PN2 final exam
A nurse teaches a patient who is at risk for colon cancer. Which dietary recommendation would the nurse teach this patient?
"Add vegetables such as broccoli and cauliflower to your new diet."
A patient is taking long-term corticosteroids for myasthenia gravis. What teaching is most important?
Avoid large crowds and people who are ill.
A patient had a percutaneous transluminal coronary angioplasty for peripheral arterial disease. What assessment finding by the nurse indicates that a priority outcome for this patient has been met?
Distal pulse on affected extremity 2+/4+
A nurse teaches a patient about self-monitoring of blood glucose levels. Which statement would the nurse include in this patient's teaching to prevent bloodborne infections?
"Do not share your monitoring equipment."
A nurse teaches a patient with a lower motor neuron lesion who wants to achieve bladder control. Which statement would the nurse include in this patient's teaching?
"Tighten your abdominal muscles to stimulate urine flow."
The nurse is caring for a patient with leukemia who has the priority problem of fatigue. What action by the patient best indicates that an important goal for this problem has been met?
Doing activities of daily living (ADLs) using rest periods
A patient in the intensive care unit is started on continuous venovenous hemofiltration (CVVH). Which finding is the cause of immediate action by the nurse?
Blood pressure of 76/58 mm Hg
When teaching a patient recently diagnosed with type 1 diabetes mellitus, the patient states, "I will never be able to stick myself with a needle." How would the nurse respond?
"Tell me what it is about the injections that are concerning you."
A nursing student is caring for a patient with leukemia. The student asks why the patient is still at risk for infection when the patient's white blood cell count (WBC) is high. What response by the registered nurse is best?
"Those WBCs are abnormal and don't provide protection."
A nurse is teaching a patient about magnesium hydroxide with aluminum hydroxide (Maalox). What instruction is most appropriate?
"Report diarrhea to your provider."
A patient has mastoiditis and is prescribed antibiotics. What instruction by the nurse is most important for this patient?
Immediately report headache or stiff neck.
A patient at risk for developing hyperkalemia states, "I love fruit and usually eat it every day, but now I can't because of my high potassium level." How will the nurse respond?
"Berries, cherries, apples, and peaches are low in potassium."
A nurse cares for a patient with infective endocarditis. Which infection control precautions would the nurse use?
Standard Precautions
A nurse cares for a patient with colon cancer who has a new colostomy. The patient states, "I think it would be helpful to talk with someone who has had a similar experience." How would the nurse respond?
"I will make a referral to the United Ostomy Associations of America."
After teaching a patient who is prescribed a long-acting beta2 agonist medication, a nurse assesses the patient's understanding. Which statement indicates that the patient comprehends the teaching?
"I will take this medication every morning to help prevent an acute attack."
A patient has a recurrence of gastric cancer and is in the gastrointestinal clinic crying. What response by the nurse is most appropriate?
"I'd like to know what you are feeling now."
After teaching a patient who is recovering from a complete thyroidectomy, the nurse assesses the patient's understanding. Which statement made by the patient indicates a need for additional instruction?
"After surgery, I won't need to take thyroid medication."
A nurse is teaching a patient with multiple sclerosis who is prescribed cyclophosphamide (Cytoxan) and methylprednisolone (Medrol). Which statement would the nurse include in this patient's discharge teaching?
"Avoid crowds and people with colds."
A patient admitted for pneumonia has been tachypneic for several days. When the nurse starts an IV to give fluids, the patient questions this action, saying "I have been drinking tons of water. How am I dehydrated?" What response by the nurse is best?
"Breathing so quickly can be dehydrating."
A nurse teaches a patient with heart failure about energy conservation. Which statement would the nurse include in this patient's teaching?
"Gather everything you need for a chore before you begin."
A nurse assesses a patient on the medical-surgical unit. Which statement made by the patient alerts the nurse to assess the patient for hypothyroidism?
"I am always tired, even with 12 hours of sleep."
The nurse is teaching a patient with chronic kidney disease (CKD) about the sodium restriction needed in the diet to prevent edema and hypertension. Which statement by the patient indicates that more teaching is needed?
"I am thrilled that I can continue to eat fast food."
A nurse plans care for a patient with hypothyroidism. Which priority problem does the nurse address first for this patient?
Depression and withdrawal
A nurse is irrigating a patient's ear when the patient becomes nauseated. What action by the nurse is most appropriate for patient comfort?
Stop the irrigation immediately.
A nurse assesses a patient in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure?
"I must stop halfway up the stairs to catch my breath."
A nurse teaches a patient who is diagnosed with diabetes mellitus. Which statement would the nurse include in this patient's plan of care to delay the onset of microvascular and macrovascular complications?
"Maintain tight glycemic control and prevent hyperglycemia."
A nurse assesses patients at a community health center. Which patient is at highest risk for the development of colorectal cancer?
A 72-year-old who eats fast food frequently
A nurse assesses a patient with a mechanical bowel obstruction who reports intermittent abdominal pain. An hour later the patient reports constant abdominal pain. Which action would the nurse take next?
Assess the patient's bowel sounds.
A nurse reviews the medication list of a patient with a 20-year history of diabetes mellitus. The patient holds up the bottle of prescribed duloxetine (Cymbalta) and states, "My cousin has depression and is taking this drug. Do you think I'm depressed?" How would the nurse respond?
"It's for peripheral neuropathy. Do you have burning pain in your feet or hands?"
An older patient with peripheral vascular disease (PVD) is explaining the daily foot care regimen to the family practice clinic nurse. What statement by the patient may indicate a barrier to proper foot care?
"My hands shake when I try to do things requiring coordination."
A nurse assesses a patient admitted to the cardiac unit. Which statement by the patient alerts the nurse to the possibility of right-sided heart failure?
"My shoes fit really tight lately."
A nurse promotes the prevention of lower back pain by teaching patients at a community center. Which instruction would the nurse include in this education?
"Participate in an exercise program to strengthen muscles."
After teaching a patient with type 2 diabetes mellitus, the nurse assesses the patient's understanding. Which statement made by the patient indicates a need for additional teaching?
"Since my diabetes is controlled with diet and exercise, I must be seen only if I am sick."
A nurse in a family practice clinic is preparing discharge instructions for a patient reporting facial pain that is worse when bending over, tenderness across the cheeks, and postnasal discharge. What instruction will be most helpful?
"Try warm, moist heat packs on your face."
A nurse cares for a middle-aged male patient who has irritable bowel syndrome (IBS). The patient states, "I have changed my diet and take bulk-forming laxatives, but my symptoms have not gotten better. I heard about a drug called Amitiza. Do you think it might help?" How would the nurse respond?
"Unfortunately, lubiprostone is approved only for use in women."
A nurse teaches a patient with diabetes mellitus who is experiencing numbness and reduced sensation. Which statement would the nurse include in this patient's teaching to prevent injury?
"Use a bath thermometer to test the water temperature."
A nurse teaches a patient who has a history of heart failure. Which statement would the nurse include in this patient's discharge teaching?
"Weigh yourself daily while wearing the same amount of clothing."
A nurse cares for a patient with right-sided heart failure. The patient asks, "Why do I need to weigh myself every day?" How would the nurse respond?
"Weight is the best indication that you are gaining or losing fluid."
A nurse cares for a patient who has a family history of colon cancer. The patient states, "My father and my brother had colon cancer. What is the chance that I will get cancer?" How would the nurse respond?
"You should have a colonoscopy more frequently to identify abnormal polyps early."
A nurse cares for a patient who has hypothyroidism as a result of Hashimoto's thyroiditis. The patient asks, "How long will I need to take this thyroid medication?" How does the nurse respond?
"You'll need thyroid pills for life because your thyroid won't start working again."
A nurse cares for a patient who has a family history of diabetes mellitus. The patient states, "My father has type 1 diabetes mellitus. Will I develop this disease as well?" How would the nurse respond?
"Your risk of diabetes is higher than the general population, but it may not occur."
A nurse cares for a patient who has diabetes mellitus. The nurse administers 6 units of regular insulin and 10 units of NPH insulin at 07:00. At which time would the nurse assess the patient for potential problems related to the NPH insulin?
16:00
A nurse assesses patients on a cardiac unit. Which patient would the nurse identify as being at greatest risk for the development of left-sided heart failure?
A 36-year-old woman with aortic stenosis
A patient with human immune deficiency virus (HIV) has had a sudden decline in status with a large increase in viral load. What action would the nurse take first?
Assess the patient for adherence to the drug regimen.
A nurse admits a patient from the emergency department. Patient data are listed below: What action by the nurse is the priority?
Administer oxygen at 4 L per nasal cannula.
A nurse cares for a patient experiencing diabetic ketoacidosis who presents with Kussmaul respirations. What action would the nurse take?
Administration of intravenous insulin
A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience would the nurse provide this service?
African-American churches
A 70-kg adult with chronic renal failure is on a 40-g protein diet. The patient has a reduced glomerular filtration rate and is not undergoing dialysis. Which result would give the nurse the most concern?
Albumin level of 2.5 g/dL (3.63 mcmol/L)
An older patient has gastric cancer and is scheduled to have a partial gastrectomy. The family does not want the patient told about her diagnosis. What action by the nurse is best?
Assess family concerns and fears.
An older patient is hospitalized with Guillain-Barré syndrome. A family member tells the nurse that the patient is restless and seems confused. What action by the nurse is best?
Assess the patient's oxygen saturation.
A nurse is assessing a patient with hypokalemia, and notes that the patient's handgrip strength has diminished since the previous assessment 1 hour ago. What action does the nurse take first?
Assess the patient's respiratory rate, rhythm, and depth.
A nurse assesses a patient with multiple sclerosis after administering prescribed fingolimod (Gilenya). For which adverse effect would the nurse monitor?
Bradycardia
A nurse assesses a patient who takes lithium. Which assessment finding should alert the nurse to a side effect of this therapy?
Bradycardia and loss of eyebrow hair
A nurse assesses a patient who is experiencing an acid-base imbalance. The patient's arterial blood gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3- 19 mEq/L (19 mmol/L). Which assessment would the nurse perform first?
Cardiac rate and rhythm
A nurse works on a unit that has admitted its first patient with acquired immune deficiency syndrome. The nurse overhears other staff members talking about the "AIDS guy" and wondering how the patient contracted the disease. What action by the nurse is best?
Confront the staff members about unethical behavior.
A nurse is caring for a patient who has a serum calcium level of 14 mg/dL (3.5 mmol/L). Which provider order does the nurse implement first?
Connect the patient to a cardiac monitor.
A nurse assesses a patient who is recovering from a total thyroidectomy and notes the development of stridor. What action does the nurse take first?
Contact the provider and prepare for intubation.
A nurse is evaluating a patient who is being treated for dehydration. Which assessment result does the nurse correlate with a therapeutic response to the treatment plan?
Decreased orthostatic light-headedness and dizziness
A preoperative nurse assesses a patient who has type 1 diabetes mellitus prior to a surgical procedure. The patient's blood glucose level is 160 mg/dL (8.9 mmol/L). What action would the nurse take?
Document the finding in the patient's chart.
A nurse assesses a patient with mitral valve stenosis. What clinical manifestation would alert the nurse to the possibility that the patient's stenosis has progressed?
Dyspnea on exertion
A nurse is preparing to administer a blood transfusion. What action is most important?
Ensuring that informed consent is obtained if required
A patient is scheduled to have a tumor of the middle ear removed. What teaching topic is most important for the nurse to cover?
Expecting hearing loss in the affected ear
A patient hospitalized with sickle cell crisis frequently asks for opioid pain medications, often shortly after receiving a dose. The nurses on the unit believe that the patient is drug seeking. When the patient requests pain medication, what action by the nurse is best?
Give the patient pain medication if it is time for another dose.
After teaching a patient who is prescribed a restricted sodium diet, a nurse assesses the patient's understanding. Which food choice for lunch indicates that the patient correctly understood the teaching?
Grilled chicken breast with glazed carrots
A nurse is caring for a patient who is about to receive a bone marrow transplant. To best help the patient cope with the long recovery period, what action by the nurse is best?
Help the patient find things to hope for each day of recovery.
A diabetic patient becomes septic after a bowel resection and is having problems with respiratory distress. The nurse reviews the labs and finds the following ABG results: pH 7.50; PaCO2 30; HCO3: 24; and PaO2 68. What does the nurse recognize as the primary factor causing this the acid-base imbalance?
Hyperventilation due to poor oxygenation
A nurse assesses a patient with a neurologic disorder. Which assessment finding would the nurse identify as a late manifestation of amyotrophic lateral sclerosis (ALS)?
Impairment of respiratory muscles
A patient with Guillain-Barré syndrome is admitted to the hospital. The nurse plans caregiving priority to interventions that address which priority patient problem?
Inadequate airway
A patient has a sickle cell crisis with extreme lower extremity pain. What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)?
Keep the lower extremities warm.
A nurse develops a dietary plan for a patient with diabetes mellitus and new-onset microalbuminuria. Which component of the patient's diet would the nurse decrease?
Proteins
After teaching a patient to increase dietary potassium intake, a nurse assesses the patient's understanding. Which dietary meal selection indicates that the patient correctly understands the teaching?
Sausage, one slice of whole-wheat toast, half cup of raisins (120 gm), and a glass of milk
A nurse cares for a patient who is recovering from a parathyroidectomy. When taking the patient's blood pressure, the nurse notes that the patient's hand has gone into flexion contractions. Which laboratory result does the nurse correlate with this condition?
Serum calcium: 6.9 mg/dL (1.73 mmol/L)
A nurse is caring for a patient with acute pericarditis who reports substernal precordial pain that radiates to the left side of the neck. Which nonpharmacologic comfort measure would the nurse implement?
Sit the patient up with a pillow to lean forward on.
A patient with peptic ulcer disease is in the emergency department and reports the pain has gotten much worse over the last several days. The patient's blood pressure when lying down was 122/80 mm Hg and when standing was 98/52 mm Hg. What action by the nurse is most appropriate?
Start a large-bore IV with normal saline.
A patient is having a peritoneal dialysis treatment. The nurse notes an opaque color to the effluent. What is the priority action by the nurse?
Take a sample of the effluent and send to the laboratory.
The nurse assesses a patient's oral cavity and makes the discovery shown in the photo below: What action by the nurse is most appropriate?
Teach the patient about cobalamin therapy.
A nurse cares for an older adult patient with heart failure. The patient states, "I don't know what to do. I don't want to be a burden to my daughter, but I can't do it alone. Maybe I should die." What is the best response by the nurse?
"Would you like to talk more about this?"
A patient has a serum potassium level of 6.5 mEq/L (6.5 mmol/L), a serum creatinine level of 2 mg/dL (176 mcmol/L), and a urine output of 350 mL/day. What is the best action by the nurse?
Place the patient on a cardiac monitor immediately.
A patient with human immune deficiency virus is admitted to the hospital with fever, night sweats, and severe cough. Laboratory results include a CD4+ cell count of 180/mm3 and a negative tuberculosis (TB) skin test 4 days ago. What action would the nurse take first?
Place the patient under Airborne Precautions.
A nurse is caring for four patients. Which one would the nurse see first?
Patient who had a first dose of captopril (Capoten) and needs to use the bathroom
A nurse is caring for four patients with leukemia. After hand-off report, which patient should the nurse see first?
Patient who had two bloody diarrhea stools this morning
A patient has been treated for a deep-vein thrombus and today presents to the clinic with petechiae. Laboratory results show a platelet count of 42,000/mm3 (42 ´ 109/L). The nurse reviews the patient's medication list to determine if the patient is taking which drug?
Unfractionated heparin
A nurse assesses a client who has a history of migraines. Which clinical manifestation would the nurse identify as an early sign of a migraine with aura?
Visual disturbances
A nursing student is instructed to remove a patient's ear packing and instill eardrops. What action by the student requires intervention by the registered nurse?
Washing the hands and removing the packing
A nurse cares for a patient who has a chest tube. When would this patient be at highest risk for developing a pneumothorax?
When the tube becomes disconnected from the drainage system
A patient is being taught about drug therapy for Helicobacter pylori infection. What assessment by the nurse is most important?
Willingness to adhere to drug therapy
A patient admitted for sickle cell crisis is distraught after learning her child also has the disease. What response by the nurse is best?
"I can see you are upset. I can stay here with you a while if you like."
The emergency department (ED) manager is reviewing patient charts to determine how well the staff performs when treating patients with community-acquired pneumonia. What outcome demonstrates that goals for this patient type have been met?
Antibiotics started before admission
A nurse cares for a patient with arthritis who reports frequent asthma attacks. What action would the nurse take first?
Ask about medications the patient is currently taking. "I will take this medication every morning to help prevent an acute attack."
A nurse evaluates a patient's arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm Hg, and HCO3- 22 mEq/L (22 mmol/L). Which intervention does the nurse implement first?
Assess the airway
A patient has frequent hospitalizations for leukemia and is worried about functioning as a parent to four small children. What action by the nurse would be most helpful?
Assist the patient to make "sick-day" plans for household responsibilities.
A nurse assesses a patient who is recovering from anterior cervical discectomy and fusion. Which complication would alert the nurse to urgently communicate with the healthcare provider?
Auscultated stridor
An older female patient has been prescribed esomeprazole (Nexium) for treatment of chronic gastric ulcers. What teaching is particularly important for this patient?
Increase intake of calcium and vitamin D.
After teaching a patient who is recovering from a colon resection, the nurse assesses the patient's understanding. Which statements by the patient indicate a correct understanding of the teaching? (Select all that apply.)
"Cutting the flange will help it fit snugly around the stoma to avoid skin breakdown." "I will use warm water and a soft washcloth to clean around the stoma." "I might start bicycling and swimming again once my incision has healed."
A patient who had a partial gastrectomy has several expected nutritional problems. What actions by the nurse are best to promote better nutrition? (Select all that apply.)
Administer vitamin B12 injections. Ask the provider about folic acid replacement. Provide iron supplements for the patient.
A student nurse is learning about human immune deficiency virus (HIV) infection. Which statements about HIV infection are correct? (Select all that apply.)
Antibodies produced are incomplete and do not function well. CD4+ cells begin to create new HIV virus particles. Macrophages stop functioning properly. Opportunistic infections and cancer are leading causes of death.
A patient with human immune deficiency virus infection is hospitalized for an unrelated condition, and several medications are prescribed in addition to the regimen already being used. What action by the nurse is most important?
Consult with the pharmacy about drug interactions.
A nurse assesses a patient with hypothyroidism who is admitted with acute appendicitis. The nurse notes that the patient's level of consciousness has decreased. What actions does the nurse perform? (Select all that apply.)
Cover the patient with warm blankets. Infuse intravenous fluids. Maintain a patent airway.
A nurse cares for a patient who has a nasogastric (NG) tube. Which actions would the nurse take? (Select all that apply.)
Disconnect suction when auscultating bowel peristalsis. Monitor the patient's skin around the tube site for irritation. Assess for proper placement of the tube every 4 hours.
A student nurse is learning about blood transfusion compatibilities. What information does this include? (Select all that apply.)
Donor blood type A can donate to recipient blood type AB. Donor blood type O can donate to anyone.
A student nurse is helping a registered nurse with a blood transfusion. Which actions by the student are most appropriate? (Select all that apply.)
Hanging the blood product using normal saline and a filtered tubing set Taking a full set of vital signs prior to starting the blood transfusion Using gloves to start the patient's IV if needed and to handle the blood product
A student studying leukemia learns the risk factors for developing this disorder. Which risk factors does this include? (Select all that apply.)
Ionizing radiation exposure Viral infections Chemical exposure
A patient is receiving plasmapheresis. What assessment findings need to be reported to the provider as a priority? (Select all that apply.)
Serum calcium level of 6.4 mg/dL (1.6 mmol/L) Urticarial rash
A nurse assesses a patient who has a chest tube. For which manifestations would the nurse immediately intervene? (Select all that apply.)
Sudden onset of shortness of breath Tracheal deviation
A nurse assesses a patient who is prescribed furosemide (Lasix) for hypertension. For which acid-base imbalance does the nurse assess to prevent complications of this therapy?
Metabolic alkalosis
A nurse cares for a patient with a 40-year smoking history who is experiencing distended neck veins and dependent edema. Which physiologic process would the nurse correlate with this patient's history and clinical manifestations?
Increased pulmonary pressure creating a higher workload on the right side of the heart
The charge nurse on a medical unit is preparing to admit several "patients" who have possible pandemic flu during a preparedness drill. What action by the nurse is best?
Inquire as to recent travel outside the United States.
A nurse cares for a patient who has a pleural chest tube. What action would the nurse take to ensure safe use of this equipment?
Keep padded clamps at the bedside for use if the drainage system is interrupted.
A nurse assessing a patient with colorectal cancer auscultates high-pitched bowel sounds and notes the presence of visible peristaltic waves. Which action would the nurse take?
Contact the provider and recommend computed tomography.
A nurse is caring for a patient who is experiencing excessive diarrhea. The patient's arterial blood gas values are pH 7.18, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3- 16 mEq/L (16 mmol/L). Which provider order does the nurse expect to receive?
Sodium bicarbonate 100 mEq diluted in 1 L of D5W
