which information given by a 70-yr-old patient during a health history indicates to the nurse that the patient should be screened for hepatitis C?
The patient used IV drugs about 20 years ago. 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.
A patient with human immunodeficiency virus (HIV) infection has developed Mycobacterium avium complex infection. Which outcome would be appropriate for the nurse to include in the plan of care?
The patient will maintain intact perineal skin. The major manifestation of M. avium infection is loose, watery stools, which would increase the risk for perineal skin breakdown.
The nurse is caring for a patient who has cirrhosis. Which data obtained by the nurse during the assessment will be of most concern?
The patient's hands flap back and forth when the arms are extended. Asterixis indicates that the patient has hepatic encephalopathy, and hepatic coma may occur.
The health care provider prescribes an infusion of heparin and daily partial thromboplastin time (PTT) testing for a patient with venous thromboembolism (VTE). The nurse will plan to
avoid giving IM medications to prevent localized bleeding. Intramuscular injections are avoided in patients receiving anticoagulation to prevent hematoma formation and bleeding from the site. A PTT of 65 seconds is within the therapeutic range. Vitamin K is used to reverse warfarin. Pulse quality is not affected by VTE.
When evaluating the discharge teaching for a patient with chronic peripheral artery disease (PAD), the nurse determines a need for further instruction when the patient says, "I will
use a heating pad on my feet at night to increase the circulation." Because the patient has impaired circulation and sensation to the feet, the use of a heating pad could lead to burns. Loose fitted clothing, walk to the point of pain, rest, and walk again 3x for 30 mins, and change position every hour and avoid periods of sitting with my legs crossed are correct and indicate that teaching has been successful.
The nurse is advising a clinic patient who was exposed a week ago to human immunodeficiency virus (HIV) through unprotected sexual intercourse. The patient's antigen and antibody test has just been reported as negative for HIV. What instructions should the nurse give to this patient?
"You will need to be retested in 2 weeks." HIV screening tests detect HIV-specific antibodies or antigens, but typically it takes a several week delay after initial infection before HIV can be detected on a screening test. Combination antibody and antigen tests (also known as fourth-generation tests) decrease the window period to within 3 weeks after infection.
A patient admitted with an abrupt onset of jaundice and nausea has abnormal liver function studies but serologic testing is negative for viral causes of hepatitis. Which question by the nurse is appropriate?
"Do you use any over-the-counter drugs?"
Which action will the nurse in the hypertension clinic take to obtain an accurate baseline blood pressure (BP) for a new patient?
Have the patient sit in a chair with the feet flat on the floor. The patient should be seated with the feet flat on the floor. The BP is obtained in both arms, and the results of the two arms are not averaged. The cuff should be deflated at 2 to 3 mm Hg per second.
Which nursing intervention is likely to be most effective when assisting the patient with coronary artery disease to make appropriate dietary changes?
Help the patient modify favorite high-fat recipes by using monounsaturated oils. Lifestyle changes are more likely to be successful when consideration is given to the patient's values and preferences. The highest percentage of calories from fat should come from monounsaturated or polyunsaturated fats. Up to 7% of calories in the therapeutic lifestyle changes diet can come from saturated fat.
Which nursing action should be included in the plan of care after endovascular repair of an abdominal aortic aneurysm?
Monitor fluid intake and urine output. Because renal artery occlusion can occur after endovascular repair, the nurse should monitor parameters of renal function such as intake and output.
The nurse is caring for a 70-yr-old patient who uses hydrochlorothiazide and enalapril (Norvasc) but whose self-monitored blood pressure (BP) continues to be elevated. Which patient information may indicate a need for a change?
Patient uses ibuprofen (Motrin) treat osteoarthritis. Because use of nonsteroidal antiinflammatory drugs (NSAIDs) can prevent adequate BP control, the patient may need to avoid the use of ibuprofen.
The nurse designs a program to decrease the incidence of human immunodeficiency virus (HIV) infection in the adolescent and young adult populations. Which information should the nurse assign as the highest priority?
Prevention of HIV transmission between sexual partners Sexual transmission is the most common way that HIV is transmitted. The nurse should also provide teaching about perinatal transmission, needle sterilization, and blood transfusion, but the rate of HIV infection associated with these situations is lower.
After teaching a patient with newly diagnosed Raynaud's phenomenon about how to manage the condition, which action by the patient best demonstrates that the teaching has been effective?
The patient exercises indoors during the winter months. Patients should avoid temperature extremes by exercising indoors when it is cold. To avoid burn injuries, the patient should use warm rather than hot water to warm the hands. Pseudoephedrine is a vasoconstrictor and should be avoided. There is no reason to avoid taking NSAIDs with Raynaud's phenomenon.
