Systems of Care 3 Exam 3 NCLEX Practice
When caring for a patient with a biliary obstruction, the nurse will anticipate administering which vitamin supplements (select all that apply)? Vitamin A Vitamin D Vitamin E Vitamin K Vitamin B
A, B, C, D Biliary obstruction prevents bile from entering the small intestine and thus prevents the absorption of fat-soluble vitamins. Vitamins A, D, E, and K are all fat-soluble and thus would need to be supplemented in a patient with biliary obstruction.
The nurse performs a physical assessment on a 74-year-old woman with possible endocrine dysfunction. The patient's weight was 142 pounds 6 months ago compared to a current weight of 125 pounds. What percent weight change will the nurse document in the patient's health record? 12% weight loss 17% weight loss 25% weight loss 74% weight loss
A - 12% weight loss 142 pounds - 125 pounds = 17 pounds; (17/142) × 100 = 12%. Weight change (%) is calculated by dividing the current body weight change by the usual body weight and multiplying the result by 100. Weight change greater than 5% in 1 month, 7.5% in 3 months, or 10% in 6 months is considered severe.
The nurse is caring for a woman recently diagnosed with viral hepatitis A. Which individual should the nurse refer for an immunoglobin (IG) injection? A caregiver who lives in the same household with the patient A friend who delivers meals to the patient and family each week A relative with a history of hepatitis A who visits the patient daily A child living in the home who received the hepatitis A vaccine 3 months ago
A - A caregiver who lives in the same household with the patient IG is recommended for persons who do not have anti-HAV antibodies and are exposed as a result of close contact with persons who have HAV or foodborne exposure. Persons who have received a dose of HAV vaccine more than 1 month previously or who have a history of HAV infection do not require IG.
When providing discharge teaching for the patient after a laparoscopic cholecystectomy, what information should the nurse include? A lower-fat diet may be better tolerated for several weeks. Do not return to work or normal activities for 3 weeks. Bile-colored drainage will probably drain from the incision. Keep the bandages on and the puncture site dry until it heals.
A - A lower-fat diet may be better tolerated for several weeks Although the usual diet can be resumed, a low-fat diet is usually better tolerated for several weeks following surgery. Normal activities can be gradually resumed as the patient tolerates. Bile-colored drainage or pus, redness, swelling, severe pain, and fever may all indicate infection. The bandage may be removed the day after surgery, and the patient can shower.
When the patient with a persisting cough is diagnosed with pertussis (instead of acute bronchitis), the nurse knows that treatment will include which type of medication? Antibiotic Corticosteroid Bronchodilator Cough suppressant
A - Antibiotic Pertussis, unlike acute bronchitis, is caused by a gram-negative bacillus, Bordella pertussis, which must be treated with antibiotics. Corticosteroids and bronchodilators are not helpful in reducing symptoms. Cough suppressants and antihistamines are ineffective and may induce coughing episodes with pertussis
Which physical assessment finding in a patient with a lower respiratory problem best supports the nursing diagnosis of ineffective airway clearance? Basilar crackles Respiratory rate of 28 Oxygen saturation of 85% Presence of greenish sputum
A - Basilar crackles The presence of adventitious breath sounds indicates that there is accumulation of secretions in the lower airways. This would be consistent with a nursing diagnosis of ineffective airway clearance because the patient is retaining secretions. The rapid respiratory rate, low oxygen saturation, and presence of greenish sputum may occur with a lower respiratory problem, but do not definitely support the nursing diagnosis of ineffective airway clearance.
When a 35-year-old female patient is admitted to the emergency department with acute abdominal pain, which possible diagnosis should you consider that may be the cause of her pain (select all that apply)? a.Gastroenteritis b.Ectopic pregnancy c.Gastrointestinal bleeding d.Irritable bowel syndrome e.Inflammatory bowel disease
A, B, C, D, E All of these conditions are associated with acute abdominal pain
When the nurse assesses the patient that has pancreatitis, what function may be altered related to the endocrine function of the pancreas? Blood glucose regulation Increased response to stress Fluid and electrolyte regulation Regulates metabolic rate of cells
A - Blood glucose regulation The endocrine functions of the pancreas are regulated by α cells that produce and secrete glucagon, β cells that produce and secrete insulin and amylin, delta cells that produce and secrete somatostatin, and F cells that secrete pancreatic polypeptide. Glucagon, insulin, and amylin, and somatostatin all affect blood glucose. Pancreatic polypeptide regulates appetite. Increased response to stress occurs from epinephrine secreted by the adrenal medulla. Fluid and electrolyte regulation occurs in response to several hormones (mineralocorticoids, antidiuretic hormone, parathyroid hormone, calcitonin) from several organs (adrenal cortex, posterior pituitary, parathyroid, thyroid). The metabolic rate of cells is regulated by triiodothyronine (T3) from the thyroid.
The surgeon was unable to save a patient's parathyroid gland during a radical thyroidectomy. The nurse should consequently pay particular attention to which laboratory value? Calcium levels Potassium levels Blood glucose levels Sodium and chloride levels
A - Calcium levels The parathyroid gland plays a key role in maintaining calcium levels. Potassium, sodium, glucose, and chloride are not directly influenced by the loss of the parathyroid gland.
A 24-year-old male with a gunshot wound to the right side of the chest walks into the emergency department while leaning on another young man. The patient exhibits severe shortness of breath and decreased breath sounds on the right side. Which action should the nurse take immediately? Cover the chest wound with a nonporous dressing taped on three sides. Pack the chest wound with sterile saline soaked gauze and tape securely. Stabilize the chest wall with tape and initiate positive pressure ventilation. Apply a pressure dressing over the wound to prevent excessive loss of blood.
A - Cover the chest wound with nonporous dressing taped on three sides The patient has a sucking chest wound (open pneumothorax). Air enters the pleural space through the chest wall during inspiration. Emergency treatment consists of covering the wound with an occlusive dressing that is secured on three sides. During inspiration the dressing pulls against the wound preventing air from entering the pleural space. During expiration the dressing is pushed out and air escapes through the wound and from under the dressing.
The nurse is caring for a 68-year-old woman after a parathyroidectomy related to hyperparathyroidism. The nurse should administer IV calcium gluconate if the patient exhibits which clinical manifestations? Facial muscle spasms or laryngospasms Decreased muscle tone or muscle weakness Tingling in the hands and around the mouth Shortened QT interval on the electrocardiogram
A - Facial muscle spasms or laryngospasms Nursing care for the patient following a parathyroidectomy includes monitoring for a sudden decrease in serum calcium levels causing tetany, a condition of neuromuscular hyperexcitability. If tetany is severe (e.g., muscular spasms or laryngospasms develop), IV calcium gluconate should be administered. Mild tetany, characterized by unpleasant tingling of the hands and around the mouth, may be present but should decrease over time without treatment. Decreased muscle tone, muscle weakness, and shortened QT interval are clinical manifestations of hyperparathyroidism.
The patient has been feeling tired lately and has gained weight; reports thickened, dry skin and increased cold sensitivity even though it is now summer. Which endocrine diagnostic test should be done first? Free thyroxine (FT4) Serum growth hormone (GH) Follicle stimulating hormone (FSH) Magnetic resonance imaging (MRI) of the head
A - Free thyroxine (FT4) The manifestations the patient is experiencing could be related to hypothyroidism. Free thyroxine (FT4) is considered a better indicator of thyroid function than total T4 and could be done to evaluate the patient for hypothyroidism. Growth hormone excess could cause thick, leathery, oily skin but does not demonstrate the other manifestations. FSH is manifest with menstrual irregularity and would be useful in distinguishing primary gonadal problems from pituitary insufficiency. MRI is the examination of choice for radiologic evaluation of the pituitary gland and the hypothalamus but would not be the first diagnostic study to further explore the basis of these manifestations.
The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, the nurse notes a temperature of 101.4° F, a productive cough with yellow sputum, and a respiratory rate of 20. Which nursing diagnosis is most appropriate based upon this assessment? Hyperthermia related to infectious illness Ineffective thermoregulation related to chilling Ineffective breathing pattern related to pneumonia Ineffective airway clearance related to thick secretions
A - Hyperthermia related to infectious illness Because the patient has spiked a temperature and has a diagnosis of pneumonia, the logical nursing diagnosis is hyperthermia related to infectious illness. There is no evidence of a chill, and her breathing pattern is within normal limits at 20 breaths/minute. There is no evidence of ineffective airway clearance from the information given because the patient is expectorating sputum.
The nurse instructs a 28-year-old man with acromegaly resulting from an unresectable benign pituitary tumor about octreotide (Sandostatin). The nurse should intervene if the patient makes which statement? "I will come in to receive this medication IV every 2 to 4 weeks." "I will inject the medication in the subcutaneous layer of the skin." "The medication will decrease the growth hormone production to normal." "If radiation treatment is not effective, I may need to take the medication."
A - I will come in to receive this medication IV every 2 to 4 weeks Drugs are most commonly used in patients who have had an inadequate response to or cannot be treated with surgery and/or radiation therapy. The most common drug used for acromegaly is octreotide (Sandostatin), a somatostatin analog that reduces growth hormone levels to within the normal range in many patients. Octreotide is given by subcutaneous injection three times a week. Two long-acting analogs, octreotide (Sandostatin LAR) and lanreotide SR (Somatuline Depot), are available as intramuscular (IM) injections given every 2 to 4 weeks.
The patient with cirrhosis is being taught self-care. Which statement indicates the patient needs more teaching? "If I notice a fast heart rate or irregular beats, this is normal for cirrhosis." "I need to take good care of my belly and ankle skin where it is swollen." "A scrotal support may be more comfortable when I have scrotal edema." "I can use pillows to support my head to help me breathe when I am in bed."
A - If I notice a fast heart rate or irregular beats, this is normal for cirrhosis If the patient with cirrhosis experiences a fast or irregular heart rate, it may be indicative of hypokalemia and should be reported to the health care provider, as this is not normal for cirrhosis. Edematous tissue is subject to breakdown and needs meticulous skin care. Pillows and a semi-Fowler's or Fowler's position will increase respiratory efficiency. A scrotal support may improve comfort if there is scrotal edema.
The appropriate collaborative therapy for the patient with acute diarrhea caused by a viral infection is to a.increase fluid intake. b.administer an antibiotic. c.administer antimotility drugs. d.quarantine the patient to prevent spread of the virus.
A - Increase fluid intake Acute diarrhea is usually self-limiting Concerns are fluid/electrolyte replacement and resolution Antibiotics are rarely used for infectious diarrhea, and in this case the infection is viral so antibiotics won't work Antidiarrheals would cause retaining of infection and prolonged exposure
A patient with type 2 diabetes and cirrhosis asks the nurse if it would be okay to take silymarin (milk thistle) to help minimize liver damage. The nurse responds based on what knowledge? Milk thistle may affect liver enzymes and thus alter drug metabolism. Milk thistle is generally safe in recommended doses for up to 10 years. There is unclear scientific evidence for the use of milk thistle in treating cirrhosis. Milk thistle may elevate the serum glucose levels and is thus contraindicated in diabetes.
A - Milk thistle may affect liver enzymes and thus alter drug metabolism There is good scientific evidence that there is no real benefit from using milk thistle to protect the liver cells from toxic damage in the treatment of cirrhosis. Milk thistle does affect liver enzymes and thus could alter drug metabolism. Therefore patients will need to be monitored for drug interactions. It is noted to be safe for up to 6 years, not 10 years, and it may lower, not elevate, blood glucose levels.
During discharge teaching for a 65-year-old patient with chronic obstructive pulmonary disease (COPD) and pneumonia, which vaccine should the nurse recommend that this patient receive? Pneumococcal Staphylococcus aureus Haemophilus influenzae Bacille-Calmette-Guérin (BCG)
A - Pneumococcal The pneumococcal vaccine is important for patients with a history of heart or lung disease, recovering from a severe illness, age 65 or over, or living in a long-term care facility. A Staphylococcus aureus vaccine has been researched but not yet been effective. The Haemophilus influenzae vaccine would not be recommended as adults do not need it unless they are immunocompromised. The BCG vaccine is for infants in parts of the world where tuberculosis (TB) is prevalent.
The nurse is caring for a 56-year-old man receiving high-dose oral corticosteroid therapy to prevent organ rejection after a kidney transplant. What is most important for the nurse to observe related to this medication? Signs of infection Low blood pressure Increased urine output Decreased blood glucose
A - Signs of infection Side effects of corticosteroid therapy include increased susceptibility to infection, edema related to sodium and water retention (decreased urine output), hypertension, and hyperglycemia. Other side effects are listed in Table 50-19.
A 73-year-old female patient who lives alone is admitted to the hospital with a diagnosis of pneumococcal pneumonia. Which clinical manifestation, if observed by the nurse, indicates that the patient is likely to be hypoxic? Sudden onset of confusion Oral temperature of 102.3o F Coarse crackles in lung bases Clutching chest on inspiration
A - Sudden onset of confusion Confusion or stupor (related to hypoxia) may be the only clinical manifestation of pneumonia in an older adult patient. An elevated temperature, coarse crackles, and pleuritic chest pain with guarding may occur with pneumonia, but these symptoms do not indicate hypoxia.
A patient has sought care because of a loss of 25 lb over the past 6 months, during which the patient claims to have made no significant dietary changes. What potential problem should the nurse assess the patient for? Thyroid disorders Diabetes insipidus Pituitary dysfunction Parathyroid dysfunction
A - Thyroid disorders Hyperthyroidism is associated with weight loss. Alterations in pituitary function, such as diabetes insipidus, and parathyroid dysfunction are not commonly associated with this phenomenon
Assessment findings suggestive of peritonitis include a.rebound abdominal pain. b.a soft, distended abdomen. c.dull, continuous abdominal pain. d.observing that the patient is restless.
A - rebound pain Abdomen is not soft with peritonitis (board-like rigidity hallmark) Severe pain w/ movement, so patient lies still
The nurse determines that the goals of dietary teaching have been met when the patient with celiac disease selects from the menu a.scrambled eggs and sausage. b.buckwheat pancakes with syrup. c.oatmeal, skim milk, and orange juice. d.yogurt, strawberries, and rye toast with butter.
A - scrambled eggs and sausage Celiac disease is treated by avoiding gluten Wheat, barley, oars, and rye should be avoided Oats do not contain gluten, but are often contaminated during processing/milling Gluten is also found in many medications, food additive, preservatives, and stabilizers
The nurse explains to the patient undergoing ostomy surgery that the procedure that maintains the most normal functioning of the bowel is a.a sigmoid colostomy. b.a transverse colostomy. c.a descending colostomy. d.an ascending colostomy.
A - sigmoid colostomy The more distal the ostomy, the more the intestinal function is normalized - contents expelled resemble feces Some patients can regulate sigmoid colostomy, so collection bag is not needed
The nurse performs a detailed assessment of the abdomen of a patient with a possible bowel obstruction, knowing that manifestations of an obstruction in the large intestine are (select all that apply) a.persistent abdominal pain. b.marked abdominal distention. c.diarrhea that is loose or liquid. d.colicky, severe, intermittent pain. e.profuse vomiting that relieves abdominal pain.
A, B Persistent abdominal pain and marked distention With lower intestinal obstruction, onset is gradual, vomiting is rare and absolute constipation occurs, no diarrhea
The patient with cirrhosis has an increased abdominal girth from ascites. The nurse should know that this fluid gathers in the abdomen for which reasons (select all that apply)? There is decreased colloid oncotic pressure from the liver's inability to synthesize albumin. Hyperaldosteronism related to damaged hepatocytes increases sodium and fluid retention. Portal hypertension pushes proteins from the blood vessels, causing leaking into the peritoneal cavity. Osmoreceptors in the hypothalamus stimulate thirst, which causes the stimulation to take in fluids orally. Overactivity of the enlarged spleen results in increased removal of blood cells from the circulation, which decreases the vascular pressure.
A, B, C The ascites related to cirrhosis are caused by decreased colloid oncotic pressure from the lack of albumin from liver inability to synthesize it and the portal hypertension that shifts the protein from the blood vessels to the peritoneal cavity, and hyperaldosteronism which increases sodium and fluid retention. The intake of fluids orally and the removal of blood cells by the spleen do not directly contribute to ascites.
When caring for a patient with liver disease, the nurse recognizes the need to prevent bleeding resulting from altered clotting factors and rupture of varices. Which nursing interventions would be appropriate to achieve this outcome (select all that apply)? Use smallest gauge needle possible when giving injections or drawing blood. Teach patient to avoid straining at stool, vigorous blowing of nose, and coughing. Advise patient to use soft-bristle toothbrush and avoid ingestion of irritating food. Apply gentle pressure for the shortest possible time period after performing venipuncture. Instruct patient to avoid aspirin and NSAIDs to prevent hemorrhage when varices are present.
A, B, C, E Using the smallest gauge needle for injections will minimize the risk of bleeding into the tissues. Avoiding straining, nose blowing, and coughing will reduce the risk of hemorrhage at these sites. The use of a soft-bristle toothbrush and avoidance of irritating food will reduce injury to highly vascular mucous membranes. The nurse should apply gentle but prolonged pressure to venipuncture sites to minimize the risk of bleeding. Aspirin and NSAIDs should not be used in patients with liver disease because they interfere with platelet aggregation, thus increasing the risk for bleeding.
During admission of a patient diagnosed with non-small cell lung carcinoma, the nurse questions the patient related to a history of which risk factors for this type of cancer (select all that apply)? Asbestos exposure Exposure to uranium Chronic interstitial fibrosis History of cigarette smoking Geographic area in which he was born
A, B, D Non-small cell carcinoma is associated with cigarette smoking and exposure to environmental carcinogens, including asbestos and uranium. Chronic interstitial fibrosis is associated with the development of adenocarcinoma of the lung. Exposure to cancer-causing substances in the geographic area where the patient has lived for some time may be a risk, but not necessarily where the patient was born.
To promote airway clearance in a patient with pneumonia, what should the nurse instruct the patient to do (select all that apply)? Maintain adequate fluid intake. Splint the chest when coughing. Maintain a 30-degree elevation. Maintain a semi-Fowler's position. Instruct patient to cough at end of exhalation.
A, B, E Maintaining adequate fluid intake liquefies secretions, allowing easier expectoration. The nurse should instruct the patient to splint the chest while coughing. This will reduce discomfort and allow for a more effective cough. Coughing at the end of exhalation promotes a more effective cough. The patient should be positioned in an upright sitting position (high Fowler's) with head slightly flexed.
When admitting a 45-year-old female with a diagnosis of pulmonary embolism, the nurse will assess the patient for which risk factors (select all that apply)? Obesity Pneumonia Malignancy Cigarette smoking Prolonged air travel
A, C, D, E An increased risk of pulmonary embolism is associated with obesity, malignancy, heavy cigarette smoking, and prolonged air travel with reduced mobility. Other risk factors include deep vein thrombosis, immobilization, surgery within the last 3 months, oral contraceptives and hormone therapy, heart failure, pregnancy, and clotting disorders.
The nurse identifies that which patient is at highest risk for developing colon cancer? a.A 28-year-old male who has a body mass index of 27 kg/m2 b.A 32-year-old female with a 12-year history of ulcerative colitis c.A 52-year-old male who has followed a vegetarian diet for 24 years d.A 58-year-old female taking prescribed estrogen replacement therapy
B - A 32-year-old female with a 12 year history of ulcerative colitis Risk includes history of inflammatory bowel disease (especially UC >10 years); obesity (BMI ≥ 30); family or personal history of colorectal cancer, adenomatous polyposis, hereditary nonpolyposis colorectal cancer syndrome; red meat; cigarette use; and alcohol.
The nurse is caring for a 40-year-old man who has begun taking levothyroxine (Synthroid) for recently diagnosed hypothyroidism. What information reported by the patient is most important for the nurse to further assess? Weight gain or weight loss Chest pain and palpitations Muscle weakness and fatigue Decreased appetite and constipation
B - Chest pain and palpitations Levothyroxine (Synthroid) is used to treat hypothyroidism. Any chest pain or heart palpitations or heart rate greater than 100 beats/minute experienced by a patient starting thyroid replacement should be reported immediately, and an electrocardiogram (ECG) and serum cardiac enzyme tests should be performed.
The patient with right upper quadrant abdominal pain has an abdominal ultrasound that reveals cholelithiasis. What should the nurse expect to do for this patient? Prevent all oral intake. Control abdominal pain. Provide enteral feedings. Avoid dietary cholesterol.
B - Control abdominal pain Patients with cholelithiasis can have severe pain, so controlling pain is important until the problem can be treated. NPO status may be needed if the patient will have surgery but will not be used for all patients with cholelithiasis. Enteral feedings should not be needed, and avoiding dietary cholesterol is not used to treat cholelithiasis.
The patient is brought to the ED following a car accident and is wearing medical identification that says she has Addison's disease. What should the nurse expect to be included in the collaborative care of this patient? Low sodium diet Increased glucocorticoid replacement Suppression of pituitary ACTH synthesis Elimination of mineralocorticoid replacement
B - Increased glucocorticoid replacement The patient with Addison's disease needs lifelong glucocorticoid and mineralocorticoid replacement and has an increased need with illness, injury, or stress, as this patient is experiencing. The patient with Addison's may also need a high sodium diet. Suppression of pituitary ACTH synthesis is done for Cushing syndrome. Elimination of mineralocorticoid replacement cannot be done for Addison's disease.
The patient with sudden pain in the left upper quadrant radiating to the back and vomiting was diagnosed with acute pancreatitis. What intervention(s) should the nurse expect to include in the patient's plan of care? Immediately start enteral feeding to prevent malnutrition. Insert an NG and maintain NPO status to allow pancreas to rest. Initiate early prophylactic antibiotic therapy to prevent infection. Administer acetaminophen (Tylenol) every 4 hours for pain relief.
B - Insert an NG and maintain NPO status to allow pancreas to rest Initial treatment with acute pancreatitis will include an NG tube if there is vomiting and being NPO to decrease pancreatic enzyme stimulation and allow the pancreas to rest and heal. Fluid will be administered to treat or prevent shock. The pain will be treated with IV morphine because of the NPO status. Enteral feedings will only be used for the patient with severe acute pancreatitis in whom oral intake is not resumed. Antibiotic therapy is only needed with acute necrotizing pancreatitis and signs of infection.
The nurse is caring for a 55-year-old man patient with acute pancreatitis resulting from gallstones. Which clinical manifestation would the nurse expect the patient to exhibit? Hematochezia Left upper abdominal pain Ascites and peripheral edema Temperature over 102o F (38.9o C)
B - Left upper abdominal pain Abdominal pain (usually in the left upper quadrant) is the predominant manifestation of acute pancreatitis. Other manifestations of acute pancreatitis include nausea and vomiting, low-grade fever, leukocytosis, hypotension, tachycardia, and jaundice. Abdominal tenderness with muscle guarding is common. Bowel sounds may be decreased or absent. Ileus may occur and causes marked abdominal distention. Areas of cyanosis or greenish to yellow-brown discoloration of the abdominal wall may occur. Other areas of ecchymoses are the flanks (Grey Turner's spots or sign, a bluish flank discoloration) and the periumbilical area (Cullen's sign, a bluish periumbilical discoloration).
When planning appropriate nursing interventions for a patient with metastatic lung cancer and a 60-pack-per-year history of cigarette smoking, the nurse recognizes that the smoking has most likely decreased the patient's underlying respiratory defenses because of impairment of cough reflex. mucociliary clearance. reflex bronchoconstriction. ability to filter particles from the air.
B - Mucociliary clearance Smoking decreases the ciliary action in the tracheobronchial tree, resulting in impaired clearance of respiratory secretions and particles, chronic cough, and frequent respiratory infections.
Which assessment parameter is of highest priority when caring for a patient undergoing a water deprivation test? Serum glucose Patient weight Arterial blood gases Patient temperature
B - Patient weight A patient is at risk for severe dehydration during a water deprivation test. The test should be discontinued and the patient rehydrated if the patient's weight drops more than 2 kg at any time. The other assessment parameters do not assess fluid balance.
When caring for the patient with a traumatic brain injury (TBI), the nurse knows that damage to which endocrine gland can affect the hormone secretion from some of the other endocrine glands? Pineal Pituitary Parathyroid Thyroid
B - Pituitary With a TBI, the anterior pituitary is likely to be damaged. The anterior pituitary gland secrets tropic hormones that control the secretion of hormones by other endocrine glands (the thyroid, adrenal cortex, and reproductive organs). The parathyroids secrete parathyroid hormone that regulates serum calcium level by acting on bone, the kidneys, and indirectly the gastrointestinal tract. The pineal gland secretes melatonin that helps regulate circadian rhythm and reproduction. The thyroid glands secrete thyroxine (T4), triiodothyronine (T3) that regulates the cell processes of cell growth and tissue differentiation, and calcitonin that affects bone tissue to regulate serum calcium and phosphorus levels.
The nurse interviews a 50-year-old man with a history of type 2 diabetes mellitus, chronic bronchitis, and osteoarthritis who has a fasting blood glucose of 154 mg/dL. Which medications, if taken by the patient, may raise blood glucose levels? Glargine (Lantus) Prednisone (Deltasone) Metformin (Glucophage) Acetaminophen (Tylenol)
B - Prednisone (Deltasone) Prednisone is a corticosteroid that may cause glucose intolerance in susceptible patients by increasing gluconeogenesis and insulin resistance. Insulin (e.g., glargine) and metformin (an oral hypoglycemic agent) decrease blood glucose levels. Acetaminophen has a glucose-lowering effect.
After admitting a patient from home to the medical unit with a diagnosis of pneumonia, which physician orders will the nurse verify have been completed before administering a dose of cefuroxime (Ceftin) to the patient? Orthostatic blood pressures Sputum culture and sensitivity Pulmonary function evaluation Serum laboratory studies ordered for AM
B - Sputum culture and sensitivity The nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory before administering the cefuroxime as this is community-acquired pneumonia. It is important that the organisms are correctly identified (by the culture) before the antibiotic takes effect. The test will also determine whether the proper antibiotic has been ordered (sensitivity testing). Although antibiotic administration should not be unduly delayed while waiting for the patient to expectorate sputum, orthostatic BP, pulmonary function evaluation, and serum laboratory tests will not be affected by the administration of antibiotics.
The nurse is caring for a group of older patients in a long-term care setting. Which physical changes in the patients should the nurse investigate as signs of possible endocrine dysfunction? Absent reflexes, diarrhea, and hearing loss Hypoglycemia, delirium, and incontinence Fatigue, constipation, and mental impairment Hypotension, heat intolerance, and bradycardia
C - Fatigue, constipation, and mental impairment Changes of aging often mimic clinical manifestations of endocrine disorders. Clinical manifestations of endocrine dysfunction such as fatigue, constipation, or mental impairment in the older adult are often missed because they are attributed solely to aging.
The nurse receives a phone call from a 36-year-old woman taking cyclophosphamide (Cytoxan) for treatment of non-Hodgkin's lymphoma. The patient tells the nurse that she has muscle cramps and weakness and very little urine output. Which response by the nurse is best? "Start taking supplemental potassium, calcium, and magnesium." "Stop taking the medication now and call your health care provider." "These symptoms will decrease with continued use of the medication." "Increase fluids to 3000 mL per 24 hours to improve your urine output."
B - Stop taking the medication now and call your health care provider Cyclophosphamide may cause syndrome of inappropriate antidiuretic hormone (SIADH). Medications that stimulate the release of ADH should be avoided or discontinued. Treatment may include restriction of fluids to 800 to 1000 mL per day. If a loop diuretic such as furosemide (Lasix) is used to promote diuresis, supplements of potassium, calcium, and magnesium may be needed.
The nurse instructs a 38-year-old female patient with a pulmonary embolism about administering enoxaparin (Lovenox) after discharge. Which statement by the patient indicates understanding about the instructions? "I need to take this medicine with meals." "The medicine will be prescribed for 10 days." "I will inject this medicine into my upper arm." "The medicine will dissolve the clot in my lung."
B - The medicine will be prescribed for 10 days Enoxaparin is a low-molecular-weight heparin that is administered for 10 to 14 days and prevents future clotting but does not dissolve existing clots. Fibrinolytic agents (e.g., tissue plasminogen activator or alteplase) dissolve an existing clot. Enoxaparin is administered subcutaneously by injection into the abdomen.
The nurse is providing discharge instructions to a patient with diabetes insipidus. Which instructions regarding desmopressin acetate (DDAVP) would be most appropriate? The patient can expect to experience weight loss resulting from increased diuresis. The patient should alternate nostrils during administration to prevent nasal irritation. The patient should monitor for symptoms of hypernatremia as a side effect of this drug. The patient should report any decrease in urinary elimination to the health care provider.
B - The patient should alternate nostrils during administration to prevent nasal irritation DDAVP is used to treat diabetes insipidus by replacing the antidiuretic hormone that the patient is lacking. Inhaled DDAVP can cause nasal irritation, headache, nausea, and other signs of hyponatremia. Diuresis will be decreased and is expected, and hypernatremia should not occur.
In contrast to diverticulitis, the patient with diverticulosis a.has rectal bleeding. b.often has no symptoms. c.has localized cramping pain. d.frequently develops peritonitis.
B - often has no symptoms Diverticulitis is inflammation, can lead to obstruction or perforation Diverticulosis is presence of outpouchings, w/o inflammation
The patient with systemic lupus erythematosus had been diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). What should the nurse expect to include in this patient's plan of care (select all that apply)? Obtain weekly weights. Limit fluids to 1000 mL per day. Monitor for signs of hypernatremia. Minimize turning and range of motion. Keep the head of the bed at 10 degrees or less elevation.
B, E The care for the patient with SIADH will include limiting fluids to 1000 mL per day or less to decrease weight, increase osmolality, and improve symptoms; and keeping the head of the bed elevated at 10 degrees or less to enhance venous return to the heart and increase left atrial filling pressure, thereby reducing the release of ADH. The weights should be done daily along with intake and output. Signs of hyponatremia should be monitored, and frequent turning, positioning, and range-of-motion exercises are important to maintain skin integrity and joint mobility.
A 20-year-old man is admitted to the emergency department after a motor vehicle crash with suspected abdominal trauma. What assessment finding by the nurse is of highest priority? a.Nausea and vomiting b.Hyperactive bowel sounds c.Firmly distended abdomen d.Abrasions on all extremities
C - Firmly distended abdomen Clinical manifestations of abdominal trauma are guarding and splinting of the abdominal wall; a hard, distended abdomen (intraabdominal bleeding); decreased bowel sounds; contusions over the abdomen; abdominal pain; pain over the scapula; hematemesis or hematuria; and signs of hypovolemic shock.
The condition of a patient who has cirrhosis of the liver has deteriorated. Which diagnostic study would help determine if the patient has developed liver cancer? Serum α-fetoprotein level Ventilation/perfusion scan Hepatic structure ultrasound Abdominal girth measurement
C - Hepatic structure ultrasound Hepatic structure ultrasound, CT, and MRI are used to screen and diagnose liver cancer. Serum α-fetoprotein level may be elevated with liver cancer or other liver problems. Ventilation/perfusion scans do not diagnose liver cancer. Abdominal girth measurement would not differentiate between cirrhosis and liver cancer.
Which patient is at highest risk of aspiration? A 58-year-old patient with absent bowel sounds 12 hours after abdominal surgery A 67-year-old patient who had a cerebrovascular accident with expressive dysphasia A 26-year-old patient with continuous enteral tube feedings through a nasogastric tube A 52-year-old patient with viral pneumonia and coarse crackles throughout the lung fields
C - A 26-year-old patient with continuous enteral tube feedings through a nasogastric tube Conditions that increase the risk of aspiration include decreased level of consciousness, difficulty swallowing (dysphagia), and nasogastric intubation with or without tube feeding. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Dysphasia is difficulty with speech. Absent bowel sounds and coarse crackles do not increase the risk for aspiration.
The nurse is caring for a group of patients. Which patient is at highest risk for pancreatic cancer? A 38-year-old Hispanic female who is obese and has hyperinsulinemia A 23-year-old who has cystic fibrosis-related pancreatic enzyme insufficiency A 72-year-old African American male who has smoked cigarettes for 50 years A 19-year-old who has a 5-year history of uncontrolled type 1 diabetes mellitus
C - A 72-year-old African American male who has smoked cigarettes for 50 years Risk factors for pancreatic cancer include chronic pancreatitis, diabetes mellitus, age, cigarette smoking, family history of pancreatic cancer, high-fat diet, and exposure to chemicals such as benzidine. African Americans have a higher incidence of pancreatic cancer than whites. The most firmly established environmental risk factor is cigarette smoking. Smokers are two or three times more likely to develop pancreatic cancer as compared with nonsmokers. The risk is related to duration and number of cigarettes smoked.
A 58-year-old woman is being discharged home today after ostomy surgery for colon cancer. The nurse should assign the patient to which staff member? a.A nursing assistant on the unit who also has hospice experience b.A licensed practical nurse who has worked on the unit for 10 years c.A registered nurse with 6 months of experience on the surgical unit d.A registered nurse who has floated to the surgical unit from pediatrics
C - A registered nurse with 6 months of experience on the surgical unit The patient needs ostomy care directions at discharge and should be assigned to a registered nurse with experience in providing discharge teaching for ostomy care. Teaching should not be delegated to a licensed practical/vocational nurse or unlicensed assistive personnel.
A patient with cholelithiasis needs to have the gallbladder removed. Which patient assessment is a contraindication for a cholecystectomy? Low-grade fever of 100° F and dehydration Abscess in the right upper quadrant of the abdomen Activated partial thromboplastin time (aPTT) of 54 seconds Multiple obstructions in the cystic and common bile duct
C - Activated partial thromboplastin time of 54 seconds An aPTT of 54 seconds is above normal and indicates insufficient clotting ability. If the patient had surgery, significant bleeding complications postoperatively are very likely. Fluids can be given to eliminate the dehydration; the abscess can be assessed, and the obstructions in the cystic and common bile duct would be relieved with the cholecystectomy.
One week after a thoracotomy, a patient with chest tubes (CTs) to water-seal drainage has an air leak into the closed chest drainage system (CDS). Which patient assessment warrants follow-up nursing interventions? Water-seal chamber has 5 cm of water. No new drainage in collection chamber Chest tube with a loose-fitting dressing Small pneumothorax at CT insertion site
C - Chest tube with a loose-fitting dressing If the dressing at the CT insertion site is loose, an air leak will occur and will need to be sealed. The water-seal chamber usually has 2 cm of water, but having more water will not contribute to an air leak, and it should not be drained from the CDS. No new drainage does not indicate an air leak but may indicate the CT is no longer needed. If there is a pneumothorax, the chest tube should remove the air.
In planning care for the patient with Crohn's disease, the nurse recognizes that a major difference between ulcerative colitis and Crohn's disease is that Crohn's disease a.frequently results in toxic megacolon. b.causes fewer nutritional deficiencies than ulcerative colitis. c.often recurs after surgery, whereas ulcerative colitis is curable with a colectomy. d.is manifested by rectal bleeding and anemia more frequently than is ulcerative colitis.
C - Crohn's disease often recurs after surgery, whereas UC is curable w/ colectomy UC only affects rectum and colon, can cause bleeding, but no nutrient malabsorption (doesn't affect SI/LI) Crohn's disease involves ileum, where bile salts and vitamins are absorbed.
The nurse provides discharge instructions for a 64-year-old woman with ascites and peripheral edema related to cirrhosis. Which statement, if made by the patient, indicates teaching was effective? "It is safe to take acetaminophen up to four times a day for pain." "Lactulose (Cephulac) should be taken every day to prevent constipation." "Herbs and other spices should be used to season my foods instead of salt." "I will eat foods high in potassium while taking spironolactone (Aldactone)."
C - Herbs and other spices should be used to season my foods instead of salt A low-sodium diet is indicated for the patient with ascites and edema related to cirrhosis. Table salt is a well-known source of sodium and should be avoided. Alternatives to salt to season foods include the use of seasonings such as garlic, parsley, onion, lemon juice, and spices. Pain medications such as acetaminophen, aspirin, and ibuprofen should be avoided as these medications may be toxic to the liver. The patient should avoid potentially hepatotoxic over-the-counter drugs (e.g., acetaminophen) because the diseased liver is unable to metabolize these drugs. Spironolactone is a potassium-sparing diuretic. Lactulose results in the acidification of feces in bowel and trapping of ammonia, causing its elimination in feces.
The patient with HIV has been diagnosed with Candida albicans, an opportunistic infection. The nurse knows the patient needs more teaching when she says, "I will be given amphotericin B to treat the fungus." "I got this fungus because I am immunocompromised." "I need to be isolated from my family and friends so they won't get it." "The effectiveness of my therapy can be monitored with fungal serology titers."
C - I need to be isolated from my family and friends so they won't get it The patient with an opportunistic fungal infection does not need to be isolated because it is not transmitted from person to person. This immunocompromised patient will be likely to have a serious infection so it will be treated with IV amphotericin B. The effectiveness of the therapy can be monitored with fungal serology titers.
Which clinical manifestation should the nurse expect to find during assessment of a patient admitted with pneumonia? Hyperresonance on percussion Vesicular breath sounds in all lobes Increased vocal fremitus on palpation Fine crackles in all lobes on auscultation
C - Increased vocal fremitus on palpation A typical physical examination finding for a patient with pneumonia is increased vocal fremitus on palpation. Other signs of pulmonary consolidation include bronchial breath sounds, egophony, and crackles in the affected area. With pleural effusion, there may be dullness to percussion over the affected area.
The nurse is caring for a patient admitted with suspected hyperparathyroidism. Because of the potential effects of this disease on electrolyte balance, the nurse should assess this patient for what manifestation? Neurologic irritability Declining urine output Lethargy and weakness Hyperactive bowel sounds
C - Lethargy and weakness Hyperparathyroidism can cause hypercalcemia. Signs of hypercalcemia include muscle weakness, polyuria, constipation, nausea and vomiting, lethargy, and memory impairment. Neurologic irritability, declining urine output, and hyperactive bowel sounds do not occur with hypercalcemia.
The surgeon was unable to spare a patient's parathyroid gland during a thyroidectomy. Which assessments should the nurse prioritize when providing postoperative care for this patient? Assessing the patient's white blood cell levels and assessing for infection Monitoring the patient's hemoglobin, hematocrit, and red blood cell levels Monitoring the patient's serum calcium levels and assessing for signs of hypocalcemia Monitoring the patient's level of consciousness and assessing for acute delirium or agitation
C - Monitoring the patient's serum calcium levels and assessing for signs of hypocalcemia Loss of the parathyroid gland is associated with hypocalcemia. Infection and anemia are not associated with loss of the parathyroid gland, whereas cognitive changes are less pronounced than the signs and symptoms of hypocalcemia.
The nurse is caring for a 36-year-old woman with possible hypoparathyroidism after a thyroidectomy. It is most appropriate for the nurse to assess for which clinical manifestations? Polyuria, polydipsia, and weight loss Cardiac dysrhythmias and hypertension Muscle spasms and hyperactive deep tendon reflexes Hyperpigmentation, skin ulcers, and peripheral edema
C - Muscle spasms and hyperactive deep tendon reflexes Common assessment abnormalities associated with hypoparathyroidism include tetany (muscle spasms) and increased deep tendon reflexes. Hyperpigmentation is associated with Addison's disease. Skin ulcers occur in patient with diabetes. Edema is associated with hypothyroidism. Polyuria and polydipsia occur in patients with diabetes mellitus or diabetes insipidus. Weight loss occurs in hyperthyroidism or diabetic ketoacidosis. Hypertension and cardiac dysrhythmias may be caused by hyperthyroidism, hyperparathyroidism, or pheochromocytoma.
While ambulating a patient with metastatic lung cancer, the nurse observes a drop in oxygen saturation from 93% to 86%. Which nursing intervention is most appropriate based upon these findings? Continue with ambulation since this is a normal response to activity. Obtain a physician's order for arterial blood gas determinations to verify the oxygen saturation. Obtain a physician's order for supplemental oxygen to be used during ambulation and other activity. Move the oximetry probe from the finger to the earlobe for more accurate monitoring during activity.
C - Obtain a physician's order for supplemental oxygen to be used during ambulation and other activity An oxygen saturation level that drops below 90% with activity indicates that the patient is not tolerating the exercise and needs to use supplemental oxygen. The patient will need to rest to resaturate. ABGs or moving the probe will not be needed as the pulse oximeter was working at the beginning of the walk.
The nurse cares for a 50-year-old patient with pneumonia that has been unresponsive to two different antibiotics. Which task is most important for the nurse to complete before administering a newly prescribed antibiotic? Teach the patient to cough and deep breathe. Take the temperature, pulse, and respiratory rate. Obtain a sputum specimen for culture and Gram stain. Check the patient's oxygen saturation by pulse oximetry.
C - Obtain a sputum specimen for culture and Gram stain A sputum specimen for culture and Gram stain to identify the organism should be obtained before beginning antibiotic therapy. However, antibiotic administration should not be delayed if a specimen cannot be readily obtained because delays in antibiotic therapy can increase morbidity and mortality risks.
When the patient is diagnosed with a lung abscess, what should the nurse teach the patient? Lobectomy surgery is usually needed to drain the abscess. IV antibiotic therapy will be used for a prolonged period of time. Oral antibiotics will be used when the patient and x-ray shows evidence of improvement. No further culture and sensitivity tests are needed if the patient takes the medication as ordered.
C - Oral antibiotics will be used when the patient and x-ray shows evidence of improvement IV antibiotics are used until the patient and x-ray show evidence of improvement. Then oral antibiotics are used for a prolonged period of time. Culture and sensitivity testing is done during the course of antibiotic therapy to ensure that the infecting organism is not becoming resistant to the antibiotic as well as at the completion of the antibiotic therapy. Lobectomy surgery is only needed when reinfection of a large cavitary lesion occurs or to establish a diagnosis when there is evidence of a neoplasm or other underlying problem.
What is a nursing priority in the care of a patient with a diagnosis of hypothyroidism? Providing a dark, low-stimulation environment Closely monitoring the patient's intake and output Patient teaching related to levothyroxine (Synthroid) Patient teaching related to radioactive iodine therapy
C - Patient teaching related to levothyroxine (Synthroid) A euthyroid state is most often achieved in patients with hypothyroidism by the administration of levothyroxine (Synthroid). It is not necessary to carefully monitor intake and output, and low stimulation and radioactive iodine therapy are indicated in the treatment of hyperthyroidism.
What nursing intervention is most appropriate to enhance oxygenation in a patient with unilateral malignant lung disease? Positioning patient on right side Maintaining adequate fluid intake Positioning patient with "good lung" down Performing postural drainage every 4 hours
C - Positioning patient with good lung down Therapeutic positioning identifies the best position for the patient, thus assuring stable oxygenation status. Research indicates that positioning the patient with the unaffected lung (good lung) dependent best promotes oxygenation in patients with unilateral lung disease. For bilateral lung disease, the right lung down has best ventilation and perfusion. Increasing fluid intake and performing postural drainage will facilitate airway clearance, but positioning is most appropriate to enhance oxygenation.
A patient has been taking oral prednisone for the past several weeks after having a severe reaction to poison ivy. The nurse has explained the procedure for gradual reduction rather than sudden cessation of the drug. What is the rationale for this approach to drug administration? Prevention of hypothyroidism Prevention of diabetes insipidus Prevention of adrenal insufficiency Prevention of cardiovascular complications
C - Prevention of adrenal insufficiency Sudden cessation of corticosteroid therapy can precipitate life-threatening adrenal insufficiency. Diabetes insipidus, hypothyroidism, and cardiovascular complications are not common consequences of suddenly stopping corticosteroid therapy.
When planning care for a patient on a mechanical ventilator, the nurse understands that the application of positive end-expiratory pressure (PEEP) to the ventilator settings has which therapeutic effect? Increased inflation of the lungs Prevention of barotrauma to the lung tissue Prevention of alveolar collapse during expiration Increased fraction of inspired oxygen concentration (FIO2) administration
C - Prevention of alveolar collapse during expiration PEEP is positive pressure that is applied to the airway during exhalation. This positive pressure prevents the alveoli from collapsing, improving oxygenation and enabling a reduced FIO2 requirement. PEEP does not cause increased inflation of the lungs or prevent barotrauma. Actually auto-PEEP resulting from inadequate exhalation time may contribute to barotrauma.
The nurse instructs a 50-year-old woman about cholestyramine to reduce pruritis caused by gallbladder disease. Which statement by the patient to the nurse indicates she understands the instructions? "This medication will help me digest fats and fat-soluble vitamins." "I will apply the medicated lotion sparingly to the areas where I itch." "The medication is a powder and needs to be mixed with milk or juice." "I should take this medication on an empty stomach at the same time each day."
C - This medication is a powder and needs to be mixed with milk or juice For treatment of pruritus, cholestyramine may provide relief. This is a resin that binds bile salts in the intestine, increasing their excretion in the feces. Cholestyramine is in powder form and should be mixed with milk or juice before oral administration.
When instructing a patient regarding a urine study for free cortisol, what is most important for the nurse to tell the patient? Save the first voided urine in the morning. Maintain a high-sodium diet 3 days before collection. Try to avoid stressful situations during the collection period. Complete at least 30 minutes of exercise before collecting the urine sample.
C - Try to avoid stressful situations during the collection period A urine study for free cortisol requires a 24-hour urine collection. The patient should be instructed to avoid stressful situations and excessive physical exercise that could unduly increase cortisol levels. The patient should also maintain a low-sodium diet before and during the urine collection period.
A 54-year-old patient admitted with diabetes mellitus, malnutrition, osteomyelitis, and alcohol abuse has a serum amylase level of 280 U/L and a serum lipase level of 310 U/L. To what diagnosis does the nurse attribute these findings? Malnutrition Osteomyelitis Alcohol abuse Diabetes mellitus
C - alcohol abuse The patient with alcohol abuse could develop pancreatitis as a complication, which would increase the serum amylase (normal 30-122 U/L) and serum lipase (normal 31-186 U/L) levels as shown.
A patient with stage I colorectal cancer is scheduled for surgery. Patient teaching for this patient would include an explanation that a.chemotherapy will begin after the patient recovers from the surgery. b.both chemotherapy and radiation can be used as palliative treatments. c.follow-up colonoscopies will be needed to ensure that the cancer does not recur. d.a wound, ostomy, and continence nurse will visit the patient to identify an abdominal site for the ostomy.
C - follow-up colonoscopies will be needed to ensure that cancer does not recur Stage 1 colorectal cancer is treated surgically, no ostomy, no chemotherapy Colorectal cancer can recur
Which interventions should the nurse perform prior to suctioning a patient who has an endotracheal (ET) tube using open-suction technique (select all that apply)? Put on clean gloves. Administer a bronchodilator. Perform a cardiopulmonary assessment. Hyperoxygenate the patient for 30 seconds. Insert a few drops of normal saline into the ET to break up secretions.
C, D Suctioning is preceded by a thorough assessment and hyperoxygenation for 30 seconds. Sterile, not clean, gloves are necessary, and it is not necessary to administer a bronchodilator. Instillation of normal saline into the ET tube is not an accepted standard practice.
A patient who has hepatitis B surface antigen (HBsAg) in the serum is being discharged with pain medication after knee surgery. Which medication order should the nurse question because it is most likely to cause hepatic complications? Tramadol (Ultram) Hydromorphone (Dilaudid) Oxycodone with aspirin (Percodan) Hydrocodone with acetaminophen (Vicodin)
D - Hydrocodone with acetaminophen (Vicodin) The analgesic with acetaminophen should be questioned because this patient is a chronic carrier of hepatitis B and is likely to have impaired liver function. Acetaminophen is not suitable for this patient because it is converted to a toxic metabolite in the liver after absorption, increasing the risk of hepatocellular damage.
An 18-year-old male patient is undergoing a growth hormone stimulation test. The nurse should monitor the patient for hypothermia. hypertension. hyperreflexia. hypoglycemia.
D - Hypoglycemia Insulin or arginine (agent that stimulates insulin secretion) is administered for a growth hormone stimulation test. The nurse should monitor the patient closely for hypoglycemia. Hypothermia and hypertension are not expected in response to insulin or arginine. Hyperreflexia is an autonomic complication of spinal cord injury.
What should a patient be taught after a hemorrhoidectomy? a.Take mineral oil before bedtime. b.Eat a low-fiber diet to rest the colon. c.Administer oil-retention enema to empty the colon. d.Use prescribed pain medication before a bowel movement.
D - use prescribed pain medication before bowel movements Reduces discomfort Avoid straining - high-fiber diet is recommended, stool softeners If no BM for several days, use oil-retention enema
A patient with a severe pounding headache has been diagnosed with hypertension. However, the hypertension is not responding to traditional treatment. What should the nurse expect as the next step in management of this patient? Administration of β-blocker medications Abdominal palpation to search for a tumor Administration of potassium-sparing diuretics A 24-hour urine collection for fractionated metanephrines
D - A 24-hour urine collection for fractionated metanephrines Pheochromocytoma should be suspected when hypertension does not respond to traditional treatment. The 24-hour urine collection for fractionated metanephrines is simple and reliable with elevated values in 95% of people with pheochromocytoma. In a patient with pheochromocytoma preoperatively an α-adrenergic receptor blocker is used to reduce BP. Abdominal palpation is avoided to avoid a sudden release of catecholamines and severe hypertension. Potassium-sparing diuretics are not needed. Most likely they would be used for hyperaldosteronism, which is another cause of hypertension.
The family of a patient newly diagnosed with hepatitis A asks the nurse what they can do to prevent becoming ill themselves. Which response by the nurse is most appropriate? "The hepatitis vaccine will provide immunity from this exposure and future exposures." "I am afraid there is nothing you can do since the patient was infectious before admission." "You will need to be tested first to make sure you don't have the virus before we can treat you." "An injection of immunoglobulin will need to be given to prevent or minimize the effects from this exposure."
D - An injection of immunoglobulin will need to be given to prevent or minimize the effects from this exposure Immunoglobulin provides temporary (1-2 months) passive immunity and is effective for preventing hepatitis A if given within 2 weeks after exposure. It may not prevent infection in all persons, but it will at least modify the illness to a subclinical infection. The hepatitis vaccine is only used for preexposure prophylaxis.
The hypothalamus secretes releasing hormones and inhibiting hormones. What is the target tissue of these releasing hormones and inhibiting hormones? Pineal Adrenal cortex Posterior pituitary Anterior pituitary
D - Anterior pituitary The anterior pituitary is the target tissue of the releasing hormones (corticotropin releasing hormone, thyrotropin releasing hormone, growth hormone releasing factor, gonadotropin releasing hormone, prolactin releasing factor) and the inhibiting hormones (somatostatin, prolactin inhibiting factor). These hormones release or inhibit other hormones that affect the thyroid, adrenal cortex, pancreas, reproductive organs, and all body cells. The pineal gland is not directly affected by the releasing and inhibiting hormones from the hypothalamus. The posterior pituitary releases antidiuretic hormone (ADH) in response to plasma osmolality changes that is not directly affected by the hypothalamus hormones.
The nurse should monitor for increases in which laboratory value for the patient as a result of being treated with dexamethasone (Decadron)? Sodium Calcium Potassium Blood glucose
D - Blood glucose Hyperglycemia or increased blood glucose level is an adverse effect of corticosteroid therapy. Sodium, calcium, and potassium levels are not directly affected by dexamethasone
The patient who had idiopathic pulmonary fibrosis had a bilateral lung transplantation. Now he is experiencing airflow obstruction that is progressing over time. It started with a gradual onset of exertional dyspnea, nonproductive cough, and wheezing. What are these manifestations signs of in the lung transplant patient? Pulmonary infarction Pulmonary hypertension Cytomegalovirus (CMV) Bronchiolitis obliterans (BOS)
D - Bronchiolotis obliterans (BOS) Bronchiolitis obliterans (BOS) is a manifestation of chronic rejection and is characterized by airflow obstruction progressing over time with a gradual onset of exertional dyspnea, nonproductive cough, wheezing, and/or low-grade fever. Pulmonary infarction occurs with lack of blood flow to the bronchial tissue or preexisting lung disease. With pulmonary hypertension, the pulmonary pressures are elevated and can be idiopathic or secondarily due to parenchymal lung disease that causes anatomic or vascular changes leading to pulmonary hypertension. CMV pneumonia is the most common opportunistic infection 1 to 4 months after lung transplant.
The nurse is admitting a 68-year-old man with severe dehydration and frequent watery diarrhea. He just completed a 10-day outpatient course of antibiotic therapy for bacterial pneumonia. It is most important for the nurse to take which action? a.Wear a mask to prevent transmission of infection. b.Wipe equipment with ammonia-based disinfectant. c.Instruct visitors to use the alcohol-based hand sanitizer. d.Don gloves and gown before entering the patient's room.
D - Don gloves and gown before entering the patient's room C diff is an antibiotic-associated diarrhea transmitted by contact, and the spores are extremely difficult to kill. Patients should be placed in a private room and gloves and gowns should be worn. Alcohol-based hand cleaners and ammonia-based disinfectants are ineffective. Equipment cannot be shared with other patients, and a disposable stethoscope and individual patient thermometer are kept in the room. Objects should be disinfected with a 10% solution of household bleach.
The nurse evaluates that discharge teaching for a patient hospitalized with pneumonia has been effective when the patient makes which statement about measures to prevent a relapse? "I will seek immediate medical treatment for any upper respiratory infections." "I should continue to do deep-breathing and coughing exercises for at least 12 weeks." "I will increase my food intake to 2400 calories a day to keep my immune system well." "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution."
D - I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution The follow-up chest x-ray will be done in 6 to 8 weeks to evaluate pneumonia resolution. A patient should seek medical treatment for upper respiratory infections that persist for more than 7 days. It may be important for the patient to continue with coughing and deep breathing exercises for 6 to 8 weeks, not 12 weeks, until all of the infection has cleared from the lungs. Increased fluid intake, not caloric intake, is required to liquefy secretions.
When teaching the patient with acute hepatitis C (HCV), the patient demonstrates understanding when the patient makes which statement? "I will use care when kissing my wife to prevent giving it to her." "I will need to take adofevir (Hepsera) to prevent chronic HCV." "Now that I have had HCV, I will have immunity and not get it again." "I will need to be checked for chronic HCV and other liver problems."
D - I will need to be checked for chronic HCV and other liver problems The majority of patients who acquire HCV usually develop chronic infection, which may lead to cirrhosis or liver cancer. HCV is not transmitted via saliva, but percutaneously and via high-risk sexual activity exposure. The treatment for acute viral hepatitis focuses on resting the body and adequate nutrition for liver regeneration. Adofevir (Hepsera) is taken for severe hepatitis B (HBV) with liver failure. Chronic HCV is treated with pegylated interferon with ribavirin. Immunity with HCV does not occur as it does with HAV and HBV, so the patient may be reinfected with another type of HCV.
What is the priority nursing intervention in helping a patient expectorate thick lung secretions? Humidify the oxygen as able. Administer cough suppressant q4hr. Teach patient to splint the affected area. Increase fluid intake to 3 L/day if tolerated.
D - Increase fluid intake to 3 L/day if tolerated Although several interventions may help the patient expectorate mucus, the highest priority should be on increasing fluid intake, which will liquefy the secretions so that the patient can expectorate them more easily. Humidifying the oxygen is also helpful but is not the primary intervention. Teaching the patient to splint the affected area may also be helpful in decreasing discomfort but does not assist in expectoration of thick secretions.
When planning care for a patient with cirrhosis, the nurse will give highest priority to which nursing diagnosis? Impaired skin integrity related to edema, ascites, and pruritus Imbalanced nutrition: less than body requirements related to anorexia Excess fluid volume related to portal hypertension and hyperaldosteronism Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume
D - Ineffective breathing pattern related to presure on the diaphragm and reduced lung volume Although all of these nursing diagnoses are appropriate and important in the care of a patient with cirrhosis, airway and breathing are always the highest priorities.
The patient had video-assisted thoracic surgery (VATS) to perform a lobectomy. What does the nurse know is the reason for using this type of surgery? The patient has lung cancer. The incision will be medial sternal or lateral. Chest tubes will not be needed postoperatively. Less discomfort and faster return to normal activity
D - Less discomfort and faster return to normal activity The VATS procedure uses minimally invasive incisions that cause less discomfort and allow faster healing and return to normal activity as well as lower morbidity risk and fewer complications. Many surgeries can be done for lung cancer, but pneumonectomy via thoracotomy is the most common surgery for lung cancer. The incision for a thoracotomy is commonly a medial sternotomy or a lateral approach. A chest tube will be needed postoperatively for VATS.
After an abdominal hysterectomy, a 45-year-old woman complains of severe gas pains. Her abdomen is distended. It is most appropriate for the nurse to administer which prescribed medication? a.Morphine sulfate b.Ondansetron (Zofran) c.Acetaminophen (Tylenol) d.Metoclopramide (Reglan)
D - Metoclopramide (Reglan) Swallowed air and reduced peristalsis after surgery can result in abdominal distention and gas pains. Early ambulation helps restore peristalsis and eliminate flatus and gas pain. Medications used to reduce gas pain include metoclopramide (Reglan) or alvimopan (Entereg) to stimulate peristalsis.
The nurse is caring for a patient who has been on a mechanical ventilator for several days. Which weaning parameter would tell the nurse whether or not the patient has enough muscle strength to breathe without assistance? Tidal volume Minute ventilation Forced vital capacity Negative inspiratory force
D - Negative inspiratory force The negative inspiratory force (NIF) measures inspiratory muscle strength. Tidal volume and minute ventilation assess the patient's respiratory endurance. Forced vital capacity is not used as a measure to determine weaning from a ventilator.
A 71-year-old patient is admitted with acute respiratory distress related to cor pulmonale. Which nursing intervention is most appropriate during admission of this patient? Perform a comprehensive health history with the patient to review prior respiratory problems. Complete a full physical examination to determine the effect of the respiratory distress on other body functions. Delay any physical assessment of the patient and review with the family the patient's history of respiratory problems. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress.
D - Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress Because the patient is having respiratory difficulty, the nurse should ask specific questions about this episode and perform a physical assessment of this system. Further history taking and physical examination of other body systems can proceed once the patient's acute respiratory distress is being managed.
The patient with an adrenal hyperplasia is returning from surgery for an adrenalectomy. For what immediate postoperative risk should the nurse plan to monitor the patient? Vomiting Infection Thomboembolism Rapid BP changes
D - Rapid BP Changes The risk of hemorrhage is increased with surgery on the adrenal glands as well as large amounts of hormones being released in the circulation, which may produce hypertension and cause fluid and electrolyte imbalances to occur for the first 24 to 48 hours after surgery. Vomiting, infection, and thromboembolism may occur postoperatively with any surgery.
A patient's daughter asks the nurse what SIMV means on the settings of the mechanical ventilator attached to her father. Which statement best describes this mode of ventilation? "SIMV provides additional inspiratory pressure so that your father does not have to work as hard to breathe, thus enabling better oxygenation and a quicker recovery with fewer complications." "SIMV is a mode that allows the ventilator to totally control your father's breathing. It will prevent him from hyperventilating or hypoventilating, thus ensuring the best oxygenation." "SIMV is a mode that allows your father to breathe on his own, but the ventilator will control how deep a breath he will receive. The ventilator can sense when he wants a breath, and it will deliver it." "SIMV is a mode that allows your father to breathe on his own while receiving a preset number of breaths from the ventilator. He can breathe as much or as little as he wants beyond what the ventilator will breathe for him."
D - SIMV is a mode that allows your father to breathe on his own while receiving a preset number of breaths from the ventilator. He can breathe as much or as little as he wants beyond what the ventilator will breathe for him. SIMV stands for synchronized intermittent mandatory ventilation, a mode of ventilation in which the ventilator delivers a preset tidal volume at a preset frequency in synchrony with the patient's spontaneous breathing. Between ventilator-delivered breaths the patient is able to breathe spontaneously, receiving the preset FIO2 but self-regulates the rate and depth of those breaths. Pressure support ventilation (PSV) applies positive pressure only during inspiration. PSV is not used as a sole ventilator support during acute respiratory failure because of the risk of hypoventilation, but it does decrease the work of breathing. Pressure-control inverse ratio ventilation (PC-IRV) sets the ventilation pressure and the ratio of inspiration to expiration to control the patient's breathing. Assist-control ventilation (ACV) or assisted mandatory ventilation (AMV) delivers a preset rate of breaths but allows the patient to breathe spontaneously, with a preset tidal volume.
The nurse is caring for a 73-year-old patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient complains of shortness of breath, slight chest pain, and that "something is wrong." Temperature is 98.4° F, blood pressure 130/88, respirations 36/minute, and oxygen saturation 91% on room air. What action should the nurse take first? Notify the physician. Administer a nitroglycerin tablet sublingually. Conduct a thorough assessment of the chest pain. Sit the patient up in bed as tolerated and apply oxygen.
D - Sit the patient up in bed as tolerated and apply oxygen The patient's clinical picture is most likely pulmonary embolus, and the first action the nurse takes should be to assist with the patient's respirations. For this reason, the nurse should sit the patient up as tolerated and apply oxygen before notifying the physician. The nitroglycerin tablet would not be helpful, and the oxygenation status is a bigger problem than the slight chest pain at this time.
A 50-year-old female patient smokes, is getting a divorce, and is reporting eye problems. On assessment of this patient, the nurse notes exophthalmos. What other abnormal assessments should the nurse expect to find in this patient? Puffy face, decreased sweating, and dry hair Muscle aches and pains and slow movements Decreased appetite, increased thirst, and pallor Systolic hypertension and increased heart rate
D - Systolic hypertension and increased heart rate The patient's manifestations point to Graves' disease or hyperthyroidism, which would also include systolic hypertension and increased heart rate and increased thirst. Puffy face, decreased sweating; dry, coarse hair; muscle aches and pains and slow movements; decreased appetite and pallor are all manifestations of hypothyroidism.
The patient with a history of lung cancer and hepatitis C has developed liver failure and is considering liver transplantation. After the comprehensive evaluation, the nurse knows that which factor discovered may be a contraindication for liver transplantation? Has completed a college education Has been able to stop smoking cigarettes Has well-controlled type 1 diabetes mellitus The chest x-ray showed another lung cancer lesion.
D - The chest x-ray showed another lung cancer lesion Contraindications for liver transplant include severe extrahepatic disease, advanced hepatocellular carcinoma or other cancer, ongoing drug and/or alcohol abuse, and the inability to comprehend or comply with the rigorous post-transplant course.
Which hematologic problem most significantly increases the risks associated with pulmonary artery (PA) catheter insertion? Leukocytosis Hypovolemia Hemolytic anemia Thrombocytopenia
D - Thrombocytopenia PA catheter insertion carries a significant risk of bleeding, a fact that is exacerbated when the patient has low levels of platelets. Leukocytosis, hypovolemia, and anemia are less likely to directly increase the risks associated with PA insertion.
A patient's recent medical history is indicative of diabetes insipidus. The nurse would perform patient teaching related to which diagnostic test? Thyroid scan Fasting glucose test Oral glucose tolerance Water deprivation test
D - Water deprivation test A water deprivation test is used to diagnose the polyuria that accompanies diabetes insipidus. Glucose tests and thyroid tests are not directly related to the diagnosis of diabetes insipidus.
A nursing intervention that is most appropriate to decrease postoperative edema and pain after an inguinal herniorrhaphy is a.applying a truss to the hernia site. b.allowing the patient to stand to void. c.supporting the incision during coughing. d.applying a scrotal support with ice bag.
D - applying a scrotal support with ice bag Scrotal edema is a painful complication of inguinal hernia repair Scrotal support w/ ice can relieve pain and edema
The patient with suspected pancreatic cancer is having many diagnostic studies done. Which one can be used to establish the diagnosis of pancreatic adenocarcinoma and for monitoring the response to treatment? Spiral CT scan A PET/CT scan Abdominal ultrasound Cancer-associated antigen 19-9
D - cancer-associated antigen 19-9 The cancer-associated antigen 19-9 (CA 19-9) is the tumor marker used for the diagnosis of pancreatic adenocarcinoma and for monitoring the response to treatment. Although a spiral CT scan may be the initial study done and provides information on metastasis and vascular involvement, this test and the PET/CT scan or abdominal ultrasound do not provide additional information.
The health care provider orders lactulose for a patient with hepatic encephalopathy. The nurse will monitor for effectiveness of this medication for this patient by assessing what? Relief of constipation Relief of abdominal pain Decreased liver enzymes Decreased ammonia levels
D - decreased ammonia levels Hepatic encephalopathy is a complication of liver disease and is associated with elevated serum ammonia levels. Lactulose traps ammonia in the intestinal tract. Its laxative effect then expels the ammonia from the colon, resulting in decreased serum ammonia levels and correction of hepatic encephalopathy.
