Med surg ch. 12,,13,14,41,42

The home health nurse gives instructions to a patient in avoiding recurrence of athlete's foot. Which information should the nurse include? (select all that apply.) a. Wear clean cotton socks. b. Wear shoes that allow ventilation. c. Use only clean towels. d. Wash and dry feet daily. e. Apply antibacterial medication to feet.

ANS: A, B, C, D

The nurse is caring for a first-day postoperative thoracotomy patient. The nurse assesses that the level of drainage has not increased over the last 3 hours. After assessing the patient's respiratory status, what should the nurse do next? a. Raise the system above the patient's heart. b. Check the tubing for kinks. c. Reposition the patient. d. Notify the physician.

B

The nurse is caring for a patient with a stage III pressure ulcer that is not healing. Which statement accurately describes the goal of electrical stimulation of the pressure ulcer? a. To sterilize the wound b. To increase blood vessel growth c. To cause the ulcer to close by scabbing d. To coagulate the drainage

B

The patient with shingles has been on an antiviral medication since the vesicles appeared. The goal of early treatment is to prevent which complication? a. Postherpetic pain b. Outbreak of additional vesicles c. Lesions of the eye d. Transmission to health care workers

A

The nurse is bathing a patient with poison ivy. Which action is most appropriate? a. Bathe the patient with warm water. b. Maintain a room temperature of 78° to 80° F to prevent chills. c. Cover vesicles with gauze dressings. d. Pat skin dry.

D

The clinic nurse is giving discharge instructions to the mother of a 10-year-old boy who has been diagnosed with a mild cold. Which statements indicate that the mother accurately understands the nurse's instructions? (Select all that apply.) a. "I will be sure he takes the entire prescription of antibiotic." b. "I will be sure he drinks plenty of apple and orange juice." c. "If he runs a fever, I will give him two aspirin every 4 hours until his fever comes down." d. "I will be sure he washes his hands well so he doesn't pass this cold on to his younger sister." e. "Since his cold symptoms just started, zinc lozenges may be helpful for him to take."

: B, D, E

After a medicated bath, the patient is assisted from the tub. Which statement about lotion application is correct? a. Apply lotion immediately after drying the patient. b. Apply lotion in a thick layer to warm skin. c. Apply lotion after returning the patient to bed. d. Allow the patient to apply the lotion.

A

The nurse is assessing a patient with chronic obstructive pulmonary disease (COPD). Which assessment finding indicates a potential complication and requires the nurse's immediate attention? a. Distended neck veins b. Left lower quadrant tenderness c. Urinary output of 40 mL/hr d. Excessive coughing

A

The nurse is assessing an older adult patient's hydration status. The nurse observes that a fold of skin on the upper chest returns to normal position. The nurse should conclude that hydration is adequate if the skin returns to normal position in how many seconds? a. 6 seconds b. 9 seconds c. 10 seconds d. 15 seconds

A

The nurse is assisting the physician with the insertion of a new tracheostomy tube. The physician asks for the obturator. The nurse correctly hands the physician which device? a. The guide for the tracheostomy tube to be inserted b. The scalpel used to make the tracheostomy stoma c. A single-cannula tracheostomy tube d. A cuffed tracheostomy tube

A

The nurse is aware that the patient is in respiratory failure when the blood gas findings contain which values? a. PaO2 46 mm Hg; PaCO2 52 mm Hg b. PaO2 50 mm Hg; PaCO2 45 mm Hg c. PaO2 52 mm Hg; PaCO2 42 mm Hg d. PaO2 55 mm Hg; PaCO2 58 mm Hg

A

The nurse is caring for a burn patient. Which action best prevents contractures? a. Assist the patient with ambulation as soon as fluid shifts stabilize. b. Medicate the patient approximately 30 minutes prior to dressing changes. c. Ensure adequate hydration. d. Ensure adequate nutritional intake.

A

The nurse is caring for a patient diagnosed with shingles who complains of constant pain along the sciatic nerve. What intervention best helps to provide pain relief? a. Distract the patient with conversation. b. Massage the area of pain. c. Move the affected leg through range-of-motion (ROM). d. Change the patient's position frequently.

A

The nurse is caring for a patient with a closed-chest drainage system with chest tubes. Which observation confirms that the system is intact and working? a. The water level in the water-seal chamber fluctuates. b. The level of fluid in the collection chamber rises. c. There are constant bubbles in the water-seal chamber. d. The suction has been attached.

A

The nurse is caring for a patient with a stage III pressure ulcer. Which assessment findings are consistent with this stage of ulcer? a. A crater-like lesion b. Skin that does not blanch with fingertip pressure c. Presence of mottled skin d. Excoriation around the lesion

A

The nurse is educating a patient who requires daily postural drainage treatments. Which statement indicates that the patient understands when and why treatments will be scheduled? a. "I will have treatments first thing in the morning to get rid of fluids that have built up over night." b. "I will have my treatments after an hour after breakfast to make sure that I am fully alert." c. "I will have treatments after lunch to prevent an unsafe drop in my blood sugar." d. "I will have treatments right before bed to ensure that I breathe more easily at night."

A

The patient reports to the nurse that the physician has ordered a Wood light examination. The nurse correctly recognizes the physician is concerned that the patient may have which condition? a. Tinea corpus b. Scabies c. Herpes simplex d. Dermatitis

A

The patient with sleep apnea is fitted with a continuous positive airway pressure (CPAP) mask and asks the nurse how this device will help. How should the nurse respond? a. "The device delivers constant positive pressure to keep your airway open." b. "The device will require you to be intubated to open your airway." c. "The device delivers oxygen only when you are apneic." d. "The device delivers negative pressure to stimulate your respirations."

A

When creating a visual aid to show the mechanics of inhaling, the nurse correctly illustrates which scenario? a. The diaphragm moves downward. b. The negative pressure of the lung converts to positive pressure. c. The muscles contract and pull the rib cage downward. d. The bronchi enlarge.

A

When the nurse places the diaphragm of the stethoscope over one of the main bronchi, which expected normal breath sound should the nurse hear? a. Bronchovesicular sounds b. Bronchial sounds c. Sonorous sounds d. Vesicular sounds

A

Which chemical irritant causes the most damage to skin of the immobilized patient? a. Urine b. Topical medication c. Bath soap d. Laundry soap

A

While bathing a patient, the nurse assesses a red, unblanchable area on the coccyx. Which type of dressing should the nurse apply? a. Transparent film b. Hydrocolloid c. Fluffy absorbent d. Wet-to-dry

A

While bathing a patient, the nurse discovers a grayish black, nodular growth that resembles a blackberry in the middle of the patient's back. What action should the nurse take? a. Report the findings to the patient's health care provider. b. Teach the patient how to assess for changes in the growth. c. Document the finding of an actinic keratosis on the back. d. Inform the patient that he has a growth that is a melanoma.

A

While performing an assessment, the nurse auscultates a coarse low-pitched sonorous rattling in the left lower lobe. Based on the presence of this adventitious lung sound, which action should the nurse take next? a. Instruct the patient to turn, cough, and deep-breathe. b. Administer the diuretic as ordered. c. Administer the bronchodilator as ordered. d. Instruct the patient to blow into the incentive spirometer.

A

The nurse is caring for a patient on a mechanical ventilator that it is set on assist-control mode. Which statement(s) accurately describe this function? (Select all that apply.) a. The ventilator delivers a set tidal volume. b. The ventilator delivers a set number of breaths if the patient's rate falls. c. The ventilator automatically cuts off if the patient is breathing independently. d. The ventilator delivers more oxygen at the end of an inspiration. e. The ventilator helps correct respiratory acidosis.

A,B

The nurse is performing an occupational history as part of the respiratory assessment. Which occupation(s) place the patient at increased risk for an occupational lung disorder? (Select all that apply.) a. A firefighter b. A cotton gin worker c. A construction contractor d. A bartender e. A landscaper

A,B,C

The nurse is teaching a patient with a newly resolved episode of epistaxis. Which information is important for the nurse to include? (Select all that apply.) a. Avoid sneezing. b. Rest for several hours until all threat of epistaxis is gone. c. Avoid rubbing the nose. d. Gently remove clotted blood from the occluded nostril. e. Blow the nose gently in small breaths.

A, B, C

The nurse is assessing an older adult with a family tendency of developing laryngeal cancer. The nurse should ask the patient about which risk factors? (Select all that apply.) a. History of smoking b. Alcohol abuse c. Exposure to asbestos d. Occupational exposure to wood dust e. Infection with Streptococcus bacteria

A, B, C, D

Which physical signs indicate labored breathing? (Select all that apply.) a. Grunting on expiration b. Elevating shoulders and ribs on inspiration c. Tensing neck and shoulder muscles d. Substernal retraction e. Productive cough

A, B, C, D

Which action(s) may help to reduce the risk of transmitting a common cold? (Select all that apply.) a. Cover the mouth and nose when sneezing. b. Wash the hands frequently. c. Use saline nose sprays. d. Turn the head to the crook of the arm when coughing. e. Drink juices with vitamin C.

A, B, D

The nurse is setting up the environment for tracheal suction on a newly postoperative tracheostomy patient. Which action(s) should the nurse perform? (Select all that apply.) a. Auscultate lungs for retained secretions. b. Wash hands and open sterile suction kit. c. Don clean gloves and lift out catheter and connect to suction. d. Inform the patient about the procedure. e. Perform suction with sterile supplies.

A, B, D, E

Which age-related change(s) occur(s) in the integumentary system? (select all that apply.) a. Elastic fibers and adipose tissue diminish. b. Skin thins and becomes transparent. c. Hair thickens as follicles decrease. d. Skin becomes dry. e. Thinned skin leads to cold intolerance.

A, B, D, E

Which manifestation(s) are age-related changes that alter the respiratory system? (Select all that apply.) a. Weakened cough b. Kyphosis c. Increased ciliary movement d. Decrease in body fluid e. Muscle weakness

A, B, D, E

For which individual(s) does U.S. Public Health Service recommend the influenza immunization? (Select all that apply.) a. Physicians b. Compromised infants c. Older adults d. Chronically ill e. Nurses

A, C, D, E

The nurse clarifies that when interstitial edema occurs in the lung tissue, it inhibits ventilation by causing which problem(s)? (Select all that apply.) a. Thickening alveolar membranes b. Pus formation c. Alveoli filling with fluid d. Evaporating surfactant e. Gas failing to diffuse across membrane

A, C, E

Which organism(s) are common causative agents for sinusitis? (Select all that apply.) a. Pneumococci b. Pseudomonas c. Staphylococci d. Haemophilus influenzae e. Streptococci

A, D, E

The nurse is assessing the patient with influenza. The patient reports having general malaise and aching muscles over the past 2 weeks. The nurse suspects that the patient may have developed which complication of influenza? a. Bronchitis b. Bacterial pneumonia c. Urinary infection d. Encephalitis

B

The radical neck resection removes a large amount of tissue on the same side as the lesion. Which statement(s) about the tissue removed is/are correct? (Select all that apply.) a. The tissue includes all muscle, lymph nodes, and soft tissue from the lower edge of the mandible to the top of the clavicle. b. The tissue includes all muscle, lymph nodes, and soft tissue from the top of the trapezius to the midline. c. The tissue includes all muscle, lymph nodes, and soft tissue from the lower edge of the eye socket to the bottom of the maxilla, including the zygomatic arch. d. The tissue includes part of the tongue and parotid salivary glands. e. The tissue includes all lower lip to midline.

A,B,C

The home health nurse is educating a 60-year-old patient with emphysema with a nutritional deficit. Which instructions should the nurse include in the teaching plan to address this problem? (Select all that apply.) a. Rest before eating. b. Avoiding gas-producing foods. c. Eat four to six small meals instead of three large meals. d. Lie down after eating. e. Take small bites and chew slowly.

A,B,C,E

The nurse is caring for a patient with advanced emphysema. Which signs are manifestations of this disorder? (Select all that apply.) a. Productive cough b. Dyspnea c. Barrel chest d. Wheezing e. Cyanotic skin tone

A,B,C,E

Through which method(s) can influenza spread? (Select all that apply.) a. Direct contact b. Indirect contact c. Vector d. Blood-borne method e. Droplets

A,B,E

The nurse is advising an older adult regarding age-appropriate bathing practices. Which instruction(s) is/are most important for the nurse to include? (select all that apply.) a. Using lotion-based soaps. b. Using hot water to stimulate skin. c. Towel skin dry with quick, brisk motions. d. Apply lotion twice a day. e. Apply talcum powder after bathing.

A,D

The nurse differentiates the various type of dermatitis. Match each option with the characteristics that best describe it. (Options may be used once, more than once, or not at all.) a. Contact dermatitis b. Atopic dermatitis c. Stasis dermatitis d. Seborrheic dermatitis

A. Cell-mediated immunity resulting in inflammatory response A. Appearance of vesicular lesions following inflammatory response A. Rash associated with poison ivy B. Mast cell-stimulated release of histamine C. Erythema and pruritus with scaling associated with phlebitis C. Lesions may become ulcerated D. Scaly lesions on scalp, ear canals, and eyebrows

The nurse clarifies the descriptive terms for skin disorders. Match each option with the characteristic that best describes it. a. Erythrasma b. Wheal c. Fungal infection d. Keratosis e. Keloid

A. Chronic bacterial infection in skinfolds, especially axilla and between toes B. Smooth, elevated area that is pale or reddened C. Fluoresces under Wood light D. Benign wartlike lesions on trunk, arms, and scalp E. Thick ridge of scar tissue

The nurse is aware that the patient seeking antibiotic treatment for pharyngitis will only receive the desired medication if the condition is caused by what type of pathogen? a. Protozoa b. Bacteria c. A virus d. Fungi

B

The nurse describes common complications that burn patients may experience. Match the burn complication with the description that best fits it. a. Edema b. Hyperkalemia c. Hypovolemia d. Tissue hypoxia e. Hypermetabolism

A. Inflammatory response causing fluid shift B. Potassium released from damaged cells C. Loss of fluid from vascular space D. Increased viscosity of blood slowing blood flow to small vessels E. Negative nitrogen balance

The nurse uses a picture to show the structure of the integument. Match the options with the characteristic that best describes them. (Each option may be used once, more than once, or not at all.) a. Epidermis b. Dermis c. Sebaceous glands d. Sweat glands

A. Squamous epithelium, no blood vessels B. Contains vessels, nerves, and hair follicles B. Consists of dense connective tissue C. Keeps skin and hair pliable D. Excretes water and salt

The nurse is caring for a patient experiencing epistaxis. What action should the nurse take first? a. Obtain the patient's vital signs. b. Firmly pack the nostrils with gauze. c. Apply a cold compress. d. Instruct the patient to sit forward and pinch the nose below the bone.

D

The nurse describes several types of burn treatment. Match the burn treatment to the statement that best describes it. a. Open technique b. Closed technique c. Escharotomy d. Allograft e. Xenograft

A. Wound covered with ointment, and additional environmental warmth provided B. Wound covered with ointment, then covered with layers of gauze saturated with topical medication C.Incision into subcutaneous tissue to increase circulation D. Biologic dressing obtained from a cadaver E.Biologic dressing obtained from a pig

An adult male patient enters the emergency department with full- and partial-thickness burns on the entire right leg, front of the right arm, and one half of the front torso. The nurse, using the "rule of nines," assesses the burn as ____%.

ANS: 31 31.5 32

Using the Parkland formula, the fluid needed for a person weighing 140 pounds with a 25% burn would be _____ mL.

ANS: 6360

The home health nurse is making an initial call on a newly diagnosed tuberculosis (TB) patient. The patient lives with his wife and child. Which infection control instructions should the nurse include in the teaching plan? (Select all that apply.) a. Place contaminated tissues in sealable plastic bag. b. Take medications exactly as directed. c. Implement airborne precautions. d. Wash hands frequently. e. Wear a mask when in crowds.

ANS: A, B, D, E

The nurse is educating patients about dietary selections that will promote wound healing. Which menu options should the nurse include? (select all that apply.) a. Tofu b. White bread c. Lean beef d. Citrus fruits e. Leafy green vegetables

ANS: A, C, D, E

The nurse is caring for a 20-year-old patient who recently underwent a tonsillectomy. The patient is fully awake and clearing his throat frequently but denies pain. Which action is most important for the nurse to take first? a. Place the patient in a side-lying position. b. Look in the patient's mouth. c. Offer the patient a grape popsicle. d. Remove the straw from the patient's tray.

B

The nurse is caring for a patient immediately postoperative after a left pneumonectomy. How should the nurse position the patient? a. In high Fowler position b. In semi-Fowler position c. In a right side-lying position d. In a left side-lying position

D

A newly admitted 86-year-old patient has scratch marks in the groin and axilla and on her limbs. There are small, punctate red lesions that the patient says itch "like crazy." Which nursing action is most appropriate? a. Employ skin tear precautions b. Employ Standard Precautions c. Employ use of emollient d. Employs focused assessment for cause

B

A patient is admitted to the medical unit with an acute illness accompanied by a fever for the last 3 days. What will likely be the patient's respiratory response? a. Hypercarbia b. Respiratory alkalosis c. Kussmaul respirations d. Respiratory acidosis

B

A patient with emphysema presents to the emergency room with severe dyspnea; O2 saturation is 74%, pulse is 120, and respirations are 26. The nurse positions the patient in high Fowler. What action should the nurse take next? a. Collect a sputum specimen. b. Coach the patient in pursed-lip breathing. c. Give oxygen at 5 L/min by nasal cannula. d. Ensure patent intravenous (IV) access.

B

An 84-year-old patient has had a low-grade fever for 2 days. This morning, the patient complains of burning, tingling hip pain that shoots down the leg. The nurse observes a small group of vesicles on the leg. These findings are consistent with which disorder? a. Herpes simplex b. Herpes zoster c. Syphilis lesions d. Furuncles

B

For which patient would the nurse question an order for isotretinoin (Accutane)? a. A 20-year-old epileptic man with nodular acne and epilepsy b. A 22-year-old pregnant woman with severe acne c. A 46-year-old woman on oral contraceptive pills with cystic acne d. A 50-year-old hypertensive man with cystic acne

B

The 75-year-old patient presents to the emergency department with shortness of breath, fatigue, and a dry cough. When information leads the nurse to suspect that this patient should undergo workup for histoplasmosis? a. The patient reports drinking pond water. b. The patient lives on a farm and raises chickens. c. The patient recently went hunting in a wooded area. d. The patient owns a landscaping company.

B

The 79-year-old patient with bacterial pneumonia becomes increasingly restless, confused, and agitated. The patient's temperature is 100° F, and his pulse, blood pressure, and respirations are elevated since the last assessment 6 hours ago. What action should the nurse take first? a. Auscultate the patient's lungs. b. Assess the patient's oxygen saturation. c. Administer the mild sedative as ordered. d. Administer an ordered analgesic for discomfort.

B

The nurse is advising a 20-year-old college sophomore with acne vulgaris. Which information is most important for the nurse to include in the teaching plan? a. Avoid all chocolate. b. Wash your face gently with mild soap. c. Scrub your face with a soft brush. d. Gently express clogged sebum from your pores.

B

The nurse is caring for a patient with an order for an "open dressing." Which action indicates that the nurse accurately understands the order? a. The nurse leaves the entire lesion open to air. b. The nurse changes wet compresses frequently enough to keep them wet. c. The nurse applies medicated ointment directly in the open wound. d. The nurse applies dressings to the perimeter of the wound while leaving the center of the wound open to air.

B

The nurse is caring for a patient with sleep apnea. The patient complains that he is constantly fatigued. Which response is most appropriate for the nurse to make? a. "Patients with sleep apnea experience oxygen overloads, which lead to drowsiness." b. "Patients with sleep apnea often wake frequently during the night." c. "Patients with mild sleep apnea benefit from a small amount of red wine right before bed." d. "All patients have difficulty sleeping properly in the hospital."

B

The nurse is caring for a patient with suspected sinusitis. Which assessment finding supports this diagnosis? a. Maxillary sinuses nontender on percussion. b. Generalized pain in the upper teeth. c. Clear drainage from the ear. d. Ear pain when lying down

B

The nurse is caring for a postoperative patient. After instructing the patient to cough and deep-breathe, what action should the nurse take next? a. Offer a warm drink. b. Perform mouth care. c. Deliver oxygen by mask. d. Take the patient's temperature.

B

The nurse is educating a patient with psoriasis. Which information is most important for the nurse to include in the teaching plan? a. Liberally apply a lubricating cream three times daily. b. Use a humidifier at night. c. Use an alcohol-based cleanser in the morning. d. Take hot baths to reduce skin discomfort.

B

The nurse is educating an asthma patient about proper use of the peak flowmeter. The nurse determines that the patient needs further teaching when observing which action? a. The patient repeats the procedure and obtains three readings. b. The patient breathes deeply through the mouthpiece. c. The patient stands while performing the test. d. The patient reports the highest reading on the peak flow sheet.

B

The nurse is providing discharge teaching of a patient. Which instructions should the nurse include to teach reduction of soap in bed linens and sleeping garments? a. Only use high-efficiency detergents. b. Use vinegar in the rinse water. c. Only wash clothing in hot water. d. Send linens to a professional laundry.

B

The nurse is teaching a group of teenagers about skin care and sun damage. Which statement by a participant indicates the need for further instruction? a. "Although I have a darker complexion, I am still at risk for sun damage." b. "The safest time of day to engage in water sports and avoid sun damage is from 10 A.M. to noon." c. "My sunscreen should ideally have SPF 30 or higher." d. "It is important to apply sunscreen about 30 mins before sun exposure.

B

The nurse is teaching a patient who underwent a laryngectomy. Which statement describes the correct technique for warming inspired air during cold weather? a. Cover the stoma with a clean hand. b. Cover the stoma with a scarf. c. Apply a moist dressing over the stoma. d. Carry a portable humidifier.

B

The nurse observes the CNA who is changing a patient's bed. Which action demonstrates that the CNA requires additional teaching? a. Lifting the patient on the draw sheet to the stretcher. b. Pulling the draw sheet out from under the patient. c. Rolling the patient to the side to change the draw sheet. d. Using the gait belt to lift the patient from the bed to a wheelchair.

B

The patient with asthma is prescribed a leukotriene modifier drug, montelukast (Singulair). Which statement describes an advantage of this medication? a. Limited gastrointestinal (GI) side effects b. Bronchodilation and anti-inflammatory effects c. Stringent control of acute episodes of asthma d. Ability to replace all other asthma remedies

B

The school nurse is advising a group of high school girls about ways to avoid permanent skin damage from sun exposure. Which information is most important to include in the teaching plan? a. Avoid using cosmetics that have sunscreen added. b. Consider a spray tan in the summer. c. Limit sunbathing times on a cloudy day. d. Wear light, loose clothing while in sun.

B

What is the contagion period of a cold? a. 2 days b. 3 days c. 4 days d. 7 days

B

What is the primary purpose of a whirlpool bath given to the patient with a stage III pressure ulcer? a. To prevent infection b. To stimulate granulation tissue growth c. To improve circulation in surrounding skin d. To provide moisture to the ulcer

B

What is the purpose of mucus? a. To warm the air entering the lungs. b. To trap particles and bacteria. c. To protect the cilia. d. To clean the sinus cavity.

B

When planning care for an 80-year-old African American woman, which intervention is most important for the nurse to include? a. Bathe the patient twice weekly. b. Use liberal amounts of soap and water. c. Use quick, brisk motions to dry the patient's skin. d. Apply emollient to limbs and back.

B

Which intervention is most important for a person who is in a wheelchair for long periods? a. Reposition self every 2 hours. b. Lift weight on the arms of the chair every 15 minutes. c. Massage bony prominences of the buttocks and hips. d. Use a donut device to keep weight off of the buttocks.

B

Which substance decreases the surface tension of the alveolar walls? a. Plasma b. Surfactant c. Cilia d. Mucus

B

The nurse is caring for a patient who has a tracheostomy with a one-way valve box. The nurse explains to the CNA that this valve allows the patient to carry out which function? a. Drinking b. Eating c. Coughing d. Talking

D

An 86-year-old resident struck her forearm on a table, causing a category I L-shaped skin tear 6 cm × 2 cm. Which action(s) is/are appropriate for the nurse to take? (select all that apply.) a. Clean the tear with alcohol. b. Approximate the edges of the tear. c. Secure the skin flap with Steri-Strips. d. Cover with a nonadherent dressing. e. Assess closely for 5 days for signs of infection.

B, C, D, E

The nurse is caring for a patient with a respiratory disorder who complains of anorexia. Which factor(s) may contribute to the patient's anorexia? (Select all that apply.) a. Increased sense of taste b. Bad taste in mouth c. Fear of exacerbate coughing by eating d. Fatigue e. Altered sense of smell

B, C, D, E

The nurse is preparing a presentation that highlights the benefits of annual influenza vaccination. The nurse correctly targets which groups? (Select all that apply.) a. Parents of children 3 to 6 months of age. b. Diabetics who are over 50 years old. c. Pregnant women. d. Home health aides. e. CNAs who work in long-term care facilities.

B, C, D, E

The nurse is teaching an adult post-tonsillectomy patient. Which dietary instructions are most important for the nurse to include? (Select all that apply.) a. Increase intake of citrus fruits. b. Avoid hot fluids. c. Avoid milk products. d. Avoid foods with red dye. e. Use a straw to drink liquids.

B, D

The nurse is performing discharge teaching for a patient who underwent a microlaryngoscopy with laser removal of polyps. Which instruction(s) should the nurse include? (Select all that apply.) a. Be alert for massive swelling. b. You can return to work in 3 days. c. Cough gently to expectorate blood. d. Observe 2 days of voice rest. e. Take opioids as needed for pain control.

B,D

Which factor(s) could increase the risk for skin tears in a 90-year-old resident? (select all that apply.) a. Incontinence b. Bruised areas c. Obesity d. Prolonged use of corticosteroids e. History of congestive heart disease

B,D,E

The nurse is caring for a patient who was recently admitted with a traumatic head injury. The nurse anticipates that the patient may display which type of respirations? a. Apneustic respirations b. Cheyne-Stokes c. Kussmaul d. Biot

D

A 75-year-old patient questions the nurse about vaccination to prevent shingles. Which response is most appropriate? a. "The incidence of shingles in people your age is not overly common, so vaccination is unnecessary." b. "The vaccination has not yet been approved for use in the older adults." c. "Because of the incidence of shingles in your age group, you should consider taking the vaccination." d. "The vaccination is expensive but will provide lifelong immunity."

C

A patient with psoriasis is placed on PUVA therapy. What factors compose this therapy? a. Radiation and corticosteroids b. X-rays and methotrexate c. Artificial ultraviolet (UV) rays and a coal tar product d. Laser treatment and antimetabolites

C

A skin biopsy has been scheduled on a patient to rule out the presence of a malignancy. Which instruction is most important for the nurse to include in patient teaching? a. General anesthesia will be used during the procedure. b. Change the bandage the day after the procedure and then weekly for 2 weeks. c. Sutures placed at the site of the biopsy will be removed in approximately 10 days. d. Do not eat or drink anything after midnight the night before the procedure.

C

Acceptable urine output for an adult is at least how many milliliters per hour? a. 10 mL b. 20 mL c. 30 mL d. 40 mL

C

An 80-year-old resident prefers to lie in bed on her left side. The nurse anticipates that the risk for skin breakdown is greatest over which area? a. Left buttock b. Left heel c. Left trochanter d. Left ribs

C

In caring for a stage IV pressure ulcer, the nurse assesses creamy yellow drainage with a necrotic odor. Which type of bacteria most likely causes this exudate? a. Proteus b. Bacteroides c. Staphylococcus d. Pseudomonas

C

Most of the inspired oxygen is carried to the tissues via which component of the body? a. Plasma b. Lymphatic system c. Red blood cells d. White blood cells

C

The home health nurse is educating the family of a child with head lice. Which instructions are most important for the nurse to include? a. Lice cannot be transmitted to pets. b. Insects must be moving across the scalp to confirm diagnosis of head lice. c. Wash and dry all linens on the hottest setting. d. Apply a dime-sized amount of alcohol-based lotion to hair.

C

The mother of a 4-year-old child reports concerns about how to completely rid her home of lice. Which response indicates that the mother needs further instruction? a. "I should wash all bedding in hot water." b. "I should re-treat my child's hair 1 week after the first application." c. "I should discard my child's stuffed animals." d. "My children should not share hats or hairbrushes."

C

The nurse is caring for a 30-year-old American Indian female who is taking Rifater, a drug containing rifampin, isoniazid, and pyrazinamide. The patient asks how long she will have to take the medication. Which response explains when the patient may discontinue the medication? a. When the sputum culture comes back negative b. When the medication has been taken for 9 months c. When three consecutive sputum cultures are negative d. When the tuberculin skin test (TST) is no longer positive

C

The nurse is caring for a patient and during the assessment, observes a full-thickness 2 cm × 1 cm skin tear on the right buttock. How should the nurse stage this pressure ulcer? a. Category I b. Category II c. Category III d. Category IV

C

The nurse is caring for a patient during the immediate postoperative period following a rhinoplasty. Which finding is most concerning to the nurse? a. The patient complains of being cold and chilled. b. The patient complains of nausea. c. The nurse notices the patient is swallowing frequently. d. The nurse notices drainage on the nasal drip pad.

C

The nurse is caring for a patient who has had a cold for 1 week. The patient questions why the health care provider issued a prescription for an antibiotic. Which explanation is best? a. "The antibiotic will cure your cold." b. "The antibiotic will help to reduce your symptoms." c. "The antibiotic will treat the secondary bacterial infection that has developed." d. "The antibiotic will decrease the amount of time for which you are contagious."

C

The nurse is caring for a patient who underwent a laryngectomy. Which need should the nurse address first? a. Pain control b. Family support c. Communication method d. Plan for long-term care

C

The nurse is caring for a patient with chronic obstructive pulmonary disorder (COPD) who has been in the hospital for several days. The patient complains of shortness of breath and asks the nurse to turn up his oxygen to compensate for his labored breathing. What is the best nursing response? a. Turn up the patient's oxygen flow by 1 liter. b. Call the physician for an order to turn up the oxygen. c. Assess the patient in an attempt to identify the cause of the shortness of breath. d. Ask the patient what he usually keeps his oxygen set on at home

C

The nurse is caring for a patient with suspected bacterial pneumonia. Which finding supports the potential diagnosis? a. Elevated white blood cell (WBC) count b. Consolidation of lung tissue c. Interstitial inflammation d. Copious exudate

C

The nurse is educating a patient with acne rosacea that has facial erythema and telangiectases. Which information should the nurse include in the teaching plan? a. Drink 4 ounces of wine daily to promote vasodilation. b. Wash your face at least three times daily. c. Avoid direct sunlight. d. Apply tea bags to the affected areas.

C

The nurse is performing deep tracheal suctioning of a patient with a respiratory disorder. Which action demonstrates appropriate technique? a. The nurse maintains clean technique. b. The nurse places the patient in a side-lying position. c. The nurse suctions the patient for 10 to 15 seconds. d. The nurse reassures the patient that he will feel no discomfort.

C

The nurse is providing fluid resuscitation for a burn victim according to the Parkland formula. The nurse determines that the patient requires 8000 mL in a 24-hour time period. The burn occurred at noon, and the present time is 1400. How many milliliters of fluid should infuse by 2000? a. 2000 mL b. 3000 mL c. 4000 mL d. 7000 mL

C

The nurse is caring for a patient with an obstructive respiratory disorder. Which of these conditions is an example of an obstructive lung disorder? a. Atelectasis b. Lung cancer c. Guillain-Barré syndrome d. Chronic bronchitis

D

The patient with acute bronchitis asks if antibiotics will be ordered for the condition. Which response is best for the nurse to make? a. "Antibiotics are the best treatment option." b. "Antibiotics will not help a viral condition." c. "Antibiotics will be given if the sputum culture indicates your bronchitis is caused by bacteria." d. "Antibiotics will inhibit the inflammatory response of your body to the invasion of this infection."

C

What is the purpose of treatment with amantadine (Symmetrel)? a. To prevent viral pneumonia if taken regularly. b. To prevent avian flu if taken at the first signs and symptoms of disease. c. To lessen the severity of type A flu symptoms if taken within 48 hours of exposure. d. To reduce irritation of bronchitis if taken weekly.

C

Which method is best to use for lotion application? a. Avoid shaking lotion to prevent bubble formation. b. Apply lotion heavily as the water from lotion evaporates. c. Wash off residue before applying fresh lotion. d. Apply a scant film of lotion on eyelids and in the nose.

C

Which statement best describes a "shave biopsy" of a skin lesion? a. A removal of the central core of a lesion b. Excision of an entire lesion with a -inch border around it c. Removal of the top of a lesion that stands above the skin line d. Excision of a lesion down to the dermis

C

Which interventions are appropriate for a burn patient newly admitted to the emergency department? (select all that apply.) a. Cover burns with sterile saline-saturated towels. b. Carefully remove clothing adhered to burned areas. c. Carefully avoid disturbing blisters. d. Remove jewelry from injured limbs. e. Determine the causative agent of the burn.

C, D, E

The 75-year-old patient asks the nurse if the Pneumovax immunization he took when he was 65 is still protecting him. Which reply is most accurate? a. "Pneumovax protects you for your lifetime." b. "Immunity afforded you by Pneumovax lasts only 2 years." c. "Pneumovax protection varies according to your risk factors and living situation." d. "After 6 years, you need a repeat dose of Pneumovax for full immunity."

D

The nurse carefully applies suction prior to deflating the cuff on a cuffed tracheostomy in order to prevent which complication? a. Bleeding b. Excessive negative pressure c. Accidental dislodgement of the tube d. Aspiration

D

The nurse explains that the mechanism that triggers rate and depth of respiration is based on which factor? a. Ease of respiration. b. Alveolar pressure. c. Patency of bronchi. d. Blood pH.

D

A 93-year-old resident eats only a few bites at meals and then refuses to eat more. Which intervention might the nurse use to help delay skin breakdown from diminished nutrition? a. Spoon-feed the resident. b. Request an order for a feeding tube. c. Inform the resident of the need to increase intake. d. Offer 4 ounces of fluid every hour.

D

After using a nasal cannula delivery system at 3 L/min, a patient with chronic airflow limitation (CAL) changes to a simple face mask. The nasal equipment oxygen was set at 3 L/min. How should the nurse adjust the oxygen flow for the new delivery system? a. Decrease it to 2 L. b. Keep it the same. c. Increase it to 4 L. d. Increase it to 6 L.

D

The nurse is caring for multiple patients. After reviewing the patients' histories, the nurse determines that which patient possesses the highest risk of throat cancer? a. A male patient who drinks four cups of coffee per day b. A female patient who smokes a pack of cigarettes weekly c. A female patient who drinks three carbonated drinks per day d. A male patient who drinks four vodka tonics per day

D

The nurse is preparing to administer the influenza immunization to four patients. Allergy to which substance should cause the nurse to question giving the immunization? a. Strawberries b. Ragweed c. Penicillin d. Eggs

D

The nurse reading a tuberculin skin test (TST) on a new employee who lives in the Midwest, is 20-years-old, and has no known history of contact with any people with tuberculosis (TB). The nurse should interpret the reading as positive if the area around the injection site has an induration of how many millimeters? a. 0 mm b. 5 mm c. 10 mm d. 15 mm

D

The nurse teaches the patient the "ABCD" technique for evaluating melanomas. What does the "D" in this memory prompt represent? a. Darkness b. Drainage c. Dimpling d. Diameter

D

The student nurse is preparing to document a suspicious area over a bony prominence. Which description would be most appropriate? a. Reddened area on left hip b. Reddened, nonblanching area approximately 1 cm × 1 cm c. Suspicious area over left trochanter d. Nonblanching area over left trochanter 0.8 cm × 1.2 cm

D

What underlying pathophysiology explains the gradual graying of an older adult's hair? a. Reduced hair follicles b. Less sebaceous gland activity c. Loss of collagen fibers in dermis d. Decreased melanocytes at hair follicle

D

When caring for a patient with acquired immune deficiency syndrome (AIDS), the nurse is aware that this patient is most at risk for developing which type of pneumonia? a. Hypostatic b. Streptococcus pneumoniae c. Atypical d. Pneumocystis jiroveci

D

When doing routine cleaning of a double-lumen tracheostomy tube, the nurse should include which action? a. Place the patient supine. b. Reinsert the inner cannula without touching the faceplate of the tracheostomy tube. c. Rinse the inner cannula in a basin of hydrogen peroxide. d. Clean the inner cannula with a pipe cleaner.

D

When teaching a patient about esophageal speech, which technique should the nurse instruct the patient to use first? a. Coordinate lip and tongue movements with produced sound. b. Relax the diaphragm to allow air into the esophagus. c. Cough to express air. d. Swallow air and force it back up through the esophagus.

D

Which statement is most important for the nurse to make when caring for an anxious patient with a new tracheostomy? a. "I have cared for patients who were able to have the tracheostomy reversed." b. "I will be efficient and give care quickly." c. "I will wait until your tracheostomy heals before teaching." d. "I understand that you might be apprehensive."

D

Which symptom is consistent with an inhalation burn? a. Full-thickness burns to chest b. Hypotension c. Agitation d. Persistent coughing

D

The nurse reminds the junior high school health class that the first line of defense from pathogens for the body is the ____________.

Skin

Rapid opening and closing of the glottis combined with movement of the mouth, lips, and tongue is what makes _____________.

Speech

Place in the appropriate sequence the steps of auscultation of the chest. a. Place diaphragm of stethoscope above clavicles. b. Listen in midaxillary line to level of diaphragm. c. Move stethoscope from side to side down midline of the chest. d. Place diaphragm of stethoscope above scapulae. e. Move stethoscope side to side on either side of the spine.

Step 1 A Step 2 C Step 3 D Step 4 E Step 5 B

Place the events of an asthma attack in proper sequence. a. Mast cell-mediated inflammatory response in bronchi b. Mucus production c. Plugging of small airways d. Contact with precipitator e. Mucosal edema

Step 1 D Step 2 A Step 3 E Step 4 B Step 5 C

Place the steps of abdominal thrusts in proper sequence. a. Wrap hand around fist. b. Squeeze and thrust five times. c. Make a fist. d. Check status of breathing. e. Position fist, thumb foremost, over umbilicus

Step 1 D Step 2 C Step 3 E Step 4 A Step 5 B

The nurse describes the ability of the lungs to respond to change in the volume and pressure of inhaled air by expanding as lung __________.

compliance

he nurse uses a visual aid to show the "hinged door" that helps prevent aspiration. This "hinged door" is the __________.

epiglottis

The nurse encourages a patient with larynx cancer that the "near-total laryngectomy" is a new procedure that preserves the ability to __________ and to __________.

speak; swallow swallow; speak

Trace the route of a molecule of oxygen inhaled from room air to the point of gas exchange. a. Larynx b. Left and right bronchi c. Trachea d. Oxygen is inhaled through the nose e. Bronchioles f. Alveoli

step 1 D step 2 A Step 3 C Step 4 B Step 5 E Step 6 F