VSIM
Which patients have an increased risk for developing colorectal cancer? (Select all that apply.) 1.A 30 y.o. with a 13- year history of Crohn's disease 2.A 50 y.o. whose diet includes red meat daily 3.A 63 y.o. who is healthy 4.A 70 y.o. who has been diagnosed as obese 5.A 40 y.o. with a history of lupus
1.A 30 y.o. with a 13- year history of Crohn's disease 2.A 50 y.o. whose diet includes red meat daily 3.A 63 y.o. who is healthy 4.A 70 y.o. who has been diagnosed as obese
Which intervention takes priority when the nurse determines that a postoperative patient has hypoactive bowel sounds? 1.Assess the abdomen for signs of distention 2.Notify the surgeon of this assessment finding 3.Advance the patient's diet to soft, solid food 4.Assess the patient for indications of hypotension
1.Assess the abdomen for signs of distention
The nurse is preparing discharge education for a patient with a permanent colostomy. What information concerning diet and nutrition will the nurse include? (Select all that apply). 1.Avoid foods that previously caused diarrhea 2.Gradually add new foods into the diet 3.Drink at least two quarts of water daily 4.Avoid high fiber foods for eight weeks after the surgery 5.Be aware that colostomies are prone to develop food blockages
1.Avoid foods that previously caused diarrhea 2.Gradually add new foods into the diet 3.Drink at least two quarts of water daily 4.Avoid high fiber foods for eight weeks after the surgery
The nurse is preparing to insert an intermittent urinary catheter in a paralyzed female patient. What would be the appropriate action by the nurse? 1.Call for a co-worker to help hold the patient's legs in position 2.Instruct the patient to turn over on her side 3.Notify the provider that the procedure could not be completed because the patient is paralyzed 4.Ask a family member to assist you with the catheterization
1.Call for a co-worker to help hold the patient's legs in position
After completing an intermittent catheterization, what information concerning the procedure will the nurse include in Ms. Johnson's medical record? (Select all that apply.) 1.Characteristics of the urine obtained 2.Time procedure was performed 3.Size of catheter used 4.Description of the cleansing process preceding the procedure 5.Description of the patient's tolerance for the procedure
1.Characteristics of the urine obtained 2.Time procedure was performed 3.Size of catheter used 5.Description of the patient's tolerance for the procedure
The nurse has received an order to collect a urine sample. Which characteristics would the nurse observe for when assessing the patient's specimen? (Select all that apply.) 1.Color 2.Odor 3.pH 4.Sediment 5.Clarity
1.Color 2.Odor 4.Sediment 5.Clarity
What information should the nurse include in the documentation associated with the changing of a patient's colostomy pouch? (Select all that apply.) 1.Condition of the skin around the stoma 2.How often the process will be done 3.Description of the stoma 4.Characteristics of the fecal matter 5.Patient's response to the process
1.Condition of the skin around the stoma 3.Description of the stoma 4.Characteristics of the fecal matter 5.Patient's response to the process
The nurse is caring for a patient who is unable to urinate voluntarily since a gunshot injury. Patient data associated with which intervention will provide information regarding the patient's kidney function? 1.Daily serum creatinine levels 2.Results of precatheterization bladder scans 3.Number of times the patient requests oxybutynin over a 24-hour period 4.Urinary output over eight hours
1.Daily serum creatinine levels
The nurse is completing an admission assessment on a paitent afmitted for impaired skin integrity. Which questions would be appropriate for the nurse to ask the patient? (Select all that apply.) 1.Do some areas of your skin seem warmer or colder than others? 2.Do you have any sores on your body? 3.What kind of activities cause you to be fatigued? 4.Have you used pads or special pants because you can't control your urine? 5.Have you noticed any swelling on your feet, ankles, or fingers?
1.Do some areas of your skin seem warmer or colder than others? 2.Do you have any sores on your body? 4.Have you used pads or special pants because you can't control your urine? 5.Have you noticed any swelling on your feet, ankles, or fingers?
Which interventions will the nurse implement to help minimize a postoperative patient's risk for surgical site complications? (Select all that apply.) 1.Following strict aseptic techniques when changing surgical dressing 2.Monitoring for elevation in body temperature 3.Providing sufficient fluids to maintain hydration 4.Advancing diet as appropriate to provide adequate nutrition 5.Encouraging deep, sustained breathing and supported coughing
1.Following strict aseptic techniques when changing surgical dressing 2.Monitoring for elevation in body temperature 3.Providing sufficient fluids to maintain hydration 4.Advancing diet as appropriate to provide adequate nutrition
Which statements will guide the nurse when preparing to educate a patient whose condition requires a permanent colostomy? (Select all that apply.) 1.Help the patient get accustomed to looking at the ostomy 2.Encourage the patient to take part in the care process 3.Assess the patient for signs of depression 4.If the patient is accepting, include family members in the teaching 5.Schedule the teaching two to three days after the surgery
1.Help the patient get accustomed to looking at the ostomy 2.Encourage the patient to take part in the care process 3.Assess the patient for signs of depression 4.If the patient is accepting, include family members in the teaching
The nurse is completing a focused assessment on a female patient admitted for altered urinary elimination. What questions would the nurse include when assessing the patient? (Select all that apply.) 1.How often do you urinate? 2.Is there anything that you do that helps you urinate? 3.Do you ever leak urine? 4.When was your last menstrual period? 5.Have you noticed any change in your usual voiding pattern?
1.How often do you urinate? 2.Is there anything that you do that helps you urinate? 3.Do you ever leak urine? 5.Have you noticed any change in your usual voiding pattern?
Which statements best support the nurse's evaluation that a patient who recently experienced a sigmoid colostomy has begun to accept the body change? (Select all that apply.) 1.I'm anxious to get a bathing suit that accommodates my colostomy 2.My stoma continues to be red and moist 3.My ostomy nurse always has helpful suggestions about daily care routine 4.Having a colostomy is a small price to pay for being healthy 5.I really hope no one else I know has to ever deal with a colostomy
1.I'm anxious to get a bathing suit that accommodates my colostomy 2.My stoma continues to be red and moist 3.My ostomy nurse always has helpful suggestions about daily care routine 4.Having a colostomy is a small price to pay for being healthy
What assessment data will the nurse expect to find to support the assumption that Mr. Haye's surgical incision is in the inflammatory phase of wound healing? (Select all that apply.) 1.Increased white blood cell count 2.Incision is slightly edematous 3.Incisional site pain 4.Redness surrounding the incision 5.Signs of scabbing are noted at the incision site
1.Increased white blood cell count 2.Incision is slightly edematous 3.Incisional site pain 4.Redness surrounding the incision
While inserting an intermittent urinary catheter in a female patient, the nurse accidentally inserts the catheter into the vagina. What is the appropriate action by the nurse? 1.Leave the catheter in the vagina as a landmark and begin the procedure again with new supplies 2.Remove the catheter and re-start the procedure using a new sterile kit 3.Allow the patient a period of rest and attempt the procedure at a later time 4.Carefully remove the catheter and reinsert it into the urethra
1.Leave the catheter in the vagina as a landmark and begin the procedure again with new supplies
The nurse has an order to check a patient's post-void residual urine. How would the nurse carry out this order? 1.Measure the amount of urine in the bladder using a bladder scanner 2.Insert a straight catheter and measure the urinary output in two hours 3.Calculate the difference between the patient's intake and output 4.Palpate the bladder for distention and record findings in the chart
1.Measure the amount of urine in the bladder using a bladder scanner
The nurse has created a sterile field and is preparing to catheterize a patient. While using sterile cotton balls to clean the patient prior to the procedure, the nurse drops a contaminated cotton ball in the middle of the sterile field. What is the correct action of the nurse at this time? 1.Obtain a new catheter kit and restart the procedure 2.Remove the contaminated cotton ball from the field with the non-dominant hand 3.Continue with the procedure while avoiding the contaminated cotton ball 4.Ask a co-worker to remove the contaminated cotton ball from the field
1.Obtain a new catheter kit and restart the procedure
Which nursing interventions are implemented primarily to prevent respiratory complication in a patient after abdominal surgery? (Select all that apply.) 1.Prompting to cough 2.Assisting in early ambulation 3.Encouraging deep breathing 4.Providing pain medication as required 5.Education on incentive spirometer use
1.Prompting to cough 2.Assisting in early ambulation 3.Encouraging deep breathing 5.Education on incentive spirometer use
The nurse is preparing to catheterize a female patient and is positioning the patient. Which position(s) would be appropriate for this procedure? (Select all that apply.) 1.Side lying 2.Supine 3.Semi-Fowler's 4.Dorsal recumbent 5.Lithotomy
1.Side lying 4.Dorsal recumbent
Which statement by the nurse indicates a thorough understanding of the purpose of postoperative nursing care? 1.The goal is to ensure uneventful recovery from surgery 2.The goal is well-managed postoperative pain 3.The goal is to prevent infection 4.The goal is frequent assessment of the surgical incision site
1.The goal is to ensure uneventful recovery from surgery
With information presented to a patient concerning a bladder scan will assist in addressing anxieties about the procedure? (Select all that apply.) 1.The patient's body is draped to promote modesty 2.The scan typically does not cause the patient any pain 3.The scan produces an image of the patient's bladder and the amount of urine it contains 4.The scanner is moved over the skin of the patient's lower abdomen 5.The procedure is necessary when a patient experienced difficulty voiding
1.The patient's body is draped to promote modesty 2.The scan typically does not cause the patient any pain 4.The scanner is moved over the skin of the patient's lower abdomen
The nurse is providing discharge education on complications associated with intermittent self-catheterization. Which possible complication should the nurse include in the teaching session? (Select all that apply.) 1.Urinary tract infections 2.Nephrotic syndrome 3.Bladder perforation 4.Urethral strictures 5.Bladder spasms
1.Urinary tract infections 3.Bladder perforation 4.Urethral strictures 5.Bladder spasms
What information will the nurse include when providing education for a patient who is scheduled for a sigmoid colostomy? (Select all that apply.) 1.When an ostomy is needed, intestinal mucosa is brought through the abdominal wall 2.The fecal matter that will pass through the stoma will be liquid in form 3.A healthy stoma is bright red, moist, and rounded 4.A stoma is the portion of the intestinal mucosa that is secured to the skin of the abdomen 5.The term ostomy refers to an opening from the inside of an organ to the outside of the body.
1.When an ostomy is needed, intestinal mucosa is brought through the abdominal wall 3.A healthy stoma is bright red, moist, and rounded 4.A stoma is the portion of the intestinal mucosa that is secured to the skin of the abdomen 5.The term ostomy refers to an opening from the inside of an organ to the outside of the body.
What instruction should the nurse provide to a patient concerning how often the colostomy pouch should be emptied? 1.Whenever the pouch is one-third full of fecal drainage 2.When the pouch isn't well attached to the skin 3.After each meal 4.At least four to five times daily
1.Whenever the pouch is one-third full of fecal drainage
When should the nurse caring for a patient with a new colostomy plan to change the pouching system? 1.After any meal 2.Before breakfast 3.Right before bed 4.Before the patient showers
2.Before breakfast
The nurse is assessing a patient admitted with a venous stasis ulcer on the right lower extremity. What would the nurse expect to find when assessing the leg? 1.Pale, white toes with decreased sensation 2.Dark discoloration of the skin surrounding the wound site 3.Shiny skin with hair loss over legs, feet, and toes 4.Scaly rash between the toes with itchiness
2.Dark discoloration of the skin surrounding the wound site
The nurse is conducting a skin assessment using the Braden Scale. How would the nurse interpret a score of 12? 1.Low risk 2.High risk 3.Moderate risk 4.Not at risk
2.High risk
The nurse is preparing to irrigate a wound. Which statement, if made by the nurse, indicates an understanding of the procedure? 1.I will make sure the tip of the syringe touched the wound bed while performing the irrigation? 2.I will gently direct a stream of fluid into the wound, keeping the syringe tip at least one inch from the upper tip of the wound 3.I will use a sterile specimen cup to slowly pour irrigation solution over the entire wound bed 4.In order to debride the wound, I will use a moderate amount of force to instill the solution
2.I will gently direct a stream of fluid into the wound, keeping the syringe tip at least one inch from the upper tip of the wound
Which statement made by the patient indicates an understanding of diet progression after surgery? 1.I know it is important to get my strength back, so I will ask for a milkshake after surgery 2.I'll start drinking water as soon this nausea subsides 3.I love coffee, so I'll have some as soon as I get back from surgery 4.I can't tolerate a soft diet, so I'll simply go back to drinking clear liquids
2.I'll start drinking water as soon this nausea subsides
Which statements indicate that a patient who recently required a colostomy has achieved the outcomes set for regular bowel elimination? (Select all that apply.) 1.Getting a short nap each afternoon makes me feel so much better 2.I've learned to implement the techniques I learned in stress management 3.I've gotten accustomed to drinking at least two quarts of water a day 4.My routine includes about 30 minutes of exercise daily 5.I know that what I eat has a large impact on my bowel function
2.I've learned to implement the techniques I learned in stress management 3.I've gotten accustomed to drinking at least two quarts of water a day 4.My routine includes about 30 minutes of exercise daily 5.I know that what I eat has a large impact on my bowel function
The nurse is recording fluid intake for Mr. Johnson. Which items on the dinner trap should the nurse include when completing this documentation? (Select all that apply.) 1.Applesauce 2.Ice cream 3.Tomato soup 4.Iced tea 5.Creamed corn
2.Ice cream 3.Tomato soup 4.Iced tea
Which diagnostic test is used as a screening tool for the possible diagnosis of colon cancer? 1.Stool pinworms 2.Occult blood 3.Timed stool specimen 4.Stool culture
2.Occult blood
The nurse is completing documentation following the insertion of an intermittent urinary catheter. What should be included in the documentation? (Select all that apply.) 1.The length of time for completion of the procedure 2.Size of the catheter 3.Patient's tolerance of the procedures 4.Date the procedure was performed 5.Time the procedure was performed
2.Size of the catheter 3.Patient's tolerance of the procedures 4.Date the procedure was performed 5.Time the procedure was performed
Ms. Johnson asks: why do I need to self-catheterize at regular intervals? What would be the appropriate response by the nurse? 1.You will only need to self-catheterize once daily 2.This helps prevent your bladder from becoming over distended 3.Self-catheterization helps reduce your risk of infection 4.This allows you to accurately measure your urine
2.This helps prevent your bladder from becoming over distended
The nurse is providing patient education on self-catheterization. What statement by Mr. Johnson indicates the need for additional teaching? 1.I should store my reusable catheters in a clean, dry container 2.I should report signs and symptoms of potential complications to the provider immediately 3.I can use either an indwelling or intermittent catheter 4.I may be eligible for free catheters through Medicare
3.I can use either an indwelling or intermittent catheter
The nurse is providing Mr. Johnson with discharge education about intermittent self-catheterization. What statement, if made by the patient, would indicate the need for further instruction? 1.It is important that I self-catheterize at regular intervals 2.There are risks associated with self-catheterization, such as bleeding and infection 3.I should maintain sterile technique throughout the procedure 4.If I do not catheterize myself, I may develop urinary problems
3.I should maintain sterile technique throughout the procedure
The need for a sigmoid colostomy is generally a result of cancer at what point in the intestinal tract? 1.Anywhere in the descending colon 2.Anywhere in the transverse colon 3.Near the rectum 4.Near the ileocecal valve
3.Near the rectum
The nurse is caring for a patient experiencing the effects of paraplegia. What urinary condition is associated with this diagnosis? 1.Chronic cystitis 2.Oliguria 3.Neurogenic bladder 4.Stress incontinence
3.Neurogenic bladder
A patient is placed on omeprazole 20 mg daily. When will the nurse administer the medication? 1.At bedtime 2.One hour after any meal 3.One hour before breakfast 4.With breakfast
3.One hour before breakfast
A postoperative patient is receiving enoxaparin sodium therapy. Which assessment data would the nurse report immediately to the patient's health care provider? 1.A platelet reading of 260,000 per mcL 2.Small amount of gum bleeding after completing oral hygiene 3.Patient has reported self-medicating with aspirin three times since surgery 4.Patient reports no bowel movement for two days
3.Patient has reported self-medicating with aspirin three times since surgery
The nurse removes a dressing and assesses yellow, foul smelling drainage. How would the nurse document this finding? 1.Serous 2.Serosanguineous 3.Purulent 4.Sanguineou
3.Purulent
What information will the nurse include when providing education for a patient scheduled for a colostomy as treatment for rectal cancer? 1.The surgeon will determine whether the ostomy can be temporary once surgery has begun 2.Permanency will depend on how much colon function has been affected by the surgery 3.The ostomy will be permanent because of the nature of the illness 4.Once the inflammation in the colon subsides, the ostomy will be reversed
3.The ostomy will be permanent because of the nature of the illness
Mr. Johnson is being discharged with an order to continue the medication oxybutynin. What information should be included in the teaching session? 1.You may have to urinate more frequently while taking this medication 2.You may experience excessive saliva production while taking this medication 3.This medication helps reduce bladder spasms 4.Your urine may appear reddish-orange
3.This medication helps reduce bladder spasms
The nurse is performing a sterile dressing change. After donning sterile gloves, the nurse drops the dressing on the bed and does not have a replacement. What is the appropriate action at this time? 1.Reapply the original dressing until a new one can be obtained 2.Pick up the dressing and use the side that did not touch the bed 3.Remove gloves and go to the supply room to obtain more supplies 4.Ask the patient to press the call bell to summon a co-worker to obtain another dressing
4.Ask the patient to press the call bell to summon a co-worker to obtain another dressing
The nurse is reviewing the patient's laboratory results. Which lab test most accurately represents current nutritional status? 1.Iron 2.Calcium 3.Albumin 4.Prealbumin
4.Prealbumin
The nurse is caring for a patient admitted with bilateral lower extremity edema. What questions should the nurse ask when completing a health history?
When did the edema start? Can you describe the edema? What were you doing just before you noticed the edema? Do you have any recent history of surgery or illness? What are your usual daily activities? Do you stand a lot? What medications do you take? Do you have heart disease or blood vessel disease?
Calculate the IV infusion rate using the following provider's order: 1000 mL of NS over 8 hours. Infusion set has a drop rate of 10 drops/mL. a. 21 drops/minute b. 30 drops/minute c. 10 drops/minute d. 41 drops/minute
a. 21 drops/minute
What pathology is responsible for metabolic acidosis? a. A decrease in bicarbonate or an increase in hydrogen ions b. An increase of CO2 c. A decrease of carbonic acid d. An excess of HCO3 and/or a decrease in H+ ions
a. A decrease in bicarbonate or an increase in hydrogen ions
The nurse titrates the patients oxygen to 3L per nasal cannula in order to maintain an oxygen saturation of at least 94%, per the provider's orders. What is the rationale for this order? (Select all that apply.) a. Allows the body to meet metabolic demands b. Promotes a decrease in myocardial workload c. Prevents atelectasis in a patient with pneumonia d. Promotes a decrease in respiratory effort e. Allows the patient to receive 100% oxygen
a. Allows the body to meet metabolic demands b. Promotes a decrease in myocardial workload d. Promotes a decrease in respiratory effort
A nurse is planning to administering a tube feeding to a patient with a NG tube. The patient appears asleep flat in bed. What should the nurse do first. a. Assist the patient to a semi-fowlers position or higher b. Flush the NG tube with 30 to 60 mL water c. Administer the feeding quietly without waking the patient d. Carefully connect the NG tube to the tube feeding
a. Assist the patient to a semi-fowlers position or higher
Mona Hernandez's blood gas results indicate respiratory acidosis. Her oxygen saturation is 95% per the pulse oximeter. Which interventions should the nurse provide? (Select all that apply.) a. Assist the patient with adequate ventilation b. Promote voluntary coughing activities to clear secretions c. None; the patient has a 95% oxygenation d. Provide supplemental oxygen as ordered e. Ensure the patient is well hydrated
a. Assist the patient with adequate ventilation b. Promote voluntary coughing activities to clear secretions d. Provide supplemental oxygen as ordered e. Ensure the patient is well hydrated
A nurse is planning patient education about a prescribed medication for a patient. What should the nurse do first? a. Find out what the patient already knows about the medication. b. Review the signs and symptoms of drug toxicity with the patient. c. Educate the patient about potential allergic reactions to the medication. d. Educate the patient about potential drug interactions.
a. Find out what the patient already knows about the medication.
Mona Hernandez asks the nurse why it is necessary to use the incentive spirometer when she is already having difficulty breathing. What is the BEST response by the nurse? a. It helps prevent atelectasis or collapsing o the alveoli in the lungs b. It increases the oxygen taken in by the lungs when you inhale c. It was ordered by your provider d. It decreases cardiac workload during inspiration
a. It helps prevent atelectasis or collapsing o the alveoli in the lungs
What information is to be included when documenting a change in infusion rate of an IV solution? (Select all that apply.) a. Nurse's initials b. Change made to flow rate c. Patients response to IV therapy d. Date and time change was made e. Original flow rate
a. Nurse's initials b. Change made to flow rate c. Patients response to IV therapy d. Date and time change was made
Reduced skin turgor is characteristically altered among which population? a. Older adults b. Premenstrual females c. Infants d. Smokers
a. Older adults
The nurse is planning to discharge Mona Hernandez from the hospital. Which of the following instructions should the nurse include in the discharge education? (Select all that apply.) a. Take your antibiotics as directed, even if you're feeling better b. Quitting smoking will improve your recovery c. Continue to focus on ambulating several times a day d. Use the incentive spirometer every one to two hours to move secretions out of your lungs. e. Stop taking your antibiotics once you are feeling better
a. Take your antibiotics as directed, even if you're feeling better b. Quitting smoking will improve your recovery c. Continue to focus on ambulating several times a day d. Use the incentive spirometer every one to two hours to move secretions out of your lungs.
What determines the acidity of a substance like body fluids? a. The number of existing H+ ions b. The fluids pH measurements c. The amount of available HCO3 d. The bodies ability to trigger chemical reactions
a. The number of existing H+ ions
What is the initial step in assessing a patient for orthostatic hypotension? a. Encouraging the patient to drink 8 oz of fluid, then take and record blood pressure and pulse b. After having the patient lie in a supine position for 3 to 10 minutes, take and record blood pressure and pulse c. Assist patient into a standing position lasting two to three minutes, then take and record blood pressure and pulse d. After having the patient sit up right with legs dangling for 1 to 3 minutes, take and record blood pressure and pulse
b. After having the patient lie in a supine position for 3 to 10 minutes, take and record blood pressure and pulse
A patient with a low BMI is found to have low albumin and pre-albumin levels. Which of the following nursing actions should be considered? (Select all that apply.) a. Assess for signs and symptoms of infection b. Assess gastrointestinal function c. Monitor input and output for the patient d. Request a nutrition consult e. Encourage oral intake of foods and liquids as ordered
b. Assess gastrointestinal function c. Monitor input and output for the patient d. Request a nutrition consult e. Encourage oral intake of foods and liquids as ordered
Upon entering the room, the nurse notes Mona Hernandez slumped over in semi-Fowlers position, struggling to catch her breath. What is the priority nursing action at this time? a. Obtain vital signs b. Assist the patient into a high-Fowlers position c. Titrate her oxygen so that her oxygen is greater than or equal to 95% d. Obtain an oxygen saturation level
b. Assist the patient into a high-Fowlers position
A nurse is assessing a patient with cystic fibrosis. Based on a diagnoses with cystic fibrosis, the nurse expects to find which of the following common symptoms upon assessment? a. Shortness of breath, headache, and vision changes. b. Cyanosis or pallor, dyspnea, and arrhythmias. c. Nausea, vomiting, and hyperreflexia. d. Increased activity, diaphoresis, and tachycardia.
b. Cyanosis or pallor, dyspnea, and arrhythmias.
The nurse is caring for adolescent teen who appears to be withdrawn and isolated. What strategy should the nurse use to work with this patient? a. Tell the patient what the patient needs to do to get better. b. Develop a therapeutic, trusting relationship with the patient. c. Leave the patient alone as much as possible. d. Talk to the patients parents about what is going on with the patient.
b. Develop a therapeutic, trusting relationship with the patient.
Identify the following potential problems or actual problems that the nurse should include when planning care for the patient diagnosed with pneumonia? (Select all that apply. ) a. Metabolic acidosis b. Difficulty breathing c. Ineffective respiratory gas exchange d. Not able to tolerate activity e. Acute pain
b. Difficulty breathing c. Ineffective respiratory gas exchange d. Not able to tolerate activity e. Acute pain
What statement by Mr. Ahmed best reflects his ability to assume some responsibility in tracking his urinary output? a. I understand that it's important to measure my urine with the calibrated urinal. b. I will always use the calibrated urinal to measure my urine c. I will notify staff when I need to use the calibrated urinal d. I listened as you discussed the instructions about the calibrated urinal
b. I will always use the calibrated urinal to measure my urine
Considering Mr. Ahmed's diagnosis of dehydration and the possibility of neurological impairment, which nursing intervention is directed toward minimizing his risk for possible injury? a. Administering ondansetron with a full glass of water b. Implementing falls precaution c. Assessing for orthostatic hypertension daily d. Educating the patient on the use of a calibrated urinal
b. Implementing falls precaution
What information will the nurse provide to a patient to best assure minimizing the risk of side effects associated with sulfamethoxazole-trimethoprim therapy? a. Increased dietary consumption of dairy products b. Increased fluid intake in order to remain well hydrated c. Notify health care provider immediately if experiencing palpitations d. Arrange for a yearly flu vaccine
b. Increased fluid intake in order to remain well hydrated
A patient demonstrates correct usage of the incentive spirometer when the patient places the mouthpiece in the mouth and does which of the following? a. Inhales quickly and forcefully b. Inhales slowly and deeply c. Exhales slowly and deeply d. Exhales quickly and forcefully
b. Inhales slowly and deeply
A nurse is teaching a patient with cystic fibrosis about nutrition in the high-fat, high-protein, high-carbohydrate diet that has been recommended. Which of the following should be included in this education? a. It is not necessary to monitor dietary intake. b. It is important to select a variety of nutrient dense foods. c. It is important to focus on eating calorie dense foods. d. It is important to only eat high-fat, high-protein, and high-carbohydrate food.
b. It is important to select a variety of nutrient dense foods.
Expected assessment findings of a patient with pneumonia may include which of the following? (Select all that apply.) a. Enuresis b. Malaise c. Use of accessory muscles d. Tachypnea e. Fever
b. Malaise c. Use of accessory muscles d. Tachypnea e. Fever
During her hospitalization for pneumonia, the provider orders arterial blood gases for Mona Hernandez. What is the best explanation for why this is ordered? a. Patient has a productive cough with rust colored sputum b. Patient has shallow, ineffective breathing c. Patient has fever and malaise d. Patient has a history of smoking 1/2 a pack of cigarettes per day
b. Patient has shallow ineffective breathing
A nurse is creating a care plan for a young adult patient a chronic illness. Which of the following nursing diagnoses might be included in the care plan? (Select all that apply.) a. Caregiver role strain b. Risk-prone health behavior c. Social isolation d. Activity intolerance e. Ineffective health maintenance
b. Risk-prone health behavior c. Social isolation d. Activity intolerance e. Ineffective health maintenance
Which statement involving fluid balance demonstrates a need for additional instruction concerning fluid intake and output? a. Fluid output is comprised of feces, sweat, and exhaled air b. The balance between fluid intake and output must be achieved each day to maintain homeostasis c. It is recommended that a healthy adult consumes 1 1/2 quarts of water daily d. A desirable amount of fluid intake and output in adults ranges from 1500 to 3500 mL daily
b. The balance between fluid intake and output must be achieved each day to maintain homeostasis
In preparation for calculating the infusion rate for a newly ordered IV solution, the nurse must first secure what information? a. When the IV is to be started b. The infusion sets drop factor c. The status of the patients IV site d. Patients history of allergies
b. The infusion sets drop factor
The nurse plans on assessing the patients GI system. Which statement below reflects the best prioritization of the assessment? a. The nurse should percuss then inspect the abdomen b. The nurse should auscultate then palpate the abdomen c. The nurse should percuss then auscultate the abdomen d. The nurse should palpate then auscultate the abdomen
b. The nurse should auscultate then palpate the abdomen
Which statement by the nurse indicates a need for further education on the role of water as a body fluid? a. Waste products are removed from the cell by water b. Water is transported to cells when it's to electrolytes c. Tissue lubrication is facilitated by water d. Water helps maintain normal body temperature
b. Water is transported to cells when it's to electrolytes
A nurse is assessing an adolescent patient. Which of the following questions best represents therapeutic communication techniques? a. Are you feeling well? b. What do you hope happens here today? c. You don't smoke, do you? d. Do you know what to do to stay healthy?
b. What do you hope happens here today?
Which statement concerning the measurement of input and output is true? a. Only foods that are consumed in liquids are included in the intake calculations b. When possible, intake and output should be measured rather than estimated c. Healthcare agencies have adopted standard volumes for common beverage containers d. Liquid medications are not considered when calculating intake
b. When possible, intake and output should be measured rather than estimated
As the nurse administers Mona Hernandez's prescribed medication, guaifenesin, the patient states: "I don't like this medication, it makes me cough too much." How should the nurse respond? a. This medication will help make your breathing easier b. When you cough out secretions, oxygenation is more effective. c. I will let your provider know you have questions about your medication d. This medication is given to you because of your pneumonia
b. When you cough out secretions, oxygenation is more effective.
A nurse rounding on a patient with pneumonia notices the patient is more confused than at the beginning of the shift. What is the best response by the nurse? a. Notify the provider b. Ensure a sitter is available to watch the patient c. Check oxygen saturation level d. Document findings in the medical record
c. Check oxygen saturation level
The provider orders a high-fat, high-protein, high-carbohydrate diet for a patient with cystic fibrosis. What is the best rationale for this order? a. The diet was ordered according to the patient's preferred food intake. b. Cystic fibrosis is a chronic disease characterized by altered electrolytes. c. Cystic fibrosis interferes with the digestion of food and absorption of nutrients. d. Thickened mucus secretions expose the patient to anemia.
c. Cystic fibrosis interferes with the digestion of food and absorption of nutrients.
A patient complains of nausea after a tube feeding. What is the priority action of the nurse at this time? a. Flush the tube with 30 to 60 mL of water. b. Position the patient on left side. c. Ensure the head of the bed remains elevated. d. Aspirate the tube feedings contents from the patients stomach.
c. Ensure the head of the bed remains elevated.
Mona Hernandez complains of shortness of breath with activity and does not want to exacerbate her condition by moving to the chair or ambulating three times a day as ordered. How should the nurse respond? a. You really need to walk as much as possible in order to prevent your pneumonia from getting worse b. Pneumonia causes thick secretions in your lungs, making it difficult to breathe. c. Even short activities such as moving to the chair will help you cough mucus out of your lungs. d. You should wait until your breathing improves to try to get out of bed again, because it makes you short of breath.
c. Even short activities such as moving to the chair will help you cough mucus out of your lungs.
A patient is concerned about a medication the nurse is administering. The patient that the medication is not normally something that is administered. What is the best response by the nurse? a. The provider has ordered it for you b. It is probably a generic medication for something you normally get c. I will hold the medication and find out for you. d. We should probably update your medication reconciliation forms.
c. I will hold the medication and find out for you.
Which physical finding poses the greatest safety risk for a patient diagnosed with hyponatremia? a. Dry mucus membranes b. Anxiety c. Orthostatic hypotension d. Cold, clammy skin
c. Orthostatic hypotension
Hypokalemia is confirmed by what serum blood result? a. Sodium 146 mEq/L b. Sodium 133 mEq/L c. Potassium 3.0 mEq/L d. Potassium 5.5 mEq/L
c. Potassium 3.0 mEq/L
In addition to regular monitoring of serum potassium level, which intervention will the nurse implement to address safety needs of a patient prescribed IV potassium chloride? a. Delivering the medication by slow IV push b. Shading windows to minimize sun exposure c. Securing ECGs regularly d. Monitoring for hyperactivity
c. Securing ECGs regularly
Hyponatremia is associated with a decrease of which electrolytes? a. Chloride b. Phosphorous c. Sodium d. Potassium
c. Sodium
A patient states he does not want to use the incentive spirometer because it makes the patient cough up too much sputum, and it is difficult to breathe. What is the correct information to teach the patient about the incentive spirometer? a. You have to use your incentive spirometer because your provider has ordered it for you. b. The incentive spirometer will cause you to cough less because you are moving more air through your lungs. c. The incentive spirometer helps you to maximize lung function and minimize the risk for atelectasis. d. You should wait to use your incentive spirometer until you are not coughing up so much sputum.
c. The incentive spirometer helps you to maximize lung function and minimize the risk for atelectasis.
A patient has just completed a tube feeding that has run throughout the night. What is the best education the nurse can provide to the patient at this time? a. You should wear pneumatic compression device when you're in bed b. You should lie down to get some sleep c. You should remain upright for the next hour. d. It is important that you ambulate three times a day.
c. You should remain upright for the next hour.
Which diagnostic test serves as the basis for determining acid-base imbalances? a. Specific gravity of urine b. Serum potassium c. Blood urea nitrogen (BUN) d. Arterial blood gas (ABG)
d. Arterial blood gas (ABG)
The nurse has just finished placing an NG tube into a patient for the purpose of administering feedings. What should the nurse do first? a. Irrigate the NG tube with 30 to 60 mL of water b. Assess how much of the tube was inserted into the patient to verify placement c. Administer the tube feeding as ordered d. Confirm the placement of the NG tube per facility policy
d. Confirm the placement of the NG tube per facility policy
A patient with newly diagnosed pneumonia has an oxygen saturation of 94% on room air, an increased respiratory rate, and an increased pulse rate. The patient is pale and anxious. The nurse questions the oxygen saturation results and looks up which of the following test results? a. WBC count b. Gram stain c. Chest X-ray d. Hemoglobin
d. Hemoglobin
A patient with cystic fibrosis has five capsules of pancrelipase ordered to be administered now with his breakfast. The patient is currently experiencing nausea and intermittent vomiting. What should the nurse do with the medication? a. Administer the medication as ordered. b. Call the provider immediately. c. Crush the medication to administer to the patient. d. Hold the medication until the patient is able to eat again.
d. Hold the medication until the patient is able to eat again.
While completing discharge instructions with a patient, the nurse notices the patient is short of breath. What is the priority nursing action at this time? a. Ask if the patient has support at home b. Determine if the patient has any questions c. Reassure the patient d. Listen to the patients lungs
d. Listen to the patients lungs
Christopher Parrish has a low BMI and has lost 12 pounds over the past two weeks. Which method could the nurse use to assess his overall dietary intake in order to provide nutrition education? a. Ask the patient if he has a healthy diet. b. Track the percentage of food eaten at each meal while in the hospital. c. Ask the patient to keep a food diary log. d. Obtain a food frequency assessment.
d. Obtain a food frequency assessment.
A nurse is caring for an 18-year-old who has recently started living on his own and has experienced a greater than 5% weight loss over two weeks. He has a low BMI and complains of feeling fatigued. According to Maslow's hierarchy of needs, the nurse identifies which of the following as the patient's priority need at this time? a. Self-esteem needs b. Love and belonging needs c. Safety and security needs d. Physiologic needs
d. Physiologic needs
A patient in semi-fowlers is having difficulty breathing. What is the priority action of the nurse? a. Auscultate the lungs b. Call respiratory therapy c. Conduct a pain assessment d. Raise the head of the bed
d. Raise the head of the bed
Which of Mr. Ahmed's lab results best supports his diagnosis of dehydration? a. Hemoglobin: 16.7 g/dL b. WBC: 21 x 10^9 c. Creatinine: 1.1 ng/dL d. Sodium: 130 mEq/L
d. Sodium: 130 mEq/L
A nurse is preparing to admit a patient with cystic fibrosis and altered nutrition status. The nurse implements which precaution to be used in the patients care? a. Contact precautions. b. Airborne precautions. c. Droplet precautions. d. Standard precautions.
d. Standard precautions.
Mona Hernandez's lab work indicates an elevated WBC count with a left shift in the differential. The nurse interprets this to mean which of the following? a. There is a high number of WBC, but not immature WBC, present in the circulation. b. There is a high number of WBC to fight the infection, and the RBC are compensation. c. A left shift in the differential means that there is no infection present. d. There is a high number of WBC and immature WBC present to fight infection.
d. There is a high number of WBC and immature WBC present to fight infection.
