med surge III

A maintance dose of 2 mcg/min has been ordered usinga 8 mg in 250 mL solution. Calculate the mL/hr flow rate.

3.75 mL/hr

A 1,200-calorie diet and exercise are prescribed for a patient with newly diagnosed type 2 diabetes. The nurse is teaching the patient about meal planning using exchange lists. The teaching is determined to be effective based on which of the following statements?

A. "For dinner I ate a 3-ounce hamburger on a bun, with ketchup, pickle, and onion, a green salad with 1 teaspoon Italian dressing, 1 cup of watermelon, and a diet soda."

A patient has just been told that her illness is terminal. The patient tearfully states, "I can't believe I am going to die. Why me?" What is your best response?

A. "This must be very difficult for you."

The nurse at a long-term care facility is assessing each of the residents. Which resident most likely faces the greatest risk for aspiration?

A. A resident who suffered a severe stroke several weeks ago

A nurse who sits on the hospital's ethics committee is reviewing a complex case that has many of the hallmarks of assisted suicide. Which of the following would be an example of assisted suicide?

A. Administering a lethal dose of medication to a patient whose death is imminent

The triage nurse in the ED is assessing a patient who has presented with complaint of pain and swelling in her right lower leg. The patient's pain became much worse last night and appeared along with fever, chills, and sweating. The patient states, "I hit my leg on the car door 4 or 5 days ago and it has been sore ever since." The patient has a history of chronic venous insufficiency. What intervention should the nurse anticipate for this patient?

A. Antibiotics to treat cellulitis

The nurse is caring for an 84-year-old man who has just returned from the OR after inguinal hernia repair. The OR report indicates that the patient received large volumes of IV fluids during surgery and the nurse recognizes that the patient is at risk for left-sided heart failure. What signs and symptoms would indicate left-sided heart failure?

A. Bibasilar fine crackles

The physician has ordered continuous positive airway pressure (CPAP) with the delivery of a patient's high-flow oxygen therapy. The patient asks the nurse what the benefit of CPAP is. What would be the nurse's best response?

A. CPAP allows a lower percentage of oxygen to be used with a similar effect.

The nurse is assessing a 73-year-old patient who was diagnosed with metastatic prostate cancer. The nurse notes that the patient is exhibiting signs of loss, grief, and intense sadness. Based on this assessment data, the nurse will document that the patient is most likely in what stage of death and dying?

A. Depression

The nurse is reviewing the echocardiography results of a patient who has just been diagnosed with dilated cardiomyopathy (DCM). What changes in heart structure characterize DCM?

A. Dilated ventricles without hypertrophy of the ventricles

One aspect of the nurse's comprehensive assessment when caring for the terminally ill is the assessment of hope. The nurse is assessing a patient with liver failure for the presence of hope. What would the nurse identify as a hope-fostering category?

A. Uplifting memories

The nurse is creating a care plan for a patient diagnosed with HF. When addressing the problem of anxiety, what interventions should the nurse include in the care plan? Select all that apply.

Answers: A. A. Provide validation of the patient's expressions of anxiety. C. Facilitate the presence of friends and family whenever possible. E. Provide supplemental oxygen, as needed.

An adult patient has sought care for the treatment of headaches that have become increasingly severe and frequent over the past several months. Which of the following questions addresses potential etiological factors? Select all that apply.

Answers: A. "Does anyone else in your family struggle with headaches?" " C. "What medications are you currently taking?" D. "Are you exposed to any toxins or chemicals at work?" E. "How would you describe your ability to cope with stress?"

A critical care nurse is planning assessments in the knowledge that patients in shock are vulnerable to developing fluid replacement complications. For what signs and symptoms should the nurse monitor the patient? Select all that apply.

Answers: A. Difficulty breathing B. Cardiovascular overload D. Pulmonary edema

A patient has been admitted to a medical unit with a diagnosis of polymyalgia rheumatica (PMR). The nurse should be aware of what aspects of PMR? Select all that apply.

Answers: A. PMR has an association with the genetic marker HLA-DR4. D. PMR occurs predominately in Caucasians. E. Immunoglobulin deposits occur in PMR.

A client is being treated for trichomoniasis. The client has received instructions about the prescribed drug therapy. The nurse determines that the client needs additional teaching when she states which of the following?

B. "My partner will not need any treatment."

The nurse is teaching a young adult male how to perform testicular self-examination (TSE). The nurse determines that the client has understood the instructions when he states which of the following?

B. "The best time to do it is once a month after I take my warm morning shower."

The critical care nurse is precepting a new nurse on the unit. Together they are caring for a patient who has a tracheostomy tube and is receiving mechanical ventilation. What action should the critical care nurse recommend when caring for the cuff?

B. Monitor the pressure in the cuff at least every 8 hours

The nurse is planning the care of a patient with HF. The nurse should identify what overall goals of this patient's care? Select all that apply.

B. Relieve patient symptoms. C. Extend survival. D. Improve functional status

What would the critical care nurse recognize as a condition that may indicate a patient's need to have a tracheostomy?

D. A patient requires permanent ventilation.

A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care?

D. Monitoring is needed as rapid neurologic deterioration may occur.

The nurse is caring for a patient with mitral stenosis who is scheduled for a balloon valvuloplasty. The patient tells the nurse that he is unsure why the surgeon did not opt to replace his damaged valve rather than repairing it. What is an advantage of valvuloplasty that the nurse should cite?

D. Repaired valves tend to function longer than replaced valves.

You are working on a burns unit and one of your acutely ill patients is exhibiting signs and symptoms of third spacing. Based on this change in status, you should expect the patient to exhibit signs and symptoms of what imbalance?

Hypovolemia

The nurse is assessing an adult patient following a motor vehicle accident. The nurse observes that the patient has an increased use of accessory muscles and is complaining of chest pain and shortness of breath. The nurse should recognize the possibility of what condition?

Pneumothorax

Clients involved in a mass casualty incident are triaged and assigned a color-coded tag. When prioritizing care, clients tagged with which color would be treated first?

Red

A patient is receiving chemotherapy with paclitaxel as treatment for ovarian cancer. The patient arrives at the facility for laboratory testing prior to her next dose of chemotherapy. The results are as follows: Hemoglobin: 12.9 gm/dL White blood cell count: 2,200 /cu mm Platelets: 250,000 /cu mm Red blood cell count: 4,400,00/cu mm Which result would be a cause for concern?

WBC count

The nurse in the ICU is admitting a 57-year-old man with a diagnosis of possible septic shock. The nurse's assessment reveals that the patient has a normal blood pressure, increased heart rate, decreased bowel sounds, and cold, clammy skin. The nurse's analysis of these data should lead to what preliminary conclusion?

B. The patient is in the compensatory stage of shock.

A nurse who works in the specialty of palliative care frequently encounters issues and situations that constitute ethical dilemmas. What issue has most often presented challenging ethical issues, especially in the context of palliative care?

C. Ability of technology to prolong life beyond meaningful quality of life

An adult patient with third-degree AV block is admitted to the cardiac care unit and placed on continuous cardiac monitoring. What rhythm characteristic will the ECG most likely show?

D. Fewer QRS complexes than P waves

A 16-year-old female patient experiences alopecia resulting from chemotherapy, prompting the nursing diagnoses of disturbed body image and situational low self-esteem. What action by the patient would best indicate that she is meeting the goal of improved body image and self-esteem?

B. The patient requests that her family bring her makeup and wig.

The nurse is caring for a patient who has been in a motor vehicle accident and the care team suspects that the patient has developed pleurisy. Which of the nurse's assessment findings would best corroborate this diagnosis?

B. The patient's pain intensifies when he coughs or takes a deep breath.

A gerontologic nurse is assessing a patient who has numerous comorbid health problems. What assessment findings should prompt the nurse to suspect a UTI? Select all that apply.

B. Uncharacteristic fatigue D. New onset of confusion

A home health nurse is caring for a patient with multiple myeloma. Which of the following interventions should the nurse prioritize when addressing the patient's severe bone pain?

D. Helping the patient manage the opioid analgesic regimen

The nurse is caring for an adult patient who has gone into ventricular fibrillation. When assisting with defibrillating the patient, what must the nurse do?

B. Maintain firm contact between paddles and patient skin.

You are an emergency-room nurse caring for a trauma patient. Your patient has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would you interpret these results?

B. Metabolic acidosis with a compensatory respiratory alkalosis

The nurse is caring for a patient whose progressing infection places her at high risk for shock. What assessment finding would the nurse consider a potential sign of shock?

B. Shallow, rapid respirations

A patient is in the acute phase of a burn injury. One of the nursing diagnoses in the plan of care is Ineffective Coping Related to Trauma of Burn Injury. What interventions appropriately address this diagnosis? Select all that apply.

B. Teach the patient coping strategies. C. Promote truthful communication. E. Provide positive reinforcement.

A nurse is providing care for a patient who has a recent diagnosis of Paget's disease. When planning this patient's nursing care, interventions should address what nursing diagnoses? Select all that apply.

A. Risk for Injury B. Disturbed Auditory Sensory Perception C. Impaired Physical Mobility D. Acute Pain

The nurse is caring for a patient who is believed to have just experienced an MI. The nurse notes changes in the ECG of the patient. What change on an ECG most strongly suggests to the nurse that ischemia is occurring?

A. T wave inversion

An 84-year-old woman diagnosed with cancer is admitted to the oncology unit for surgical treatment. The patient has been on chemotherapeutic agents to decrease the tumor size prior to the planned surgery. The nurse caring for the patient is aware that what precipitating factors in this patient may contribute to AKI? Select all that apply.

Answers: A. Age-related physiologic changes D. Chronic systemic disease

The nurse has entered a patient's room and found the patient unresponsive and not breathing. What is the nurse's next appropriate action?

B. Activate the Emergency Response System (ERS).

A patient has been discharged home after a total mastectomy without reconstruction. The patient lives alone and has a home health referral. When the home care nurse performs the first scheduled visit this patient, what should the nurse assess? Select all that apply.

B. Adherence to the exercise plan C. Integrity of surgical drains D. Overall psychological functioning

A nurse in the ICU is planning the care of a patient who is being treated for shock. Which of the following statements best describes the pathophysiology of this patient's health problem?

B. Cells lack an adequate blood supply and are deprived of oxygen and nutrients.

A nurse working at a disaster scene is assisting in triaging clients. Which client would the nurse triage as expectant?

B. Client states that feeling in her breast area will gradually subside with time.

The nurse is caring for a patient who is scheduled for a lobectomy for a diagnosis of lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes the client's oxygen saturation rapidly dropping. The patient complains of shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Further assessment findings supporting the presence of a pneumothorax include what?

B. Diminished or absent breath sounds on the affected side

The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient has been receiving high-flow oxygen therapy for an extended time. What symptoms should the nurse anticipate if the patient were experiencing oxygen toxicity?

B. Dyspnea and substernal pain

The nurse and the other members of the team are caring for a patient who converted to ventricular fibrillation (VF). The patient was defibrillated unsuccessfully and the patient remains in VF. According to national standards, the nurse should anticipate the administration of what medication?

B. Epinephrine 1 mg IV push

A patient who is being treated for pneumonia starts complaining of sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect?

A. Respiratory acidosis

Traditionally, nurses have been involved with tertiary cancer prevention. However, an increasing emphasis is being placed on both primary and secondary prevention. What would be an example of primary prevention?

B. Teaching patients to wear sunscreen

A patient who has undergone valve replacement surgery is being prepared for discharge home. Because the patient will be discharged with a prescription for warfarin (Coumadin), the nurse should educate the patient about which of the following?

B. The need for regularly scheduled testing of the patient's International Normalized Ratio (INR)

An adult oncology patient has a diagnosis of bladder cancer with metastasis and the patient has asked the nurse about the possibility of hospice care. Which principle is central to a hospice setting?

B. The patient and family should be viewed as a single unit of care.

A patient presents to the ED stating she was in a boating accident about 3 hours ago. Now the patient has complaints of headache, fatigue, and the feeling that he "just can't breathe enough." The nurse notes that the patient is restless and tachycardic with an elevated blood pressure. This patient may be in the early stages of what respiratory problem?

C. Acute respiratory failure

After teaching about self-care measures to a client who has been diagnosed with prostatitis, the nurse determines that the teaching was successful when the client states which of the following?

C. "I should avoid fluids like coffee and tea."

A patient is undergoing diagnostic testing for mitral stenosis. What statement by the patient during the nurse's interview is most suggestive of this valvular disorder?

C. "Whenever I do any form of exercise I get terribly short of breath."

During a patient's care conference, the team is discussing whether the patient is a candidate for cardiac conduction surgery. What would be the most important criterion for a patient to have this surgery?

C. Atrial and ventricular tachycardias not responsive to other treatments

Which of the following outcomes would be most appropriate to include in the plan of care for a client diagnosed with a muscular dystrophy?

C. Client participates in activities of daily living using adaptive devices.

A nurse is planning the care of a patient who has been admitted to the medical unit with a diagnosis of multiple myeloma. In the patient's care plan, the nurse has identified a diagnosis of Risk for Injury. What pathophysiologic effect of multiple myeloma most contributes to this risk?

C. Decreased bone density

The cardiac nurse is caring for a patient who has been diagnosed with dilated cardiomyopathy (DCM). Echocardiography is likely to reveal what pathophysiological finding?

C. Decreased ejection fraction

A clinic nurse is caring for a patient admitted with AIDS. The nurse has assessed that the patient is experiencing a progressive decline in cognitive, behavioral, and motor functions. The nurse recognizes that these symptoms are most likely related to the onset of what complication?

C. HIV encephalopathy

The nurse is performing patient education for a patient who is being discharged on mini-nebulizer treatments. What information should the nurse prioritize in the patient's discharge teaching?

C. How to perform diaphragmatic breathing

The nurse is caring for an adult patient who had symptoms of unstable angina upon admission to the hospital. What nursing diagnosis underlies the discomfort associated with angina?

C. Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD)

The triage nurse in the ED assesses a 66-year-old male patient who presents to the ED with complaints of midsternal chest pain that has lasted for the last 5 hours. If the patient's symptoms are due to an MI, what will have happened to the myocardium?

C. It may have developed an increased area of infarction during the time without treatment.

A nurse is providing care for a patient who has just been diagnosed as being in the early stage of rheumatoid arthritis. The nurse should anticipate the administration of which of the following?

C. Methotrexate (Rheumatrex)

The nurse is caring for a patient who is experiencing mild shortness of breath during the immediate postoperative period, with oxygen saturation readings between 89% and 91%. What method of oxygen delivery is most appropriate for the patient's needs?

C. Nasal cannula

A nurse in the ICU receives report from the nurse in the ED about a new patient being admitted with a neck injury he received while diving into a lake. The ED nurse reports that his blood pressure is 85/54, heart rate is 53 beats per minute, and his skin is warm and dry. What does the ICU nurse recognize that that patient is probably experiencing?

C. Neurogenic shock

An immunocompromised older adult has developed a urinary tract infection and the care team recognizes the need to prevent an exacerbation of the patient's infection that could result in urosepsis and septic shock. What action should the nurse perform to reduce the patient's risk of septic shock?

C. Remove invasive devices as soon as they are no longer needed

The critical care nurse and the other members of the care team are assessing the patient to see if he is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify?

C. Stable vital signs and ABGs

A 73-year-old man comes into the emergency department (ED) by ambulance after slipping on a small carpet in his home. The patient fell on his hip with a resultant fracture. He is alert and oriented; his pupils are equal and reactive to light and accommodation. His heart rate is elevated, he is anxious and thirsty, a Foley catheter is placed, and 40 mL of urine is present. What is the nurse's most likely explanation for the low urine output?

C. The man is having a sympathetic reaction, which has stimulated the renin-angiotensin-aldosterone system that results in diminished urine output.

The nurse is caring for a patient who has been recently diagnosed with late stage pancreatic cancer. The patient refuses to accept the diagnosis and refuses to adhere to treatment. What is the most likely psychosocial purpose of this patient's strategy?

C. The patient may be trying to protect loved ones from the emotional effects of the illness.

The nurse in a rural nursing outpost has just been notified that she will be receiving a patient in hypovolemic shock due to a massive postpartum hemorrhage after her home birth. You know that the best choice for fluid replacement for this patient is what?

C. Whatever fluid is most readily available in the clinic, due to the nature of the emergency

The home care nurse is planning to begin breathing retraining exercises with a client newly admitted to the home health service. The home care nurse knows that breathing retraining is especially indicated if the patient has what diagnosis?

COPD

The emergency nurse is admitting a patient experiencing a GI bleed who is believed to be in the compensatory stage of shock. What assessment finding would be most consistent with the early stage of compensation?

Cool, clammy skin

A client with a malignant glioma is scheduled for surgery. The client demonstrates a need for additional teaching about the surgery when he states which of the following?

D. "The surgeon will be able to remove all of the tumor."

The clinic nurse is caring for a 42-year-old male oncology patient. He complains of extreme fatigue and weakness after his first week of radiation therapy. Which response by the nurse would best reassure this patient?

D. "These symptoms usually result from radiation therapy; however, we will continue to monitor your laboratory and x-ray studies."

A patient's electronic health record notes that the patient has hallux valgus. What signs and symptoms would the nurse expect this patient to manifest?

D. Deviation of a great toe laterally

You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patient's most recent laboratory reports, you note that the patient's magnesium levels are high. You should prioritize assessment for which of the following health problems?

D. Diminished deep tendon reflexes

The nurse is admitting a 32-year-old woman to the presurgical unit. The nurse learns during the admission assessment that the patient takes oral contraceptives. Consequently, the nurse's postoperative plan of care should include what intervention?

D. Early ambulation and leg exercises

You are the surgical nurse caring for a 65-year-old female patient who is postoperative day 1 following a thyroidectomy. During your shift assessment, the patient complains of tingling in her lips and fingers. She tells you that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should you first suspect?

D. Hypocalcemia

An older adult woman's current medication regimen includes alendronate (Fosamax). What outcome would indicate successful therapy?

D. Increased bone mass

The medical nurse is creating the care plan of an adult patient requiring mechanical ventilation. What nursing action is most appropriate?

D. Monitor cuff pressure every 8 hours.

The nurse is providing discharge education to a patient diagnosed with HF. What should the nurse teach this patient to do to assess her fluid balance in the home setting?

D. Monitor her weight daily

The nurse caring for a patient with an endotracheal tube recognizes several disadvantages of an endotracheal tube. What would the nurse recognize as a disadvantage of endotracheal tubes?

D. The cough reflex is depressed.

The nurse caring for a patient whose sudden onset of sinus bradycardia is not responding adequately to atropine. What might be the treatment of choice for this patient?

D. Trancutaneous pacemaker

A group of students are reviewing the anatomy and physiology of the breasts. The students demonstrate understanding of breast structure when they identify the tail of Spence as an extension of which quadrant?

D. Upper outer

After demonstrating to a group of nursing students the proper technique for handwashing using soap and water, the nursing instructor determines that the teaching has been successful when the students demonstrate which of the following?

D. Vigorously scrubbing between the fingers

A nurse is caring for a patient who is exhibiting ventricular tachycardia (VT). Because the patient is pulseless, the nurse should prepare for what intervention?

Defibrillation