Adult 1 Final

Which method individualizes learning for a patients unique needs

Have the pt arrange topic cards in order of priority.

A nurse is caring for a client who is dehydrated. Which of the following clinical manifestations shouldthe nurse assess for that is indicative of fluid volume deficit?

Tachycardia

Teaching for patient with SIADH Which patient statement indicates to the nurse that additional instruction is needed for a patient with chronic syndrome of inappropriate antidiuretic hormone (SIADH)?

"I need to shop for foods low in sodium and avoid adding salt to food."

Teaching following middle ear surgery A nurse is completing discharge teaching to a client following middle ear surgery. Which of the following statements by the client indicates understanding of the teaching?

"I should restrict rapid movements and avoid bending from the waist for several weeks."

Teaching of thyroid replacement with levothyroxine (Synthroid) - what statement do you want to hear from patient after teaching to indicate understanding A patient has been given instructions about levothyroxine (Synthroid). Which statement by the patient indicates understanding of these instructions?

"I'll take this medication in the morning so as not to interfere with sleep. A) Levothyroxine is used to treat hypothyroidism by increasing the basal metabolism and thus wakefulness. It is administered as a once-daily dose and is a lifelong therapy. It is best taken on an empty stomach to enhance absorption.

Difference between benign and malignant tumor Know the difference between a benign tumor and a malignant tumor. Benign tumor is an abnormal growth of cells that serves no purpose. It does not invade nearby tissue or spread to other parts of the body the way cancer can. Malignant tumors invade adjacent tissues and spread to distant tissues; it is a cancer A patient who is scheduled for a breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is accurate?

"Malignant tumors may spread to other tissues or organs."

Teach about procedure for prostate needle biopsy The nurse teaches a patient who is scheduled for a prostate needle biopsy about the procedure. Which statement by the patient indicates that teaching was effective?

"The biopsy will help decide the treatment for my enlarged prostate."

Manifestations of stress/shock A hospitalized patient with diabetes tells the nurse, "I don't understand why I can keep my blood sugar under control at home with diet alone, but when I get sick, my blood sugar goes up. This is so frustrating." Which response by the nurse is accurate?

"The stress of illness causes release of hormones that increase blood glucose."

What do ABG's measure

-Measures PaO2, PaCO2, acidity (pH), and bicarbonate (HCO3) in the arterial blood Normal ABG values pH: (Acid) 7.35-7.45 (alkaline)PaCO2: (alkaline) 35-45 (acidic) mmHgHCO3 Bicarb: (acidic) 22-26 (alkaline)PaO2: 80-100 mmHgSaO2: > 95% Analyzing Arterial Blood Gas 1. Determine whether the pH is acid or base2. Analyze PaCO2 to determine if patient has respiratory acidosis or alkalosis3. Analyze bicarbonate to determine if patient has metabolic acidosis or alkalosis4. Determine if CO2 or HCO3- changes match the pH alteration5. Decide if the body is trying to compensate

The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply.

1. Administer antacids as prescribed 2. Encourage coughing and deep breathing 3. Administer anticholinergics as prescribed 4. Give small, frequent high-calorie feedings 5. Maintain the client in a supine and flat position 6. Give meperidine (Demerol) as prescribed for pain.

The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? Select all that apply.

1. Avoid activities that require bending over. 2. Contact the surgeon if eye scratchiness occurs. 3. Take acetaminophen for minor eye discomfort. 4. Expect episodes of sudden severe pain in the eye. 5. Place an eye shield on the surgical eye at bedtime. 6. Contact the surgeon if a decrease in visual acuity occurs.

REM: REM sleep accounts for what percentage of total sleep?

20-25%

When doing a breast exam what findings would need further evaluation Which assessment finding in a 36-year-old patient is most indicative of a need for further evaluation?

A breast nodule that is 1 cm in size, nontender, and fixed

The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit?

A client with an ileostomy

What situation would require focused assessment 1. Which situation would require the nurse to obtain a focused assessment (select all that apply)?

A patient reports a new symptom during rounds. A previously identified problem need reassessment.

Pain has been defined as "whatever the person experiencing the pain says it is, existing whenever the patient says it does." This definition is problematic for the nurse when caring for which type of patient?

A patient with decreased cognitive function

The nurse is caring for a client with a diagnosis of dehydration, and the client is receiving intravenous (IV) fluids. Which assessment finding would indicate to the nurse that the dehydration remains unresolved?

A urine specific gravity of 1.043

Define health disparities 1. Limited health literacy may be associated with which conditions that lead to health disparities (select all that apply)? (3)

A. Age B. Place E. Language barrier F. Income/Education

What technique would be most appropriate to enhance patient learning Which techniques would be most appropriate to enhance patient learning (select all that apply)?

A. Obtain frequent feedback. B. Have a quiet environment. D. Involve the patient and caregiver in the process. E. Emphasize relevancy of the information to the patient's lifestyle.

Identify measures that the nurse should use to reduce health care disparities (select all that apply) (16)

A. use cultural competency guidelines C. use standardized, evidence-based care guidelines

Assessment finding consistent with panhypopituitarism The nurse is assessing a 41 year old African American male patient diagnosed with a pituitary tumor causing panhypopituitarism. Assessment findings consistent with panhypopituitarism include:

ANS Decreased facial hair

What tests should be ordered annual for a patient with DM To monitor for complications in a patient with type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually (select all that apply)?

Blood pressure Serum creatinine Urine for microalbuminuria Monofilament testing of the foot

Manifestations of fluid volume excess 1. Which patient is most at risk for fluid excess?

An elderly patient receiving IV therapy

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic (difficulty in breathing), and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present?

An increase in blood pressure and increased respirations

2. Acute pain can be distinguished from chronic pain by assessing which characteristic?

Acute pain is specific and localized.

Collaborative action nurse anticipates after patient who had subtotal thyroidectomy earlier in the day and is developing laryngeal stridor and cramping in the right hand A patient who had a subtotal thyroidectomy earlier today develops laryngeal stridor and a cramp in the right hand upon returning to the surgical nursing unit. Which collaborative action will the nurse anticipate next?

Administer IV calcium gluconate.

Client with metastatic colon ca has severe vomiting after each administration of chemotherapy. What action by nurse is appropriate A patient with metastatic colon cancer has severe vomiting after each administration of chemotherapy. Which action by the nurse is appropriate?

Administer prescribed antiemetics 1 hour before the treatments.

Patient with type 2 DM is scheduled for cholecystectomy, what nursing action can be delegated to the LPN When a patient with type 2 diabetes is admitted for a cholecystectomy, which nursing action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)?

Administer the prescribed lispro (Humalog) insulin before transporting the patientto surgery.

What should the nurse do for a client who just had cataract surgery?

Advise the client to refrain from vigorous brushing of the teeth and hair.

36 year old patient dx with fibrocystic breast changes and calls clinic reporting symptoms. What information would change treatment plan A 36-yr-old patient who has a diagnosis of fibrocystic breast changes calls the nurse in the clinic reporting symptoms. Which information is likely to change the treatment plan?

An area on the breast is hot, pink, and tender to the touch.

Patient has severe H/A and confusion with serum sodium level of 118 mEq/L. Which diagnostic test should nurse anticipate A patient seen in the emergency department for severe headache and acute confusion has a serum sodium level of 118 mEq/L. The nurse should anticipate the need for which diagnostic test?

Antidiuretic hormone level

Teaching for patient newly diagnosed with Graves' disease Which information will the nurse teach a patient who has been newly diagnosed with Graves' disease?

Antithyroid medications may take several months for full effect.

Nursing intervention for patient with presbycusis Which action should the nurse take when providing patient teaching to a 76-year-old with mild presbycusis?

Ask for permission to turn off the television before teaching

Initial nursing action - older patient no energy and weak, lost 12 lbs over past year: An older patient reports having "no energy" and feeling increasingly weak. The patient has lost 12 pounds over the past year. Which action should the nurse take initially?

Ask the patient about daily dietary intake.

Actions that support self-management and goal of medication adherence for older adult who lives alone Which nursing action will be most helpful in decreasing the risk for drug-drug interactions in an older adult?

Ask the patient to bring all medications, supplements, and herbs to eachappointment.

What is the most pertinent question to ask a 43 year old patient about her risk for breast cancer During a well woman physical exam, a 43-year-old patient asks about her risk for breast cancer. Which question is most pertinent for the nurse to ask?

At what age did you start having menstrual periods?

What is the leading determinant of a patient's health?

Behavior

Teaching about CBI Which information about continuous bladder irrigation will the nurse teach to a patient who is being admitted for a transurethral resection of the prostate (TURP)?

Bladder irrigation prevents obstruction of the catheter after surgery.

A nurse is preparing an older adult client who had a transient ischemic attack (TIA) for discharge. The nurse should teach the client to monitor which of the following parameters at home?

Blood pressure A temporary disturbance of the blood supply to the brain causes TIAs, which are brief alterations in neurologic function. The most common causes are atherosclerotic plaque in the carotid arteries and hypertension; therefore, the client should track his BP regularly to promote hypertension management and reduce the risk of another TIA or cerebrovascular accident.

Which words are most likely to be used to describe neuropathic pain (select all that apply)?

Burning Shooting Shock-like

Problems nurse anticipates with patient who is admitted with diabetes insipidus Which problem should the nurse anticipate for a patient admitted to the hospital with diabetes insipidus?

C. Disturbed sleep pattern

Side effects of motrin IBUPROFEN Side effects most common:

CNS: headache GI: constipation, dyspepsia, nausea, vomiting. Peripheral edema, fluid retention with edema, tinnitus, purpura, petechiae, anorexia, diarrhea, rash, nausea, vomiting, GI upset, fatigue, dizziness, lightheadedness, anxiety, confusion.

The nurse is performing an assessment on a client admitted to the hospital with a diagnosis of dehydration. Which assessment finding should the nurse expect to note?

Changes in mental status

Patient with Somogyi effect whose 6:00 AM BLOOD GLUCOSE IS 230. What action will nurse teach the patient to take. The health care provider suspects the Somogyi effect in a 50-yr-old patient whose 6:00 AM blood glucose is 230 mg/dL. Which action will the nurse teach the patient to take?

Check the blood glucose during the night

Manifestations of fluid volume deficit 1.A patient comes to the clinic complaining of frequent, watery stools for the last 2 days. Which action should the nurse take first?

Check the patient's blood pressure.

The nurse is caring for a group of clients on the clinical nursing unit. Which client should the nurse plan to monitor for signs of fluid volume deficit?

Client with diabetes insipidus

In identifying patients at the greatest risk for health disparities, the nurse would note that

Cultural differences exist in patients' ability to communicate with their health care provider.

A nurse is caring for a client who has diabetes insipidus. Which of the following urinalysis lab findings should the nurse anticipate?

Decreased specific gravity The urine of a client with DI will be dilute and less than 1.005

Smoker - what action by the nurse could help reduce the patient's risk of lung cancer The nurse is caring for a patient who smokes 2 packs/day. Which action by the nurse could help reduce the patient's risk of lung cancer?

Discuss risks associated with cigarettes during each patient encounter.

A nurse is admitting a client who reports nausea, vomiting, and weakness. Upon assessment, the client has dry oral mucous membranes, temperature 38.5° C (101.3° F), pulse 92/min, respirations 24/min, skin cool with tenting present, and blood pressure 102/64 mm Hg. His urine is concentrated with a high specificgravity. Which of the following are clinical manifestations of fluid volume deficit?

Decreased Skin Turgor Concentrated Urine Low-grade Fever

Lab values expected for patient who has secondary hypothyroidism A nurse in a provider's office is reviewing laboratory results of a client who is being evaluated for secondary hypothyroidism. Which of the following laboratory findings is expected for a client with this condition?

Decreased serum T3

A 56-year-old patient who is disoriented and reports a headache and muscle cramps is hospitalized with syndrome of inappropriate antidiuretic hormone (SIADH). Which initial laboratory result should the nurse expect?

Decreased serum sodium

Patient who is dx with benign prostatic hyperplasia (BPH) doesn't want a transurethral resection of the prostate because he is afraid it might affect his ability to have sexual intercourse. What action should the nurse take? A 58-year-old patient who has been recently diagnosed with benign prostatic hyperplasia (BPH) tells the nurse that he does not want to have a transurethral resection of the prostate (TURP) because it might affect his ability to maintain an erection during intercourse. Which action should the nurse take?

Discuss that TURP does not commonly affect erectile function.

Manifestations of dehydration A 93-year-old patient with diarrhea and dehydration is admitted to the hospital from an extended care facility. For which of the following symptoms of dehydration should the nurse assess?

Disorientation, poor skin turgor

Teaching abdominal and pelvic US for ovarian cyst After scheduling a patient with a possible ovarian cyst for ultrasound, the nurse will teach the patient that she should

Drink several glasses of fluids before the procedure.

During which sleep cycle does the most vivid dreaming occur?

During the REM sleep period

A nurse is admitting an older adult client who is experiencing dyspnea, weakness, and weight gainof 2 lb, with 1+ bilateral edema of the lower extremities. Upon assessment, the client has a temperature37.2° C (99° F), pulse 96/min, respirations 26/min, oxygen saturation 94% on 3 L oxygen via nasalcannula, and blood pressure 152/96 mm Hg. Which of the following clinical manifestations are indicativeof fluid volume excess?

Dyspnea Edema Hypertension

Potassium 5.4 expected manifestations A nurse is caring for a pt who has a serum potassium 5.4 mEq/L. The nurse should assess for which of the following manifestations?

ECG changes

Serum protein of 5.2. What clinical manifestation should the nurse expect? An older adult client who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation?

Edema

When caring for a patient with fluid excess, which of the following interventions will best help relieve respiratory distress?

Elevate the head of the bed

Older patient in rural area - nursing interventions: The nurse cares for an older adult patient who lives in a rural area. Which intervention should the nurse plan to implement to meet this patient's needs?

Ensure transportation to appointments with the health care provider.

A nurse is completing an admission assessment of a client who has pancreatitis. Which of the following findings should the nurse expect?

Epigastric pain radiating to the left shoulder

The nurse need to get an apical pulse of a client from a different culture. What action should be taken The nurse needs to determine the apical pulse of a client from a different culture. In order to show appropriate sensitivity to the client, the nurse should take which action?

Explain the procedure, then wait for permission to continue.

When planning care for a patient with dehydration related to nausea and vomiting, the nurse would anticipate which fluid shift to occur because of the fluid volume deficit?

Fluid movement from the interstitial space into the blood vessels

The nurse asks an older adult patient with rectal bleeding, "Have you ever had a colonoscopy?" The nurse is performing what type of assessment?

Focused assessment

When assessing a patient admitted with nausea and vomiting, which finding supports the nursing diagnosis of deficient fluid volume?

General restlessness

What are the leading determinates of a patient's health (select all that apply)

Genetics Health behaviors Social and physical environment

Patient with bg level of 62 was given 4 oz OJ, 15 minutes later bg is 67. What is the next nursing action? The nurse has administered 4 oz of orange juice to an alert patient whose blood glucose was 62 mg/dL. Fifteen minutes later, the blood glucose is 67 mg/dL. Which action should the nurse take next?

Give the patient 4 to 6 oz more orange juice.

82 year old with new diagnosis of type 2 DM placed on metformin. The home health nurse makes a visit. Which finding should the nurse promptly discuss with the HCP? A few weeks after an 82-yr-old patient with a new diagnosis of type 2 diabetes has been placed on metformin (Glucophage) therapy and taught about appropriate diet and exercise, the home health nurse makes a visit. Which finding should the nurse promptly discuss with the health care provider?

Glomerular filtration rate is decreased.

Lab test expected for patient with type 2 DM after several months of treatment A patient with type 2 diabetes is scheduled for a follow-up visit in the clinic several months from now. Which test will the nurse schedule to evaluate the effectiveness of treatment for the patient?

Glycosylated hemoglobin

What is the focus of hygienic care The nurse is preparing to provide hygienic care to a client. On what will the nurse focus this care?

Hair

Assessment finding for acute pancreatitis 1. A nurse is completing the admission assessment of a client who has acute pancreatitis. Which finding is the first priority?

Hand spasms present when blood pressure is checked

S/S that patient might need a lower dose of levothyroxine being given to treat hypothyroidism A nurse in a provider's office is assessing a client who has hypothyroidism and recently began treatment with thyroid hormone replacement therapy. Which of the following findings should indicate to the nurse that the client might need a decrease in the dosage of the medication?

Hand tremors

Older patient presents with bruises, broken arm. What action should nurse take first An older adult patient presents with a broken arm and visible scattered bruises healing at different stages. Which action should the nurse take first?

Have the family member stay in the waiting area while the patient is assessed.

Leading determinants of client's health A 62 year old African American man has been diagnosed with lung cancer and has been scheduled for surgery. The nurse recognizes what as the most likely major determinant of this patient's health? (1)

He chose to smoke all of his adult life.

What urinalysis finding would you expect to see for patient with diabetes insipidus A nurse caring for a patient with diabetes insipidus is reviewing laboratory results. What is an expected urinalysis finding?

Highly dilute urine

Home care measures for patient who had cataract surgery 1. The nurse is reinforcing home-care instructions to a client and family regarding care after cataract removal from the right eye. Which statement made by the client indicates an understanding of the instructions?

I should not sleep on my right side

A client is being discharged from the ambulatory care unit following cataract removal, and the nurse provides instructions regarding home care. Which statement by the client indicates an understanding of the instructions?

I will wear my eye shield at night and my glasses during the day

Teaching for patient with dry macular degeneration A nurse is providing teaching for a client who has a new diagnosis of dry macular degeneration. Which of the following instructions should the nurse include in the teaching?

Increase intake of deep yellow and orange vegetables

A pt is admitted to the hospital with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition?

Increase intake of fluids, including juice.

Patient has excessive secretion of the anterior pituitary hormones. What lab test results should the nurse expect. A young adult patient who is being seen in the clinic has excessive secretion of the anterior pituitary hormones. Which laboratory test result should the nurse expect?

Increased urinary cortisol

A nurse is assessing a client who has pancreatitis. Which of the following actions should the nurse take to assess the presence of Cullen's sign.

Inspect the skin around the umbilicus

What causes cystic fibrosis The parents of a child diagnosed with cystic fibrosis ask the nurse what happened to cause this disease. What is the best response by the nurse?

It is autosomal recessive, so both copies of the gene are abnormal.

A nurse is caring for a client who is experiencing mild acute pain after spraining an ankle. Which of the following analgesics should the nurse expect to administer?

Ketorolac

The nurse is caring for a 55-yr-old man patient with acute pancreatitis resulting from gallstones. Which clinical manifestation would the nurse expect?

Left upper abdominal pain

Patient with type 2 DM who is starting on intensive insulin therapy - what insulin will be used for mealtime coverage A patient with diabetes is starting on intensive insulin therapy. Which type of insulin will the nurse discuss using for mealtime coverage?

Lispro (Humalog)

What actions does the nurse take when using an interpreter for communication The nurse is caring for a Spanish-speaking patient that speaks no English. What action should the nurse take when using an interpreter for communication with this patient?

Maintain eye contact with the patient.

Assessment finding for patient developing hepatitis A after eating contaminated oysters A pt has developed hepatitis A after eating contaminated oysters. The nurse assesses the pt for which expected assessment finding?

Malaise

Nursing actions and post op care for a patient who is having transsphenoidal resection of pituitary tumor. The nurse is planning postoperative care for a patient who is being admitted to the surgical unit from the recovery room after transsphenoidal resection of a pituitary tumor. Which nursing action should be included?

Measure urine volume every hour.

What is the classic triad of Meniere's disease?

Meniere disease - The classic triad of symptoms (episodic vertigo, tinnitus, and hearing loss), likely caused by endolymphatic hydrops of the labyrinthine system of the inner ear.

A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results?

Metabolic acidosis

Which nursing intervention is most appropriate when caring for a patient with dehydration?

Monitor daily weight and intake and output.

Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient with acute pancreatitis?

Muscle twitching and finger numbness

Patient receiving iso-osmolar enteral nutrition and develops restlessness, agitation and weakness. What lab result should the nurse report to the HCP? An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately?

Na+ 154 mEq/L (154 mmol/L)

Nursing management for patient with acute pancreatitis What treatment measure is used in the management of the patient with acute pancreatitis?

Nasogastric (NG) suction to prevent gastric contents from entering the duodenum

Metabolic acidosis s/s

Neuro Sign & Symptoms of Metabolic Acidosis? -Drowsiness -Confusion -HA -Coma CV S&S of Metabolic Acidosis? -Decrease BP -Dysrhythmias (related to hyperkalemia from compensation) -Warm, flushed skin (peripheral vasodilation) GI S&S of Metabolic Acidosis? -N/V/D, abdominal pain Resp. S&S of Metabolic Acidosis? -Deep, rapid respiration (compensation by the lungs)

Different types of pain - define/descriptors An 82-year-old client has a long history of diabetes mellitus and developed diabetic neuropathy more than 25 years ago. He is without breakthrough pain at this point in time. How would his pain be classified?

Neuropathic and chronic

Patient with DKA secondary to DKA has been weaned off an insulin drip 30 minutes ago. The patient feels lightheaded and sweaty. What action should the nurse take. A patient who was admitted with diabetic ketoacidosis secondary to a urinary tract infection has been weaned off an insulin drip 30 minutes ago. The patient reports feeling lightheaded and sweaty. Which action should the nurse take first?

Obtain a glucose reading using a finger stick.

Patient with DM who has progressive loss of peripheral vision - what is this a manifestation of? An older adult client who has diabetes mellitus reports a gradual loss of peripheral vision. The nurse should recognize that this is a manifestation of which of the following diseases?

Open angle glaucoma

Which assessment finding is of most concern for a patient with acute pancreatitis?

Palpable abdominal mass

Know assessment findings consistent with acute pancreatitis

Palpable abdominal mass would be of MOST concern; absent bowel sounds, abdominal tenderness, and left upper quadrant pain

You are caring for a patient admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) who has the following arterial blood gas results: pH 7.33, PaO2 47 mm Hg, PaCO2 60 mm Hg, HCO3 32 mEq/L, and O2 saturation of 92%. What is the correct interpretation of these results?

Partially compensated respiratory acidosis

Laboratory findings for Hepatitic C A nurse is caring for a client who has a new diagnosis of hepatitis C. Which of the following is an expected laboratory finding?

Presence of enzyme immunoassay (EIA)

Plan of care for patient with hepatitis B with ascites A nurse on a medical-surgical unit is admitting a client who has hepatitis B with ascites. Which of the following actions should the nurse include in the plan of care?

Provide a high-calorie, high-carbohydrate diet.

Nursing Care: Hepatitis

Provide a high-carbohydrate, high-calorie, low- to moderate-fat, and low- to moderate-protein diet, and small, frequent meals to promote nutrition and healing.

Interventions for patient with acute pancreatitis NURSING INTERVENTIONS- ACUTE PANCREATITIS

Relieving Pain and Discomfort Improving Breathing Pattern Improving Nutritional Status Maintaining Skin Integrity Monitoring and Managing Potential Complications Educating Patients About Self-Care/Continuing and Transitional Care

Identify blood gases and how to interpret the results A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L?

Respiratory alkalosis

What type of data is it when the patient describes symptoms to the nurse

SUBJECTIVE data : Symptoms: What the pt/caregiver tells you.

29 yr old patient at first prenatal visit. Patient reports no history of diabetes but mother has diabetes. Which action will the nurse expect to take. The nurse is taking a health history from a 29-yr-old pregnant patient at the first prenatal visit. The patient reports that she has no personal history of diabetes, but her mother has diabetes. Which action will the nurse plan to take?

Schedule the patient for a fasting blood glucose level.

Patient fatigued and confused - what lab value will the nurse report A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse?

Serum calcium is 18 mg/dL.

Which words are often used to describe pain arising from skin, mucous membranes, and subcutaneous tissue? Select all that apply.

Sharp Prickly Burning

Analgesic for sprained ankle and acute mild pain The patient with a sprained ankle is complaining of pain in the injured area. Which term will the nurse use when documenting this patient's pain?

Somatic pain

What action is appropriate for nurse who is administering IV vesicant chemo agent to a patient. The nurse administers an IV vesicant chemotherapeutic agent to a patient. Which action is most important for the nurse to take?

Stop the infusion if swelling is observed at the site.

What action can be delegated to UAP in adult day care center The nurse manages the care of older adults in an adult health day care center. Which action can the nurse delegate to unlicensed assistive personnel (UAP)?

Take blood pressures daily and document in individual patient records.

On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess?

The client with kidney disease and a 12-year history of diabetes mellitus

What action demonstrates a nursing focus rather than a medical focus Which action most clearly demonstrates a nursing focus rather than a medical focus?

The nurse assesses the effect that a recent diagnosis of diabetes has on the patient's lifestyle and routines.

What information about breast cancer will the nurse provide for a 53 year old woman in menopause who is considering hormone therapy A 53-yr-old woman who is experiencing menopause is discussing the use of hormonetherapy (HT) with the nurse. Which information about the risk of breast cancer will the nurse provide?

The patient and her health care provider must weigh the benefits of HT against therisks of breast cancer. Because HT has been linked to increased risk for breast cancer, the patient and health care provider must determine whether or not to use HT. Breast cancer incidence is increased in women using HT, independent of other risk factors. HT increases the risk for both non-BRCA-associated cancer and BRCA-related cancers. Alternative therapies can be used but are not consistent in relieving menopausalsymptoms.

Teaching about administration of aspart (Novolog) insulin Which patient action indicates good understanding of the nurse's teaching about administration of aspart (NovoLog) insulin?

The patient cleans the skin with soap and water before insulin administration.

The nurse at the eye clinic made a follow-up telephone call to a patient who underwent cataract extraction and intraocular lens implantation the previous day. Which information is the priority to communicate to the health care provider?

The patient has eye pain rated at a 5 (on a 0 to 10 scale).

Teaching for patient with type 1 diabetes A 28-yr-old male patient with type 1 diabetes reports how he manages his exercise and glucose control. Which behavior indicates that the nurse should implement additional teaching?

The patient increases daily exercise when ketones are present in the urine.

Serum calcium 7.0 - what assessment finding is important to report to HCP A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider?

The patient is experiencing laryngeal stridor.

Goal in plan of care for patient with type 2 DM who has BMI of 31 kg/m2 The nurse is assessing a 55-yr-old female patient with type 2 diabetes who has a body mass index (BMI) of 31 kg/m2.Which goal in the plan of care is most important for this patient?

The patient will reach a glycosylated hemoglobin level of less than 7%

What happens to the postural muscles during the REM sleep cycle?

They are inhibited, and muscle tone is greatly reduced. During REM sleep, an individual cannot initiate muscle movement (cannot stand up, sleep walk).

Guided imagery Imagery is the use of one's mind to generate images that have a calming effect on the body. When using imagery for relaxation, the patient should visualize a comfortable and peaceful place. The nurse is teaching a patient how to use imagery as a relaxation technique for managing workplace stress. Which statement by the nurse would be appropriate?

Think of a place where you feel peaceful and comfortable.

Which lab value should nurse review to determine whether a patient's hypothyroidism is caused by a problem with the anterior pituitary gland. Which laboratory value should the nurse review to determine whether a patient's hypothyroidism is caused by a problem with the anterior pituitary gland?

Thyroid-stimulating hormone (TSH) level

The nurse is preparing to reinforce a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures should the nurse include in the plan? Select all that apply.

To avoid activities that require bending over To place an eye shield on the surgical eye at bedtime To contact the surgeon if a decrease in visual acuity occurs To take acetaminophen (Tylenol) for minor eye discomfort

What is the purpose of nursing assessment

To enable the nurse to make clinical judgements or nursing diagnoses about your pt's health status.

Coping mechanisms, stress control A female patient who initially came to the clinic with incontinence was recently diagnosed with endometrial cancer. She is usually well organized and calm, but the nurse who is giving her preoperative instructions observes that the patient is irritable, has difficulty concentrating, and yells at her husband. Which action should the nurse take?

Try to calm the patient before repeating information about the surgical process.

Manifestations of Meniere's disease A nurse is caring for a client who has suspected Ménière's disease. Which of the following is an expected finding?

Unilateral hearing loss

Priority nursing diagnosis for older client alone all day who takes multiple medications: The home health nurse cares for an older adult patient who lives alone and takes several different prescribed medications for chronic health problems. Which intervention, if implemented by the nurse, would support both the patient's self-management and the goal of medication adherence?

Use a marked pillbox to set up the patient's medications.

Discharge teaching for older patient with TIA

When caring for an older patient with hypertension who has been hospitalized after a transient ischemic attack (TIA), which topic is the most important for the nurse to include in the discharge teaching? Symptoms indicating that the patient should contact the health care provider Instruction on recognition of symptoms of hypertension and TIA and appropriate actions to take if these symptoms occur

Low pitched, bubbling sound during inhalation in the lower 1/3 bilaterally - how does the nurse document this finding On auscultation of a patient's lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding?

a. Inspiratory crackles at the bases

Patient takes Novolog insulin at 8:00 am. What time is the high risk for hypoglycemia? A patient receives aspart (NovoLog) insulin at 8:00 AM. At which time would the nurse anticipate the highest risk for hypoglycemia?

a. 10:00 AM

What action is indicative of stereotyping The charge nurse observes a staff nurse. What observed action would be most indicative of stereotyping?

advocating for bronchodilators to be prescribed for all newly admitted black patients

New diagnosis of type 2 DM. When would the nurse recommend a dilated eye examination? A 30-yr-old patient has a new diagnosis of type 2 diabetes. The nurse will discuss the need to schedule a dilated eye examination

as soon as possible

Food choice for patient scheduled for external-beam radiation for abdominal cancer The nurse should suggest which food choice for a patient scheduled to receive external-beam radiation for abdominal cancer?

b. Baked chicken

Type 1 DM plans to swim 1 hour a day at 1:00 pm. What advice will nurse give this patient. A patient who has type 1 diabetes plans to swim laps for an hour daily at 1:00 PM. The clinic nurse will plan to teach the patient to

check glucose level before, during, and after swimming.

2. .Nursing management of the patient with acute pancreatitis includes (select all that apply)

checking for signs of hypocalcemia. monitoring for infection, particularly respiratory tract infection

Post op teaching for cataract surgery A nurse is providing postoperative teaching to a client following cataract surgery. Which of the following statements should the nurse include in the teaching?

you need to limit your housekeeping activities"

A patient has the following arterial blood gas results: pH 7.52; PaCO2 30 mmHg; HCO3- 24 mEq/L. The nurse determines that these results indicate:

d. respiratory alkalosis

Conditions associated with hyperkalemia A nurse is assessing a client who has hyperkalemia. Which of the following conditions is associated withthis electrolyte imbalance?

diabetic ketoacidosis

Define pain Pain is objective, true or false?

false

STI has positive Rapid Plasma Reagin (RPR) test, no visible chancre on assessment. What specimens and tests should the nurse expect to do/send A 44-year-old patient in the sexually transmitted infection clinic has a positive Venereal Disease Research Laboratory (VDRL) test, but no chancre is visible on assessment. The nurse will plan to send specimens for

fluorescent treponemal antibody absorption (FTA-Abs).

Patient with NG tube attached to low intermittent suctioning. What electrolyte imbalances are expected. A nurse is caring for a pt who has an NG tube attached to low intermittent suctioning. The nurse should monitor for which of the following electrolyte imbalances?

hyponatremia

What is associated with insufficient sleep Insufficient sleep is associated with (select all that apply):

increased body mass index increased insulin resistance impaired cognitive functioning

Patient is unresponsive in ED with HHS. What should the nurse anticipate doing An unresponsive patient with type 2 diabetes is brought to the emergency department and diagnosed with hyperosmolar hyperglycemic syndrome (HHS). The nurse will anticipate the need to

insert an IV catheter

Acid-base imbalance expected from 24 hr of vomiting A nurse is obtaining arterial blood gases for a client who has vomited for 24hr. The nurse should expect which of the following acid-base imbalances to result from vomiting for 24 hr?

metabolic alkalosis

Teaching for 67 year old patient who is dx with orchitis The nurse will plan to provide teaching for a 67-year-old patient who has been diagnosed with orchitis about

pain management.

What is the potential cause of infection with perineal radical prostatectomy A patient returning from surgery for a perineal radical prostatectomy will have a nursing diagnosis of risk for infection related to

possible fecal wound contamination.

Teaching for 26 year old who is treated for pelvic inflammatory disease After a 26-yr-old patient has been treated for pelvic inflammatory disease, the nurse willplan to teach about the

potential complication of infertility. Pelvic inflammatory disease may cause scarring of the fallopian tubes and result in difficulty in fertilization or implantation of the fertilized egg. Because ovarian function is not affected, the patient will not require HT, have irregular menstrual cycles, or experience changes in secondary sex characteristics.

After returning home, a client who has had cataract surgery will need to continue to instill eye drops in the affected eye. The client is instructed to apply slight pressure against the nose at the inner canthus of the eye after instilling the eye drops. The expected outcome of applying pressure is that the pressure:

prevents the medication from entering the tear duct.(systemic effects).

Nutrition for viral hepatitis 1. One of the most challenging nursing interventions to promote healing in the patient with viral hepatitis is

providing adequate nutritional intake

Technique to assess for Chvotek's sign A nurse is assessing a client for Chovstek's sign. Which of the following techniques should the nurse useto perform this test?

tap lightly on the pt's cheek

Patient dx with breast cancer asks what "triple negative" means. What is the correct response A patient diagnosed with breast cancer asks the nurse what "triple negative" means. Anaccurate response from the nurse about triple-negative breast cancer should include that

the tumor is not likely to be responsive to hormone therapy. A. patient whose breast cancer tests negative for all three receptors (estrogen, progesterone, and HER-2) has triple-negative breast cancer. These cancers do not usually respond to hormone therapy or therapy for the human epidermal growth factor receptor 2 (HER-2). Chemotherapy appears to have the most success in treating triple-negative breast cancer.

An older woman was admitted to the medical unit with dehydration. Clinical indications of this problem are (select all that apply):

weight loss dry oral mucosa decreased central venous pressure

You are caring for a patient admitted with an exacerbation of asthma. After several treatments, the ABG results are pH 7.40, PaCO2 40 mm Hg, HCO3 24 mEq/L, PaO2 92 mm Hg, and O2 saturation of 99%. You interpret these results as

within normal limits.