MS3 Final Exam Review

Which statement by the patient who has had an organ transplant would indicate that the patient understands the teaching about the immunosuppressive medications? "My drug dosages will be lower because the medications enhance each other." "Taking more than one medication will put me at risk for developing allergies." "I will be more prone to malignancies because I will be taking more than one drug." "The lower doses of my medications can prevent rejection and minimize the side effects."

"The lower doses of my medications can prevent rejection and minimize the side effects." Because immunosuppressants work at different phases of the immune response, lower doses of each drug can be used to produce effective immunosuppression while minimizing side effects.

Which patient is at risk for developing graft-versus-host disease (GVHD)? A 65-yr-old man who received an autologous blood transfusion A 40-yr-old man who received a kidney transplant from a living donor A 65-yr-old woman who received a pancreas and kidney from a deceased donor A 40-yr-old woman who received a bone marrow transplant from a close relative

A 40-yr-old woman who received a bone marrow transplant from a close relative GVHD occurs when an immunoincompetent patient is transfused or transplanted with immunocompetent cells. Examples include blood transfusions or the transplantation of bone marrow, fetal thymus, or fetal liver. An autologous blood transfusion is the collection and reinfusion of the individual's own blood or blood components. There is no risk for GVHD in this situation.

A patient who is receiving an IV antibiotic develops wheezes and dyspnea. In which order should the nurse implement these prescribed actions? (Put a comma and a space between each answer choice [A, B, C, D, E]). a. Discontinue the antibiotic. b. Give diphenhydramine IV. c. Inject epinephrine IM or IV. d. Prepare an infusion of dopamine. e. Provide 100% oxygen using a nonrebreather mask.

A, E, C, B, D a. Discontinue the antibiotic. e. Provide 100% oxygen using a nonrebreather mask. c. Inject epinephrine IM or IV. b. Give diphenhydramine IV d. Prepare an infusion of dopamine.

When planning emergent care for a patient with a suspected MI, what should the nurse anticipate administrating? A. Oxygen, nitroglycerin, aspirin, and morphine B. Oxygen, furosemide (Lasix), nitroglycerin, and meperidine C. Aspirin, nitroprusside (Nipride), dopamine (Intropin), and oxygen D. Nitroglycerin, lorazepam (Ativan), oxygen, and warfarin (Coumadin)

A. Oxygen, nitroglycerin, aspirin, and morphine The American Heart Association's guidelines for emergency care of the patient with chest pain include the administration of oxygen, nitroglycerin, aspirin, and morphine. These interventions serve to relieve chest pain, improve oxygenation, decrease myocardial workload, and prevent further platelet aggregation. The other medications may be used later in the patient's treatment.

A patient with dilated cardiomyopathy has new-onset atrial fibrillation that has been unresponsive to drug therapy for several days. Teaching for this patient would include information about a. anticoagulant therapy. b. permanent pacemakers. c. emergency cardioversion. d. IV adenosine (Adenocard).

ANS: A Atrial fibrillation therapy that has persisted for more than 48 hours requires anticoagulant treatment for 3 weeks before attempting cardioversion. This is done to prevent embolization of clots from the atria. Cardioversion may be done after several weeks of anticoagulation therapy. Adenosine is not used to treat atrial fibrillation. Pacemakers are routinely used for patients with bradydysrhythmias. Information does not indicate that the patient has a slow heart rate.DIF: Cognitive Level: Apply (application)

Which finding indicates to the nurse that the current therapies are effective for a patient with acute adrenal insufficiency? a. Increasing serum sodium levels b. Decreasing blood glucose levels c. Decreasing serum chloride levels d. Increasing serum potassium levels

ANS: A Clinical manifestations of Addison's disease include hyponatremia and an increase in sodiumlevel indicates improvement. The other values indicate that treatment has not been effective.DIF: Cognitive Level: Apply (application) REF: 1178TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrit

A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the nurse collect to determine whether the patient is developing postconcussion syndrome? a. Short-term memory b. Muscle coordination c. Glasgow Coma Scale d. Pupil reaction to light

ANS: A Decreased short-term memory is one indication of postconcussion syndrome. The other data may be assessed but are not indications of postconcussion syndrome.DIF: Cognitive Level: Apply (application)

A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate? a. "The obstructing plaque is surgically removed from inside an artery in the neck." b. "The diseased portion of the artery in the brain is replaced with a synthetic graft." c. "A wire is threaded through an artery in the leg to the clots in the carotid artery,and the clots are removed." d. "A catheter with a deflated balloon is positioned at the narrow area, and theballoon is inflated to flatten the plaque."

ANS: A In a carotid endarterectomy, the carotid artery is incised, and the plaque is removed. Theresponse beginning, "The diseased portion of the artery in the brain is replaced" describes anarterial graft procedure. The answer beginning, "A catheter with a deflated balloon ispositioned at the narrow area" describes an angioplasty. The final response beginning, "Awire is threaded through the artery" describes the mechanical embolus removal in cerebralischemia (MERCI) procedure.DIF: Cognitive Level: Understand (comprehension) REF: 1353TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A 20-yr-old patient has a mandatory electrocardiogram (ECG) before participating on a college soccer team and is found to have sinus bradycardia, rate 52. Blood pressure (BP) is 114/54 mm Hg, and the student denies any health problems. What action by the nurse is most appropriate? a. Allow the student to participate on the soccer team. b. Refer the student to a cardiologist for further testing. c. Tell the student to stop playing immediately if any dyspnea occurs. d. Obtain more detailed information about the student's family health history.

ANS: A In an aerobically trained individual, sinus bradycardia is normal. The student's normal BP and negative health history indicate that there is no need for a cardiology referral or for more detailed information about the family's health history. Dyspnea during an aerobic activity such as soccer is normal.DIF: Cognitive Level: Apply (application)

The nurse determines that additional instruction is needed for a patient with chronic syndromeof inappropriate antidiuretic hormone (SIADH) when the patient makes which statement? a. "I need to shop for foods low in sodium and avoid adding salt to food." b. "I should weigh myself daily and report any sudden weight loss or gain." c. "I need to limit my fluid intake to no more than 1 quart of liquids a day." d. "I should eat foods high in potassium because diuretics cause potassium loss."

ANS: A Patients with SIADH are at risk for hyponatremia, and a sodium supplement may beprescribed. The other patient statements are correct and indicate successful teaching hasoccurred.DIF: Cognitive Level: Apply (application) REF: 1160TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

Which action will the nurse include in the plan of care for a patient who has a cauda equina spinal cord injury? a. Catheterize patient every 3 to 4 hours. b. Assist patient to ambulate 4 times daily. c. Administer medications to reduce bladder spasm. d. Stabilize the neck when repositioning the patient.

ANS: A Patients with cauda equina syndrome have areflexic bladder, and intermittent catheterization will be used for emptying the bladder. Because the bladder is flaccid, antispasmodic medications will not be used. The legs are flaccid with cauda equina syndrome, and the patient will be unable to ambulate. The head and neck will not need to be stabilized after a cauda equina injury, which affects the lumbar and sacral nerve roots.DIF: Cognitive Level: Apply (application)

Admission vital signs for a brain-injured patient are blood pressure of 128/68 mm Hg, pulse of 110 beats/min, and of respirations 26 breaths/min. Which set of vital signs, if taken 1 hour later, will be of most concern to the nurse? a. Blood pressure of 154/68 mm Hg, pulse of 56 beats/min, respirations of 12 breaths/min b. Blood pressure of 134/72 mm Hg, pulse of 90 beats/min, respirations of 32 breaths/min c. Blood pressure of 148/78 mm Hg, pulse of 112 beats/min, respirations of 28 breaths/min d. Blood pressure of 110/70 mm Hg, pulse of 120 beats/min, respirations of 30 breaths/min

ANS: A Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad. These findings indicate that the intracranial pressure (ICP) has increased, and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process.DIF: Cognitive Level: Apply (application)

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? a. Encourage adequate nutrition, exercise, and sleep. b. Teach about the side effects of antiretroviral agents. c. Explain opportunistic infections and antibiotic prophylaxis. d. Monitor symptoms of acquired immunodeficiency syndrome (AIDS).

ANS: A 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. AIDS and increased incidence of opportunistic infections typically develop when the CD4+ count is much lower than normal. Although the initiation of ART is highly individual, it would not be likely that a patient with a normal CD4+ level would receive ART.

During change-of-shift report, the nurse learns that a patient with a head injury has decorticate posturing to noxious stimulation. Which positioning shown in the accompanying figure will the nurse expect to observe? a. (1) hands curled up to chest. b.(2) hands flexed and externally rotated to side of torso. c.(3) one hand on chest and one hand on the side of the torso. d.(4)Torso prosturing

ANS: A With decorticate posturing, the patient exhibits internal rotation and adduction of the arms with flexion of the elbows, wrists, and fingers. The other illustrations are of decerebrate, mixed decorticate and decerebrate posturing, and opisthotonic posturing.DIF: Cognitive Level: Understand (comprehension)

The nurse is admitting a patient who has a neck fracture at the C6 level to the intensive care unit. Which assessment findings indicate neurogenic shock? a. Involuntary and spastic movement b. Hypotension and warm extremities c. Hyperactive reflexes below the injury d. Lack of sensation or movement below the injury

ANS: B Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of spinal cord injury. Lack of movement and sensation indicate spinal cord injury but not neurogenic shock.DIF: Cognitive Level: Understand (comprehension)

After the nurse has finished teaching a patient with osteoarthritis (OA) of the right hip abouthow to manage the OA, which patient statement indicates a need for more teaching? a. "I can exercise every day to help maintain joint motion." b. "I will take 1 g of acetaminophen (Tylenol) every 4 hours." c. "I will take a shower in the morning to help relieve stiffness." d. "I can use a cane to decrease the pressure and pain in my hip."

ANS: B No more than 4 g of acetaminophen (1 g every 6 hours) should be taken daily to decrease therisk for liver damage. Regular exercise, moist heat, and supportive equipment arerecommended for OA management.DIF: Cognitive Level: Apply (application) REF: 1523TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

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)? a. Hepatitis B vaccine b. Pneumococcal vaccine c. Influenza virus vaccine d. Trimethoprim-sulfamethoxazole e. Varicella zoster immune globulin

ANS: A, B, C 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. Antibiotics and immune globulin are used to prevent and treat infections that occur later in the course of the disease when the CD4+ counts have dropped or when infection has occurred.

A patient develops neutropenia after receiving chemotherapy. Which information about waysto prevent infection will the nurse include in the teaching plan (select all that apply)? a. Cook food thoroughly before eating. b. Choose low fiber, low residue foods. c. Avoid public transportation such as buses. d. Use rectal suppositories if needed for constipation. e. Talk to the oncologist before having any dental work.

ANS: A, C, E Eating only cooked food and avoiding public transportation will decrease infection risk. Ahigh-fiber diet is recommended for neutropenic patients to decrease constipation. Becausebacteria may enter the circulation during dental work or oral surgery, the patient may need topostpone dental work or take antibiotics.DIF: Cognitive Level: Apply (application) REF: 253TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

Which action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness? a. Coordinate the transfer of the patient to the operating room. b. Provide discharge instructions about monitoring neurologic status. c. Transport the patient to radiology for magnetic resonance imaging (MRI). d. Arrange to admit the patient to the neurologic unit for 24 hours of observation.

ANS: B A patient with a minor head trauma is usually discharged with instructions about neurologic monitoring and the need to return if neurologic status deteriorates. MRI, hospital admission, and surgery are not usually indicated in a patient with a concussion.DIF: Cognitive Level: Apply (application)

Which action will the nurse include in the plan of care for a patient with a new diagnosis ofrheumatoid arthritis (RA)? a. Instruct the patient to purchase a soft mattress. b. Encourage the patient to take a nap in the afternoon. c. Teach the patient to use lukewarm water when bathing. d. Suggest exercise with light weights several times daily.

ANS: B Adequate rest helps decrease the fatigue and pain associated with RA. Patients are taught toavoid stressing joints, use warm baths to relieve stiffness, and use a firm mattress. When thedisease is stabilized, a therapeutic exercise program is usually developed by a physicaltherapist to include exercises that improve flexibility and strength of affected joints, as well asthe patient's general endurance.DIF: Cognitive Level: Apply (application) REF: 1531TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. The nurse will anticipate teaching the patient about a. tPA. b. aspirin c. warfarin (Coumadin). d. nimodipine

ANS: B After a transient ischemic attack, patients typically are started on medications such as aspirinto inhibit platelet function and decrease stroke risk. tPA is used for acute ischemic stroke.Coumadin is usually used for patients with atrial fibrillation. Nimodipine is used to preventcerebral vasospasm after a subarachnoid hemorrhage.DIF: Cognitive Level: Apply (application) REF: 1353TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

After endotracheal suctioning, the nurse notes that the intracranial pressure (ICP) for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action should the nurse take first? a. Document the increase in intracranial pressure. b. Ensure that the patient's neck is in neutral position. c. Notify the health care provider about the change in pressure. d. Increase the rate of the prescribed propofol (Diprivan) infusion.

ANS: B Because suctioning will cause a transient increase in ICP, the nurse should initially check for other factors that might be contributing to the increase and observe the patient for a few minutes. Documentation is needed, but this is not the first action. There is no need to notify the health care provider about this expected reaction to suctioning. Propofol is used to control patient anxiety or agitation. There is no indication that anxiety has contributed to the increase in ICP.DIF: Cognitive Level: Analyze (analysis)

A patient with a head injury opens his eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. The nurse records the patient's Glasgow Coma Scale score as a. 9 b. 11. c. 13. d. 15.

ANS: B The patient has scores of 3 for eye opening, 3 for best verbal response, and 5 for best motor response.DIF: Cognitive Level: Apply (application)

A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic bladder. Which action will the nurse include in the plan of care? a. Teach the patient the Credé method. b. Instruct the patient how to self-catheterize. c. Catheterize for residual urine after voiding. d. Assist the patient to the toilet every 2 hours.

ANS: B Because the patient's bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty. The Credé method is more appropriate for a bladder that is flaccid, such as occurs with areflexic neurogenic bladder. Catheterization after voiding will not resolve the patient's incontinence.DIF: Cognitive Level: Apply (application)

When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebralatherosclerosis a. to monitor and record the blood pressure daily. b. to call the health care provider if stools are tarry. c. that clopidogrel will dissolve clots in the cerebral arteries. d. that clopidogrel will reduce cerebral artery plaque formation.

ANS: B Clopidogrel inhibits platelet function and increases the risk for gastrointestinal bleeding, sopatients should be advised to notify the health care provider about any signs of bleeding. Themedication does not lower blood pressure, decrease plaque formation, or dissolve clots.DIF: Cognitive Level: Apply (application) REF: 1353TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

The nurse determines that demeclocycline is effective for a patient with syndrome of inappropriate antidiuretic hormone (SIADH) based on finding that the patient's a. weight has increased. b. urinary output is increased. c. peripheral edema is increased. d. urine specific gravity is increased.

ANS: B Demeclocycline blocks the action of antidiuretic hormone (ADH) on the renal tubules andincreases urine output. An increase in weight or an increase in urine specific gravity indicatesthat the SIADH is not corrected. Peripheral edema does not occur with SIADH. A suddenweight gain without edema is a common clinical manifestation of this disorder.DIF: Cognitive Level: Apply (application) REF: 1160TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

The cardiac telemetry unit charge nurse receives status reports from other nursing units about four patients who need cardiac monitoring. Which patient should be transferred to the cardiac unit first? a. Patient with Hashimoto's thyroiditis and a heart rate of 102 b. Patient with tetany who has a new order for IV calcium chloride c. Patient with Cushing syndrome and a blood glucose of 140 mg/dL d. Patient with Addison's disease who takes hydrocortisone twice daily

ANS: B Emergency treatment of tetany requires IV administration of calcium; electrocardiographicmonitoring will be required because cardiac arrest may occur if high calcium levels resultfrom too-rapid administration. The information about the other patients indicates that they aremore stable than the patient with tetany.DIF: Cognitive Level: Analyze (analysis) REF: 1168OBJ: Special Questions: Multiple Patients | Special Questions: PrioritizationTOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse would indicate a need for further teaching? a. The patient ambulates around the room. b. The patient's visitors bring in fresh peaches. c. The patient cleans with a warm washcloth after having a stool. d. The patient uses soap and shampoo to shower every other day.

ANS: B Fresh, thinned-skin fruits are not permitted in a neutropenic diet because of the risk of bacteriabeing present. The patient should ambulate in the room rather than the hospital hallway toavoid exposure to other patients or visitors. Because overuse of soap can dry the skin andincrease infection risk, showering every other day is acceptable. Careful cleaning after havinga bowel movement will help prevent skin breakdown and infection.DIF: Cognitive Level: Apply (application) REF: 253TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

Which finding will the nurse expect when assessing a patient who has osteoarthritis (OA) of the knee? a. Presence of Heberden's nodules b. Discomfort with joint movement c. Redness and swelling of the knee joint d. Stiffness that increases with movement

ANS: B Initial symptoms of OA include pain with joint movement. Heberden's nodules occur on thefingers. Redness of the joint is associated with inflammatory arthritis such as rheumatoidarthritis. Stiffness in OA is worse right after the patient rests and decreases with jointmovement.DIF: Cognitive Level: Understand (comprehension) REF: 1518TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A 29-yr-old woman is taking methotrexate to treat rheumatoid arthritis. Which information from the patient's health history is important for the nurse to report to the health care provider related to the methotrexate? a. The patient had a history of infectious mononucleosis as a teenager. b. The patient is trying to get pregnant before her disease becomes more severe. c. The patient has a family history of age-related macular degeneration of the retina. d. The patient has been using large doses of vitamins and health foods to treat the RA.

ANS: B Methotrexate is teratogenic, and the patient should be taking contraceptives duringmethotrexate therapy. The other information will not impact the choice of methotrexate astherapy.DIF: Cognitive Level: Apply (application) REF: 1528TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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? a. The antiretroviral medications used to treat HIV infection are teratogenic. b. Most infants born to HIV-positive mothers are not infected with the virus. c. Because it is an early stage of HIV infection, the infant will not contract HIV. d. Her newborn will be born with HIV unless she uses antiretroviral therapy (ART)

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

A patient who had radical neck surgery to remove a malignant tumor developedhypoparathyroidism. The nurse should plan to teach the patient about a. bisphosphonates to reduce bone demineralization. b. calcium supplements to normalize serum calcium levels. c. increasing fluid intake to decrease risk for nephrolithiasis. d. including whole grains in the diet to prevent constipation.

ANS: B Oral calcium supplements are used to maintain the serum calcium in normal range andprevent the complications of hypocalcemia. Whole grain foods decrease calcium absorptionand will not be recommended. Bisphosphonates will lower serum calcium levels further bypreventing calcium from being reabsorbed from bone. Kidney stones are not a complication ofhypoparathyroidism and low calcium levels.DIF: Cognitive Level: Apply (application) REF: 1174TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

Which patient assessment will help the nurse identify potential complications of trigeminal neuralgia? a. Have the patient clench the jaws. b. Inspect the oral mucosa and teeth. c. Palpate the face to compare skin temperature bilaterally. d. Identify trigger zones by lightly touching the affected side.

ANS: B Oral hygiene is frequently neglected because of fear of triggering facial pain and may lead to gum disease, dental caries, or an abscess. Having the patient clench the facial muscles will not be useful because the sensory branches (rather than motor branches) of the nerve are affected by trigeminal neuralgia. Light touch and palpation may be triggers for pain and should be avoided.DIF: Cognitive Level: Apply (application)

When a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30, the nurse willexpect an assessment finding of a. persistent skin tenting b. rapid, deep respirations. c. hot, flushed face and neck. d. bounding peripheral pulses.

ANS: B Patients with metabolic acidosis caused by AKI may have Kussmaul respirations as the lungstry to regulate carbon dioxide. Bounding pulses and vasodilation are not associated withmetabolic acidosis. Because the patient is likely to have fluid retention, poor skin turgorwould not be a finding in AKI.DIF: Cognitive Level: Apply (application) REF: 1072TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? a. The pulse rate is 102 beats/min. b. The patient has difficulty speaking. c. The blood pressure is 144/86 mm Hg. d. There are fine crackles at the lung bases.

ANS: B Small emboli can occur during carotid artery angioplasty and stenting, and the aphasiaindicates a possible stroke during the procedure. Slightly elevated pulse rate and bloodpressure are not unusual because of anxiety associated with the procedure. Fine crackles at thelung bases may indicate atelectasis caused by immobility during the procedure. The nurseshould have the patient take some deep breaths.DIF: Cognitive Level: Analyze (analysis) REF: 1351OBJ: Special Questions: Prioritization TOP: Nursing Process: AssessmentMSC: NCLEX: Physiological Integrity

A 25-yr-old male patient has been admitted with a severe crushing injury after an industrialaccident. Which laboratory result will be most important to report to the health care provider? a. Serum creatinine level of 2.1 mg/dL b. Serum potassium level of 6.5 mEq/L c. White blood cell count of 11,500/μL d. Blood urea nitrogen (BUN) of 56 mg/dL

ANS: B The hyperkalemia associated with crushing injuries may cause cardiac arrest and should betreated immediately. The nurse also will report the other laboratory values, but abnormalitiesin these are not immediately life threatening.DIF: Cognitive Level: Analyze (analysis) REF: 1072OBJ: Special Questions: Prioritization TOP: Nursing Process: AssessmentMSC: NCLEX: Physiological Integrity

The nurse assessing a patient with newly diagnosed trigeminal neuralgia will ask the patient about a. visual problems caused by ptosis. b. triggers leading to facial discomfort. c. poor appetite caused by loss of taste. d. weakness on the affected side of the face.

ANS: B The major clinical manifestation of trigeminal neuralgia is severe facial pain triggered by cutaneous stimulation of the nerve. Ptosis, loss of taste, and facial weakness are not characteristics of trigeminal neuralgia.DIF: Cognitive Level: Apply (application)

A 37-yr-old patient has just arrived in the postanesthesia recovery unit (PACU) after a thyroidectomy. Which information about the patient is most important to communicate to the surgeon? a. Difficult to awaken. b. Increasing neck swelling. c. Reports 7/10 incisional pain. d. Cardiac rate 112 beats/minute.

ANS: B The neck swelling may lead to respiratory difficulty, and rapid intervention is needed toprevent airway obstruction. The incisional pain should be treated but is not unusual aftersurgery. A heart rate of 112 beats/min is not unusual in a patient who has been hyperthyroidand has just arrived in the PACU from surgery. Sleepiness in the immediate postoperativeperiod is expected.DIF: Cognitive Level: Analyze (analysis) REF: 1168OBJ: Special Questions: Prioritization TOP: Nursing Process: AssessmentMSC: NCLEX: Physiological Integrity

The nurse admits a patient to the hospital in Addisonian crisis. Which patient statement supports the need to plan additional teaching? a. "I frequently eat at restaurants, and my food has a lot of added salt." b. "I had the flu earlier this week, so I couldn't take the hydrocortisone." c. "I always double my dose of hydrocortisone on the days that I go for a long run." d. "I take twice as much hydrocortisone in the morning dose as I do in the afternoon."

ANS: B The need for hydrocortisone replacement is increased with stressors such as illness, and thepatient needs to be taught to call the health care provider because medication and IV fluidsand electrolytes may need to be given. The other patient statements indicate appropriatemanagement of the Addison's disease.DIF: Cognitive Level: Apply (application) REF: 1179TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity25. A 29-yr-old woman with systemic lupus erythematosus has been prescribed 2 weeks

A patient who had a subtotal thyroidectomy earlier today develops laryngeal stridor and a cramp in the right hand upon returning to the surgical nursing unit. Which collaborative action will the nurse anticipate next? a. Suction the patient's airway. b. Administer IV calcium gluconate. c. Plan for emergency tracheostomy. d. Prepare for endotracheal intubation.

ANS: B The patient's clinical manifestations of stridor and cramping are consistent with tetany causedby hypocalcemia resulting from damage to the parathyroid glands during surgery.Endotracheal intubation or tracheostomy may be needed if the calcium does not resolve thestridor. Suctioning will not correct the stridor.DIF: Cognitive Level: Apply (application) REF: 1168TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

After receiving change-of-shift report on a heart failure unit, which patient should the nurse assess first? a. Patient who is taking carvedilol (Coreg) and has a heart rate of 58 b. Patient who is taking digoxin and has a potassium level of 3.1 mEq/L c. Patient who is taking isosorbide dinitrate/hydralazine (BiDil) and has a headache d. Patient who is taking captopril (Capoten) and has a frequent nonproductive cough

ANS: B The patient's low potassium level increases the risk for digoxin toxicity and potentially fatal dysrhythmias. The nurse should assess the patient for other signs of digoxin toxicity and then notify the health care provider about the potassium level. The other patients also have side effects of their medications, but their symptoms do not indicate potentially life-threatening complications.

The nurse notes that a patient's heart monitor shows that every other beat is earlier than expected, has no visible P wave, and has a QRS complex that is wide and bizarre in shape. How will the nurse document the rhythm? a. Ventricular couplets b. Ventricular bigeminy c. Ventricular R-on-T phenomenon d. Multifocal premature ventricular contractions

ANS: B Ventricular bigeminy describes a rhythm in which every other QRS complex is wide and bizarre looking. Pairs of wide QRS complexes are described as ventricular couplets. There is no indication that the premature ventricular contractions are multifocal or that the R-on-T phenomenon is occurring.DIF: Cognitive Level: Apply (application)

A 56-yr-old patient who is disoriented and reports a headache and muscle cramps ishospitalized with possible syndrome of inappropriate antidiuretic hormone (SIADH). The nurse would expect the initial laboratory results to include a(n) a. elevated hematocrit. b. decreased serum sodium. c. increased serum chloride. d. low urine specific gravity.

ANS: B When water is retained, the serum sodium level will drop below normal, causing the clinicalmanifestations reported by the patient. The hematocrit will decrease because of the dilutioncaused by water retention. Urine will be more concentrated with a higher specific gravity. Theserum chloride level will usually decrease along with the sodium level.DIF: Cognitive Level: Understand (comprehension) REF: 1160TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Which information will the nurse include when preparing teaching materials for a patient with an exacerbation of rheumatoid arthritis? a. Affected joints should not be exercised when pain is present. b. Applying cold packs before exercise may decrease joint pain. c. Exercises should be performed passively by someone other than the patient. d. Walking may substitute for range-of-motion (ROM) exercises on some days.

ANS: B Cold application is helpful in reducing pain during periods of exacerbation of RA. Becausethe joint pain is chronic, patients are instructed to exercise even when joints are painful. ROMexercises are intended to strengthen joints and improve flexibility, so passive ROM alone isnot sufficient. Recreational exercise is encouraged but is not a replacement for ROMexercises.DIF: Cognitive Level: Apply (application) REF: 1531TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

The nurse suggests that a patient recently diagnosed with rheumatoid arthritis (RA) plan to start each day with a. a brief routine of isometric exercises. b. a warm bath followed by a short rest. c. active range-of-motion (ROM) exercises. d. stretching exercises to relieve joint stiffness.

ANS: B Taking a warm shower or bath is recommended to relieve joint stiffness, which is worse in themorning. Isometric exercises would place stress on joints and would not be recommended.Stretching and ROM should be done later in the day, when joint stiffness is decreased.DIF: Cognitive Level: Apply (application) REF: 1531TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient has just arrived on the unit after a thyroidectomy. Which action should the nurse take first? a. Observe the dressing for bleeding. b. Check the blood pressure and pulse. c. Assess the patient's respiratory effort. d. Support the patient's head with pillows.

ANS: C Airway obstruction is a possible complication after thyroidectomy because of swelling orbleeding at the site or tetany. The priority nursing action is to assess the airway. The otheractions are also part of the standard nursing care postthyroidectomy but are not as high of apriority.DIF: Cognitive Level: Analyze (analysis) REF: 1168OBJ: Special Questions: Prioritization TOP: Nursing Process: ImplementationMSC: NCLEX: Physiological Integrity

A patient with a T4 spinal cord injury asks the nurse if he will be able to be sexually active. Which initial response by the nurse is best? a. Reflex erections frequently occur, but orgasm may not be possible. b. Sildenafil (Viagra) is used by many patients with spinal cord injury. c. Multiple options are available to maintain sexuality after spinal cord injury. d. Penile injection, prostheses, or vacuum suction devices are possible options.

ANS: C Although sexuality will be changed by the patient's spinal cord injury, there are options for expression of sexuality and for fertility. The other information also is correct, but the choices will depend on the degrees of injury and the patient's individual feelings about sexuality.DIF: Cognitive Level: Analyze (analysis)

A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160mg daily. When the nurse is administering medications, the patient says, "I don't need the aspirin today. I don't have a fever." Which action should the nurse take? a. Document that the aspirin was refused by the patient. b. Tell the patient that the aspirin is used to prevent a fever. c. Explain that the aspirin is ordered to decrease stroke risk. d. Call the health care provider to clarify the medication order.

ANS: C Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation ofthe patient's refusal to take the medication is an inadequate response by the nurse. There is noneed to clarify the order with the health care provider. The aspirin is not ordered to preventaches and pains.DIF: Cognitive Level: Apply (application) REF: 1353TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

When evaluating outcomes of a glycerol rhizotomy for a patient with trigeminal neuralgia, the nurse will a. assess if the patient is doing daily facial exercises. b. question if the patient is using an eye shield at night. c. ask the patient about social activities with family and friends. d. remind the patient to chew on the unaffected side of the mouth.

ANS: C Because withdrawal from social activities is a common manifestation of trigeminal neuralgia, asking about social activities will help in evaluating if the patient's symptoms have improved. Glycerol rhizotomy does not damage the corneal reflex or motor functions of the trigeminal nerve, so there is no need to use an eye shield, do facial exercises, or take precautions with chewing.DIF: Cognitive Level: Apply (application)

Which laboratory result is important to communicate to the health care provider for a patient who is taking methotrexate to treat rheumatoid arthritis (RA)? a. Rheumatoid factor is positive. b. Fasting blood glucose is 90 mg/dL. c. The white blood cell (WBC) count is 1500/μL. d. The erythrocyte sedimentation rate is elevated.

ANS: C Bone marrow suppression is a possible side effect of methotrexate, and the patient's lowWBC count places the patient at high risk for infection. The elevated erythrocytesedimentation rate and positive rheumatoid factor are expected in RA. The blood glucose isnormal.DIF: Cognitive Level: Apply (application) REF: 1528TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

When the nurse brings medications to a patient with rheumatoid arthritis, the patient refusesthe prescribed methotrexate. The patient tells the nurse, "My arthritis isn't that bad yet. Theside effects of methotrexate are worse than the arthritis." The most appropriate response bythe nurse is a. "You have the right to refuse to take the methotrexate." b. "Methotrexate is less expensive than some of the newer drugs." c. "It is important to start methotrexate early to decrease the extent of joint damage." d. "Methotrexate is effective and has fewer side effects than some of the other drugs."

ANS: C Disease-modifying antirheumatic drugs (DMARDs) are prescribed early to prevent the jointdegeneration that occurs as soon as the first year with RA. The other statements are accurate,but the most important point for the patient to understand is that it is important to startDMARDs as quickly as possible.DIF: Cognitive Level: Analyze (analysis) REF: 1528TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care? a. Apply an eye patch to the right eye. b. Approach the patient from the right side. c. Place needed objects on the patient's left side. d. Teach the patient that the left visual deficit will resolve.

ANS: C During the acute period, the nurse should place objects on the patient's unaffected side.Because there is a visual defect in the right half of each eye, an eye patch is not appropriate.The patient should be approached from the left side. The visual deficit may not resolve,although the patient can learn to compensate for the defect.DIF: Cognitive Level: Apply (application) REF: 1362TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A 37-yr-old female patient is hospitalized with acute kidney injury (AKI). Which informationwill be most useful to the nurse in evaluating improvement in kidney function? a. Urine volume b. Creatinine level c. Glomerular filtration rate (GFR) d. Blood urea nitrogen (BUN) level

ANS: C GFR is the preferred method for evaluating kidney function. BUN levels can fluctuate basedon factors such as fluid volume status and protein intake. Urine output can be normal or highin patients with AKI and does not accurately reflect kidney function. Creatinine alone is notan accurate reflection of renal function.DIF: Cognitive Level: Analyze (analysis) REF: 1079TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

A patient has recently started on digoxin (Lanoxin) in addition to furosemide (Lasix) and captopril (Capoten) for the management of heart failure. Which assessment finding by the home health nurse is a priority to communicate to the health care provider? a. Presence of 1 to 2+ edema in the feet and ankles b. Palpable liver edge 2 cm below the ribs on the right side c. Serum potassium level 3.0 mEq/L after 1 week of therapy d. Weight increase from 120 pounds to 122 pounds over 3 days

ANS: C Hypokalemia can predispose the patient to life-threatening dysrhythmias (e.g., premature ventricular contractions), and potentiate the actions of digoxin and increase the risk for digoxin toxicity, which can also cause life-threatening dysrhythmias. The other data indicate that the patient's heart failure requires more effective therapies, but they do not require nursing action as rapidly as the low serum potassium level.

When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, the nurse reports the response as a. flexion withdrawal. b. localization of pain. c. decorticate posturing. d. decerebrate posturing.

ANS: C Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is generalized, it does not indicate localization of pain or flexion withdrawal.DIF: Cognitive Level: Understand (comprehension)

The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication's effectiveness? a. Blood pressure b. Oxygen saturation c. Intracranial pressure d. Hemoglobin and hematocrit

ANS: C Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure. It may initially reduce hematocrit and increase blood pressure, but these are not the best parameters for evaluation of the effectiveness of the drug. O2 saturation will not directly improve as a result of mannitol administration.DIF: Cognitive Level: Apply (application)

The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide (HydroDIURIL). Appropriate instructions for the patient include a. limit dietary sources of potassium. b. take the hydrochlorothiazide before bedtime. c. notify the health care provider if nausea develops. d. skip the digoxin if the pulse is below 60 beats/minute.

ANS: C Nausea is an indication of digoxin toxicity and should be reported so that the provider can assess the patient for toxicity and adjust the digoxin dose, if necessary. The patient will need to include potassium-containing foods in the diet to avoid hypokalemia. Patients should be taught to check their pulse daily before taking the digoxin and if the pulse is less than 60, to call their provider before taking the digoxin. Diuretics should be taken early in the day to avoid sleep disruption.

An expected patient problem for a patient admitted to the hospital with symptoms of diabetes insipidus is a. excess fluid volume related to intake greater than output. b. impaired gas exchange related to fluid retention in lungs. c. sleep pattern disturbance related to frequent waking to void. d. risk for impaired skin integrity related to generalized edema.

ANS: C Nocturia occurs as a result of the polyuria caused by diabetes insipidus. Edema, excess fluidvolume, and fluid retention are not expected.DIF: Cognitive Level: Apply (application) REF: 1161TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

Which menu choice by the patient who is receiving hemodialysis indicates that the nurse'steaching has been successful? a. Split-pea soup, English muffin, and nonfat milk b. Oatmeal with cream, half a banana, and herbal tea c. Poached eggs, whole-wheat toast, and apple juice d. Cheese sandwich, tomato soup, and cranberry juice

ANS: C Poached eggs would provide high-quality protein, and apple juice is low in potassium. Cheeseis high in salt and phosphate, and tomato soup is high in potassium. Split-pea soup is high inpotassium, and dairy products are high in phosphate. Bananas are high in potassium, andcream is high in phosphate.DIF: Cognitive Level: Apply (application) REF: 1087TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first? a. Complete blood count (CBC) b. Chest radiograph (chest x-ray) c. Computed tomography (CT) scan d. 12-Lead electrocardiogram (ECG)

ANS: C Rapid screening with a noncontrast CT scan is needed before administration of tissueplasminogen activator (tPA), which must be given within 4.5 hours of the onset of clinicalmanifestations of the stroke. The sooner the tPA is given, the less brain injury. The otherdiagnostic tests give information about possible causes of the stroke and do not need to becompleted as urgently as the CT scan.DIF: Cognitive Level: Analyze (analysis) REF: 1354OBJ: Special Questions: Prioritization TOP: Nursing Process: ImplementationMSC: NCLEX: Physiological Integrity

IV sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to titrate the nitroprusside rate if the patient develops a. ventricular ectopy. b. a dry, hacking cough. c. a systolic BP <90 mm Hg. d. a heart rate <50 beats/minute.

ANS: C Sodium nitroprusside is a potent vasodilator, and the major adverse effect is severe hypotension. Coughing and bradycardia are not adverse effects of this medication. Nitroprusside does not cause increased ventricular ectopy.

Which intervention will the nurse include in the plan of care for a patient with syndrome of inappropriate antidiuretic hormone (SIADH)? a. Encourage fluids to 2 to 3 L/day. b. Monitor for increasing peripheral edema. c. Offer the patient hard candies to suck on. d. Keep head of bed elevated to 30 degrees.

ANS: C Sucking on hard candies decreases thirst for a patient on fluid restriction. Patients withSIADH are on fluid restrictions of 800 to 1000 mL/day. Peripheral edema is not seen withSIADH. The head of the bed is elevated no more than 10 degrees to increase left atrial fillingpressure and decrease antidiuretic hormone (ADH) release.DIF: Cognitive Level: Apply (application) REF: 1161TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

The nurse working on the heart failure unit knows that teaching an older female patient with newly diagnosed heart failure is effective when the patient states that a. she will take furosemide (Lasix) every day at bedtime. b. the nitroglycerin patch is applied when any chest pain develops. c. she will call the clinic if her weight goes from 124 to 128 pounds in a week. d. an additional pillow can help her sleep if she is feeling short of breath at night.

ANS: C Teaching for a patient with heart failure includes information about the need to weigh daily and notify the health care provider about an increase of 3 pounds in 2 days or 3 to 5 pounds in a week. Nitroglycerin patches are used primarily to reduce preload (not to prevent chest pain) in patients with heart failure and should be used daily, not on an "as needed" basis. Diuretics should be taken earlier in the day to avoid nocturia and sleep disturbance. The patient should call the clinic if increased orthopnea develops, rather than just compensating by further elevating the head of the bed.

After change-of-shift report on the oncology unit, which patient should the nurse assess first? a. Patient who has a platelet count of 82,000/μL after chemotherapy b. Patient who has xerostomia after receiving head and neck radiation c. Patient who is neutropenic and has a temperature of 100.5° F (38.1° C) d. Patient who is worried about getting the prescribed long-acting opioid on time

ANS: C Temperature elevation is an emergency in neutropenic patients because of the risk for rapidprogression to severe infections and sepsis. The other patients also require assessments orinterventions but do not need to be assessed as urgently. Patients with thrombocytopenia donot have spontaneous bleeding until the platelets are 20,000/μL. Xerostomia does not requireimmediate intervention. Although breakthrough pain needs to be addressed rapidly, the patientdoes not appear to have breakthrough pain.DIF: Cognitive Level: Analyze (analysis) REF: 253OBJ: Special Questions: Prioritization | Special Questions: Multiple PatientsTOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

A patient with chronic heart failure who is taking a diuretic and an angiotensin-converting enzyme (ACE) inhibitor and who is on a low-sodium diet tells the home health nurse about a 5-pound weight gain in the last 3 days. The nurse's priority action will be to a. have the patient recall the dietary intake for the last 3 days. b. ask the patient about the use of the prescribed medications. c. assess the patient for clinical manifestations of acute heart failure. d. teach the patient about the importance of restricting dietary sodium.

ANS: C The 5-pound weight gain over 3 days indicates that the patient's chronic heart failure may be worsening. It is important that the patient be assessed immediately for other clinical manifestations of decompensation, such as lung crackles. A dietary recall to detect hidden sodium in the diet, reinforcement of sodium restrictions, and assessment of medication compliance may be appropriate interventions but are not the first nursing actions indicated.

A patient reports dizziness and shortness of breath for several days. During heart monitoring in the emergency department (ED), the nurse obtains the following electrocardiographic (ECG) tracing. The nurse interprets this heart rhythm as a. junctional escape rhythm. b. accelerated idioventricular rhythm. c. third-degree atrioventricular (AV) block. d. sinus rhythm with premature atrial contractions (PACs).

ANS: C The inconsistency between the atrial and ventricular rates and the variable PR interval indicate that the rhythm is third-degree AV block. Sinus rhythm with PACs will have a normal rate and consistent PR intervals with occasional PACs. An accelerated idioventricular rhythm will not have visible P waves.DIF: Cognitive Level: Apply (application)

While assessing a 68-year-old with ascites, the nurse also notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. The nurse knows this finding indicates a. decreased fluid volume. b. jugular vein atherosclerosis c. increased right atrial pressure. d. incompetent jugular vein valves.

ANS: C The jugular veins empty into the superior vena cava and then into the right atrium, so JVD with the patient sitting at a 45-degree angle reflects increased right atrial pressure. JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid volume. JVD is not caused by incompetent jugular vein valves or atherosclerosis.

A patient who is scheduled for a breast biopsy asks the nurse the difference between a benigntumor and a malignant tumor. Which answer by the nurse is correct? a. "Benign tumors do not cause damage to other tissues." b. "Benign tumors are likely to recur in the same location." c. "Malignant tumors may spread to other tissues or organs." d. "Malignant cells reproduce more rapidly than normal cells."

ANS: C The major difference between benign and malignant tumors is that malignant tumors invadeadjacent tissues and spread to distant tissues and benign tumors do not metastasize. The otherstatements are inaccurate. Both types of tumors may cause damage to adjacent tissues.Malignant cells do not reproduce more rapidly than normal cells. Benign tumors do notusually recur.DIF: Cognitive Level: Understand (comprehension) REF: 240TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

After obtaining the information shown in the accompanying figure regarding a patient with Addison's disease, which prescribed action will the nurse take first? a. Give 4 oz of fruit juice orally. b. Recheck the blood glucose level. c. Infuse 5% dextrose and 0.9% saline. d. Administer O2 therapy as needed.

ANS: C The patient's poor skin turgor, hypotension, and hyponatremia indicate an Addisonian crisis.Immediate correction of the hypovolemia and hyponatremia is needed. The other actions mayalso be needed but are not the initial action for the patient.DIF: Cognitive Level: Analyze (analysis) REF: 1179OBJ: Special Questions: Prioritization TOP: Nursing Process: PlanningMSC: NCLEX: Physiological Integrity

After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with noresidual effects, the nurse anticipates teaching the patient about a. cerebral aneurysm clipping. b. heparin intravenous infusion. c. oral low-dose aspirin therapy. d. tissue plasminogen activator (tPA).

ANS: C The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs thatinhibit platelet aggregation are prescribed after a TIA to prevent a stroke. Continuous heparininfusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptomsare not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, notfor TIA.DIF: Cognitive Level: Apply (application) REF: 1353TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

During the change of shift report, a nurse is told that a patient has an occluded left posteriorcerebral artery. The nurse will anticipate that the patient may have a. dysphasia. b. confusion. c. visual deficits. d. poor judgment.

ANS: C Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs withmiddle cerebral artery involvement. Cognitive deficits and changes in judgment are moretypical of anterior cerebral artery occlusion.DIF: Cognitive Level: Apply (application) REF: 1350TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Which information is most important for the nurse to communicate rapidly to the health care provider about a patient admitted with possible syndrome of inappropriate antidiuretic hormone (SIADH)? a. The patient has a recent weight gain of 9 lb. b. The patient complains of dyspnea with activity. c. The patient has a urine specific gravity of 1.025. d. The patient has a serum sodium level of 118 mEq/L.

ANS: D A serum sodium of less than 120 mEq/L increases the risk for complications such as seizuresand needs rapid correction. The other data are not unusual for a patient with SIADH and donot indicate the need for rapid action.DIF: Cognitive Level: Analyze (analysis) REF: 1160OBJ: Special Questions: Prioritization TOP: Nursing Process: AssessmentMSC: NCLEX: Physiological Integrity

Following an acute myocardial infarction, a previously healthy 63-year-old develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about a. digitalis preparations. b. -adrenergic blockers. c. calcium channel blockers. d. angiotensin-converting enzyme (ACE) inhibitors.

ANS: D ACE inhibitor therapy is currently recommended to prevent the development of heart failure in patients who have had a myocardial infarction and as a first-line therapy for patients with chronic heart failure. Digoxin therapy for heart failure is no longer considered a first-line measure, and digoxin is added to the treatment protocol when therapy with other medications such as ACE-inhibitors, diuretics, and -adrenergic blockers is insufficient. Calcium channel blockers are not generally used in the treatment of heart failure. The -adrenergic blockers are not used as initial therapy for new onset heart failure.

When monitoring the effectiveness of treatment for a patient with a large anterior wall myocardial infarction, the most pertinent measurement for the nurse to obtain is a. central venous pressure (CVP). b. systemic vascular resistance (SVR). c. pulmonary vascular resistance (PVR). d. pulmonary artery wedge pressure (PAWP).

ANS: D PAWP reflects left ventricular end diastolic pressure (or left ventricular preload) and is a sensitive indicator of cardiac function. Because the patient is high risk for left ventricular failure, the PAWP must be monitored. An increase will indicate left ventricular failure. The other values would also provide useful information, but the most definitive measurement of changes in cardiac function is the PAWP.DIF: Cognitive Level: Apply (application)

When reviewing the health record for a new patient with rheumatoid arthritis, the nurse reads that the patient has swan neck deformities. Which deformity will the nurse expect to observe when assessing the patient? a. A b. B c. C d. D (Image from textbook page 1527, figure 64-4)

ANS: D Swan neck deformity involves distal interphalangeal joint hyperflexion and proximalinterphalangeal joint hyperextension of the hands. The other deformities are also associatedwith rheumatoid arthritis: ulnar drift, boutonniere deformity, and hallux vagus.DIF: Cognitive Level: Understand (comprehension) REF: 1527TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, PR interval not measurable, ventricular rate of 162, R-R interval regular, and QRS complex wide and distorted, and QRS duration of 0.18 second. The nurse interprets the patient's cardiac rhythm as a. atrial flutter. b. sinus tachycardia. c. ventricular fibrillation. d. ventricular tachycardia.

ANS: D The absence of P waves, wide QRS, rate greater than 150 beats/min, and the regularity of the rhythm indicate ventricular tachycardia. Atrial flutter is usually regular, has a narrow QRS configuration, and has flutter waves present representing atrial activity. Sinus tachycardia has P waves. Ventricular fibrillation is irregular and does not have a consistent QRS duration.DIF: Cognitive Level: Apply (application)

The home health nurse is making a follow-up visit to a patient with recently diagnosed rheumatoid arthritis (RA). Which assessment made by the nurse indicates more patientteaching is needed? a. The patient takes a 2-hour nap each day. b. The patient has been taking 16 aspirins each day. c. The patient sits on a stool while preparing meals. d. The patient sleeps with two pillows under the head.

ANS: D The joints should be maintained in an extended position to avoid contractures, so patientsshould use a small, flat pillow for sleeping. Rest, aspirin, and energy management areappropriate for a patient with RA and indicate teaching has been effective.DIF: Cognitive Level: Apply (application) REF: 1531TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

The nurse reviews the laboratory results of a patient who is receiving chemotherapy. Which laboratory result is most important to report to the health care provider? a. Hematocrit 30% b. Platelets 95,000/μL c. Hemoglobin 10 g/L d. White blood cells (WBC) 2700/μL

ANS: D The low WBC count places the patient at risk for severe infection and is an indication that thechemotherapy dose may need to be lower or that WBC growth factors such as filgrastim(Neupogen) are needed. Although the other laboratory data indicate decreased levels, they donot indicate any immediate life-threatening adverse effects of the chemotherapy.DIF: Cognitive Level: Apply (application) REF: 235OBJ: Special Questions: Prioritization TOP: Nursing Process: AssessmentMSC: NCLEX: Physiological Integrity

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? a. Take this medication on an empty stomach. b. Take this medication with a full glass of water. c. You may have vivid and bizarre dreams as a side effect. d. Continue to use contraception while taking this medication.

ANS: D 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. The other information is also accurate, but it does not directly prevent harm. The medication should be taken on an empty stomach with water and patients should be informed that many people who use the drug have reported vivid and sometimes bizarre dreams.

Four hours after mechanical ventilation is initiated, a patient's arterial blood gas (ABG) results include a pH of 7.51, PaO2 of 82 mm Hg, PaCO2 of 26 mm Hg, and HCO3- of 23 mEq/L (23 mmol/L). The nurse will anticipate the need to a. increase the FIO2. b. increase the tidal volume. c. increase the respiratory rate. d. decrease the respiratory rate.

ANS: D The patient's PaCO2 and pH indicate respiratory alkalosis caused by too high a respiratory rate. The PaO2 is appropriate for a patient with COPD and increasing the respiratory rate and tidal volume would further lower the PaCO2.DIF: Cognitive Level: Analyze (analysis)

24. Which assessment finding in a patient who is admitted with infective endocarditis (IE) is most important to communicate to the health care provider? a. Generalized muscle aching b. Sudden onset right flank pain c. Janeway's lesions on the palms d. Temperature 100.7° F (38.1° C)

B Sudden onset of flank pain indicates possible embolization to the kidney and may require diagnostic testing such as a renal arteriogram and interventions to improve renal perfusion. The other findings are typically found in IE, but do not require any new interventions.DIF: Cognitive Level: Apply (application) REF: 812OBJ: Special Questions: Prioritization TOP: Nursing Process: AssessmentMSC:

A patient's vital signs are pulse 90, respirations 24, and BP 128/64 mm Hg, and cardiac output is 4.7 L/min. The patient's stroke volume is _____ mL. (Round to the nearest whole number.)

ANS:52 Stroke volume = Cardiac output/heart rate52 mL = (4.7 L x 1000 mL/L)/90

In which order will the nurse perform the following actions when caring for a patient with possible C5 spinal cord trauma who is admitted to the emergency department? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Infuse normal saline at 150 mL/hr. b. Monitor cardiac rhythm and blood pressure. c. Administer O2 using a nonrebreather mask. d. Immobilize the patient's head, neck, and spine. e. Transfer the patient to radiology for spinal computed tomography (CT).

ANS:D, C, B, A, E The first action should be to prevent further injury by stabilizing the patient's spinal cord if the patient does not have penetrating trauma. Maintenance of oxygenation by administration of 100% O2 is the second priority. Because neurogenic shock is a possible complication, monitoring of heart rhythm and BP are indicated followed by infusing normal saline for volume replacement. A CT scan to determine the extent and level of injury is needed once initial assessment and stabilization are accomplished.DIF: Cognitive Level: Analyze (analysis)

To assess the patient with pericarditis for evidence of a pericardial friction rub, the nurse should a. listen for a rumbling, low-pitched, systolic murmur over the left anterior chest. b. auscultate by placing the diaphragm of the stethoscope on the lower left sternal border. c. ask the patient to cough during auscultation to distinguish the sound from a pleural friction rub. d. feel the precordial area with the palm of the hand to detect vibrations with cardiac contraction.

B Pericardial friction rubs are heard best with the diaphragm at the lower left sternal border. The nurse should ask the patient to hold his or her breath during auscultation to distinguish the sounds from a pleural friction rub. Friction rubs are not typically low pitched or rumbling and are not confined to systole. Rubs are not assessed by palpation.DIF: Cognitive Level: Understand (comprehension) REF: 815TOP: Nursing Process: Assessment MSC:

23. Which admission order written by the health care provider for a patient admitted with infective endocarditis (IE) and a fever would be a priority for the nurse to implement? a. Administer ceftriaxone (Rocephin) 1 g IV. b. Order blood cultures drawn from two sites. c. Give acetaminophen (Tylenol) PRN for fever. d. Arrange for a transesophageal echocardiogram.

B Treatment of the IE with antibiotics should be started as quickly as possible, but it is essential to obtain blood cultures before initiating antibiotic therapy to obtain accurate sensitivity results. The echocardiogram and acetaminophen administration also should be implemented rapidly, but the blood cultures (and then administration of the antibiotic) have the highest priority.DIF: Cognitive Level: Apply (application) REF: 812-813OBJ: Special Questions: Prioritization TOP: Nursing Process: ImplementationMSC:

After teaching a patient with chronic stable angina about nitroglycerin, the nurse recognizes the need for further teaching when the patient makes which statement? A. "I will replace my nitroglycerin supply every 6 months." B. "I can take up to five tablets every 3 minutes for relief of my chest pain." C. "I will take acetaminophen (Tylenol) to treat the headache caused by nitroglycerin." D. "I will take the nitroglycerin 10 minutes before planned activity that usually causes chest pain."

B. "I can take up to five tablets every 3 minutes for relief of my chest pain." The recommended dose of nitroglycerin is one tablet taken sublingually (SL) or one metered spray for symptoms of angina. If symptoms are unchanged or worse after 5 minutes, the patient should be instructed to activate the emergency medical services (EMS) system. If symptoms are improved, repeat the nitroglycerin every 5 minutes for a maximum of three doses and contact EMS if symptoms have not resolved completely.

17. During discharge teaching with a 68-year-old patient who had a mitral valve replacement with a mechanical valve, the nurse instructs the patient on the a. use of daily aspirin for anticoagulation. b. correct method for taking the radial pulse. c. need for frequent laboratory blood testing. d. need to avoid any physical activity for 1 month.

C Anticoagulation with warfarin (Coumadin) is needed for a patient with mechanical valves to prevent clotting on the valve. This will require frequent international normalized ratio (INR) testing. Daily aspirin use will not be effective in reducing the risk for clots on the valve. Monitoring of the radial pulse is not necessary after valve replacement. Patients should resume activities of daily living as tolerated.DIF: Cognitive Level: Apply (application) REF: 826TOP: Nursing Process: Implementation MSC:

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

C Current American Heart Association guidelines recommend the use of prophylactic antibiotics before dental procedures for patients with prosthetic valves to prevent infective endocarditis (IE). The other patients are not at risk for IE.DIF: Cognitive Level: Apply (application) REF: 813TOP: Nursing Process: Planning MSC:

14. A 21-year-old woman is scheduled for percutaneous transluminal balloon valvuloplasty to treat mitral stenosis. Which information should the nurse include when explaining the advantages of valvuloplasty over valve replacement to the patient? a. Biologic valves will require immunosuppressive drugs after surgery. b. Mechanical mitral valves need to be replaced sooner than biologic valves. c. Lifelong anticoagulant therapy will be needed after mechanical valve replacement. d. Ongoing cardiac care by a health care provider is not necessary after valvuloplasty.

C Long-term anticoagulation therapy is needed after mechanical valve replacement, and this would restrict decisions about career and childbearing in this patient. Mechanical valves are durable and last longer than biologic valves. All valve repair procedures are palliative, not curative, and require lifelong health care. Biologic valves do not activate the immune system, and immunosuppressive therapy is not needed.DIF: Cognitive Level: Apply (application) REF: 824-825TOP: Nursing Process: Implementation MSC:

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

C The pressure gradient changes in mitral stenosis lead to fluid backup into the lungs, resulting in hypoxemia and dyspnea. The other findings also may be associated with mitral valve disease but are not indicators of possible hypoxemia.DIF: Cognitive Level: Apply (application) RE

Ten days after receiving a bone marrow transplant, a patient develops a skin rash on the palms and soles, jaundice, and diarrhea. What does the nurse determine these clinical manifestations are indicating? The patient is experiencing a type I allergic reaction. An atopic reaction is causing the patient's symptoms. The patient is experiencing rejection of the bone marrow. Cells in the transplanted bone marrow are attacking the host tissue.

Cells in the transplanted bone marrow are attacking the host tissue.

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

D Dental procedures place the patient with a prosthetic mitral valve at risk for infective endocarditis (IE). Myocardial infarction (MI), immunizations, and a family history of endocarditis are not risk factors for IE.DIF: Cognitive Level: Apply (application) REF: 812TOP: Nursing Process: Assessment MSC:

A patient with systemic lupus erythematosus is receiving plasmapheresis to treat an acute attack. What symptoms will the nurse monitor to determine if the patient develops complications related to the procedure? Hypotension, paresthesias, and dizziness Polyuria, decreased reflexes, and lethargy Intense thirst, flushed skin, and weight gain Abdominal cramping, diarrhea, and leg weakness

Hypotension, paresthesias, and dizziness Common complications associated with plasmapheresis are hypotension and citrate toxicity. Citrate is used as an anticoagulant and may cause hypocalcemia, which may manifest as headache, paresthesias, and dizziness.

The patient with an autoimmune disease will be treated with plasmapheresis. What should the nurse teach the patient about this treatment? It will gather platelets for use later when needed. It will cause anemia because it removes whole blood and red blood cells are damaged. It will remove the IgG autoantibodies and antigen complexes from the plasma. It will remove the peripheral stem cells in order to cure the autoimmune disease.

It will remove the IgG autoantibodies and antigen complexes from the plasma. Plasmapheresis removes plasma that contains autoantibodies (usually IgG class) and antigen-antibody complexes to remove the pathologic substances in the plasma without causing anemia.

A patient has a hemoglobin level of 8.2 gm/dL and hematocrit of 28%, and is receiving a transfusion of packed red blood cells. The patient reports back pain, chills, and has a fever during the transfusion. What is the priority nursing action? Call the physician Stop the transfusion Administer acetaminophen for the pain and fever Monitor the patient for the remainder of the transfusion

Stop the transfusion

An older adult patient who is having an annual check-up tells the nurse, "I feel fine, and I don't want to pay for all these unnecessary cancer screening tests!" Which information should the nurse plan to teach this patient? a. Consequences of aging on cell-mediated immunity b. Decrease in antibody production associated with aging c. Impact of poor nutrition on immune function in older people d. Incidence of cancer-associated infections in older individuals

a. Consequences of aging on cell-mediated immunity The primary impact of aging on immune function is on T cells, which are important for immune surveillance and tumor immunity.

Ten days after receiving a bone marrow transplant, a patient develops a skin rash. What would the nurse suspect is the cause of the rash? a. The donor T cells are attacking the patient's skin cells. b. The patient needs treatment to prevent hyperacute rejection. c. The patient's antibodies are rejecting the donor bone marrow. d. The patient is experiencing a delayed hypersensitivity reaction.

a. The donor T cells are attacking the patient's skin cells. The patient's history and symptoms indicate that the patient is experiencing graft-versus-host disease, in which the donated T cells attack the patient's tissues.

The nurse teaches a patient about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions? a. "I need to be monitored closely for development of malignant tumors." b. "After a couple of years I will be able to stop taking the cyclosporine." c. "If I develop acute rejection episode, I will need additional types of drugs." d. "The drugs are combined to inhibit different ways the kidney can be rejected."

b. "After a couple of years I will be able to stop taking the cyclosporine." Cyclosporine, a calcineurin inhibitor, will need to be continued for life.

What instructions about plasmapheresis should the nurse include in the teaching plan for a patient diagnosed with systemic lupus erythematosus (SLE)? a. Plasmapheresis eliminates eosinophils and basophils from blood. b. Plasmapheresis decreases the damage to organs from T lymphocytes. c. Plasmapheresis removes antibody-antigen complexes from circulation. d. Plasmapheresis prevents foreign antibodies from damaging various body tissues.

c. Plasmapheresis removes antibody-antigen complexes from circulation. Plasmapheresis is used in SLE to remove antibodies, antibody-antigen complexes, and complement from blood. T lymphocytes, foreign antibodies, eosinophils, and basophils do not directly contribute to the tissue damage in SLE.

The nurse should assess the patient undergoing plasmapheresis for which clinical manifestation? a. Shortness of breath b. High blood pressure c. Transfusion reaction d. Extremity numbness

d. Extremity numbness Numbness and tingling may occur as the result of the hypocalcemia caused by the citrate used to prevent coagulation.