Adult Health Exam II

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A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis? A.) Oral mucosa B.) Conjunctivae C.) Ear lobes D.) Soles of the feet

Which finding would the nurse expect when assessing the legs of a patient who has a lower motor neuron lesion? A.) Spasticity B.) Flaccidity C.) No sensation D.) Hyperactive reflexes

A 17 year old patient with a leg fracture who is scheduled for surgery is an emancipated minor. She has a statement from the court for verification. Which intervention is the most appropriate? A.) Witness the permit after consent is obtained by the surgeon B.) Call a parent or legal guardian to sign the permit, since the patient is under 18 C.) Obtain verbal consent, since written consent is not necessary for emancipated minors D.) Investigate your state's nurse practice act related to emancipated minors and informed consent

A 40-year-old patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan? A.) Apply intermittent pneumatic compression stockings B.) Assist to dangle on edge of bed and assess for dizziness C.) Encourage patient to cough and deep breathe every 4 hours D.) Insert an oropharyngeal airway to prevent airway obstruction

A 42-year-old patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care? A.) Encourage family members to remain at the bedside B.) Apply soft restraints to protect the patient from injury C.) Keep the room well-lighted to improve patient orientation D.) Minimize contact with the patient to decrease sensory input

A 45-year-old patient has a dysfunction of the cerebellum. The nurse will plan interventions to: A.) Prevent falls B.) Stabilize mood C.) Avoid aspiration D.) Improve memory

A 59 year old man scheduled for a herniorrhaphy in 2 day reports that he takes ginkgo daily. What is the priority intervention? A.) Inform the surgeon. since the procedure may have to be rescheduled B.) Notify the anesthesia care provider, since this herb interferes with anesthesics C.) Ask the patient if he has noticed any side effects from taking this herbal supplement D.) Tell the patient to continue to take the herbal supplement up to the day before surgery

A 68-year-old male patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by his spouse. Which action will the nurse take first? A.) Check oxygen saturation B.) Assess pupil reaction to light C.) Verify Glasgow Coma Scale (GCS) score D.) Palpate the head for hematoma or bony irregularities

A client who had a stroke needs to be fed. What instruction should the nurse give to the unlicensed assistive personnel (UAP) who will feed the client? A.) Position the client sitting up in bed before he or she is fed B.) Check the client's gag and swallowing reflexes C.) Feed the client quickly because there are three more clients to feed D.) Suction the client's secretions between bites of food

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

A female patient who had a stroke 24 hours ago has expressive aphasia. The nurse identifies the nursing diagnosis of impaired verbal communication. An appropriate nursing intervention to help the patient communicate is to: A.) Ask questions that the patient can answer with yes or no B.) Develop a list of words that the patient can read and practice reciting C.) Have the patient practice her facial and tongue exercises with a mirror D.) Prevent embarrassing the patient by answering for her if she does not respond

A male patient who has possible cerebral edema has a serum sodium level of 116 mEq/L (116 mmol/L) and a decreasing level of consciousness (LOC). He is now complaining of a headache. Which prescribed interventions should the nurse implement first? A.) Administer IV 5% hypertonic saline B.) Draw blood for arterial blood gases (ABGs) C.) Send patient for computed tomography (CT) D.) Administer acetaminophen (Tylenol) 650 mg orally

A nurse in a clinic is caring for a client whose partner states the client woke up this morning, did not recognize him, and did not know where she was. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nursing priority? A.) Obtain baseline vital signs and oxygen saturation B.) Obtain a sputum culture C.) Obtain a complete history from the client D.) Provide a pneumococcal vaccine

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? A.) Hand tremors B.) Bradycardia C.) Pallor D.) Slow speech

A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care? A.) Airway protection B.) Decreasing intracranial pressure C.) Stabilizing cardiac arrhythmias D.) Preventing musculoskeletal disability

A nurse in the emergency department is caring for a client who has extensive partial and full thickness burnets of the head, neck and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention? A.) Airway obstruction B.) Infection C.) Fluid imbalance D.) Paralytic ileus

A nurse in the emergency department is caring for a client who has pulmonary edema, reports dyspnea, and appears anxious. The client's blood pressure is 108/79 and his apical pulse is 112. Which of the following interventions is the nurse's priority? A.) Administer high flow oxygen at 5 L/min by facemark to the client B.) Place the client in high-Fowler's position with legs dependent C.) Give the client sublingual nitroglycerin D.) Reassure the client

A nurse in the post-anesthesia care unit is caring for a client who is the postoperative following a thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse give the highest priority to? A.) Arterial blood gasses B.) Urinary output C.) Chest tube drainage D.) Pain level

A nurse is admitting a client who is having an exacerbation of his asthma. When reviewing the provider's orders, the nurse recognizes that clarification is needed for which of the following medications? A.) Propranolol B.) Theophylline C.) Montelukast D.) Prednisone

A nurse is assessing a client immediately after the provider removed the client's endotracheal tube. Which of the following findings should the nurse report tot he provider? A.) Stridor B.) Copious oral secretions C.) Hoarseness D.) Sore throat

A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication? A.) Increased respiratory rate from 18 to 44/min B.) Increased oral temperature from 36.6 C to 37 C C.) Increased blood pressure from 112/68 to 120/72 mmHg D.) Increased heart rate from 68 to 72/min

A nurse is assisting an anesthesiologist in the delivery of nitrous oxide by face mask to a client during the induction of anesthesia. Which of the following is the priority nursing action? A.) Assess oxygen saturation B.) Measure blood pressure C.) Palpate pulse rate D.) Check temperature

A nurse is auscultating the lungs of a client who has pleurisy. Which of the following adventitious breath sounds should the nurse expect to hear? A.) Loud, scratchy sounds B.) Squeaky, musical sounds C.) Popping sounds D.) Snoring sounds

A nurse is caring for a client who has a disposal three-chamber chest tube in place. Which of the following findings should indicate to the nurse that the client is experiencing a complication? A.) Continuous bubbling in the water-seal chamber B.) Occasional bubbling in the water-seal chamber C.) Constant bubbling in the suction-control chamber D.) Fluctuations in the fluid level in the water-seal chamber

A nurse is caring for a client who has a three-chamber chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration? A.) Continue to monitor the client B.) Immediately notify the provider C.) Reposition the client toward the left side D.) Clamp the chest tube near the water seal

A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client had inter maxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority for the nurse to take? A.) Prevent aspiration B.) Ensure adequate nutrition C.) Promote oral hygiene D.) Relieve the client's pain

A nurse is caring for a client who is postoperative and whose respirations are shallow and 9/min. Which of the following acid-based imbalances should the nurse identify the client as being at risk for developing initially? A.) Respiratory acidosis B.) Respiratory alkalosis C.) Metabolic acidosis D.) Metabolic alkalosis

A nurse is caring for a client who is postoperative following an inter maxillary fixation as a result of multiple facial fractures. Which of the following types of equipment should the nurse plan to have at the client's bedside? A.) Wire cutters B.) NG tube C.) Urinary catheter tray D.) IV infusion pump

A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take? A.) Position the client in an upright position, leaning over the bedside table B.) Explain the procedure C.) Obtain ABGs D.) Administer benzocaine spray

A nurse is caring for a client who is scheduled for an exploratory laparotomy. The client's temperature is 102.2 F orally. Which of the following actions should the nurse take? A.) Inform the surgeon of the elevated temperature B.) Transfer the client to the preoperative unit C.) Apply ice packs to the groin D.) Encourage the client to increase intake of clear liquids

A nurse is caring for a client who is to receive thrombolytic therapy. Which of the following factors should the nurse recognize as a contraindication to the therapy? A.) Hip arthroplasty 2 weeks ago B.) Elevated sedimentation rate C.) Incident of exercise-induced asthma 1 week ago D.) Elevated platelet count

A nurse is caring for a client who reports nausea and vomiting 2 days postoperative following hysterectomy. Which of the following actions should the nurse perform first? A.) Assess bowel sounds B.) Administer antiemetic medication C.) Restart prescribed IV fluids D.) Insert a prescribed nasogastric tube

A nurse is caring for a client who was recently admitted to the emergency department following a head-on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, and has a laceration on his forehead that is bleeding. Which of the following is the priority nursing action at this time? A.) Keep neck stabilized B.) Insert nasogastric tube C.) Monitor pulse and blood pressure frequently D.) Establish IV access and start fluid replacement

A nurse is creating a plan of care for a client who is in the late stage of inhalation anthrax. Which of the following is appropriate to include in the plan of care? A.) Provide respiratory support B.) Place the client in droplet isolation C.) Administer antihypertensive medications D.) Monitor ascites

A nurse is discharging a client who has COPD. Upon discharge, the client is concerned that he will never be able to leave his house now that he is on continuous oxygen. Which of the following is an appropriate response by the nurse? A.) "There are portable oxygen delivery systems that you can take with you" B.) "When you go out, you can remove the oxygen and then reapply it when you get home" C.) "You probably will not be able to go out as much as you used to" D.) "Home health services will come to you so you will not need to get out"

A nurse is preparing an adolescent client who has pneumonia for percussion, vibration and postural drainage. Prior to the procedure, which of the following nursing actions should the nurse complete first? A.) Auscultate lung fields B.) Assess pulse and respirations C.) Assess characteristics of her sputum D.) Instruct to slowly exhale with pursed lips

A nurse is reviewing the arterial blood gas values for a client. The pH is 7.32, PaCO2 48 mmHg, and the HCO3 is 23 mEq/L. The nurse should recognize that these findings indicate which of the following acid bases? A.) Respiratory acidosis B.) Respiratory alkalosis C.) Metabolic acidosis D.) Metabolic alkalosis

A nurse is teaching a group of clients about influenza. Which of the following client statements indicates an understanding of the teaching? A.) "I should wash my hands after blowing my nose to prevent spreading the virus" B.) "I need to avoid drinking fluids if I develop symptoms" C.) "I need a flu shot every 2 years because of the different flu strains" D.) "I should cover my mouth with my hand when I sneeze"

A nurse obtains a health history for a patient who has a 35 pack year smoking history. The patient complains of hoarseness and tightness in the throat and difficulty swallowing. Which question is most important for the nurse to ask? A.) How much alcohol do you drink in an average week B.) Do you have a family history of head or neck cancer C.) Have you had frequent streptococcal throat infections D.) Do you use antihistamines for upper airway congestion

A patient arrives at the ambulatory surgery center for a scheduled laparoscopy procedure in outpatient surgery. Which information is of most concern to the nurse? A.) The patient is planning to drive home after surgery B.) The patient had a sip of water 4 hours before arriving C.) The patient's insurance does not cover outpatient surgery D.) The patient has not had surgery using general anesthesia before

A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment? A.) Paradoxi chest movement B.) Complain of chest wall pain C.) Heart rate of 110 beats/minute D.) Large bruised area on the chest

A patient has a serum sodium level of 152 mEq/L (152 mmol/L). The normal hormonal response to this situation is: A.) Release of ADH B.) Release of ACTH C.) Secretion of aldosterone D.) Secretion of corticotropin-releasing hormone

A patient has a total serum calcium level of 3 mg/dL (1.5 mEq/L). If this finding reflects hypoparathyroidism, the nurse would expect further diagnostic testing to reveal: A.) Decreased serum PTH B.) Increased serum ACTH C.) Increased serum glucose D.) Decreased serum cortisol levels

A patient has been receiving high dose corticosteroids and broad-spectrum antibiotics for treatment secondary to a traumatic injury and infection. The nurse plans care for the patient knowing that the patient is most susceptible to: A.) Candidiasis B.) Aspergillosis C.) Histoplasmosis D.) Coccidiodomycosis

A patient has chronic obstructive pulmonary disease (COPD). Which intervention for airway management should the nurse delegate to the unlicensed assistive personnel (UAP)? A.) Assisting the patient to sit up on the side of the bed B.) Instructing the patient to cough effectively C.) Teaching the patient to use incentive spirometry D.) Auscultating breath sounds every 4 hours

A patient in the clinic with cystic fibrosis (CF) reports increased sweating and weakness during the summer months. Which action by the nurse would be most appropriate? A.) Have the patient add dietary salt to meals B.) Teach the patient about the signs of hypoglycemia C.) Suggest decreasing intake of dietary fat and calories D.) Instruct the patient about pancreatic enzyme replacements

A patient is admitted to the emergency department complaining of sudden onset shortness of breath and is diagnosed with a possible pulmonary embolus. How should the nurse prepare the patient for diagnostic testing for confirm the diagnosis? A.) Start an IV so contrast media may be given B.) Ensure that the patient has been NPO for at least 6 hours C.) Inform radiology that radioactive glucose preparation is needed D.) Instruct the patient to undress to the waist and remove any metal objects

A patient is admitted to the emergency department with a severe exacerbation of asthma. Which finding is of most concern to the nurse? A.) Unable to speak and sweating profusely B.) PaO2 of 80 mm Hg and PaCO2 of 50 mm Hg C.) Presence of inspiratory and expiratory wheezing D.) Peak expiratory flow rate at 60% of personal best

A patient is admitted with a headache, fever and general malaise. The HCP has asked that the patient be prepared for a lumbar puncture. What is a priority nursing action to avoid complications? A.) Ensure that CT scan is performed prior to lumbar puncture B.) Assess laboratory results for changes in the white cell count C.) Provide acetaminophen for the headache and fever before the procedure D.) Administer antibiotics before the procedure to treat the potential meningitis

A patient is suspected of having a brain tumor. The signs and symptoms include memory deficits, visual disturbances, weakness of right upper and lower extremities, and personality changes. The nurse recognizes that the tumor is most likely located in the: A.) Frontal lobe B.) Parietal lobe C.) Occipital lobe D.) Temporal lobe

A patient scheduled for an elective hysterectomy tells the nurse, "I am afraid that I will die in surgery like my mother did!" Which response by the nurse is most appropriate? A.) "Tell me more about what happened to your mother." B.) "You will receive medications to reduce your anxiety." C.) "You should talk to the doctor again about the surgery." D.) "Surgical techniques have improved a lot in recent years."

A patient scheduled to undergo total knee replacement under general anesthesia asks the nurse, "Will the doctor put me to sleep with a mask over my face?" Which response by the nurse is most appropriate? A.) A drug may be given to you through your IV line first. I will check with the anesthesia care provider B.) Only your surgeon can tell you for sure what method of anesthesia will be used. Should I ask your surgeon C.) General anesthesia is now given by injecting medication in your veins, so you will not need a mask over your face D.) Masks are not used anymore for anesthesia. A tube will be inserted into your throat to deliver a gs that will put you to sleep

A patient who had knee surgery received intramuscular ketorolac (Toradol) 30 minutes ago and continues to complain of pain at a level of 7. Which action is best for the nurse to take at this time? A.) Administer the prescribed PRN IV morphine sulfate B.) Notify the health care provider about the ongoing knee pain C.) Reassure the patient that postoperative pain is expected after knee surgery D.) Teach the patient that the effects of ketorolac typically lasts about 6 to 8 hours

A patient who has bronchiectasis asks the nurse, "What conditions would warrant a call to the client?" A.) Blood clots in the sputum B.) Sticky sputum on a hot day C.) Increased shortness of breath after eating a large meal D.) Production of large amounts of sputum on a daily basis

A patient who is experiencing an acute asthma attack is admitted to the emergency department. Which assessment should the nurse complete first? A.) Listen to the patient's breath sounds B.) Ask about inhaled corticosteroid use C.) Determine when the dyspnea started D.) Obtain the forced expiratory volume (FEV) flow rate

A patient who is experiencing an asthma attack develops bradycardia and a decrease in wheezing. Which action should the nurse take first? A.) Notify the health care provider B.) Document changes in respiratory status C.) Encourage the patient to cough and deep breathe D.) Administer IV methylprednisolone (Solu-Medrol)

A patient who is scheduled for a therapeutic abortion tells the nurse, "having an abortion is not right." What functional health pattern should the nurse further assess? A.) Value-belief B.) Cognitive-perceptual C.) Sexuality-reproductive D.) Coping-stress tolerance

A patient who was admitted the previous day with pneumonia complains of a sharp pain of 7 whenever "I take a deep breath." Which action will the nurse take next? A.) Auscultate breath sounds B.) Administer the PRN morphine C.) Have the patient cough forcefully D.) Notify the patient's health care provider

A patient who was admitted with myxedema coma and diagnosed with hypothyroidism is improving and expected to be discharged in 2 days. Which teaching strategy will be best for the nurse to use? A.) Provide written reminders of self care information B.) Offer multiple options for management of therapies C.) Ensure privacy for teaching by asking visitors to leave D.) Delay teaching until patient discharge data is confirmed

A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan. Which information obtained by the nurse is a priority to communicate to the health care provider before the CT? A.) Allergy to shellfish B.) Apical pulse of 104 C.) Respiratory rate of 30 D.) Oxygen saturation of 90%

A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by nonrebreather mask, but arterial blood gas measurements continue to show poor oxygenation. Which action does the nurse anticipate that the health care provider will prescribe? A.) Perform endotracheal intubation and initiate mechanical ventilation B.) Immediately begin continuous positive airway pressure (CPAP) via the patient's nose and mouth C.) Administer furosemide (Lasix) 100 mg IV push immediately (STAT) D.) Call a code for respiratory arrest

A patient with bacterial pneumonia has rhonchi and thick sputum. Which action will the nurse use to promote airway clearance? A.) Assist the patient to splint the chest when coughing B.) Educate the patient about the need for fluid restrictions C.) Encourage the patient to wear the nasal oxygen cannula D.) Instruct the patient on the pursed lip breathing technique

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

A patient with chronic obstructive pulmonary disease (COPD) has rapid shallow respirations. Which is an appropriate action to assign to the experienced LPN/LVN under RN supervision? A.) Observing how well the patient performs pursed-lip breathing B.) Planning a nursing care regimen that gradually increases activity tolerance C.) Assisting the patient with basic activities of daily livings (ADLs) D.) Consulting with the physical therapy department about reconditioning exercises

A patient's eyes jerk while the patient looks to the left. You will record this finding as: A.) Nystagmus B.) CN VI palsy C.) Oculocephalia D.) Ophthalmic dyskinesia

A postoperative patient has not voided for 8 hours after return to the clinical unit. Which action should the nurse take first? A.) Perform a bladder scan B.) Encourage increased oral fluid intake C.) Assist the patient to ambulate to the bathroom D.) Insert a straight catheter as indicated on the PRN order

A priority nursing interventions for a patient who has just undergone a chemical pleurodesis for recurrent pleural effusion is: A.) Administering ordered analgesia B.) Monitoring chest tube drainage C.) Sending pleural fluid for laboratory analysis D.) Monitoring the patient's level of consciousness

A young adult patient who denies any history of smoking is seen in the clinic with a new diagnosis of chronic obstructive pulmonary disease (COPD). It is most appropriate for the nurse to teach the patient about: A.) A1-antitrypsin testing B.) Use of the nicotine patch C.) Continuous pulse oximetry D.) Effects of leukotriene modifiers

Admission vital signs for a brain-injured patient are blood pressure 128/68, pulse 110, and respirations 26. Which set of vital signs, if taken 1 hour after admission, will be of most concern to the nurse? A.) Blood pressure 154/68, pulse 56, respirations 12 B.) Blood pressure 134/72, pulse 90, respirations 32 C.) Blood pressure 148/78, pulse 112, respirations 28 D.) Blood pressure 110/70, pulse 120, respirations 30

After admission of the postoperative patient to the clinical unit, which assessment data require the most immediate attention? A.) Oxygen saturation of 85% B.) Respiratory rate of 13/min C.) Temperature of 100.4F D.) Blood pressure of 90/60 mmHg

After being hit by a baseball, a patient arrives in the emergency department with a possible nasal fracture. Which finding by the nurse is most important to report to the health care provider? A.) Clear nasal drainage B.) Complaint of nasal pain C.) Bilateral nose swelling and bruising D.) Inability to breathe through the nose

After receiving change of shift report about these postoperative patients, which patient should the nurse assess first? A.) Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating B.) Patient who has 30 mL of sanguineous drainage in the wound drain 10 hours after hip replacement surgery C.) Patient who has bibasilar crackles and a temperature of 100 F on the first postoperative day after chest surgery D.) Patient who continues to have incisional pain 15 minutes after hydrocodone and acetaminophen (Vicodin) administration

After receiving change-of-shift report on the following four patients, which patient should the nurse see first? A.) A 60-year-old patient with right-sided weakness who has an infusion of tPA prescribed B.) A 50-year-old patient who has atrial fibrillation and a new order for warfarin (Coumadin) C.) A 40-year-old patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due D.) A 30-year-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop) scheduled

An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse should notify the health care provider if the patient exhibits which finding? A.) Yellow-tinged skin B.) Orange-colored sputum C.) Thickening of the fingernails D.) Difficulty hearing high-pitched voices

During admission of a patient with a severe head injury to the emergency department the nurse places the highest priority on assessment for: A.) Patency of airway B.) Presence of neck injury C.) Neurologic status with Glasgow coma scale D.) Cerebrospinal fluid leakage from the ears or nose

During change-of-shift report, the nurse learns that a patient with a head injury has decorticate posturing to noxious stimulation. Which positioning shown in the accompanying figure will the nurse expect to observe? A.) 1 B.) 2 C.) 3 D.) 4

Endocrine disorders often go unrecognized in the older adult, because: A.) Symptoms are often attributed to aging B.) Older adults rarely have identifiable symptoms C.) Endocrine disorders are relatively rare in the older adult D.) Older adults usually have subclinical endocrine disorders that minimize symptoms

Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which information best supports this diagnosis? A.) Weak, nonproductive cough effort B.) Large amounts of greenish sputum C.) Respiratory rate of 28 breaths/minute D.) Resting pulse oximetry (SpO2) of 85%

For a patient who had a right hemisphere stroke the nurse establishes a nursing diagnosis of: A.) Risk for injury related to denial of deficits and impulsiveness B.) Impaired physical mobility related to right-sided hemiplegia C.) Impaired verbal communication related to speech-language deficit D.) Ineffective coping related to depression and distress about disability

In evaluating an asthmatic patient's knowledge of self-care, the nurse recognizes that additional instruction is needed when the patient says, A.) "I use my corticosteroid inhaler when I feel short of breath" B.) "I get a flu shot every year and see my health care provider if I have an upper respiratory tract infection" C.) "I use my inhaler before I visit my aunt who has a cat, but I only visit for a few minutes because of my allergies" D.) "I walk 30 minutes every day but sometimes I have to use my bronchodilator inhaler before walking to prevent me from getting short of breath"

On auscultation of a patient's lungs, the nurse hears low pitches, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding? A.) Inspiratory crackles at the bases B.) Expiratory wheezes in both lungs C.) Abnormal lung sounds in the apices of both lungs D.) Pleural friction rub in the right and left lower lobes

The RN is supervising a senior nursing student who is caring for a client with a right hemisphere stroke. Which action by the nurse requires that the RN intervenes? A.) Instructing the client to sit up straight and the client responds with a puzzled expression B.) Moving the client's food tray to the right ride of his over-bed table C.) Assisting the client with passive range-of-motion (ROM) exercises D.) Combing the hair on the left side of the client's head when the client always combs his hair on the right side

The best method for determining the risk of aspiration in a patient with a tracheostomy to: A.) Consult a speech therapist for swallowing assessment B.) Have the patient drink plain water and assess for coughing C.) Have for change of sputum color 48 hours after patient drinks small amount of blue dye D.) Suction above the cuff after the patient eats or drinks to determine presence of food in trachea

The clinical nurse teaches a patient with a 42 pack year history of cigarette smoking about lung disease. Which information will be most important for the nurse to include? A.) Options for smoking cessation B.) Reasons for annual sputum cytology testing C.) Erlotinib (Tarceva) therapy to prevent tumor risk D.) Computed tomography (CT) screening for lung cancer

The critical care charge nurse is responsible for the care of four patients receiving mechanical ventilation. Which patient is most at risk for failure to wean and ventilator dependence? A.) A 68 year old patient with a history of smoking and emphysema B.) A 57 year old patient who experienced a cardiac arrest C.) A 49 year old postoperative patient who has a colectomy D.) A 29 year old patient who is recovering from flail chest

The emergency department nurse is caring for patients exposed to a chlorine leak from a local factory. The nurse would closely monitor the patients for: A.) Pulmonary edema B.) Anaphylactic shock C.) Respiratory alkalosis D.) Acute tubular necrosis

The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment would best evaluate the effectiveness of the therapies? A.) Observe for distended neck veins B.) Auscultate for crackles in the lungs C.) Palpate for heaves or thrills over the heart D.) Review hemoglobin and hematocrit values

The nurse assess a patient with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea over the last 3 days. Which finding is most important for the nurse to report to the health care provider? A.) Respirations are 36 breaths/minute B.) Anterior-Posterior chest ratio is 1:1 C.) Lung expansion is decreased bilaterally D.) Hyperresonance to percussion is present

The nurse assess the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect? A.) Increased tactile fremitus B.) Dry, nonproductive cough C.) Hyperresonance to percussion D.) A grating sound of auscultation

The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider? A.) The right calf is swollen, warm and painful B.) The patient's temperature is 100.3 F C.) The 24 hour oral intake is 600 mL greater than the total output D.) The patient complains of abdominal pain at level 6 when ambulating

The nurse care for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider? A.) Oxygen saturation is 88% B.) Blood pressure is 145/90 mmHg C.) Respiratory rate is 22 breaths/minute when lying flat D.) Pain level is 5 with a deep breath

The nurse completes discharge instructions for a patient with a total laryngectomy. Which statement by the patient indicates that additional instruction is needed? A.) "I must keep the stoma covered with an occlusive dressing at all times." B.) "I can participate in most of my prior fitness activities except swimming." C.) "I should wear a Medic-Alert bracelet that identifies me as a neck breather." D.) "I need to be sure that I have smoke and carbon monoxide detectors installed."

The nurse in the emergency department receives arterial blood gas results for four recently admitted patients with obstructive pulmonary disease. Which patient will require the most rapid action by the nurse? A.) 22-year-old with ABG results: pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg B.) 34-year-old with ABG results: pH 7.48, PaCO2 30 mm Hg, and PaO2 65 mm Hg C.) 45-year-old with ABG results: pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg D.) 65-year-old with ABG results: pH 7.31, PaCO2 58 mm Hg, and PaO2 64 mm Hg

The nurse in trauma unit has received report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first? A.) Evaluate chest expansion B.) Check pupillary response to light C.) Assess the capillary refill D.) Check client's response to questions about place and time

The nurse is admitting a patient for whom a diagnosis of pulmonary embolus must be ruled out. The patient's history and assessment reveal all of these findings. Which findings support the diagnosis of pulmonary embolus? A.) The patient was recently in a motor vehicle crash B.) The patient participated in an aerobic exercise program for 6 months C.) The patient gave birth to her youngest child 1 year ago D.) The patient on bed rest for 6 months after a diagnostic procedure

The nurse is caring for a client who has heart failure and a history of asthma. The nurse reviews the provider's orders and recognizes that clarification is needed for which of the following medications? A.) Carvedilol B.) Fluticasone C.) Captopril D.) Isosorbide denigrate

The nurse is caring for a client with a glioblastoma who is receiving dexamethasone 4 mg IV push every 6 hours to relieve symptoms of right arm weakness and headache. Which assessment information concerns the nurse the most? A.) The client no longer recognizes family members C.) The blood glucose level is 234 mg/dL C.) The client reports a continuing headache D.) The daily weight has increased by 2.2 lbs

The nurse is caring for a hospitalized older patient who has nasal packing in place to treat a nosebleed. Which assessment finding will require the most immediate action by the nurse? A.) The oxygen saturation is 89% B.) The nurse appears red and swollen C.) The patient's temperature is 100.1 F D.) The patient complains of level 8/10 pain

The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy tube. Which action by the nurse would best determine if the cuff has been properly inflated? A.) Use a manometer to ensure cuff pressure is at an appropriate level B.) Check the amount of cuff pressure ordered by the health care provider C.) Suction the patient first with a fenestrated inner cannula to clear secretions D.) Insert the decannulation plug before the nonfenestrated inner cannula is removed

The nurse is caring for a patient who has right sided tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)? A.) Document the amount of drainage every eight hours B.) Obtain samples of drainage for cultures from the system C.) Assess patient pain level associated with the chest tube D.) Check the water seal chamber for the correct fluid level

The nurse is caring for a patient with cor pulmonale. The nurse should monitor the patient for which expected finding? A.) Peripheral edema B.) Elevated temperature C.) Clubbing of the fingers D.) Complaints of chest pain

The nurse is caring for a patient with hyperthyroidism who had a partial thyroidectomy yesterday. Which change in assessment would the nurse report to the health care provider immediately? A.) Temperature elevation to 100.2 F B.) Heart rate increase from 64 to 76 beats/min C.) Respiratory rate decrease from 26 to 16 breaths/min D.) Pulse oximetry reading of 92%

The nurse is mentoring a student nurse in the intensive care unit while caring for a client with meningococcal meningitis. Which action by the student requires that the nurse intervene most rapidly? A.) Entering the room without putting on a protective mask and gown B.) Instructing the family that visits are restricted to 10 minutes C.) Giving the client a warm blanket when he says he feels cold D.) Checking the client's pupil response to light every 30 minutes

The nurse is orienting a new graduate RN who is providing care for a postoperative patient after a thyroidectomy. The new graduate assess the patient and notes laryngeal stridor with a pulse oximetry measure of 89%. What is the priority action of the nurse and new graduate? A.) Immediately notify the Rapid Response Team (RRT) B.) Apply oxygen by face mask C.) Prepare to suction the patient D.) Assess for numbness and tingling around the mouth

The nurse is preparing the patient for a diagnostic procedure to remove pleural field for analysis. The nurse would prepare the patient for which test? A.) Thoracentesis B.) Bronchoscopy C.) Pulmonary angiography D.) Sputum culture and sensitivity

The nurse is preparing to discharge a client with chronic low back pain. Which statement by the client indicates the need for additional teaching? A.) "I will avoid exercise because the pain gets worse" B.) "I will use heat or ice to help control the pain" C.) "I will not wear high-heeled shoes at home or work" D.) "I will purchase a firm mattress to replace my old one"

The nurse is providing care for a patient who underwent thyroidectomy 2 days ago. Which laboratory value requires close monitoring by the nurse? A.) Calcium level B.) Sodium level C.) Potassium level D.) White blood cell count

The nurse notes tidaling of the water level in the tube submerged in the water-seal chamber in a patient with closed chest tube drainage. The nurse should: A.) continue to monitor the patient B.) check all connections for a leak in the system C.) lower the drainage collector further from the chest D.) clamp the tubing at progressively distal points away from the patient until the tidaling stops

The nurse reviews the medication administration record (MAR) for a patient having an acute asthma attack. Which medication should the nurse administer first? A.) Albuterol (Ventolin) 2.5 mg per nebulizer B.) Methylprednisolone (Solu-Medrol) 60 mg IV C.) Salmeterol (Serevent) 50 mcg per dry-powder inhaler (DPI) D.) Triamcinolone (Azmacort) 2 puffs per metered-dose inhaler (MDI)

The nurse working in the postanesthesia care unit (PACU) notes that a patient who has just been transported from the operating room is shivering and has a temperature of 96.5° F (35.8° C). Which action should the nurse take? A.) Cover the patient with a warm blanket and put on socks B.) Notify the anesthesia care provider about the temperature C.) Avoid the use of opioid analgesics until the patient is warmer D.) Administer acetaminophen (Tylenol) 650 mg suppository rectally

The nurse's primary responsibility for the care of the patient undergoing surgery is: A.) Developing an individualized plan of nursing care for the patient B.) Carrying out specific tasks related to surgical policies and procedures C.) Ensuring that the patient has been assessed for safe administration of anesthesia D.) Performing a preoperative history and physical assessment to identify patient needs

The surgical unit nurse has just received a patient with a history of smoking from the postanesthesia care unit. Which action is most important at this time? A.) Auscultate for adventitious breath sounds B.) Obtain the patient's blood pressure and temperature C.) Remind the patient about harmful effects of smoking D.) Ask the health care provider about prescribing a nicotine patch

The unlicensed assistive personnel (UAP) is assisting with feeding for a patient with severe end-stage chronic obstructive pulmonary disease (COPD). Which instruction will the nurse provide the UAP? A.) Encourage the patient to eat foods that are high in calories in protein B.) Feed the patient as quickly as possible to prevent early satiety C.) Offer lots of fluids between bites of food D.) Try to get the patient to eat everything on the tray

The unlicensed assistive personnel (UAP) tells the nurse that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is reporting nasal passage discomfort. What intervention should the nurse suggest to the UAP to improve the patient's comfort for this problem? A.) Humidify the patient's oxygen B.) Use a simple face mask instead of a nasal cannula C.) Provide the patient with an extra pillow D.) Have the patient sit up in a chair at the bedside

To assess the functioning of the trigeminal and facial nerves (CNs V and VII), the nurse should: A.) Shine a light into the patient's pupil B.) Check for unilateral eyelid drooping C.) Touch a cotton wisp strand to the cornea D.) Have the patient read a magazine or book

To promote the release of surfactant, the nurse encourages the patient to: A.) Take deep breaths B.) Cough five times per hour to prevent alveolar collapse C.) Decrease fluid intake to reduce fluid accumulation in the alveoli D.) Sit with head of bed elevated to promote air movement through the pores of Kohn

What is the priority nursing concern for a client experiencing a migraine headache? A.) Pain B.) Anxiety C.) Hopelessness D.) Risk for brain injury

When admitting a 42-year-old patient with a possible brain injury after a car accident to the emergency department (ED), the nurse obtains the following information. Which finding is most important to report to the health care provider? A.) The patient takes warfarin (Coumadin) daily B.) The patients blood pressure is 162/94 mm Hg C.) The patient is unable to remember the accident D.) The patient complains of a severe dull headache

When admitting an acutely confused 20-year-old patient with a head injury, which action should the nurse take? A.) Ask family members about the patients health history B.) Ask leading questions to assist in obtaining health data C.) Wait until the patient is better oriented to ask questions D.) Obtain only the physiologic neurologic assessment data

When assessing activity-exercise patterns related to respiratory health, the nurse inquires about: A.) Dyspnea during rest or exercise B.) Recent weight loss or weight gain C.) Ability to sleep through the entire night D.) Willingness to wear O2 equipment in public

When caring for a patient the second postoperative day after abdominal surgery for removal of a large pancreatic cyst, the nurse obtains an oral temperature of 100.8 F. Which action should the nurse take first? A.) Have the patient use the incentive spirometer B.) Assess the surgical incision for redness and swelling C.) Administer the ordered PRN acetaminophen (Tylenol) D.) Ask the health care provider to prescribe a different antibiotic

When caring for a patient with acute bronchitis, the nurse will prioritize: A.) Auscultating lung sounds B.) Encouraging fluid restriction C.) Administering antibiotic therapy D.) Teaching the patient to avoid cough suppressants

When obtaining subjective data for a patient during assessment of the endocrine system, the nurse asks specifically about: A.) Energy level B.) Intake of vitamin C C.) Employment history D.) Frequency of sexual intercourse

When positioning a patient in preparation for surgery, the nurse understands that injury to the patient is most likely to occur as a result of: A.) Incorrect musculoskeletal alignment B.) Loss of perception of pain or pressure C.) Pooling of blood in peripheral vessels D.) Disregarding the patient's need for modesty

When teaching a patient about the most important respiratory defense mechanism distal to the respiratory bronchioles, which topic would the nurse discuss? A.) Alveolar macrophages B.) Impaction of particles C.) Reflex bronchoconstriction D.) Mucociliary clearance mechanism

Which action included in the perioperative patient plan of care can the charge nurse delegate to a surgical technologist? A.) Pass sterile instruments and supplies to the surgeon. B.) Teach the patient about what to expect in the operating room (OR). C.) Continuously monitor and interpret the patient's echocardiogram (ECG) during surgery. D.) Give the postoperative report to the postanesthesia care unit (PACU) nurse.

Which action should the nurse take first when a patient develops a nosebleed? A.) Pinch the lower portion of the nose for 10 minutes B.) Pack the affected nare tightly with an epistaxis balloon C.) Obtain silver nitrate that will be needed for cauterization D.) Apply ice compresses over the patient's nose and cheeks

Which action should the perioperative nurse take to best protect the patient from burn injury during surgery? A.) Ensure correct placement of the grounding pad B.) Check all emergency sprinklers in the operating room C.) Verify that a fire extinguisher is available during surgery D.) Confirm that all electrosurgical equipment has been properly serviced

Which action will the nurse include in the plan of care for a patient with impaired functioning of the left glossopharyngeal nerve (CN IX) and the vagus nerve (CN X)? A.) Withhold oral fluid or foods B.) Provide highly seasoned foods C.) Insert an oropharyngeal airway D.) Apply artificial tears every hour

Which action will the public health nurse take to reduce the incidence of epidemic encephalitis in a community? A.) Encourage the use of effective insect repellents during mosquito season B.) Remind patients that most cases of viral encephalitis can be cared for at home C.) Teach about the importance of prophylactic antibiotics after exposure to encephalitis D.) Arrange for screening of school-age children for West Nile virus during the school year

Which change in vital signs would the nurse instruct the unlicensed assistive personnel to report immediately for a patient with hyperthyroidism? A.) Rapid heart rate B.) Decreased systolic blood pressure C.) Increased respiratory rate D.) Decreased oral temperature

Which finding by the nurse when assessing a patient with Hashimoto's thyroiditis and a goiter will require the most immediate action? A.) New onset changes in the patient's voice B.) Apical pulse rate at rest 112 beats/minute C.) Elevation in the patient's T3 and T4 levels D.) Bruit audible bilaterally over the thyroid gland

Which finding for a patient who has hypothyroidism and hypertension indicates that the nurse should contact the health care provider before administering levothyroxine (Synthroid)? A.) Increased thyroxine (T4) level B.) Blood pressure 112/62 mm Hg C.) Distant and difficult to hear heart sounds D.) Elevated thyroid stimulating hormone level

Which finding in a patient hospitalized with bronchiectasis is most important to report to the health care provider? A.) Cough productive of bloody, purulent mucus B.) Scattered rhonchi and wheezes heard bilaterally C.) Respiratory rate 28 breaths/minute while ambulating in hallway D.) Complaint of sharp chest pain with deep breathing

Which nursing action for a patient with chronic obstructive pulmonary disease (COPD) could the nurse delegate to experienced unlicensed assistive personnel (UAP)? A.) Obtain oxygen saturation using pulse oximetry B.) Monitor for increased oxygen need with exercise C.) Teach the patient about safe use of oxygen at home D.) Adjust oxygen to keep saturation in prescribed parameters

Which patient in the ear, nose, and throat (ENT) clinic should the nurse assess first? A.) A 23-year-old who is complaining of a sore throat and has a muffled voice B.) A 34-year-old who has a "scratchy throat" and a positive rapid strep antigen test C.) A 55-year-old who is receiving radiation for throat cancer and has severe fatigue D.) A 72-year-old with a history of a total laryngectomy whose stoma is red and inflamed

Which patient is most appropriate for the intensive care unit (ICU) charge nurse to assign to a registered nurse (RN) who has floated from the medical unit? A.) A 45-year-old receiving IV antibiotics for meningococcal meningitis B.) A 25-year-old admitted with a skull fracture and craniotomy the previous day C.) A 55-year-old who has increased intracranial pressure (ICP) and is receiving hyperventilation therapy D.) A 35-year-old with ICP monitoring after a head injury last week

Which prescribed medication should the nurse administer first to a 60-year-old patient admitted to the emergency department in thyroid storm? A.) Propranolol (Inderal) B.) Propylthiouracil (PTU) C.) Methimazole (Tapazole) D.) Iodine (Lugol's solution)

Which statement by a patient scheduled for surgery is most important to report to the health care provider? A.) I had a heart valve replacement last year B.) I had bacterial pneumonia 3 months ago C.) I have knee pain whenever I walk or jog D.) I have a strong family history of breast cancer

Which statement by the patient indicates that the teaching has been effective for a patient scheduled for radiation therapy of the larynx? A.) I will need to buy a water bottle to carry with me B.) I should not use any lotions on my neck and throat C.) Until the radiation is complete, I may have diarrhea D.) Alcohol-based mouthwashes will help clean oral ulcers

Which statement, if made by the new circulating nurse, is appropriate? A.) I will assist in preparing the operating room for the patient B.) I will remain gloved while performing activities in the sterile field C.) I will assist with suturing of incisions and maintaining hemostasis as needed D.) I must don full surgical attire and sterile gloves while obtaining items from the unsterile field

When planning health care teaching to prevent or detect early head and neck cancer, which people would be the priority to target (select all that apply): A.) 65 year old man who has used chewing tobacco most of his life B.) 45 year old rancher who uses snuff to stay awake while driving his herds of cattle C.) 21 year old college student who drinks beer on weekends with his fraternity brothers D.) 78 year old woman who has been drinking hard liquor since her husband died 15 year ago E.) 22 year old woman who has been diagnosed with human papillomavirus (HPV) of the cervix

A, B

A nurse is caring for a client following exposure to inhalation anthrax due to bioterrorism. Which of the following medications should the nurse expect as a common medication to treat anthrax (select all that apply): A.) Ciprofloxacin B.) Doxycycline C.) Amoxicillin D.) Penicillin G E.) Cefotaxime

A, B, C

For which patients with pneumonia would the nurse suspect aspiration as the likely cause of pneumonia (select all that apply)? A.) Patient with seizures B.) Patient with head injury C.) Patient who had thoracic surgery D.) Patient who had a myocardial infarction E.) Patient who is receiving nasogastric tube feeding

A, B, E

A nurse in an intensive care unit is planning care for a client who has myxedema coma. Which of the following actions should the nurse include (select all that apply): A.) Observe cardiac monitor for dysrhythmias. B.) Observe for evidence of urinary tract infection. C.) Initiate IV fluids using 0.9% sodium chloride. D.) Administer a levothyroxine IV bolus. E.) Provide warmth using a heating pad.

A, B, C, D

A nurse is caring for a female client who manifests indications of hypovolemia while in the PACU. Which of the following findings require action by the nurse (select all that apply): A.) Urine output less than 25 mL/hr B.) Hematocrit 48% C.) BUN 24 mg/dL D.) Tenting of skin over the sternum E.) Apical pulse rate 62/min

A, B, C, D

A nurse is reviewing the health records of several clients in the postanesthesia care unit (PACU) to identify risk factors that can lead to postoperative complications. Which of the following clients are at risk for complications (select all that apply): A.) A client who has a WBC of 22,500/uL B.) A client who uses an insulin pump C.) A client who takes warfarin daily D.) A client who has heart failure E.) A client who has a BMI of 26

A, B, C, D

A student nurse asks the RN what can be measured by arterial blood gas (ABG). The RN tells the student that the ABG can measure (select all that apply): A.) Acid-base balance B.) Oxygenation status C.) Acidity of the blood D.) Bicarbonate (HCO3-) in arterial blood E.) Overall balance of electrolytes in arterial blood

A, B, C, D

The nurse is creating a teaching plan for a client with newly diagnosed migraine headaches. Which key items will be included in the teaching plan (select all that apply): A.) Foods that contain tyramine, such as alcohol and aged cheese, should be avoided B.) Drugs such as nitroglycerin and nifedipine should be avoided C.) Abortive therapy is aimed at eliminating the pain during the aura D.) A potential side effect of medications is rebound headache E.) Complementary therapies such as biofeedback and relaxation may be helpful F.) Estrogen therapy should be continued as prescribed by the client's health care provider

A, B, C, D, E

A college health nurse interprets the peak expiratory flow rate for a student who has asthma and finds that the student is in the yellow zone of his asthma action plan. The nurse should base her actions on which of the following information (select all that apply): A.) The student should use his quick relief inhaler B.) The student's asthma is not well controlled C.) The student's peak flow is 50% to 80% of his best peak flow D.) The student need sot go to the hospital E.) The nurse should obtain a second expiratory flow rate

A, B, C, E

A nurse is caring for a client who develops malignant hyperthermia. Which of the following actions should the nurse take (select all that apply): A.) Infuse iced IV fluids B.) Provide 100% oxygen C.) Place the client on a cooling blanket D.) Treat the complication while continuing surgery E.) Administer IV dantrolene

A, B, C, E

A nurse is caring for a client who has experienced a right-hemispheric stroke. Which of the following are expected findings (select all that apply): A.) Impulse control difficulty B.) Left hemiplegia C.) Loss of depth perception D.) Aphasia E.) Lack of situational awareness

A, B, C, E

A nurse is planning care for a client to prevent postoperative atelectasis. Which of the following interventions should the nurse include in the plan of care (select all that apply): A.) Encourage use of the incentive spirometer every 2 hr B.) Instruct the client to splint the incision when coughing and deep breathing C.) Reposition the client every 2 hr D.) Administer antibiotic therapy E.) Assist with early ambulation

A, B, C, E

A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care (select all that apply): A.) Have suction equipment available for use B.) Feed the client thickened liquids C.) Place food on the unaffected side of the client's mouth D.) Assign an assistive personnel to feed the client slowly E.) Teach the client to swallow with her neck flexed

A, B, C, E

A nurse is preparing to care for a client following chest tube placement. Which of the following items should be available in the client's room (select all that apply): A.) Oxygen B.) Sterile water C.) Enclosed hemostat clamps D.) Indwelling urinary catheter E.) Occlusive dressing

A, B, C, E

A patient with a pulmonary embolus is reviewing anticoagulation with IV heparin. What instructions would the nurse give the unlicensed assistive personnel (UAP) who will help the patient with activities of daily living (ADLs) (select all that apply): A.) Use a life sheet when moving and position the patient in bed B.) Use an electric razor when shaving the patient each day C.) Use a soft-bristled toothbrush or tooth sponge for oral care D.) Use a rectal thermometer to obtain a more accurate body temperature E.) Be sure the patient's footwear has a firm sole when the patient ambulates F.) Assess the patient for any signs or symptoms of bleeding

A, B, C, E

Stimulation of the parasympathetic nervous system results in (select all that apply): A.) Constriction of the bronchi B.) Dilation of skin blood vessels C.) Increased secretion of insulin D.) Increased blood glucose levels E.) Relaxation of the urinary sphincters

A, B, C, E

Which actions should the nurse delegate to an experienced unlicensed assistive personnel (UAP) when caring for a client with a thrombotic stroke who has residual left-sided weakness (select all that apply): A.) Assisting the client to reposition every 2 hours B.) Reapplying pneumatic compression boots C.) Reminding the client to perform active range-of-motion (ROM) exercises D.) Assessing the extremities for redness and edema E.) Setting up meal trays and assisting with feeding F.) Using a lift to assist the client up to a bedside chair

A, B, C, E, F

Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia (select all that apply)? A.) Age B.) Blood pressure C.) Respiratory rate D.) Oxygen saturation E.) Presence of confusion F.) Blood urea nitrogen (BUN) level

A, B, C, E, F

A client is preparing to receive a client from the PACU who is postoperative following a thyroidectomy. The nurse should ensure that which of the following equipment is available (select all that apply): A.) Suction equipment B.) Humidified oxygen C.) Flashlight D.) Tracheostomy tray E.) Chest tube tray

A, B, D

A nurse in a provider's office is planning care for a client who has a new diagnosis of Graves' disease and a new prescription for methimazole. Which of the following interventions should the nurse include in the plan of care (select all that apply): A.) Monitor CBC B.) Monitor triiodothyronine (T3) C.) Instruct the client to increase consumption of shellfish D.) Advise the client to take the medication at the same time every day E.) Inform the client that an adverse effect of this medication is iodine toxicity

A, B, D

A nurse in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP (select all that apply): A.) Headache B.) Dilated pupils C.) Tachycardia D.) Decorticate posturing E.) Hypotension

A, B, D

A nurse providing preoperative teaching to a client who is to have abdominal surgery. Which of the following statements should the nurse make (select all that apply): A.) "Take your heart medication with a sip of water before surgery" B.) "Splint the abdominal incision with a pillow when coughing and deep breathing" C.) "Bed rest is recommended for the first 48 hr" D.) "Antiembolism stockings are applied before surgery" E.) "You may eat solid foods up to 4 hr before surgery"

A, B, D

An experienced LPN/LVN, under the supervision of the team leader RN, is assigned to provide nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN/LVN (select all that apply): A.) Auscultating breath sounds B.) Administering medications via metered-dose inhaler (MDI) C.) Completing in depth admission assessment D.) Checking oxygen saturation using pulse oximetry E.) Developing the nursing care plan F.) Evaluating the patient's technique for using MDIs

A, B, D

The nurse is reviewing the medical records for five patients who are scheduled for their yearly physical examinations in September. Which patients should receive the inactivated influenza vaccination (select all that apply)? A.) A 76-year-old nursing home resident B.) A 36-year-old female patient who is pregnant C.) A 42-year-old patient who has a 15 pack-year smoking history D.) A 30-year-old patient who takes corticosteroids for rheumatoid arthritis E.) A 24-year-old patient who has allergies to penicillin and cephalosporins

A, B, D

The nurse assumes care of a patient who just returned from surgery for a total laryngectomy and radical neck dissection and notes the following problems. In which order should the nurse address the problems? A.) The patient is in a side-lying position with the head of the bed flat B.) The patient is coughing blood-tinged secretions from the tracheostomy C.) The nasogastric (NG) tube is disconnected from suction and clamped off D.) The wound drain in the neck incision contains 200 mL of bloody drainage

A, B, D, C

The nurse notes new onset confusion in an older patient who is normally alert and oriented. In which order should the nurse take the following actions? A.) Obtain the oxygen saturation B.) Check the patient's pulse rate C.) Document the change in status D.) Notify the health care provider

A, B, D, C

A nurse is developing a plan of care for a client who is scheduled for cerebral angiography with contrast dye. Which of the following statements by the client should the nurse report to the provider (select all that apply): A.) "I think I might be pregnant" B.) "I take warfarin" C.) "I take antihypertensive medication" D.) "I am allergic to shrimp" E.) "I ate a light breakfast this morning"

A, B, D, E

A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing acute respiratory distress syndrome (select all that apply): A.) A client who experienced a near-drowning incident B.) A client following coronary artery bypass graft C.) A client who has a hemoglobin of 15.1 mg/dL D.) A client who has dysphagia E.) A client who experienced a drug overdose

A, B, D, E

The nurse is providing care for a patient with recently diagnosed asthma. Which key points would the nurse be sure to include in the teaching plan for this patient (select all that apply): A.) Avoid potential environmental asthma triggers such as smoke B.) Use the inhaler 30 minutes before exercising to prevent bronchospasm C.) Wash all bedding in cold water to reduce and destroy dust mites D.) Be sure to get at least 8 hours of rest and sleep every night E.) Avoid food prepared with monosodium glutamate (MSG) F.) Keep a symptom and intervention diary to learn specific triggers for your asthma

A, B, D, E, F

A patient with chronic obstructive pulmonary disease (COPD) tells the nurse that he is always tired. What advice would the nurse give this patient to cope with his fatigue (select all that apply): A.) Do not rush through your morning activities of daily living B.) Avoid working with the arms raised C.) Eat three large meals every day focusing on calories and proteins D.) Organize your work area so that what you use most is easy to reach E.) Get all of your activities accomplished then take a nap F.) Don't hold your breath while performing any activities

A, B, D, F

A nurse in a provider's office is assessing a client. The nurse should identify that which of the following findings are manifestations of pulmonary tuberculosis (select all that apply): A.) Night sweats B.) Low grade fever C.) Weight gain D.) Flushed cheeks E.) Blood in the sputum

A, B, E

A nurse is assessing a client following a gunshot wound to the chest. For which of the following findings should the nurse monitor to detect a pneumothorax (select all that apply): A.) Tachypnea B.) Deviation of the trachea C.) Bradycardia D.) Decreased use of accessory muscles E.) Pleuritic pain

A, B, E

A nurse is caring for a client who has global aphasia (both receptive and expressive). Which of the following should the nurse include in the client's plan of care (select all that apply): A.) Speak to the client at a slower rate B.) Assist the client to use flashcards with pictures C.) Speak to the client in a loud voice D.) Complete sentences that the client cannot finish E.) Give instructions one step at a time

A, B, E

A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care (select all that apply): A.) Encourage the client to cough every 2 hr B.) Check for continuous bubbling in the suction chamber C.) Strip the drainage tubing every 4 hr D.) Clamp the tube one a day E.) Obtain a chest x-ray

A, B, E

A nurse is monitoring a group of clients for increased risk for developing pneumonia. Which of the following clients should the nurse expect to be at risk (select all that apply): A.) Client who has dysphagia B.) Client who has AIDS C.) Client who was vaccinated for pneumococcus and influenza 6 months ago D.) Client who has a closed head injury and is receiving ventilation E.) Client who has a closed head injury and is receiving ventilation F.) Client who has myasthenia gravis

A, B, E, F

Which actions should the nurse assign to the experienced LPN/LVN for the care of a patient with hypothyroidism (select all that apply): A.) Assessing and recording the rate and depth of respirations B.) Auscultating lung sounds every 4 hours C.) Creating an individualized nursing care plan for the patient D.) Administering sedation medications every 6 hours E.) Checking blood pressure, heart rate and respirations every 4 hours F.) Reminding the patient to report any episodes of chest pain or discomfort

A, B, E, F

A 23 year old client with a recent history of encephalitis is admitted to the medical unit with new-onset generalized tonic-clonic seizures. Which nursing activities included in the client's care will be best to assign to LPN/LVN whom the nurse is supervising (select all that apply): A.) Observing and documenting the onset and duration of any seizure activity B.) Administering phenytoin 200 mg PO three times a day C.) Teaching the client about the need for frequent tooth brushing and flossing D.) Developing a discharge plan that includes referral to the Epilepsy Foundation E.) Assessing for adverse effects caused by new antiseizure medications F.) Turning the client to his or her side to avoid aspiration

A, B, F

The nurse is acting as preceptor for a newly-graduated RN during the second week of orientation. The nurse would assign and supervise the new RN to provide nursing care for which patients (select all that apply): A.) A 38 year old patient with moderate persistent asthma awaiting discharge B.) A 63 year old patient with a tracheostomy needing tracheostomy care every shift C.) A 56 year old patient with lung cancer who has just undergone left lower lobectomy D.) A 49 year old patient just admitted with a new diagnosis of esophageal cancer E.) A 76 year old patient newly diagnosed with type 2 diabetes F.) A 69 year old patient with emphysema to be discharged tomorrow

A, B, F

A nurse is caring for a client who is receiving vecuronium for acute respiratory distress syndrome. Which of the following medications should the nurse anticipate administering with the medication (select all that apply): A.) Fentanyl B.) Furosemide C.) Midazolam D.) Famotidine E.) Dexamethasone

A, C

A patient's blood pressure in the postanesthesia care unit (PACU) has dropped from an admission blood pressure of 140/86 to 102/60 with a pulse change of 70 to 96. SpO2 is 92% on 3 L of oxygen. In which order should the nurse take these actions? A.) Increase the IV infusion rate B.) Assess the patients dressing C.) Increase the oxygen flow rate D.) Check the patient's temperature

A, C, B, D

While ambulating in the room, a patient complains of feeling dizzy. In what order will the nurse accomplish the following activities? A.) Have the patient sit down in a chair B.) Give the patient something to drink C.) Take the patients blood pressure (BP) D.) Notify the patients health care provider

A, C, B, D

The nurse is the team leader RN working with a student nurse. The student nurse is to teach a patient how to use a metered dose inhaler (MDI) without a spacer. Put the steps that the student nurse should teach the patient in the correct order: A.) Remove the inhaler cap and shake the inhaler B.) Open your mouth and place the mouthpiece 1 to 2 inches (2.5 to 5.0 cm) away C.) Breathe out completely D.) Hold your breath for at least 10 seconds E.) Press down firmly on the canister and breathe deeply through your mouth F.) Wait at least 1 minute between puffs

A, C, B, E, D, F

A nurse is caring for a client following a thoracentesis. Which of the following manifestations should the nurse recognize as risks for complications (select all that apply): A.) Dyspnea B.) Localized bloody drainage on the dressing C.) Fever D.) Hypotension E.) Report of pain at the puncture site

A, C, D

A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client (select all that apply): A.) Dyspnea B.) Bradycardia C.) Barrel chest D.) Clubbing of the fingers E.) Deep respirations

A, C, D

A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure are in the client's room (select all that apply): A.) Oxygen equipment B.) Incentive spirometer C.) Pulse oximeter D.) Sterile dressing E.) Suture removal kit

A, C, D

A nurse is providing information about tuberculosis to a group of clients to a local community center. Which of the following manifestations should the nurse include in the teaching (select all that apply): A.) Persistent cough B.) Weight gain C.) Fatigue D.) Night sweats E.) Purulent sputum

A, C, D, E

A patient is concerned that he may have asthma. Of the symptoms that he relates to the nurse, which one suggests asthma or risk factors for asthma (select all that apply): A.) Allergic rhinitis B.) Prolonged inhalation C.) History of skin allergies D.) Cough, especially at night E.) Gastric reflux or heartburn

A, C, D, E

The RN is supervising a nursing student who will suction a patient on a mechanical ventilator. Which actions indicate that the student has a correct understanding of this procedure (select all that apply): A.) The student nurse should use a sterile catheter and gloves B.) The student nurse applies suction while inserting the catheter C.) The student nurse applies suction during catheter removal D.) The student nurse uses a twirling motion when withdrawing the catheter E.) The student nurse uses a no. 12 French catheter F.) The student nurse applies suction for at least 20 seconds

A, C, D, E

The clinic nurse is teaching a patient with acute sinusitis. Which interventions should the nurse plan to include in the teaching session (select all that apply)? A.) Decongestants can be used to relieve swelling B.) Blowing the nose should be avoided to decrease the nosebleed risk C.) Taking a hot shower will increase sinus drainage and decrease pain D.) Saline nasal spray can be made at home and used to wash out secretions E.) You will be more comfortable if you keep your head in an upright position

A, C, D, E

Which treatments in CF would the nurse expect to implement in the management plan of patients with CF (select all that apply): A.) Sperm banking B.) IV corticosteroids C.) Airway clearance techniques on a chronic basis D.) GoLYTELY given PRN for severe constipation E.) Inhaled tobramycin to combat Pseudomonas infection

A, C, D, E

The nurse is supervising a nursing student providing care for a patient with shortness of breath who has expressed interest in smoking cessation. Which questions would the nurse suggest the student ask to determine nicotine dependence (select all that apply): A.) How soon after you wake up in the morning do you smoke? B.) Do other members of your family smoke? C.) Do you smoke when you are ill? D.) Do you wake up in the middle of your sleep time to smoke? E.) Do you smoke indoors or outside? F.) Do you have a difficult time not smoking in places where it is not allowed?

A, C, D, F

The nurse on the neurologic acute care unit is assessing the orientation of a client with severe headaches. Which questions would the nurse use to determine orientation (select all that apply): A.) When did you first experience the headache symptoms B.) Who is the Mayor of Cleveland C.) What is your health care provider's name D.) What year and month is this E.) What is your parents' address F.) What is the name of this health care facility

A, C, D, F

A nurse is caring for a group of clients. Which of the following clients are at risk for a pulmonary embolism (select all that apply): A.) A client who has a BMI of 30 B.) A female client who is postmenopausal C.) A client who has a fractured femur D.) A client who is a marathon runner E.) A client who has chronic atrial fibrillation

A, C, E

A nurse is preparing to administer a dose of a new prescription of prednisone to a client who has COPD. The nurse should monitor for which of the following adverse effects of this medication (select all that apply): A.) Hypokalemia B.) Tachycardia C.) Fluid retention D.) Nausea E.) Black, tarry stools

A, C, E

A nurse is assessing a client's laboratory values before surgery. Which of the following results should the nurse report to the provider (select all that apply): A.) Potassium 3.9 mEq/L B.) Sodium 145 mEq/L C.) Creatinine 2.8 mg/dL D.) Blood glucose 235 mg/dL E.) WBC 17,850/mm3

A, D, E

Common psychosocial reactions of the stroke patient to the stroke include (select all that apply): A.) Depression B.) Disassociation C.) Intellectualization D.) Sleep disturbances E.) Denial of severity of stroke

A, D, E

A plan of care for the patient with COPD could include (select all that apply): A.) Exercise such as walking B.) High flow rate of O2 administration C.) Low-dose chronic oral corticosteroid therapy D.) Use of peak flow meter to monitor the progression of COPD E.) Breathing exercises such as pursed-lip breathing that focus on exhalation

A, E

The nurse is caring for a patient undergoing surgery for a knee replacement. What is critical to the patient's safety during the procedure (select all that apply): A.) Universal protocol is followed B.) The ACP is an anesthesiologist C.) The patient has adequate health insurance D.) The patient's family is in the surgery waiting area E.) The patient's allergies are conveyed to the surgical team

A, E

A 20-year-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take? A.) Have the patient gently blow the nose B.) Check the drainage for glucose content C.) Teach the patient that rhinorrhea is expected after a head injury D.) Obtain a specimen of the fluid to send for culture and sensitivity

A 23-year-old patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse plan to take? A.) Administer IV furosemide (Lasix) B.) Prepare the patient for craniotomy C.) Initiate high-dose barbiturate therapy D.) Type and crossmatch for blood transfusion

A 37 year old patient has just arrived in the postanesthesia recovery unit (PACU) after a thyroidectomy. Which information is most important to communicate to the surgeon? A.) The patient reports 7/10 incisional pain B.) The patient has increasing neck swelling C.) The patient is sleepy and difficulty to arouse D.) The patient's cardiac rate is 112 beats/minute

A 38 year old female is admitted for an elective surgical procedure. Which information obtained by the nurse during the preoperative assessment is most important to report to the anesthesiologist before surgery? A.) The patient's lack of knowledge about postoperative pain control measures B.) The patient's statement that her last menstrual period was 8 weeks previously C.) The patient's history of a postoperative infection following a prior cholecystectomy D.) The patient's concern that she will be unable to care for her children postoperatively

A 39-year-old patient with a suspected herniated intervertebral disc is scheduled for a myelogram. Which information is most important for the nurse to communicate to the health care provider before the procedure? A.) The patient is anxious about the test B.) The patient has an allergy to shellfish. C.) The patient has back pain when lying flat D.) The patient drank apple juice 4 hours earlier

A 46-year-old patient with a head injury opens the eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. The nurse records the patients Glasgow Coma Scale score as: A.) 9 B.) 11 C.) 13 D.) 15

A 63-year-old patient with primary hyperparathyroidism has a serum phosphorus level of 1.7 mg/dL (0.55 mmol/L) and calcium of 14 mg/dL (3.5 mmol/L). Which nursing action should be included in the plan of care? A.) Restrict the patient to bed rest B.) Encourage 4000 mL of fluids daily C.) Institute routine seizure precautions D.) Assess for positive Chvostek's sign

A 70 year old client with alcoholism who has become lethargic, confused and incontinent during the last week is admitted to the emergency department. His wife tells the nurse that he fell down the stairs about a month ago, but "he didn't have a scratch afterwards." Which collaborative interventions will the nurse implement first? A.) Place the client on the hospital alcohol withdrawal protocol B.) Transport the client to the radiology department for a computed tomography (CT) scan C.) Make a referral to the social services department D.) Give the client phenytoin 100 mg PO

A characteristic common to all hormones is that they: A.) Circulate in the blood bound to plasma proteins B.) Influence cellular activity of specific target tissues C.) Accelerate the metabolic process of all body cells D.) Enter a cell to alter the cell's metabolism or gene expression

A diabetic patient's arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mmHg; PaO2 85 mmHg, HCO3 18 mEq/L. The nurse would expect which finding? A.) Intercostal retractions B.) Kussmaul respirations C.) Low oxygen saturation (SpO2) D.) Decreased venous O2 pressure

A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority? A.) Increase the oxygen flow to 3 L/min B.) Assess the client's respiratory status C.) Call emergency services for the client D.) Have the client cough and expectorate secretions

A nurse assists a patient on the first postoperative day to ambulate, cough, deep breathe, and turn. Which action by the nurse is most helpful? A.) Teach the patient to fully exhale into the incentive spirometer B.) Administer ordered analgesic medications before these activities C.) Ask the patient to state two possible complications of immobility D.) Encourage the patient to state the purpose of splinting the incision

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 who has this condition? A.) Elevated serum T4 B.) Decreased serum T3 C.) Elevated serum thyroid stimulating hormone D.) Decreased serum cholesterol

A nurse in a provider's office is reviewing the health record of a client who is being evaluated for Graves's disease. The nurse should identify which of the following laboratory results is an expected finding? A.) Decreased thyrotropin receptor antibodies B.) Decreased thyroid-stimulating hormone (TSH) C.) Decreased free thyroxine index D.) Decread triiodothyronine

A nurse in the emergency department is caring for a client who was injured in a motor-vehicle crash. The client reports dyspnea and severe pain. The nurse notes that the client's chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following? A.) Atelectasis B.) Flail chest C.) Hemothorax D.) Pneumothorax

A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first? A.) Urticaria B.) Stridor C.) Vomiting D.) Hypotension

A nurse is assessing a client for changes in the Glasgow Coma Scale (GCS). The client opens his eyes when spoken to, speaks incoherently and moves his extremities when pain is applied. Which of the following GCS scores should the nurse document? A.) E2 + V3 + M5 = 10 B.) E3 + V4 + M4 = 11 C.) E4 + V5 + M6 = 15 D.) E2 + V2 + M4 = 8

A nurse is assessing a client who has a history of asthma. Which of the following factors should the nurse identify as a risk for asthma? A.) Gender B.) Environmental allergies C.) Alcohol use D.) Race

A nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer. The nurse should anticipate that the client will report that her earliest manifestation was: A.) Dysphagia B.) Hoarseness C.) Dyspnea D.) Weight loss

A nurse is assessing a client who has chronic bronchitis. Which of the following percussion sounds should the nurse expect? A.) Dullness B.) Resonance C.) Tympany D.) Flatness

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first? A.) Give morphine IV B.) Administer oxygen therapy C.) Start an IV infusion of lactated ringers D.) Initiate cardiac monitoring

A nurse is caring for a client who develops a systemic toxic reaction following a regional block. Which of the following actions should the nurse take? A.) Monitor serum creatinine levels B.) Provide airway support C.) Turn the client to the right side D.) Administer 0.9% sodium chloride 500 mL IV bolus

A nurse is caring for a client who develops an airway obstruction from a foreign body but remains conscious. Which of the following actions should the nurse take first? A.) Insert an oral airway B.) Administer the abdominal thrust maneuver C.) Turn the client to the side D.) Perform a blind finger sweep

A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter (ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy? A.) Headache B.) Infection C.) Aphasia D.) Hypertension

A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the following actions should the nurse take first? A.) Obtain a chest x-ray B.) Apply sterile gauze to the insertion site C.) Place tape around the insertion site D.) Assess respiratory status

A nurse is caring for a client who has a chest tube in place to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded? A.) Oxygen saturation of 95% B.) No fluctuations in the water seal chamber C.) No reports of pleuritic chest pain D.) Occasional bubbling in the water-seal chamber

A nurse is caring for a client who has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse? A.) "I am allergic to morphine" B.) "I take antacids several times a day" C.) "I had a blood clot in my leg several years ago" D.) "It hurts to take deep breaths"

A nurse is caring for a client who has burns to his face, ears and eyelids. The nurse should identify which of the following is the priority finding to report to the provider? A.) Urinary output 25 mL/hr B.) Difficulty swallowing C.) Heart rate 122/min D.) Pain of 6 on scale of 0 to 10

A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client? A.) Nonrebreather mask B.) Venturi mask C.) Nasal cannula D.) Simple face mask

A nurse is caring for a client who has increased ICP and a new prescription for mannitol. For which of the following adverse effects should the nurse monitor? A.) Hyperglycemia B.) Hyponatremia C.) Hypervolemia D.) Oliguria

A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention? A.) Teach the client to scan to the right to see objects on the right side of her body B.) Place the bedside table on the right side of the bed C.) Orient the client to the food on her plate using the clock method D.) Place the wheelchair on the client's left side

A nurse is caring for a client who has newly inserted chest drainage system with a water seal. Which of the following actions should the nurse take? A.) Clamp the tube when the client is ambulating B.) Keep the collection device below the level of the client's chest C.) Coil the tubes carefully to prevent kinking D.) Lay the client flat to avoid leaking in the tubing

A nurse is caring for a client who is receiving mechanical ventilation and has an idea weight of 60 kg. The nurse should expect the tidal volume to be set at which of the following A.) 300 mL B.) 480 mL C.) 800 mL D.) 950 mL

A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 mmHg. Her arterial blood gases ate pH 7.50, PaCO2 29 mmHg, PaO2 60 mmHg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority nursing intervention? A.) Prepare for mechanical ventilation B.) Administer oxygen via face mask C.) Prepare to administer a sedative D.) Assess for indications of pulmonary embolism

A nurse is dining at a restaurant when a woman begins to scream that her partner is choking. Which of the following actions should the nurse take? A.) Instruct the woman to call 911 B.) Ask the partner if he can speak C.) Use the jaw-thrust maneuver D.) Perform chest compressions

A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a client who has acute respiratory distress syndrome (ARDs). Which of the following statements by the newly licensed nurse indicates understanding of the teaching? A.) "This medication is given to treat infection" B.) "This medication is given to facilitate ventilation" C.) "This medication is given to decrease inflammation" D.) "This medication is given to reduce anxiety"

A nurse is orienting a newly licensed nurse who is caring for a client who is receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements by the newly licensed nurse indicates an understanding of PSV? A.) "It keeps the alveoli open and prevents atelectasis" B.) "It allows present pressure delivered during spontaneous ventilation" C.) "It guarantees minimal minute ventilation" D.) "It delivers a present ventilatory rate and tidal volume to the client"

A nurse is performing pulmonary hygiene for a client who has pneumonia and positions the client on his left side in Trandelenburg position. From which of the following lung segments should the nurse expect secretions to be mobilized with the client in this position? A.) Lateral segment of the left lower lobe B.) Lateral segment of the right lower lobe C.) Posterior segment of the right middle lobe D.) Posterior segment of the right lower lobe

A nurse is providing education to a client who is to undergo an electroencephalogram (EEG) the next day. Which of the following information should the nurse include in the teaching? A.) "Do not wash your hair the morning of the procedure" B.) "Try to stay awake most of the night prior to the procedure" C.) "The procedure will take approximately 15 minutes" D.) "You will need to lie flat for 4 hours after the procedure"

A nurse is providing instructions to a client who has Graves' disease and has a new prescription of for propranolol. Which of the following information should the nurse include? A.) "An adverse effect of this medication is jaundice" B.) "Take your pulse before each dose" C.) "The purpose of this medication is to decrease production of thyroid hormone" D.) "You should stop taking this medication if you have a sore throat"

A nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator. Which of the following client statements indicates an understanding of the teaching? A.) "This medication can decrease my immune response" B.) "I take this medication to prevent asthma attacks" C.) "I need to take this medication with food" D.) "This medication has a slow onset to treat my symptoms"

A nurse is reviewing ABG laboratory results of a client who is in respiratory distress. The results were pH 7.47, PaCO2 32 mmHg, HCO3 22 mmHg. The nurse should recognize that the client is experiencing which of the following acid base imbalances? A.) Respiratory acidosis B.) Respiratory alkalosis C.) Metabolic acidosis D.) Metabolic alkalosis

A nurse is reviewing the prescriptions for a client who has a pneumothorax. Which of the following actions should the nurse perform first? A.) Assess the client's plan B.) Obtain a large-bore IV needle for decompression C.) Administer lorazepam D.) Prepare for chest tube insertion

A nurse is teaching a client who has tuberculosis. Which of the following statements should the nurse include in the teaching? A.) "You will need to continue to take the multi medication regimen for 4 months" B.) "You will need to provide sputum samples every 4 week to monitor for effectiveness of the medication" C.) "You will need to remain hospitalized for treatment" D.) "You will need to wear a mask at all times"

A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive couch and is short of breath. The nurse should anticipate which of the following assessment findings of this client? A.) Respiratory alkalosis B.) Increased anteroposterior diameter of the chest C.) Oxygen saturation level 96% D.) Petechiae on chest

A nurse plans care for the patient with increased intracranial pressure with the knowledge that the best way to position the patient is to: A.) Keep the head of the bed flat B.) Elevate the head of the bed to 30 degrees C.) Maintain patient on the left side with the head supported on a pillow D.) Use a continuous-rotation bed to continuously change patient position

A nurse suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following should be the nurse's priority intervention? A.) Insert an IV line B.) Count the respiratory rate C.) Administer oxygen D.) Prepare equipment for intubation

A nursing measure that is indicated to reduce the potential for seizures and increased intracranial pressure in the patient with bacterial meningitis is: A.) Administering codeine for relief of head and neck pain B.) Controlling fever with prescribed drugs and cooling techniques C.) Keeping the room darkened and quite to minimize environmental stimulation D.) Maintaining the patient on strict bed rest with the head of the bed slightly elevated

A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first? A.) Document the BP and ICP in the patient's record B.) Report the BP and ICP to the health care provider C.) Elevate the head of the patient's bed to 60 degrees D.) Continue to monitor the patient's vital signs and ICP

A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first? A.) Chest x-ray via stretcher B.) Blood cultures from two sites C.) Ciprofloxacin (Cipro) 400 mg IV D.) Acetaminophen (Tylenol) rectal suppository

A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. The nurse will anticipate teaching the patient about: A.) Alteplase (tPA) B.) Aspirin (Ecotrin) C.) Warfarin (Coumadin) D.) Nimodipine (Nimotop)

A patient is admitted to the emergency department with an open stab wound to the left chest. What is the first action that the nurse should take? A.) Position the patient so that the left chest is dependent B.) Tape a nonporous dressing on three sides over the chest wound C.) Cover the sucking chest wound firmly with an occlusive dressing D.) Keep the head on the patient's bed at no more than 30 degrees elevation

A patient is receiving 35% oxygen via a Venturi mask. To ensure the correct amount of oxygen delivery, which action by the nurse is most important? A.) Teach the patient to keep mask on at all times B.) Keep the air entrainment ports clean and unobstructed C.) Give a high enough flow rate to keep the bag from collapsing D.) Drain moisture condensation from the oxygen tubing every hour

A patient is seen in the emergency department after diving into the pool and hitting the bottom with a blow to the face that hyperextended the neck and scraped the skin off the nose. The patient also described "having double vision," when looking down. During the neurologic exam, the nurse finds the patient is unable to abduct either eye. The nurse recognizes this finding is related to: A.) A basal skull fracture B.) A stretch injury to bilateral CN VI C.) A stiff neck from the hyperextension injury D.) Facial swelling from the scrape on the bottom of the pool

A patient seen in the asthma clinic has recorded daily peak flows that are 85% of the baseline. Which action will the nurse plan to take? A.) Teach the patient about the use of oral corticosteroids B.) Administer a bronchodilator and recheck the peak flow. C.) Instruct the patient to continue to use current medications. D.) Evaluate whether the peak flow meter is being used correctly.

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

A patient who had radical neck surgery to remove a malignant tumor developed hypoparathyroidism. The nurse should plan to teach the patient about: A.) Bisphosphonates to reduce bone demineralization B.) Calcium supplements to normalize serum calcium levels C.) Increasing fluid intake to decrease risk for nephrolithiasis D.) Including whole grains in the diet to prevent constipation

A patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU) is restless and shouting at the nurse. The patient's oxygen saturation is 96% and recent laboratory results are all normal. Which action by the nurse is most appropriate? A.) Increase the IV fluid rate B.) Assess for bladder distension C.) Notify the anesthesia care provider (ACP) D.) Demonstrate the use of the nurse call bell button

A patient who has diabetes and uses insulin to control blood glucose has been NPO since midnight before having a knee replacement surgery. Which action should the nurse take? A.) Withhold the usual scheduled insulin dose because the patient is NPO B.) Obtain a blood glucose measurement before any insulin administration C.) Give the patient the usual insulin dose because stress will increase the blood glucose D.) Administer a lower dose of insulin because there will be no oral intake before surgery

A patient who has never had any prior surgeries tells the nurse doing the preoperative assessment about an allergy to bananas and avocados. Which action is most important for the nurse to take? A.) Notify the dietitian about the food allergies B.) Alert the surgery center about a possible latex allergy C.) Reassure the patient that all allergies are noted on the medical record D.) Ask whether the patient uses antihistamines to reduce allergic reactions

A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action should the nurse take first? A.) Administer the ordered opioid B.) Check the oxygen (O2) saturation C.) Take the blood pressure and pulse D.) Apply wrist restraints to secure IV lines

A patient who normally takes 40 units of glargine insulin (long acting) at bedtime asks the nurse what to do about her does the night before surgery. The best response would be to have her: A.) Skip her insulin altogether the night before the surgery B.) Get instructions from her surgeon or HCP on any insulin adjustments C.) Take her usual dose at bedtime and eat a light breakfast in the morning D.) Eat a moderate meal before bedtime and then take half of her usual insulin dose

A patient with a chronic cough has a bronchoscopy. After the procedure, which intervention by the nurse is most appropriate? A.) Elevate the head of the bed to 80 to 90 degrees B.) Keep the patient NPO until the gag reflex returns C.) Place on bed rest for at least 4 hours after bronchoscopy D.) Notify the health care provider about blood-tinged mucus

A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure? A.) Start a peripheral IV line to administer the necessary sedative drugs B.) Position the patient sitting upright on the edge of the bed and leaning forward C.) Obtain a large collection device to hold 2 to 3 liters of pleural fluid at one time D.) Remove the water pitcher and remind the patient not to eat or drink anything for 6 hours

A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient? A.) Ask the patient to lie down to complete a full physical assessment B.) Briefly ask specific questions about this episode of respiratory distress C.) Complete the admission database to check for allergies before treatment D.) Delay the physical assessment to first complete pulmonary function tests

A patient with chronic obstructive pulmonary disease (COPD) has rhonchi throughout the lung fields and a chronic, nonproductive cough. Which nursing intervention will be most effective? A.) Change the oxygen flow rate to the highest prescribed rate B.) Teach the patient to use the Flutter airway clearance device C.) Reinforce the ongoing use of pursed lip breathing techniques D.) Teach the patient about consistent use of inhaled corticosteroids

A patient with cystic fibrosis (CF) has blood glucose levels that are consistently between 180 to 250 mg/dL. Which nursing action will the nurse plan to implement? A.) Discuss the role of diet in blood glucose control B.) Teach the patient about administration of insulin C.) Give oral hypoglycemic medications before meals D.) Evaluate the patient's home use of pancreatic enzymes

A patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving nifedipine (Procardia). Which assessment would best indicate to the nurse that the patient's condition is improving? A.) Blood pressure (BP) is less than 140/90 mm Hg B.) Patient reports decreased exertional dyspnea C.) Heart rate is between 60 and 100 beats/minute D.) Patient's chest x-ray indicates clear lung fields

A patient with newly diagnosed lung cancer tells the nurse, "I don't think I'm going to live to see my next birthday." Which response by the nurse is best? A.) Would you like to talk to the hospital chaplain about your feelings B.) Can you tell me what it is that makes you think you will die soon C.) Are you afraid that the treatment for your cancer will not be effective D.) Do you think that taking an antidepressant medication would be helpful

A patient with possible viral meningitis is admitted to the nursing unit after lumbar puncture was performed in the emergency department. Which action prescribed by the health care provider should the nurse question? A.) Elevate the head of the bed 20 degrees B.) Restrict oral fluids to 1000 mL daily C.) Administer ceftriaxone (Rocephin) 1 g IV every 12 hours D.) Give ibuprofen (Motrin) 400 mg every 6 hours as needed for headache

A young adult female patient with cystic fibrosis (CF) tells the nurse that she is not sure about getting married and having children some day. Which initial response by the nurse is best? A.) Are you aware of the normal lifespan for patients with CF? B.) Do you need any information to help you with that decision? C.) Many women with CF do not have difficulty conceiving children. D.) You will need to have genetic counseling before making a decision.

After 2 months of tuberculosis (TB) treatment with isoniazid (INH), rifampin (Rifadin), pyrazinamide (PZA), and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next? A.) Teach about treatment for drug-resistant TB treatment B.) Ask the patient whether medications have been taken as directed C.) Schedule the patient for directly observed therapy three times weekly D.) Discuss with the health care provider the need for the patient to use an injectable antibiotic

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

After evacuation of an epidural hematoma, a patients intracranial pressure (ICP) is being monitored with an intraventricular catheter. Which information obtained by the nurse is most important to communicate to the health care provider? A.) Pulse 102 beats/min B.) Temperature 101.6 F C.) Intracranial pressure 15 mm Hg D.) Mean arterial pressure 90 mm Hg

After receiving change-of-shift report about the following four patients, which patient should the nurse assess first? A.) A 31-year-old female with Cushing syndrome and a blood glucose level of 244 mg/dL B.) A 70-year-old female taking levothyroxine (Synthroid) who has an irregular pulse of 134 C.) A 53-year-old male who has Addison's disease and is due for a scheduled dose of hydrocortisone (Solu-Cortef) D.) A 22-year-old male admitted with syndrome of inappropriate antidiuretic hormone (SIADH) who has a serum sodium level of 130 mEq/L

After the nurse has received change of shift report, which patient should the nurse assess first? A.) A patient with pneumonia who has crackles in the right lung base B.) A patient with possible lung cancer who has just returned after bronchoscopy C.) A patient with hemoptysis and a 16 mm induration with tuberculin skin testing D.) A patient with chronic obstructive pulmonary disease (COPD) and pulmonary function testing (PFT) that indicates low forced vital capacity

An experienced nurse instructs a new nurse about how to care for a patient with dyspnea caused by a pulmonary fungal infection. Which action by the new nurse indicates a need for further teaching? A.) Listening to the patient's lung sounds several times during the shift B.) Placing the patient on droplet precautions and in a private hospital room C.) Increasing the oxygen flow rate to keep the oxygen saturation above 90% D.) Monitoring patient serology results to identify the specific infecting organism

An older patient is being discharged from the ambulatory surgical unit following left eye surgery. The patient tells the nurse, "I do not know if I can take care of myself with this patch over my eye." Which action by the nurse is most appropriate? A.) Refer the patient for home health care services B.) Discuss the specific concerns regarding self care C.) Give the patient written instructions regarding care D.) Assess the patient's support system for care at home

An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy twice a day. Which collaborative problem should the nurse identify as a priority for this patient? A.) Potential complication: hypovolemic shock B.) Potential complication: venous thromboembolism C.) Potential complication: fluid and electrolyte imbalance D.) Potential complication: impaired surgical wound healing

An unconscious 39-year-old male patient is admitted to the emergency department (ED) with a head injury. The patients spouse and teenage children stay at the patients side and ask many questions about the treatment being given. What action is best for the nurse to take? A.) Ask the family to stay in the waiting room until the initial assessment is completed B.) Allow the family to stay with the patient and briefly explain all procedures to them C.) Refer the family members to the hospital counseling service to deal with their anxiety D.) Call the family's pastor or spiritual advisor to take them to the chapel while care is given

An unconscious male patient has just arrived in the emergency department after a head injury caused by a motorcycle crash. Which order should the nurse question? A.) Obtain x-rays of the skull and spine B.) Prepare the patient for lumbar puncture C.) Send for computed tomography (CT) scan D.) Perform neurologic checks every 15 minutes

During admission of the patient to the holding area or operating room before surgery, the perioperative nurse must A.) Verify the patient's understanding of the risks of surgery. B.) Ensure the patient's identity with a formal identification process. C.).Prepare the skin by scrubbing the surgical site with an antimicrobial agent. D.) Perform a preoperative assessment with a patient history and physical examination.

During the admitting neurologic examination, the nurse determines the patient has speech difficulties as well as weakness of the right arm and lower face. The nurse would expect a CT scan to show pathology in the distribution of the: A.) Basilar artery B.) Left middle cerebral artery C.) Right anterior cerebral artery D.) Left posterior communicating artery

During the physical examination of a 36 year old female, the nurse finds that the patient's thyroid gland cannot be palpated. The most appropriate action by the nurse is to: A.) Palpate the patient's neck more deeply B.) Document that the thyroid was nonpalpable C.) Notify the health care provider immediately D.) Teach the patient about thyroid hormone testing

The critical care nurse is assessing a client whose baseline Glasgow Coma Scale (GCS) score in the emergency department was 5. The current GCS score is 3. What is the nurse's best interpretation of this finding? A.) The client's condition is improving B.) The client's condition is deteriorating C.) The client will need intubation and mechanical ventilation D.) The client's medication regime will need adjustments

Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Which response by the nurse is best? A.) This type of monitoring system is complex and it is managed by skilled staff B.) The monitoring system helps show whether blood flow to the brain is adequate C.) The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure D.) This monitoring system has multiple benefits including facilitation of cerebrospinal fluid drainage

Five minutes after receiving the ordered preoperative midazolam (Versed) by IV injection, the patient asks to get up to go to the bathroom to urinate. Which action by the nurse is most appropriate? A.) Assist the patient to the bathroom and stay with the patient to prevent falls B.) Offer a urinal or bedpan and position the patient in bed to promote voiding C.) Allow the patient up to the bathroom because medication onset is 10 minutes D.) Ask the patient to wait because catheterization is performed just before the surgery

Following a laryngectomy a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first? A.) Cover stoma with sterile gauze and ventilate through stoma B.) Attempt to reinsert the tracheostomy tube with the obturator in place C.) Assess the patient's oxygen saturation and notify the health care provider D.) Ventilate the patient with a manual bag and face mask until the health care provider arrives

For a patient who is suspected of having a stroke, one of the most important pieces of information that the nurse can obtain is: A.) Time of the patient's last meal B.) Time at which stroke symptoms first appeared C.) Patient's hypertension history and management D.) Family history of stroke and other cardiovascular diseases

For a patient with hyperthyroidism, which task should the nurse delegate to an experienced unlicensed assistive personnel (UAP)? A.) Instructing the patient to report any occurence of palpitations, dyspnea, vertigo or chest pain B.) Monitoring the apical pulse, blood pressure and temperature every 4 hours C.) Drawing blood to measure levels of thyroid-stimulating hormone, triiodothyronine and thyroxine D.) Teaching the patient about side effects of the drug propylthiouracil

For which client with severe migraine headaches would the nurse question an order of sumatriptan? A.) A 58 year old client with gastrointestinal reflux disease (GERD) B.) A 48 year old client with hypertension C.) A 65 year old client with mild emphysema D.) A 72 year old client with hyperthyroidism

In the postanesthesia care unit (PACU), a patients vital signs are blood pressure 116/72, pulse 74, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take first? A.) Place the patient in a side-lying position B.) Encourage the patient to take deep breaths C.) Prepare to transfer the patient to a clinical unit D.) Increase the rate of the postoperative IV fluids

Monitored anesthesia care (MAC) is going to be used for a closed, manual reduction of a dislocated shoulder. What action does the nurse anticipate? A.) Securing an airtight fit for the inhalation mask B.) Starting a 20-gauge IV in the patient's unaffected arm C.) Obtaining a nonocclusive dressing to place over the administration site D.) Teaching the patient about epidural patient-controlled anesthesia (PCA) use

On admission of a patient to the postanesthesia care unit (PACU), the blood pressure (BP) is 122/72. Thirty minutes after admission, the BP falls to 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate? A.) Increase the IV fluid rate B.) Continue to take vital signs every 15 minutes C.) Administer oxygen therapy at 100% per mask D.) Notify the anesthesia care provider (ACP) immediately

Proper attire for the semirestricted area of the surgery department is: A.) Street clothing B.) Surgical attire and head cover C.) Surgical attire, head cover, and mask. D.) Street clothing with the addition of shoe covers

Propranolol (Inderal), a b-adrenergic blocker that inhibits sympathetic nervous system activity, is prescribed for a patient who has extreme anxiety about public speaking. The nurse monitors the patient for: A.) Dry mouth B.) Bradycardia C.) Constipation D.) Urinary retention

Several patients have been hospitalized for diagnosis of neurologic problems. Which patient will the nurse assess first? A.) Patient with a transient ischemic attack (TIA) returning from carotid duplex studies B.) Patient with a brain tumor who has just arrived on the unit after a cerebral angiogram C.) Patient with a seizure disorder who has just completed an electroencephalogram (EEG) D.) Patient prepared for a lumbar puncture whose health care provider is waiting for assistance

Several weeks after a stroke, a 50-year-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention will be best to include in the initial plan for an effective bladder training program? A.) Limit fluid intake to 1200 mL daily to reduce urine volume B.) Assist the patient onto the bedside commode every 2 hours C.) Perform intermittent catheterization after each voiding to check for residual urine D.) Use an external condom catheter to protect the skin and prevent embarrassment

The RN is teaching an unlicensed assistive personnel (UAP) to check oxygen saturation by pulse oximetry. What will the nurse be sure to tell the UAP about patients with darker skin? A.) "Be aware that patients with darker skin usually show a 3% to 5% higher oxygen saturation compared with light-skinned patients" B.) "Usually dark skinned patients show a 3% to 5% lower oxygen saturation by pulse oximetry than light skinned patients" C.) "With a dark skinned patient, you may get more accurate results by measuring pulse oximetry on the patient's toes" D.) "More accurate results may result from continuous pulse oximetry monitoring than spot checking when a patient has darker skin"

The clinic nurse makes a follow-up telephone call to a patient with asthma. The patient reports having a baseline peak flow reading of 600 L/minute and the current peak flow is 420 L/minute. Which action should the nurse takefirst? A.) Tell the patient to go to the hospital emergency department B.) Instruct the patient to use the prescribed albuterol (Proventil) C.) Ask about recent exposure to any new allergens or asthma triggers D.) Question the patient about use of the prescribed inhaled corticosteroids

The effects of cigarette smoking on the respiratory system include: A.) Hypertrophy of capillaries causing hemoptysis B.) Hyperplasia of goblet cells and increased production of mucus C.) Increased proliferation of cilia and decreased clearance of mucus D.) Proliferation of alveolar macrophages to decrease the risk for infection

The emergency department nurse is evaluating the effectiveness of therapy for a patient who has received treatment during an asthma attack. Which assessment finding is the best indicator that the therapy has been effective? A.) No wheezes are audible B.) Oxygen saturation is >90% C.) Accessory muscle use has decreased D.) Respiratory rate is 16 breaths/minute.

The healthcare provider prescribes levothyroxine for a patient with hypothyroidism. After teaching regarding this drug, the nurse determines that further inspection is needed when the patient says: A.) "I can expect the medication dose may need to be adjusted" B.) "I only need to take this drug until my symptoms are improved" C.) "I can expect to return to normal function with the use of this drug" D.) "I will report any chest pain or difficulty breathing to the doctor right away"

The high pressure alarm on a patient's ventilator goes off. When the nurse enters the room to assess the patient, who has acute respiratory distress syndrome (ARDS), the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should the nurse take first? A.) Reassure the patient that the ventilator will do the work of breathing for him B.) Manually ventilate the patient while assessing possible reasons for the high-pressure alarm C.) Increase the fraction of inspired oxygen (FIO2) on the ventilator to 100% in preparation for endotracheal suctioning D.) Insert an oral airway to prevent the patient from biting on the endotracheal tube

The home health nurse is caring for an 81-year-old who had a stroke 2 months ago. Based on information shown in the accompanying figure from the history, physical assessment, and physical therapy/occupational therapy, which nursing diagnosis is the highest priority for this patient? A.) Impaired transfer ability B.) Risk for caregiver role strain C.) Ineffective health maintenance D.) Risk for unstable blood glucose level

The nurse admitting a patient who has a right frontal lobe tumor would expect the patient may have: A.) Expressive aphasia B.) Impaired judgment C.) Right-sided weakness D.) Difficulty swallowing

The nurse develops a plan of care to prevent aspiration in a high-risk patient. Which nursing action will be most effective? A.) Turn and reposition immobile patients at least every 2 hours B.) Place patients with altered consciousness in side-lying positions C.) Monitor for respiratory symptoms in patients who are immunosupressed D.) Insert nasogastric tube for feedings for patients with swallowing problems

The nurse is admitting a patient diagnosed with an acute exacerbation of chronic obstructive pulmonary disease (COPD).What is the best way for the nurse to determine the appropriate oxygen flow rate? A.) Minimize oxygen use to avoid oxygen dependency B.) Maintain the pulse oximetry level at 90% or greater C.) Administer oxygen according to the patients level of dyspnea D.) Avoid administration of oxygen at a rate of more than 2 L/minute

The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patients nose. Which admission order should the nurse question? A.) Keep the head of bed elevated B.) Insert nasogastric tube to low suction C.) Turn patient side to side every 2 hours D.) Apply cold packs intermittently to face

The nurse is assessing the muscle strength of an older adult patient. The nurse knows the findings cannot be compared with those of the younger adult because: A.) Nutritional status is better in young adults B.) Muscle bulk and strength decrease in older adults C.) Muscle strength should be the same for all adults D.) Most young adults exercise more than older adults

The nurse is assigned to provide nursing care for a patient receiving mechanical ventilation. Which action should the nurse delegate to an experienced unlicensed assistive personnel (UAP)? A.) Assessing the patient's respiratory status every 4 hours B.) Taking vital signs and pulse oximetry readings every 4 hours C.) Checking the ventilator settings to make sure they are as prescribed D.) Observing whether the patient's tube needs suctioning every 2 hours

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

The nurse is evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient is receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which finding concerns the nurse immediately? A.) Fine bibasilar crackles B.) Respiratory rate of 8 breaths/min C.) The patient sitting up and leaning over the nightstand D.) A large barrel chest

The nurse is floated from the emergency department to the neurologic floor. Which action should the nurse delegate to the unlicensed assistive personnel (UAP) when providing nursing care for a client with a spinal cord injury? A.) Assessing the client's respiratory status every 4 hours B.) Checking and recording the client's vital signs every 4 hours C.) Monitoring the client's nutritional status, including calorie counts D.) Instructing the client how to turn, cough and breathe deeply every 2 hours

The nurse is preparing to admit a client with a seizure disorder. Which action can be assigned to an LPN/LVN? A.) Completing the admission assessment B.) Setting up oxygen and suction equipment C.) Placing a padded tongue blade at the bedside D.) Padding the side rails before the client arrives

The nurse is preparing to witness the patient signing the operative consent form when the patient says, "I do not really understand what the doctor said." Which action is best for the nurse to take? A.) Provide an explanation of the planned surgical procedure B.) Notify the surgeon that the informed consent process is not complete C.) Administer the prescribed preoperative antibiotics and withhold any ordered sedative medications D.) Notify the operating room staff that the surgeon needs to give a more complete explanation of the procedure

The nurse is providing care for a patient diagnosed with laryngeal cancer who is receiving radiation therapy. The patient tells the nurse he is experiencing hoarseness and difficulty with speaking. What is the nurse's best response? A.) "Let's elevate your head of your bed and see if that helps" B.) "Your voice should improve in 6 to 8 weeks after completion of the radiation" C.) "Sometimes patients also experience dry mouth and difficulty with swallowing" D.) "I will call your healthcare provider and let him known about this"

The nurse is responsible for the care of a postoperative patient with a thoracotomy. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)? A.) Instructing the patient to alternate rest and activity periods B.) Encouraging, monitoring and recording nutritional intake C.) Monitoring cardiorespiratory response to activity D.) Planning activities for periods when the patient has the most energy

The nurse is supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would the nurse clearly instruct the nursing student to report immediately? A.) Chest tube drainage of 10 to 15 mL/hr B.) Continuous bubbling in the water-seal chamber C.) Reports of pain at the chest tube site D.) Chest tube dressing dated yesterday

The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed? A.) A large air leak in the water-seal chamber B.) 400 mL of blood in the collection chamber C.) Complaint of pain with each deep inspiration D.) Subcutaneous emphysema at the insertion site

The nurse obtains the following assessment data on an older patient who has influenza. Which information will be most important for the nurse to communicate to the health care provider? A.) Fever of 100.4 F B.) Diffuse crackles in the lungs C.) Sore throat and frequent cough D.) Myalgia and persistent headache

The nurse provides dietary teaching for a patient with chronic obstructive pulmonary disease (COPD) who has a low body mass index (BMI). Which patient statement indicates that the teaching has been effective? A.) I will drink lots of fluids with my meals B.) I can have ice cream as a snack every day C.) I will exercise for 15 minutes before meals D.) I will decrease my intake of meat and poultry

The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement, if made by the patient, indicates a good understanding of the instructions? A.) "I will call the doctor if I still feel tired after a week." B.) "I will continue to do the deep breathing and coughing exercises at home." C.) "I will schedule two appointments for the pneumonia and influenza vaccines." D.) "I'll cancel my chest x-ray appointment if I'm feeling better in a couple weeks."

The nurse receives a change-of-shift report on the following patients with chronic obstructive pulmonary disease (COPD). Which patient should the nurse assess first? A.) A patient with loud expiratory wheezes B.) A patient with a respiratory rate of 38/minute C.) A patient who has a cough productive of thick, green mucus D.) A patient with jugular venous distention and peripheral edema

The nurse receives an order for a patient with lung cancer to receive influenza vaccine and pneumococcal vaccines. The nurse will: A.) Call the health care provider to question the order B.) Administer both vaccines at the same time in different arms C.) Administer the flu shot and tell the patient to come back 1 week later to receive the pneumococcal vaccine D.) Administer the pneumococcal vaccine and suggest FluMist (nasal vaccine) instead of the influenza injection

The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first? A.) A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled B.) A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath C.) A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes D.) A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 100.2 F (37.8 C)

The nurse reviews the laboratory results for a patient on the first postoperative day after a hiatal hernia repair. Which finding would indicate to the nurse that the patient is at increased risk for poor wound healing? A.) Potassium 3.5 mEq/L B.) Albumin level 2.2 g/dL C.) Hemoglobin 11.2 g/dL D.) White blood cells 11,900/L

The nurse teaches a patient about pursed lip breathing. Which action by the patient would indicate to the nurse that further teaching is needed? A.) The patient inhales slowly through the nose B.) The patient puffs up the cheeks while exhaling C.) The patient practices by blowing through a straw D.) The patients ratio of inhalation to exhalation is 1:3

The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective? A.) I will avoid being outdoors whenever possible B.) My husband will be sleeping in the guest bedroom C.) I will take the bus instead of driving to visit my friends D.) I will keep the windows closed at home to contain the germs

The patient tells the nurse in the preoperative setting that she has noticed that she has a reaction when wearing rubber gloves. What is the most appropriate intervention? A.) Notify the surgeon so that the case can be cancelled B.) Ask additional questions to assess for a possible latex allergy C.) Notify the OR staff immediately so that latex-free supplies can be used D.) No intervention is needed because the patient's rubber sensitivity has no bearing on surgery

To assess for functional deficits, which question will the nurse ask a patient who has been admitted for treatment of a benign occipital lobe tumor? A.) Do you have difficulty in hearing? B.) Are you experiencing visual problems? C.) Are you having any trouble with your balance? D.) Have you developed any weakness on one side?

To detect early signs of symptoms of inadequate oxygenation, the nurse would examine the patient for: A.) Dyspnea and hypotension B.) Apprehension and restlessness C.) Cyanosis and cool, clammy skin D.) Increased urine output and diaphoresis

Vasogenic cerebral edema increases intracranial pressure by A.) Shifting fluid in the gray matter B.) Altering the endothelial lining of cerebral capillaries C.) Leaking molecules from the intracellular fluid to the capillaries D.) Altering the osmotic gradient flow into the intravascular component

When a patient with tuberculosis (TB) is being prepared for discharge, which statement by the patient indicates a need for further teaching? A.) "Everyone in my family needs to go and see the doctor for TB testing" B.) "I will continue to take my isoniazid until I am feeling completely well" C.) "I will cover my mouth and nose when I sneeze or cough and put my used tissues in a plastic bag" D.) "I will change my diet to include more foods rich in iron, protein, and vitamin C"

When assessing a patient with a sore throat, the nurse notes anterior cervical lymph node swelling, a temperature of 101.6 F and yellow patches on the tonsils. Which action will the nurse anticipate teaching? A.) Teach the patient about the use of expectorants B.) Use a swab to obtain a sample for a rapid strep antigen test C.) Discuss the need to rinse the mouth out after using any inhalers D.) Teach the patient to avoid use of NSAIDs

When auscultating the chest of an older patient in respiratory distress, it is best to: A.) Begin listening at the apices B.) Begin listening at the lung bases C.) Begin listening on the anterior chest D.) Ask the patient to breathe through the nose with the mouth closed

When caring for a patient who is hospitalized with active tuberculosis (TB), the nurse observes a student nurse who is assigned to take care of a patient. Which action, if performed by the student nurse, would require an intervention by the nurse? A.) The patient is offered a tissue from the box at the bedside B.) A surgical face mask in applied before visiting the patient C.) A snack is brought to the patient from the unit refrigerator D.) Hand washing is performed before entering the patient's room

When caring for a patient with a lung abscess, which is the nurse's priority intervention? A.) Postural drainage B.) Antibiotic administration C.) Obtaining a sputum specimen D.) Patient teaching regarding home care

When planning care for a patient at risk for pulmonary embolism, the nurse prioritizes: A.) Maintaining the patient on bed rest B.) Using sequential compression devices C.) Encouraging the patient to cough and deep breathe D.) Teaching the patient how to use the incentive spirometer

Which action best describes the role of the certified registered nurse anesthetist (CRNA) on the surgical care team? A.) Performs the same responsibilities as the anesthesiologist B.) Releases or discharges patients from the postanesthesia care area C.) Administers intraoperative anesthetics ordered by the anesthesiologist D.) Manages a patient's airway under the direct supervision of the anesthesiologist

Which action by a new registered nurse (RN) caring for a patient with a goiter and possible hyperthyroidism indicates that the charge nurse needs to do more teaching? A.) The RN checks the blood pressure on both arms B.) The RN palpates the neck thoroughly to check thyroid size C.) The RN lowers the thermostat to decrease the temperature in the room D.) The RN orders nonmedicated eye drops to lubricate the patient's bulging eyes

Which action could the postanesthesia care unit (PACU) nurse delegate to unlicensed assistive personnel (UAP) who help with the transfer of a patient to the clinical unit? A.) Clarify the postoperative orders with the surgeon B.) Help with the transfer of the patient onto a stretcher C.) Document the appearance of the patient's incision in the chart D.) Provide hand off communication to the surgical unit charge nurse

Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? A.) Listen to a patient's lung sounds for wheezes or rhonchi B.) Label specimens obtained during percutaneous lung biopsy C.) Instruct a patient about how to use home spirometry testing D.) Measure induration at the site of a patient's intradermal skin test

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

Which assessment finding in a patient who has received omalizumab (Xolair) is most important to report immediately to the health care provider? A.) Pain at injection site B.) Flushing and dizziness C.) Peak flow reading 75% of normal D.) Respiratory rate 22 breaths/minute

Which cerebrospinal fluid analysis result will be most important for the nurse to communicate to the health care provider? A.) Specific gravity 1.007 B.) Protein 65 mg/dL (0.65 g/L) C.) Glucose 45 mg/dL (1.7 mmol/L) D.) White blood cell (WBC) count 4 cells/mL

Which client should the charge nurse assign to a new graduate RN who is orienting to the neurological unit? A.) A 28 year old newly admitted client with a spinal cord injury B.) A 67 year old client who had a stroke 3 days ago and has left-sided weakness C.) A 85 year old client with dementia who is to be transferred to long term care today D.) A 54 year old client with Parkinson disease who needs assistance with bathing

Which data identified during the perioperative assessment alert the nurse that special protection techniques should be implemented during surgery? A.) Stated allergy to cats and dogs B.) History of spinal and hip arthritis C.) Verbalization of anxiety by the patient D.) Having a sip of water 3 hours previously

Which equipment will the nurse obtain to assess vibration sense in a diabetic patient who has peripheral nerve dysfunction? A.) Sharp pin B.) Tuning fork C.) Reflex hammer D.) Calibrated compass

Which finding by the nurse for a patient with a nursing diagnosis of impaired gas exchange will be most useful in evaluating the effectiveness of treatment? A.) Even, unlabored respirations B.) Pulse oximetry reading of 92% C.) Respiratory rate of 18 breaths/minute D.) Absence of wheezes, rhonchi, or crackles

Which finding for a patient who has a head injury should the nurse report immediately to the health care provider? A.) Intracranial pressure is 16 mm Hg when patient is turned B.) Pale yellow urine output is 1200 mL over the last 2 hours. C.) LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg D.) Ventriculostomy drained 40 mL of cerebrospinal fluid in the last 2 hours

Which information about a 76-year-old patient is most important for the admitting nurse to report to the patients health care provider? A.) Triceps reflex response graded at 1/5 B.) Unintended weight loss of 20 pounds C.) 10 mm Hg orthostatic drop in systolic blood pressure D.) Patient complaint of chronic difficulty in falling asleep

Which information about the patient who has had a subarachnoid hemorrhage is most important to communicate to the health care provider? A.) The patient complains of having a stiff neck B.) The patients blood pressure (BP) is 90/50 mm Hg C.) The patient reports a severe and unrelenting headache D.) The cerebrospinal fluid (CSF) report shows red blood cells (RBCs)

Which information in the preoperative patient's medication history is most important to communicate to the health care provider? A.) The patient uses acetaminophen (Tylenol) occasionally for aches and pains B.) The patient takes garlic capsules but did not take any on the surgical day C.) The patient has a history of cocaine but quit using the drug over 10 years ago D.) The patient took a sedative medication the previous night to assist in falling asleep

Which instruction should the nurse include in an exercise teaching plan for a patient with chronic obstructive pulmonary disease (COPD)? A.) Stop exercising if you start to feel short of breath B.) Use the bronchodilator before you start to exercise C.) Breathe in and out through the mouth while you exercise D.) Upper body exercise should be avoided to prevent dyspnea

Which nursing action could the registered nurse (RN) working in the skilled care hospital unit delegate to an experienced licensed practical/vocational nurse (LPN/LVN) caring for a patient with a permanent tracheostomy? A.) Assess the patient's risk for aspiration B.) Suction the tracheostomy when needed C.) Teach the patient about self-care of the tracheostomy D.) Determine the need for replacement of the tracheostomy tube

Which nursing action should the operating room (OR) nurse manager delegate to the registered nurse first assistant (RNFA) when caring for a surgical patient? A.) Adjust the doses of administered anesthetics B.) Make surgical incision and suture incisions as needed C.) Coordinate transfer of the patient to the operating table D.) Provide postoperative teaching about coughing to the patient

Which nursing action will be included in the plan of care for a 55 year old patient with Graves disease who has exophthalmos? A.) Place cold packs on the eyes to relieve pain and swelling B.) Elevate the head of the patient's bed to reduce periorbital fluid C.) Applying alternating eye patches to protect the corneas from irritation D.) Teach the patient to blink every few seconds to lubricate the corneas

Which nursing assessment of a 69 year old is most important to make during initiation of thyroid replacement with levothyroxine (Synthroid)? A.) Fluid balance B.) Apical pulse rate C.) Nutritional intake D.) Orientation and alertness

Which nursing diagnosis is expected to be appropriate for a patient who has a positive Romberg test? A.) Acute pain B.) Risk for falls C.) Acute confusion D.) Ineffective thermoregulation

Which question will the nurse in the endocrine clinic ask to help determine a patient's risk factors for goiter? A.) "How much milk do you drink?" B.) "What medications are you taking?" C.) "Are your immunizations up to date?" D.) "Have you had any recent neck injuries?"

Which statement by a 40-year-old patient who is being discharged from the emergency department (ED) after a concussion indicates a need for intervention by the nurse? A.) I will return if I feel dizzy or nauseated B.) I am going to drive home and go to bed C.) I do not even remember being in an accident D.) I can take acetaminophen (Tylenol) for my headache

While in the holding area, a patient reveals to the nurse that his father had a high fever after surgery. What action by the nurse is a priority? A.) Place a medical alert sticker on the front of the patient's chart B.) Alert the anesthesia care provider of the family member's reaction to surgery C.) Reassure the patient that there will be close monitoring during and after surgery D.) Administer 650 mg of acetaminophen (Tylenol) per rectum as a preventive measure

A home health nurse is teaching a client who has active tuberculosis. The provider has prescribed the following medication regimen: - isoniazid 250 mg PO daily - rifampin 500 mg PO daily - pyrazinamide 750 mg PO daily - ethambutol 1 mg PO daily Which of the following client statements indicate the client understands the teaching (select all that apply): A.) "I can substitute one medication for another if I run out because they all fight infection" B.) "I will wash my hands each time I cough" C.) "I will wear a mask when I am in a public area" D.) "I am glad I don't have to help any more sputum specimens" E.) "I don't' need to worry where I go once. I start taking my medications"

B, C

A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings (select all that apply): A.) Continuous bubbling in the water seal chamber B.) Gentle constant bubbling in the suction control chamber C.) Rise and fall in the level of water in the water seal chamber with inspiration and expiration D.) Exposed sutures without dressing E.) Drainage system upright at chest level

B, C

Which assessments will the nurse make to monitor a patient's cerebellar function (select all that apply)? A.) Assess for graphesthesia B.) Observe arm swing with gait C.) Perform the finger-to-nose test D.) Check ability to push against resistance E.) Determine ability to sense heat and cold

B, C

A nurse is caring for a client who has pneumonia. Assessment findings include temperature 100 F, respirations 30/min, blood pressure 130/76, heart rate 100/min, and SaO2 91% on room air. Prioritize the following nursing interventions: A.) Administer antibiotics B.) Administer oxygen therapy C.) Perform sputum culture D.) Administer an antipyretic medication to promote client comfort

B, C, A, D

A nurse is caring for a client who is postprocedure following lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take (select all that apply): A.) Use the Glasgow Coma Scale when assessing the client B.) Assist the client to a supine position C.) Administer an opioid medication D.) Encourage the client to increase fluid intake E.) Instruct the client to perform deep breathing and coughing exercises

B, C, D

A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following modes of ventilation that increases the effort of the client's respiratory muscles should the nurse include in the plan of care (select all that apply): A.) Assist-control B.) Synchronized intermittent mandatory ventilation C.) Continuous positive airway pressure D.) Pressure support ventilation E.) Independent lung ventilation

B, C, D

A nurse is reinforcing teaching with a client who has a new prescription for levothyroxine to treat hypothyroidism. Which of the following information should the nurse include in the teaching (select all that apply): A.) Weight gain is expected while taking this medication B.) Medication should not be discontinued without the advice of a provider C.) Follow up serum TSH levels should be obtained D.) Take the medication on an empty stomach E.) Use fiber laxatives for constipation

B, C, D

Appropriate discharge teaching for the patient with a permanent tracheostomy after a total laryngectomy for cancer would include (select all that apply): A.) Encouraging regular exercise such as swimming B.) Washing around the stoma daily with a moist washcloth C.) Encouraging participation in post-laryngectomy support growth D.) Providing pictures and "hands-on" instruction for tracheostomy care E.) Teaching how to hold breath and trying to gag to promote swallowing reflex

B, C, D

A nurse in the emergency department is assessing a client who has a suspected flail chest. Which of the following findings should the nurse expect (select all that apply) A.) Bradycardia B.) Cyanosis C.) Hypotension D.) Dyspnea E.) Paradoxic chest movement

B, C, D, E

The nurse is supervising an RN who floated from the medical surgical unit to the emergency department. The float nurse is providing care for a patient admitted with anterior epistaxis (nosebleed). Which directions would the supervising nurse clearly provide to the RN (select all that apply): A.) Position the patient supine and turned on his side B.) Apply direct lateral pressure to the nose for 5 minutes C.) Maintain standard body substance precaution D.) Apply ice or cool compresses to the nose E.) Instruct the patient not to blow the nose for several hours F.) Teach the patient to avoid vigorous nose blowing

B, C, D, E, F

A nurse in the emergency department is caring for a client who is having an acute asthma attack. Which of the following assessment indicates that the respiratory status is declining (select all that apply): A.) SaO2 95% B.) Wheezing C.) Retraction of sternal muscles D.) Pink mucous membranes E.) Premature ventricular complexes (PVCs)

B, C, E

A nurse is collecting an admission history from a female client who has hypothyroidism. Which of the following findings should the nurse expect (select all that apply): A.) Diarrhea B.) Menorrhagia C.) Dry skin D.) Increased libido E.) Hoarseness

B, C, E

Activities that the nurse might perform in the role of a scrub nurse during surgery include (select all that apply): A.) Checking electrical equipment B.) Preparing the instrument table C.) Passing instruments to the surgeon and assistants D.) Coordinating activities occuring in the operating room E.) Maintaining accurate counts of sponges, needles and instruments

B, C, E

Which statement(s) describe(s) the management of a patient following a lung transplant (select all that apply): A.) High doses of O2 are administered around the clock B.) The use of a home spirometer will help to monitor lung function C.) Immunosuppressant therapy usually involves a three drug regimen D.) Most patients experience an acute rejection episode in the first two days E.) The lung is biopsied using a transtracheal method if rejection is suspected

B, C, E

A nurse is caring for a client who has a closed head injury with ICP readings ranging from 16 to 22 mmHg. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP (select all that apply): A.) Suction the endotracheal tube frequently B.) Decrease the noise level in the client's room C.) Elevate the client's head on two pillows D.) Administer a stool softener E.) Keep the client well hydrated

B, D

A nurse is assessing a client who has a pulmonary embolism. Which of the following manifestations should the nurse expect to find (select all that apply): A.) Bradypnea B.) Pleural friction rub C.) Hypertension D.) Petechiae E.) Tachycardia

B, D, E

A nurse is planning care for a client who has severe acute respiratory distress system (SARS). Which of the following actions should be included in the plan of care for this client (select all that apply): A.) Administer antibiotics B.) Provide supplemental oxygen C.) Administer antiviral medications D.) Administer bronchodilators E.) Maintain ventilatory support

B, D, E

A nurse is reviewing the manifestations of hyperthyroidism with a client. Which of the following findings should the nurse include (select all that apply): A.) Anorexia B.) Heat intolerance C.) Constipation D.) Palpitations E.) Weight loss F.) Bradycardia

B, D, E

The nurse is caring for a patient after thoracentesis. Which actions can be delegated from the nurse to the unlicensed assistive personnel (UAP) (select all that apply): A.) Assess puncture site and dressing for leakage B.) Check vital signs every 15 minutes for 1 hour C.) Auscultate for absent or reduced lung sounds D.) Remind the patient to take deep breaths E.) Take the specimens to the laboratory F.) Teach the patient symptoms of pneumothorax

B, D, E

A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize (select all that apply): A.) Confusion B.) Pale skin C.) Bradycardia D.) Hypotension E.) Elevated blood pressure

B, E

A patient is scheduled for a computed tomography (CT) of the chest with contrast media. Which assessment findings should the nurse immediately report to the health care provide (select all that apply): A.) Patient is claustrophobic B.) Patient is allergic to shellfish C.) Patient recently used a bronchodilator inhaler D.) Patient is not able to remove a wedding band E.) Blood urea nitrogen (BUN) and serum creatinine levels are elevated

B, E

An abnormal findings by the nurse during an endocrine assessment would be (select all that apply): A.) Blood pressure of 100/70 mmHg B.) Excessive facial hair on a woman C.) Soft, formed stool every other day D.) 3 lb weight gain over the last 6 months E.) Hyperpigmented coloration in lower legs

B, E

A nurse administered midazolam IV bolus to a client before a procedure. His blood pressure is 86/40 mmHg, and his pulse is 134/min. Which of the following IV medications should the nurse administer? A.) Naloxone B.) Morphine C.) Flumazenil D.) Atropine

A 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care? A.) Encourage coughing and deep breathing B.) Position the patient with knees and hips flexed C.) Keep the head of the bed elevated to 30 degrees D.) Cluster nursing interventions to provide rest periods

A 47-year-old patient will attempt oral feedings for the first time since having a stroke. The nurse should assess the gag reflex and then: A.) Order a varied pureed diet B.) Assess the patients appetite C.) Assist the patient into a chair D.) Offer the patient a sip of juice

A 62 year old patient with hyperthyroidism is to be treated with radioactive iodine (RAI). The nurse instructs the patient: A.) About radioactive precautions to take with all body secretions B.) That symptoms of hyperthyroidism should be relieved in about a week C.) That symptoms of hypothyroidism may occur as the RAI therapy takes effect D.) To discontinue the antithyroid medications taken before the radioactive therapy

A 68-year-old patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin? A.) The patient has dysphasia B.) The patient has atrial fibrillation C.) The patient reports that symptoms began with a severe headache D.) The patient has a history of brief episodes of right-sided hemiplegia

A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? A.) Monitor the blood pressure B.) Send the patient for a computed tomography (CT) scan C.) Check the respiratory rate and effort D.) Assess the Glasgow Coma Scale score

A 72-year-old patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, I don't need the aspirin today. I don't have a fever. Which action should the nurse take? A.) Document that the aspirin was refused by the patient B.) Tell the patient that the aspirin is used to prevent a fever C.) Explain that the aspirin is ordered to decrease stroke risk D.) Call the health care provider to clarify the medication order

A male patient who has right-sided weakness after a stroke is making progress in learning to use the left hand for feeding and other activities. The nurse observes that when the patient's wife is visiting, she feeds and dresses him. Which nursing diagnosis is most appropriate for the patient? A.) Interrupted family processes related to effects of illness of a family member B.) Situational low self-esteem related to increasing dependence on spouse for care C.) Disabled family coping related to inadequate understanding by patients spouse D.) Impaired nutrition: less than body requirements related to hemiplegia and aphasia

A nurse in a provider's office is assessing an older adult client whose son reports that the client has been sick with a respiratory illness for the past 6 days. Which of the following assessment findings is a manifestation of pneumonia in the older adult client? A.) Bradycardia B.) Night sweats C.) Confusion D.) Narrowed pulse pressure

A nurse in the emergency department is assessing a client who was in a motor vehicle crash. Findings include -absent breath sounds in the left lower lobe with dyspnea -blood pressure 118/68 mmHg -respirations 38/min - heart rate 124/min - temperature 101.4 F - SaO2 92% Which of the following actions should the nurse take first? A.) Obtain a chest x-ray B.) Prepare for chest tube insertion C.) Administer oxygen via a high flow mask D.) Initiate IV access

A nurse in the intensive care unit is providing teaching for a client prior to removal of an endotracheal tube. Which of the following instructions should the nurse include in the teaching? A.) "Rest in a side lying position after the tube is removed" B.) "Use the incentive spirometer every 4 hr after the tube is removed" C.) "Avoid speaking for long periods" D.) "A nurse will monitor your vital signs every 15 minutes in the first hour after the tube is removed"

A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect? A.) Nausea B.) Dysphagia C.) Agitation D.) Hypotension

A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding? A.) Impulse control difficulty B.) Poor judgement C.) Inability to recognize familiar objects D.) Loss of depth perception

A nurse is caring for a client who had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first? A.) Observe for cerebrospinal fluid (CSF) leaks from the evacuation site B.) Assess for an increase in temperature C.) Check the oximeter D.) Monitor for manifestations for increased intracranial pressure

A nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. Which of the following is the priority assessment? A.) Glasgow Coma Scale B.) Cranial nerve function C.) Oxygen saturation D.) Pupillary response

A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering? A.) Furosemide B.) Dexamethasone C.) Heparin D.) Atropine

A nurse is caring for a client who reports a headache following an epidural regional nerve block. Which of the following actions should the nurse take? A.) Decrease the client's fluid intake B.) Apply pressure to the puncture site C.) Place the head of bed flat D.) Instruct the client to lie prone

A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mmHg. The nurse should identify that the client is experiencing which of the following acid-base imbalances? A.) Metabolic acidosis B.) Metabolic alkalosis C.) Resppiratory acidosis D.) Respiratory alkalosis

A nurse is caring fro a client who has a new diagnosis of tuberculosis and has been placed on a multi medication regimen. Which of the following instructions should the nurse give the client related to ethambutol? A.) "Your urine can turn a dark orange" B.) "Watch for a change in the sclera of your eyes" C.) "Watch for any changes in vision" D.) "Take vitamin B6 daily"

A nurse is giving a presentation at a community center about chronic bronchitis. Which of the following information should the nurse include as effective for preventing this disorder? A.) Maintenance of ideal weight B.) Annual influenza immunization C.) Smoking cessation D.) Regular moderate exercise

A nurse is monitoring a client following a thoracentesis. The nurse should identify which of the following manifestations as a complication contact the provider immediately? A.) Serosangunous drainage from the puncture site B.) Discomfort at the puncture site C.) Increased heart rate D.) Decreased temperature

A nurse is monitoring an older adult client immediately following a bronchoscopy. The nurse's priority is to monitor the client for which of the following? A.) Observing for confusion B.) Auscultating breath sounds C.) Confirming the gag reflex D.) Measuring blood pressure

A nurse is planning to instruct a client on how to perform pursed lip breathing. Which of the following should the nurse include int he plan of care? A.) Take quick breaths upon inhalation B.) Place your hand over your stomach C.) Take a deep breath in through your nose D.) Puff your cheeks upon exhalation

A nurse is preparing to administer a new prescription for isoniazid (INH) to a client who has tuberculosis. The nurse should instruct the client to report which of the following findings as an adverse effect of the medication? A.) "You might notice yellowing of your skin" B..) "You might experience pain in your joints" C.) "You might notice tingling of your hands" D.) "You might experience a loss of appetite"

A nurse is providing discharge teaching for a client who has COPD and a new prescription for albuterol. Which of the following statements by the client indicates an understanding of this teaching? A.) "This medication can increase my blood sugar levels" B.) "This medication can decrease my immune response" C.) "I can have an increase in my heart rate while taking this medication: D.) "I can have mouth sores while taking this medication"

A nurse is providing discharge teaching to a client who has a new prescription for prednisone for asthma. Which of the following client statements indicates an understanding of the teaching: A.) "I will decrease my fluid intake while taking this medication" B.) "I will expect to have black, tarry stools" C.) "I will take my medication with meals" D.) "I will monitor for weight loss while in this medication"

A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states that she is anxious and is unable to get enough air. Vital signs are: - heart rate 177/min - respirations 38.min - temperature 101.2 F - blood pressure 100/54 mmHg Which of the following nursing actions is the priority? A.) Notify the provider B.) Administer heparin via IV infusion C.) Administer IV therapy D.) Obtain a spiral CT scan

A nurse is reviewing the prescription for a client who had a total hip arthroplasty. Which of the following prescriptions should the nurse verify with the provider? A.) Administer enoxaparin 30 mg subcutaneous every 12 hr B.) Place a wedge or pillow between the client's legs when turning C.) Instruct the client to restrict flexion of the hip past 120 degrees D.) Encourage the client to perform foot and calf exercises every 2 hr

A nurse is teaching a client who ha emphysema about self management strategies. Which of the following statements by the client indicates an understanding of this teaching? A.) "I will inhale slowly through pursed lips to help me breathe better" B.) "I will avoid getting a flu shot" C.) "I will follow a daily diet high in calories and protein" D.) "I will lie on my stomach to practice abdominal breathing every day"

A nurse who is caring for patient with a tracheostomy tube in place has just auscultated rhonchi bilaterally. If the patient is unsuccessful in coughing up secretions, what action should the nurse take? A.) Encourage increased incentive spirometer use B.) Encourage the patient to increase oral fluid intake C.) Put on sterile gloves and use a sterile catheter to suction D.) Preoxygenate the patient for 3 minutes before suctioning

A patient develops carpopedal spasms and tingling of the lips following a parathyroidectomy. Which action should the nurse take first? A.) Administer the ordered muscle relaxant B.) Give the ordered oral calcium supplement C.) Have the patient rebreathe from a paper bag D.) Start the PRN oxygen at 2 L/min per cannula

A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan? A.) Purpose of antibiotic therapy B.) Ways to limit oral fluid intake C.) Appropriate use of cough suppressants D.) Safety concerns with home oxygen therapy

A patient has increased intracranial pressure and a ventriculostomy after a head injury. Which action can the nurse delegate to unlicensed assistive personnel (UAP) who regularly work in the intensive care unit? A.) Document intracranial pressure every hour B.) Turn and reposition the patient every 2 hours C.) Check capillary blood glucose level every 6 hours D.) Monitor cerebrospinal fluid color and volume hourly

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

A patient in metabolic alkalosis is admitted to the emergency department, and pulse oximetry (SpO2) indicates that the O2 saturation is 94%. Which action should the nurse take next? A.) Administer bicarbonate B.) Complete a head-to-toe assessment C.) Place the patient on high-flow oxygen D.) Obtain repeat arterial blood gases (ABGs)

A patient in surgery receives a neuromuscular blocking agent as an adjunct to general anesthesia. While in the postanesthesia care unit (PACU), what assessment finding is most important for the nurse to report? A.) Laryngospasm B.) Complaint of nausea C.) Weak chest wall movement D.) Patient unable to recall the correct date

A patient is admitted to the PACU after major abdominal surgery. During the initial assessment, the patient tells the nurse he thinks he is going to "throw up". A priority nursing intervention is to: A.) Increase the rate of IV fluid B.) Obtain vital signs, including O2 saturation C.) Position patient in lateral recovery period D.) Administer antiemetic medication as ordered

A patient is admitted to the medical unit with possible Graves disease (hyperthyroidism). Which assessment finding by the nurse supports this diagnosis? A.) Periorbital edema B.) Bradycardia C.) Exophthalmos D.) Hoarse voice

A patient is being prepared for a spinal fusion. While in the holding area, which action by a member of the surgical team requires rapid intervention by the charge nurse? A.) Wearing street clothes into the nursing station B.) Wearing a surgical mask in the holding room C.) Walking into the hallway outside an operating room without the hair covered D.) Putting on a surgical mask, cap and scrubs before entering the operating room

A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the health care provider? A.) The Mantoux test had an induration of 7 mm B.) The chest-x-ray showed infiltrates in the lower lobes C.) The patient is being treated with antiretrovirals for HIV infection D.) The patient has a cough that is productive of blood-tinged mucus

A patient is exhibiting word finding difficulty and weakness in his right arm. What area of the brain is most likely involved? A.) Brainstem B.) Vertebral artery C.) Left middle cerebral artery D.) Right middle cerebral artery

A patient is receiving radiation therapy for cancer of the kidney. The nurse monitors the patient for signs and symptoms of damage to the: A.) Pancreas B.) Thyroid gland C.) Adrenal glands D.) Posterior pituitary gland

A patient is scheduled for pulmonary function testing. Which action should the nurse take to prepare the patient for this procedure? A.) Give the rescue medication immediately before testing B.) Administer oral corticosteroids 2 hours before the procedure C.) Withhold bronchodilators for 6 to 12 hours before the examination D.) Ensure that the patient has been NPO for several hours before the test

A patient is scheduled for surgery requiring general anesthesia at an ambulatory surgical center. The nurse asks him when he ate last. He replies that he had a light breakfast a couple of hours before coming to the surgery center. What should the nurse do first? A.) Tell the patient to come back tomorrow since he ate a meal B.) Proceed with the preoperative checklist, including site identification C.) Notify the anesthesia care provider of when and what the patient last ate D.) Have the patient void before administering any preoperative medications

A patient is transferred from the postanesthesia care unit (PACU) to the clinical unit. Which action by the nurse on the clinical unit should be performed first? A.) Assess the patient's pain B.) Orient the patient to the unit C.) Take the patient's vital signs D.) Read the postoperative orders

A patient newly diagnosed with asthma is being discharged. The nurse anticipates including which topic in the discharge teaching? A.) Use of long-acting b-adrenergic medications B.) Side effects of sustained-release theophylline C.) Self-administration of inhaled corticosteroids D.) Complications associated with oxygen therapy

A patient undergoing an emergency appendectomy has been suing St. John's wort to prevent depression. Which complication would the nurse expect in the postanesthesia care unit? A.) Increased pain B.) Hypertensive episodes C.) Longer time to recover from anesthesia D.) Increased risk for postoperative bleeding

A patient who had a total laryngectomy has a nursing diagnosis of hopelessness related to loss of control of personal care. Which information obtained by the nurse is the best indicator that this identified problem is resolving? A.) The patient lets the spouse provide tracheostomy care B.) The patient allows the nurse to suction the tracheostomy C.) The patient aks show to clean the tracheostomy stoma and tube D.) The patient uses a communication board to request No Visitors

A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is most appropriate? A.) Document the presence of a large air leak B.) Notify the surgeon of a possible pneumothorax C.) Take no further action with the collection device D.) Adjust the dial on the wall regulator to decrease suction

A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which is the best response by the nurse? A.) Ask if the patient is experiencing shortness of breath, hives or itching B.) Ask the patient about any visual abnormalities such as red-green color discrimination C.) Explain that orange discolored urine and tears are normal while taking this medication D.) Advise the patient to stop the drug and report the symptoms to the healthcare provider

A patient with a diagnosis of sleep apnea has a problem with sleep deprivation related to disrupted sleep cycle. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)? A.) Discussing weight-loss strategies such as diet and exercise with the patient B.) Teaching the patient how to set up the bilevel positive airway pressure (BiPAP) machine before sleeping C.) Reminding the patient to sleep on his side instead of his back D.) Administering modafinil to promote daytime wakefulness

A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action should the nurse include in the plan of care in collaboration with the speech therapist? A.) Leave the tracheostomy inner cannula inserted at all times B.) Place the decannulation cap in the tube before cuff deflation C.) Assess the ability to swallow before using the fenestrated tube D.) Inflate the tracheostomy cuff during the use of the fenestrated tube

A patient with chronic obstructive pulmonary disease (COPD) has a nursing diagnosis of imbalanced nutrition: less than body requirements. Which intervention would be most appropriate for the nurse to include in the plan of care? A.) Encourage increased intake of whole grains B.) Increase the patient's intake of fruits and fruit juices C.) Offer high-calorie snacks between meals and at bedtime D.) Assist the patient in choosing foods with high vegetable and mineral content

A patient with chronic obstructive pulmonary disease (COPD) has poor gas exchange. Which action by the nurse would be most appropriate? A.) Have the patient rest in bed with the head elevated to 15 to 20 degrees B.) Ask the patient to rest in bed in a high-Fowler's position with the knees flexed C.) Encourage the patient to sit up at the bedside in a chair and lean slightly forward D.) Place the patient in the Trendelenburg position with several pillows behind the head

A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment has been effective? A.) Bronchial breath sounds are head at the right base B.) The patient coughs up small amounts of green mucus C.) The patient's white blood cell count is 9000/L D.) Increased tactile fremitus is palpable over the right chest

A patient's T-tube is draining dark green fluid after gallbladder surgery. What action by the nurse is the most appropriate? A.) Notify the patient's surgeon B.) Place the patient on bed rest C.) Document the color and amount of drainage D.) Irrigate the T-tube with sterile normal saline

A postoperative patient has a nursing diagnosis of ineffective airway clearance. The nurse determines that interventions for this nursing diagnosis has been successful if which is observed? A.) Patient drinks 2 to 3 L of fluids in 24 hours B.) Patient uses the spirometer 10 times every hour C.) Patient's breath sounds are clear to auscultation D.) Patient's temperature is less than 100.4 F orally

After a client has a seizure, which action can the nurse delegate to the unlicensed assistive personnel (UAP)? A.) Documenting the seizure B.) Performing neurologic checks C.) Checking the client's vital signs D.) Restraining the client for protection

After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about: A.) Cerebral aneurysm clipping B.) Heparin intravenous infusion C.) Oral low-dose aspirin therapy D.) Tissue plasminogen activator (tPA)

An 82-year-old patient in a long-term care facility has several medications prescribed. After the patient is newly diagnosed with hypothyroidism, the nurse will need to consult with the health care provider before administering: A.) Docusate (Colace) B.) Ibuprofen (Motrin) C.) Diazepam (Valium) D.) Cefoxitin (Mefoxin)

An appropriate technique to use during physical assessment of the thyroid gland is: A.) Asking the patient to hyperextend the neck during palpation B.) Percussing the neck for dullness to define the size of the thyroid C.) Having the patient swallow water during inspection and palpation of the gland D.) Using deep palpation to determine the extent of a visibly enlarged thyroid gland

The nurse is caring for a patient with idiopathic pulmonary arterial hypertension (IPAH) who is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action by the nurse? A.) The oxygen saturation is 94% B.) The blood pressure is 98/56 mmHg C.) The patient's central IV line is disconnected D.) The international normalized ratio (INR) is prolonged

An experienced nurse orients a new nurse to the postanesthesia care unit (PACU). Which action by the new nurse, if observed by the experienced nurse, indicates that the orientation was successful? A.) The new nurse assists a nauseated patient to a supine position B.) The new nurse positions an unconscious patient supine with the head elevated C.) The new nurse turns an unconscious patient to the side upon arrival in the PACU D.) The new nurse places a patient in the Trendelenburg position when the blood pressure drops

An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action, if recommended by the nurse, will be most helpful in reducing the incidence of lung disease? A.) Treat workers with pulmonary fibrosis. B.) Teach about symptoms of lung disease C.) Require the use of protective equipment D.) Monitor workers for coughing and wheezing

As the shift beings, the nurse is assigned to care for the following patients. Which patient should the nurse assess first? A.) A 38 year old patient with Graves disease and a heart rate of 94 beats/min B.) A 63 year old patient with type 2 diabetes and fingerstick glucose level of 137 mg/dL C.) A 58 year old patient with hypothyroidism and a heart rate of 48 beats/min D.) A 49 year old patient with Cushing disease and dependent edema related as +1

Bladder training in a male patient who has urinary incontinence after a stroke includes: A.) Limiting fluid intake B.) Keeping a urinal in place at all times C.) Assisting the patient to stand to void D.) Catheterizing the patient every 4 hours

During neurologic testing, the patient is able to perceive pain elicited by pinprick. Based on this finding, the nurse may omit testing for: A.) Position sense B.) Patellar reflexes C.) Temperature perception D.) Heel-to-shin movements

During the change of shift report a nurse is told that a patient has an occluded left posterior cerebral artery. The nurse will anticipate that the patient may have: A.) Dysphasia B.) Confusion C.) Visual deficits D.) Poor judgment

During the neurologic assessment, the patient is unable to respond verbally to the nurse but cooperates with the nurses directions to move his hands and feet. The nurse will suspect: A.) Cerebellar injury B.) A brainstem lesion C.) Frontal lobe damage D.) A temporal lobe lesion

Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has no symptoms of TB. Which information should the occupational health nurse plan to teach the staff nurse? A.) Standard four-drug therapy for TB B.) Need for annual repeat TB skin testing C.) Use and side effects of isoniazid (INH) D.) Bacille Calmette-Guérin (BCG) vaccine

Following a pneumonectomy, an appropriate nursing intervention is: A.) Monitoring chest tube drainage and functioning B.) Positioning the patient on the unaffected side or back C.) During range of motion exercises on the affected upper limb D.) Auscultating frequently for lung sounds on the affected side

IV induction for general anesthesia is the method of choice for most patients because: A.) The patient is not intubated B.) The agents are nonexplosive C.) Induction is rapid and pleasant D.) Emergence is longer but with fewer complications

The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months of experience) floated from the surgical unit to the medical unit? A.) A 58 year old patient on airborne precautions for tuberculosis (TB) B.) A 65 year old patient who just returned from bronchoscopy and biopsy C.) A 72 year old patient who needs teaching about the use of incentive spirometry D.) A 69 year old patient with chronic obstructive pulmonary disease (COPD) who is ventilator dependent

The charge nurse is observing a new staff nurse who is assessing a patient with a traumatic spinal cord injury for sensation. Which action indicates a need for further teaching of the new nurse about neurologic assessment? A.) The new nurse tests for light touch before testing for pain B.) The new nurse has the patient close the eyes during testing C.) The new nurse asks the patient if the instrument feels sharp D.) The new nurse uses an irregular pattern to test for intact touch

The charge nurse observes an inexperienced staff nurse caring for a patient who has had a craniotomy for resection of a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene? A.) The staff nurse assesses neurologic status every hour B.) The staff nurse elevates the head of the bed to 30 degrees C.) The staff nurse suctions the patient routinely every 2 hours D.) The staff nurse administers an analgesic before turning the patient

The factor related to cerebral blood flow that most often determines the extent of cerebral damage from a stroke is the: A.) Amount of cardiac output B.) O2 content of the blood C.) Degree of collateral circulation D.) Level of CO2 in the blood

The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take? A.) Teach about the reason for the blood tests B.) Schedule an appointment for a chest x-ray C.) Teach about the need to get sputum specimens for 2 to 3 consecutive days D.) Instruct the patient to expectorate three specimens as soon as possible

The major advantage of a Venturi mask is that it can: A.) Deliver up to 80% O2 B.) Provide continuous 100% humidity C.) Deliver a precise concentration of O2 D.) Be used while a patient eats and sleeps

The nasogastric (NG) tube is removed on the second postoperative day, and the patient is placed on a clear liquid diet. Four hours later, the patient complains of sharp, cramping gas pains. What action by the nurse is the most appropriate? A.) Reinsert the NG tube B.) Give the PRN IV opioid C.) Assist the patient to ambulate D.) Place the patient on NPO status

The nurse assesses a patient with a history of asthma. Which assessment finding indicates that the nurse should take immediate action? A.) Pulse oximetry reading of 91% B.) Respiratory rate of 26 breaths/minute C.) Use of accessory muscles in breathing D.) Peak expiratory flow rate of 240 L/minute

The nurse can best determine adequate arterial oxygenation of the blood by assessing: A.) Heart rate B.) Hemoglobin level C.) Arterial oxygen tension D.) Arterial carbon dioxide tension

The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. When auscultating the patient's lungs, which finding would the nurse most likely hear? A.) Continuous rumbling, snoring, or rattling sounds mainly on expiration B.) Continuous high-pitched musical sounds on inspiration and expiration C.) Discontinuous, high-pitched sounds of short duration heard on inspiration D.) A series of long-duration, discontinuous, low-pitched sounds during inspiration

The nurse discusses management of upper respiratory infections (URI) with a patient who has acute sinusitis. Which statement by the patient indicates that additional teaching is needed? A.) I can take acetaminophen (Tylenol) to treat my discomfort B.) I will drink lots of juices and other fluids to stay well hydrated C.) I can use my nasal decongestant spray until the congestion is all gone D.) I will watch for changes in nasal secretions or the sputum that I cough up

The nurse educator facilitates student clinical experience in the surgical suite. Which action, if performed by the student, would require the nurse educator to intervene? A.) The student wears a mask at the sink area B.) The student wears street clothes in the unrestricted area C.) The student wears surgical scrubs in the semirestricted area D.) The student covers head and facial hair in the semirestricted area

The nurse explains to the patient with a stroke who is scheduled for angiography that this test is used to determine the: A.) Presence of increased ICP B.) Site and size of the infarction C.) Patency of the cerebral blood vessels D.) Presence of blood in the cerebrospinal fluid

The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medications effectiveness? A.) Blood pressure B.) Oxygen saturation C.) Intracranial pressure D.) Hemoglobin and hematocrit

The nurse has just finished assisting the health care provider with a thoracentesis for a patient with recurrent left pleural effusion caused by lung cancer. The thoracentesis removed 1800 mL of fluid. Which patient assessment information is most important to report to the health care provider (HCP)? A.) The patient starts crying and says she can't go on with treatment any longer B.) The patient reports sharp, stabbing chest pain with every deep breath C.) The blood pressure is 100/48 mmHg, and the heart rate is 102 beats/min D.) The dressing at the thoracentesis site has 1 cm of bloody drainage

The nurse identifies a flail chest in a trauma patient when: A.) Multiple rib fractures are determined by x ray B.) A tracheal deviation to the unaffected side is present C.) Paradoxical chest movement occurs during respiration D.) There is decreased movement of the involved chest wall

The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired self-feeding ability for a left-handed patient with left-sided hemiplegia. Which intervention should be included in the plan of care? A.) Provide a wide variety of food choices B.) Provide oral care before and after meals C.) Assist the patient to eat with the right hand D.) Teach the patient the chin-tuck technique

The nurse interviews a patient with a new diagnosis of chronic obstructive pulmonary disease (COPD). Which information is most helpful in confirming a diagnosis of chronic bronchitis? A.) The patient tells the nurse about a family history of bronchitis B.) The patient's history indicates a 30 pack-year cigarette history C.)The patient complains about a productive cough every winter for 3 months D.) The patient denies having any respiratory problems until the last 12 months

The nurse is alerted to a possible acute subdural hematoma in the patient who A.) Has a linear skull fracture crossing a major artery B.) Has focal symptoms of brain damage with no recollection of a head injury C.) Develops decreased level of consciousness and a headache within 48 hours of a head injury D.) Has an immediate loss of consciousness with a brief lucid interval followed by decreasing level of consciousness

The nurse is assessing a client with a neurologic health problem and discovers a change in the level of consciousness from alert to lethargic. What is the nurse's best action? A.) Perform a complete neurological assessment B.) Assess the cranial nerve functions C.) Contact the rapid response team D.) Reassess the client in 30 minutes

The nurse is caring for a patient the first postoperative day following a laparotomy for a small bowel obstruction. The nurse notices new bright red drainage about 5 cm in diameter on the dressing. Which action should the nurse take first? A.) Reinforce the dressing B.) Apply an abdominal binder C.) Take the patient's vital signs D.) Recheck the dressing in 1 hour for increased drainage

The nurse is caring for a patient who has a head injury and fractured right arm after being assaulted. Which assessment information requires the most rapid action by the nurse? A.) The apical pulse is slightly irregular B.) The patient complains of a headache C.) The patient is more difficult to arouse. D.) The blood pressure (BP) increases to 140/62 mm Hg

The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? A.) Assess the patient's gag and cough reflexes B.) Determine when the stroke symptoms began C.) Administer the prescribed short-acting insulin D.) Infuse the prescribed IV metoprolol (Lopressor)

The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). Which information obtained from the patient would prompt the nurse to consult with the health care provider before administering the prescribd theophylline? A.) The patient reports a recent 15 pound weight gain B.) The patient denies any shortness of breath at present C.) The patient denies any shortness of breath at present D.) The patient complains about coughing up green mucus

The nurse is caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotracheal tube. To prevent ventilator-associated pneumonia (VAP), which action is most important to include in the plan of care? A.) Administer ordered antibiotica as scheduled B.) Hyperoxygenate the patient before suctioning C.) Maintain the head of bed at a 30 to 45 degree angle D.) Suction the airway when coarse crackles are audible

The nurse is initiating a nursing care plan for a patient with pneumonia. Which intervention for cough enhancement should the nurse delegate to the unlicensed assistive personnel (UAP)? A.) Teaching the patient about the important of adequate fluid intake and hydration B.) Assisting the patient to a sitting position with neck flexed, shoulders relaxed, and knees flexed C.) Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake D.) Encouraging the patient to take a deep breath, hold it for 2 seconds, and then cough two or three times in succession

The nurse is making a home visit to a 50 year old patient who was recently hospitalized with a right leg deep vein thrombosis and a pulmonary embolism (venous thromboembolism). The patient's only medication is enoxaparin subcutaneously. Which assessment information will the nurse need to communicate to the health care provider? A.) The patient says that her right leg aches all night B.) The right calf is warm to the touch and is larger than the left calf C.) The patient is unable to remember her husband's first name D.) There are multiple ecchymotic areas on the patient's abdomen

The nurse is preparing to discharge a patient from the ambulatory surgery center following an inguinal hernia repair. The nurse delays the release of the patient upon discovering that the patient A.) Had IV morphine 45 minutes ago B.) Has an oxygen saturation of 92% C.) Has not voided since before surgery D.) Had one episode of vomiting 30 minutes ago

The nurse is providing care for a client with an acute hemorrhagic stroke. The client's spouse tells the nurse that he has been reading a lot about strokes and asks why his wife has not received alteplase. What is the nurse's best response? A.) "Your wife was not admitted within the time frame that alteplase is usually given" B.) "This drug is used primarily for clients who experience an acute heart attack" C.) "Alteplase dissolves clots and may cause more bleeding into your wife's brain" D.) "Your wife had gallbladder surgery just 6 months ago, so we can't use alteplase"

The nurse is supervising a student nurse who is performing tracheostomy care for a patient. Which action by the student would cause the nurse to intervene? A.) Suctioning the tracheostomy tube before performing tracheostomy care B.) Removing old dressings and cleaning off excess secretions C.) Removing the inner cannula and cleaning using standard precautions D.) Replacing the inner cannula and cleaning the stoma site

The nurse is the preceptor for an RN who is undergoing orientation to the intensive care unit. The RN is providing care for a patient with acute respiratory distress syndrome (ARDS) who has just been intubated in preparation for mechanical ventilation. The preceptor observes the RN performing all of these actions. For which action must the preceptor intervene immediately? A.) Assess for bilateral breath sounds and symmetrical chest movement B.) Uses an end-tidal carbon dioxide detector to confirm endotracheal tube (ET) position C.) Marks the tube 1 cm from where it touches the incisor tooth or nares D.) Orders chest radiography to verify that tube placement is correct

The nurse notes that a patient has incisional pain, a poor cough effort and scattered rhonchi after a thoracotomy. Which action should the nurse take first? A.) Assist the patient to sit upright in a chair B.) Splint the patient's chest during coughing C.) Medicate the patient with prescribed morphine D.) Observe the patient use the incentive spirometer

The nurse observes a student who is listening to a patient's lungs who is having no problems with breathing. Which action by the student indicates a need to review respiratory assessment skills? A.) The student starts at the apices of the lungs and moves to the bases B.) The student compares breath sounds from side to side avoiding bony areas C.) The student places the stethoscope over the posterior chest and listens during inspiration D.) The student instructions the patient to breathe slowly and a little more deeply than normal through the mouth

The nurse on the clinical unit is assigned to four patients. Which patient should she assess first? A.) Patient with a skull fracture whose nose is bleeding B.) Elderly patient with a stroke who is confused and whose daughter is present C.) Patient with meningitis who is suddenly agitated and reporting a HA of 10 on a 0 to 10 scale D.) Patient who had a craniotomy for a brain tumor who is now 3 days postoperative and has had continued emesis

The nurse plans to provide preoperative teaching to an alert older man who has hearing and vision deficits. His wife usually answers most questions that are directed to the patient. Which action should the nurse take when doing the teaching? A.) Use printed materials for instruction so that the patient will have more time to review the material B.) Direct the teaching toward the wife because she is the obvious support and caregiver to the patient C.) Provide additional time for the patient to understand preoperative instructions and carry out procedures D.) Ask the patient's wife to wait in the hall in order to focus preoperative teaching with the patient himself

The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy for cancer of the lung. Which information should the nurse include about the patient's postoperative care? A.) Positioning on the right side B.) Bed rest for the first 24 hours C.) Frequent use of an incentive spirometer D.) Chest tube placement with continuous drainage

The nurse takes an admission history on a patient with possible asthma who has new-onset wheezing and shortness of breath. Which information may indicate a need for a change in therapy? A.) The patient has chronic inflammatory bowel disease B.) The patient has a history of pneumonia 6 months ago C.) The patient takes propranolol (Inderal) for hypertension D.) The patient uses acetaminophen (Tylenol) for headaches

The nurse teaches a patient about pulmonary function testing (PFT). Which statement, if made by the patient, indicates teaching was effective? A.) I will use my inhaler right before the test B.) I won't eat or drink anything 8 hours before the test C.) I should inhale deeply and blow out as hard as I can during the test D.) My blood pressure and pulse will be checked every 15 minutes after the test

The nurse teaches a patient with chronic bronchitis about a new prescription for Advair Diskus (combined fluticasone and salmeterol). Which action by the patient would indicate to the nurse that teaching about medication administration has been successful? A.) The patient shakes the device before use B.) The patient attaches a spacer to the Diskus C.) The patient rapidly inhales the medication D.) The patient performs huff coughing before inhalation

The patient experiencing TIA is scheduled for a carotid endarterectomy. The nurse explains that this procedure is done to: A.) Decrease cerebral edema B.) Reduce the brain damage that occurs during a stroke in evolution C.) Prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow D.) Provide a circulatory bypass around thrombotic plaques obstructing cranial circulation

The public health nurse is planning a program to decrease the incidence of meningitis in adolescents and young adults. Which action is most important? A.) Encourage adolescents and young adults to avoid crowds in the winter B.) Vaccinate 11- and 12-year-old children against Haemophilus influenzae C.) Immunize adolescents and college freshman against Neisseria meningitides. D.) Emphasize the importance of hand washing to prevent the spread of infection

When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, the nurse reports the response as A.) Flexion withdrawal B.) Localization of pain C.) Decorticate posturing D.) Decerebrate posturing

When a patient is admitted to the PACU, what are the priority interventions the nurse performs? A.) Assess the surgical site, noting presence and character of drainage B.) Assess the amount of urine output and the presence of bladder distension C.) Assess for airway patency and quality of respirations and obtain vital signs D.) Review results of intraoperative laboratory values and medications received

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

Which action by the nurse will be most effective in decreasing the spread of pertussis in a community setting? A.) Providing supportive care to patients diagnosed with pertussis B.) Teaching family members about the need for careful hand washing C.) Teaching patients about the need for adult pertussis immunizations D.) Encouraging patients to complete the prescribed course of antibiotics

Which action most effectively demonstrates that a new staff member understands the role of scrub nurse? A.) Documents all patient care accurately B.) Labels all specimens to send to the lab C.) Keeps both hands above the operating table level D.) Takes the patient to the postanesthesia recovery area

Which assessment finding for a 33 year old female patient admitted with Graves disease requires the most rapid intervention by the nurse? A.) Bilateral exophthalmos B.) Heart rate 136 beats/minute C.) Temperature 103.8 F D.) Blood pressure 166/100 mmHg

Which client in the neurologic intensive care unit should the charge nurse assign to an RN who has been floated in from the medical unit? A.) A 26 year old client with a basilar skull fracture who has clear drainage coming out of the nose B.) A 42 year old client admitted several hours ago with a headache and a diagnosis of a ruptured berry aneurysm C.) A 46 year old client who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due D.) A 65 year old client with an astrocytoma who has just returned to the unit after undergoing a craniotomy

Which information about a 30-year-old patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse? A.) Intracranial pressure of 15 mm Hg B.) Cerebrospinal fluid (CSF) drainage of 25 mL/hour C.) Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg D.) Cardiac monitor shows sinus tachycardia at 128 beats/minute

Which information will the nurse teach a 48 year old patient who has been newly diagnosed with Graves disease? A.) Exercise is contraindicated to avoid increasing metabolic rate B.) Restriction of iodine intake is needed to reduce thyroid activity C.) Antithyroid medications may take several months for full effect D.) Surgery will eventually be required to remove the thyroid 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 or with the thyroid gland? A.) Thyroxine (T4) level B.) Triiodothyronine (T3) level C.) Thyroid stimulating hormone (TSH) level D.) Thyrotropin releasing hormone (TRH) level

Which nursing action will be included in the care for a patient who has had cerebral angiography? A.) Monitor for headache and photophobia B.) Keep patient NPO until gag reflex returns C.) Check pulse and blood pressure frequently D.) Assess orientation to person, place, and time

Which nursing action would be of highest priority when suctioning a patient with a tracheostomy? A.) Auscultating lung sounds after suctioning is complete B.) Providing a means of communications for the patient during the procedure C.) Assessing the patient's oxygenation saturation before, during and after suctioning D.) Administering pain and/or anti-anxiety medication 30 minutes before suctioning

Which question will provide the most useful information to a nurse who is interviewing a patient about a possible thyroid disorder? A.) "What methods do you use to help cope with stress?" B.) "Have you experienced any blurring or double vision?" C.) "Have you had a recent unplanned weight gain or loss?" D.) "Do you have to get up at night to empty your bladder?"

Which stroke risk factor for a 48-year-old male patient in the clinic is most important for the nurse to address? A.) The patient is 25 pounds above the ideal weight B.) The patient drinks a glass of red wine with dinner daily C.) The patient's usual blood pressure (BP) is 170/94 mm Hg D.) The patient works at a desk and relaxes by watching television

Which topic is most important for the nurse to discuss preoperatively with a patient who is scheduled for abdominal surgery for an open cholecystectomy? A.) Care for the surgical incision B.) Medications used during surgery C.) Deep breathing and coughing techniques D.) Oral antibiotic therapy after discharge home

While caring for a patient with respiratory disease, the nurse observes that the patient's SpO2 drops from 93% to 88% while the patient is ambulating in the hallway. What is the priority action of the nurse? A.) Notify the health care provider B.) Document the response to exercise C.) Administer the PRN supplemental O2 D.) Encourage the patient to pace activity

Preoperative considerations for older adults include (select all that apply) A.) Only using large-print educational materials B.) Speaking louder for patients with hearing aids C.) Recognizing that sensory deficits may be present D.) Providing warm blankets to prevent hypothermia E.) Teaching important information early in the morning

C, D

A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions that the nurse should take: A.) Establish IV access B.) Remove clothing for a thorough assessment C.) Open the airway using a jaw-thrust maneuver D.) Determine effectiveness of ventilator efforts E.) Perform clothing for a thorough assessment

C, D, A, B, E

A nurse is assessing a client who is 12 hour postoperative following a thyroidectomy. The nurse should identify which of the following findings as indicative of thyroid crisis (select all that apply): A.) Bradycardia B.) Hypothermia C.) Dyspnea D.) Abdominal pain E.) Mental confusion

C, D, E

A nurse is verifying informed consent for a client who is having a paracentesis. Which of the following actions should the nurse take (select all that apply): A.) Explain to the client the purpose of having the procedure B.) Inform the client of risks to having the procedure C.) Ensure the client understands information about the procedure D.) Witness the client signing the informed consent form E.) Determine if the client is capable of understanding the reason for the procedure

C, D, E

A patient is seen at the clinic with fever, muscle aches, sore throat with yellowish exudate, and headache. The nurse anticipates that the interprofessional management will include (select all that apply): A.) Antiviral agents to treat influenza B.) Treatment with antibiotics starting ASAP C.) A throat culture or rapid strep antigen tests D.) Supportive care, including cool, bland liquids E.) Comprehensive history to determine possible etiology

C, D, E

A patient with TB has been admitted to the hospital and is placed in an airborne infection isolation room. What should the patient be taught (select all that apply)? A.) Expect routine TST to evaluate infection B.) Visitors will not be allowed while in airborne isolation C.) Take all medications for full length of time to prevent multidrug-resistant TB D.) Wear a standard isolation mask if leaving the airborne infection isolation room E.) Maintain precautions in airborne infection isolation room by coughing into a paper tissue

C, D, E

Discharge criteria for the Phase II patient include (select all that apply): A.) No nausea or vomiting B.) Ability to drive self home C.) No respiratory depression D.) Written discharge instructions understood E.) Opioid pain medication given 45 minutes ago

C, D, E

During the respiratory assessment of an older adult, the nurse would expect to find (select all that apply): A.) A vigorous reflex cough B.) Increased chest expansion C.) Increased residual volume D.) Diminished lung sounds at base of lungs E.) Increased anteroposterior (AP) chest diameter

C, D, E

When caring for a preoperative patient on the day of surgery, which actions included in the plan of care can the nurse delegate to unlicensed assistive personnel (UAP) (select all that apply): A.) Teach incentive spirometer use B.) Explain preoperative routine care C.) Obtain and document baseline vital signs D.) Remove nail polish and apply pulse oximeter E.) Transport the patient by stretcher to the operating room

C, D, E

Which actions will the nurse include in the surgical time-out procedure before surgery (select all that apply)? A.) Check for placement of IV lines B.) Have the surgeon identify the patient C.) Have the patient state name and date of birth D.) Verify the patient identification band number E.) Ask the patient to state the surgical procedure F.) Confirm the hospital chart identification number

C, D, E, F

Nursing management of a patient with a brain tumor includes (select all that apply): A.) Discussing with the patient methods to control inappropriate behavior B.) Using diversion techniques to keep the patient stimulated and motivated C.) Assisting and supporting the family in understanding any changes in behavior D.) Limiting self-care activities until the patient has regained maximum physical functioning E.) Planning for seizure precautions and teaching the patient and the caregiver about antiseizure drugs

C, E

A 55-year-old patient with increasing dyspnea is being evaluated for a possible diagnosis of chronic obstructive pulmonary disease (COPD). When teaching a patient about pulmonary function testing (PFT) for this condition, what is the most important question the nurse should ask? A.) Are you claustrophobic? B.) Are you allergic to shellfish? C.) Do you have any metal implants or prostheses? D.) Have you taken any bronchodilators in the past 6 hours?

A 56-year-old patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for: A.) Surgical endarterectomy B.) Transluminal angioplasty C.) Intravenous heparin administration D.) Tissue plasminogen activator (tPA) infusion

A 58-year-old patient with a left-brain stroke suddenly bursts into tears when family members visit. The nurse should: A.) Use a calm voice to ask the patient to stop the crying behavior B.) Explain to the family that depression is normal following a stroke C.) Have the family members leave the patient alone for a few minutes D.) Teach the family that emotional outbursts are common after strokes

A 61 year old female patient admitted with pneumonia has a total serum calcium level of 13.3 mg/dL. The nurse will anticipate the need to teach the patient for testing for ______ levels. A.) Calcitonin B.) Catecholamine C.) Thyroid hormone D.) Parathyroid hormone

A 70 kg postoperative patient has an average urine output of 25 mL/hr during the first 8 hours. The priority nursing intervention(s) given this assessment would be to: A.) Perform a straight catheterization to measure the amount of urine in the bladder B.) Notify the physician and anticipate obtaining blood work to evaluate renal function C.) Continue to monitor the patient because this is a normal finding during this period D.) Evaluate the patient's fluid volume status since surgery and obtain a bladder ultrasound

A 73-year-old patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find? A.) Impulsive behavior B.) Right-sided neglect C.) Hyperactive left-sided tendon reflexes D.) Difficulty comprehending instructions

A nurse is planning care for a client who has acute respiratory distress syndrome (ARDs). Which of the following interventions should the nurse include in the plan? A.) Administer low-flow oxygen continuously via nasal vanilla B.) Encourage oral intake of at least 3,000 mL of fluids per day C.) Offer high protein and high carbohydrate foods frequently D.) Place in a prone position

A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The patient tells the nurse, "I would rather have chemotherapy than surgery." Which response by the nurse is most appropriate? A.) "Are you afraid that the surgery will be very painful?" B.) "Did you have bad experiences with previous surgeries?" C.) "Surgery is the treatment of choice for stage I lung cancer." D.) "Tell me what you know about the various treatments available."

A nurse in a clinic is assessing a client who has sinusitis. Which of the following techniques should the nurse use to identify manifestations of this disorder? A.) Percussion of posterior lobes of lungs B.) Auscultation of the trachea C.) Inspection of the conjuntiva D.) Palpation of the orbital areas

A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mmHg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take? A.) Raise the foot of the bed to a 90 degree angle B.) Remove the dressing to inspect the wound C.) Prepare to insert a central line D.) Administer oxygen via nasal cannula

A nurse in the emergency department is assessing an older adult client who has community-acquired pneumonia. Which of the following findings would the nurse expect? A.) Unequal pupils B.) Hypertension C.) Tympany under chest percussion D.) Confusion

A nurse is assessing a client following a bronchoscopy. Which of the following findings should the nurse report to the provider? A.) Blood tinged sputum B.) Dry, nonproductive cough C.) Sore throat D.) Bronchospasms

A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes? A.) Pigeon B.) Funnel C.) Kyphotic D.) Barrel

A nurse is assisting a provider with the removal of a chest tube. Which of the following should the nurse instruct the client to do? A.) Lie on his left side B.) Use the incentive spirometer C.) Cough at regular intervals D.) Perform the valsalva maneuver

A nurse is caring for a client 2 hr after admission. The client has an SaO2 of 91% exhibits audible wheezes and is using accessory muscles when breathing. Which of the following classes of medication should the nurse expect to administer? A.) Antibiotic B.) Beta blocker C.) Antiviral D.) Beta agonist

A nurse is caring for a client who arrived in the PACU following a total hip arthroplasty. The client is not responding to verbal stimuli. Which of the following actions should the nurse perform first? A.) Compare and contract the peripheral pulses B.) Apply a warm blanket C.) Assess dressings D.) Place the client in a lateral position

A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, "I can feel the congestion in my lungs and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions? A.) Maintaining a semi-Fowler's position as often as possible B.) Administering oxygen via nasal cannula at 2 L/min C.) Helping the client select a low salt diet D.) Encouraging the client to drink 2 to 3 L of water daily

A nurse is caring for a client who is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first? A.) Pain severity B.) Wound drainage C.) Tissue integrity D.) Airway patency

A nurse is caring for a patient who has had total laryngectomy and radical neck dissection, During the first 24 hours after surgery what is the priority nursing action? A.) Monitor for bleeding B.) Maintain adequate IV fluid intake C.) Suction tracheostomy every eight hours D.) Keep the patient in semi-Fowlers position

A nurse is caring for a patient with peripheral neuropathy who is schedules for EMG studies tomorrow morning. The nurse should: A.) Ensure the patient has an empty bladder B.) Instruct the patient about the risk of electric shock C.) Ensure the patient has no metallic jewelry or metal fragment D.) Instruct the patient that pain may be experienced during the study

A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan? A.) Restrict the client's fluid intake to less than 2 L/day B.) Provide the client with a low-protein diet C.) Have the client use the early morning hours for exercise and activity D.) Instruct the client to use pursed-lip breathing

A nurse is instructing a client on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching? A.) "I will place the adaptor on my finger to read my blood oxygen saturation level" B.) "I will lie on my back with my knees bent" C.) "I will rest my hand over my abdomen to create resistance" D.) "I will take in a deep breath and hold it before exhaling"

A nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of their chest burning. Which of the following actions should the nurse take? A.) Increase the client's wall suction B.) Strip the client's chest tube C.) Clamp the client's chest tube D.) Reposition the client

A nurse is observing the closed chest drainage system of a client who has 24 hour post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take? A.) Check the tubing connections for leaks B.) Check the suction control outlet on the wall C.) Clamp the chest tube D.) Continue to monitor the client's respiratory status

A nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching? A.) Apply a vest restraint if self-extubation is attempted B.) Monitor ventilator settings every 8 hour C.) Document tube placement in centimeters at the angle of jaw D.) Assess breath sounds every 1 to 2 hr

A nurse is preparing for a client for transfer to the ICU for placement of a pulmonary artery catheter. The nurse should explain to the client that this catheter is used to monitor which of the following conditions? A.) Intracranial pressure B.) Spinal cord perfusion C.) Renal function D.) Hemodynamic status

A nurse is reviewing discharge instructions for a client who experienced a pneumothorax. Which of the following statements should the nurse use when teaching the client? A.) "Notify the provider if you experience weakness" B.) "You should be able to return to work in 1 week" C.) "You need to wear a mask when in crowded areas" D.) "Notify your provider if you experience a productive cough"

A nursing student is teaching a client and family about epilepsy before the client's discharge. For which statement should the nurse intervene? A.) "You should avoid consumption of all forms of alcohol" B.) "Wear your medical alert bracelet at all times" C.) "Protect your loved one's airway during a seizure" D.) "It's OK to take over the counter medications"

A patient admitted with possible stroke has been aphasic for 3 hours and his current blood pressure (BP) is 174/94 mm Hg. Which order by the health care provider should the nurse question? A.) Keep head of bed elevated at least 30 degrees B.) Infuse normal saline intravenously at 75 mL/hr C.) Administer tissue plasminogen activator (tPA) per protocol D.) Administer a labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg

A patient arrives in the ear, nose and throat clinic complaining of "a piece of tissue being stuck up my nose" and with foul-smelling nasal drainage from the right nare. Which action should the nurse take first? A.) Notify the clinic health care provider B.) Obtain aerobic culture specimens of the drainage C.) Ask the patient about how the cotton get into the nose D.) Have the patient occlude the left nare and blow the nose

A patient becomes restless and agitated in the postanesthesia care unit (PACU) as he begins to regain consciousness. The first action the nurse should take is to A.) Turn the patient to a lateral position. B.) Orient the patient and tell him that the surgery is over. C.) Administer the ordered postoperative pain medication. D.) Check the patient's oxygen saturation with pulse oximetry.

A patient being admitted with bacterial meningitis has a temperature of 102.5 F (39.2 C) and a severe headache. Which order for collaborative intervention should the nurse implement first? A.) Administer ceftizoxime (Cefizox) 1 g IV B.) Give acetaminophen (Tylenol) 650 mg PO C.) Use a cooling blanket to lower temperature D.) Swab the nasopharyngeal mucosa for cultures

A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action? A.) The bedrails at the head and foot of the bed are both elevated B.) The patient receives a regular diet from the dietary department C.) The lights in the patient's room are turned off and the blinds are shut D.) Unlicensed assistive personnel enter the patient's room without a mask

A patient has received atropine before surgery and complains of dry mouth. Which action by the nurse is best? A.) Check for skin tenting B.) Notify the health care provider C.) Ask the patient about any dizziness D.) Tell the patient dry mouth is an expected side effect

A patient hospitalized with chronic obstructive pulmonary disease (COPD) is being discharged home on oxygen therapy. Which instruction should the nurse include in the discharge teaching? A.) Storage of oxygen tanks will require adequate space in the home B.) Travel opportunities will be limited because of the use of oxygen C.) Oxygen flow should be increased if the patient has more dyspnea D.) Oxygen use can improve the patients prognosis and quality of life

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? A.) The patient's speech is difficult to understand B.) The patients blood pressure is 144/90 mm Hg C.) The patient takes a diuretic because of a history of hypertension D.) The patient has atrial fibrillation and takes warfarin (Coumadin)

A patient is admitted with active tuberculosis (TB). The nurse should question a health care providers in order to discontinue airborne precautions which assessment finding is documented? A.) Chest x-ray shows no upper lobe infiltrates B.) TB medications have been taken for 6 months C.) Mantoux testing shows an induration of 10 mm D.) Three sputum smears for acid-fast bacilli are negative

A patient received inhalation anesthesia during surgery. Postoperatively, the nurse should monitor the patient for which complication? A.) Tachypnea B.) Myoclonus C.) Hypertension D.) Laryngospasm

A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, "Will I be able to talk normally after surgery?" What is the best response to the nurse? A.) You will breathe through a permanent opening in your neck, but you will not be able to communicate orally B.) You won't be able to talk right after surgery, but you will be able to speak again after the tracheostomy tube is removed C.) You won't be able to speak as you used to, but there are artificial voice devices that will give you the ability to speak normally D.) You will have a permanent opening into your neck, and you will need to have rehabilitaton for some type of voice restoration

A patient was seen in the clinic for an episode of epistaxis, which was controlled by placement of anterior nasal packing. During discharge teaching, the nurse instructs the patient to: A.) Use aspirin for pain relief B.) Remove the packing later that day C.) Skin the next dose of antihypertensive medication D.) Avoid vigorous nose bleeding and strenuous activity

A patient who has a history of chronic obstructive pulmonary disease (COPD) was hospitalized for increasing shortness of breath and chronic hypoxemia (SaO2 levels of 89% to 90%). In planning for discharge, which action by the nurse would be most effective in improving compliance with discharge teaching? A.) Start giving the patient discharge teaching on the day of admission B.) Have the patient repeat the instructions immediately after teaching C.) Accomplish the patient teaching just before the scheduled discharge D.) Arrange for the patient's caregiver to be present during the teaching

A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6 F with a frequent cough and is complaining of severe pleuritic chest pain. Which prescribed medication should the nurse give first? A.) Codeine B.) Guaifenesin (Robitussin) C.) Acetaminophen (Tylenol) D.) Piperacillin/Tazobactam (Zosyn)

A patient who takes a diuretic and a beta blocker to control blood pressure is scheduled for breast reconstruction surgery. Which patient information is most important to communicate to the health care provider before surgery? A.) Hematocrit 36% B.) Blood pressure 144/82 C.) Pulse rate 58 bpm D.) Serum potassium 3.2 mEq/L

A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 bpm., blood pressure of 100/60 mmHg and respirations of 42. Which action should the nurse take first? A.) Administer anticoagulant therapy B.) Notify the patient's health care provider C.) Prepare patient for a spiral computed tomography (CT) D.) Elevate the head of the bed to a semi-Fowler's position

A patient with a respiratory condition asks, "How does air get into my lungs?" The nurse bases her answer on the knowledge that air moves into the lungs behave of: A.) Increased CO2 and decreased O2 in the blood B.) Contraction of the accessory abdominal muscles C.) Stimulation of the respiratory muscles by the chemoreceptors D.) Decrease in intrathoracic pressure relative to pressure at the airway

A patient with allergic rhinitis reports severe nasal congestion; sneezing; and watery, itchy eyes and nose at various times of the year. To teach the patient to control these symptoms, the nurse advises the patient to: A.) Avoid all intranasal sprays and oral antihistamines B.) Limit the usage of nasal decongestant spray 10 days C.) Use oral decongestants at bedtime to prevent symptoms during the night D.) Keep a diary of when the allergic reaction occurs and what precipitates it

A patient with chronic obstructive pulmonary disease (COPD) has a nursing diagnosis of impaired breathing pattern related to anxiety. Which nursing action is most appropriate to include in the plan of care? A.) Titrate oxygen to keep saturation at least 90% B.) Discuss a high protein, high calorie diet with a patient C.) Suggest the use of over the counter sedative medications D.) Teach the patient how to effectively use pursed lip breathing

A patient with chronic obstructive pulmonary disease (COPD) tells the unlicensed assistive personnel (UAP) that he did not get his annual flu shot this year and has not had a pneumonia vaccination. Which vital sign change will be most important for the nurse to instruct the UAP to report? A.) Blood pressure of 152/84 mmHg B.) Respiratory rate of 27 breaths/min C.) Heart rate of 92 beats/min D.) Oral temperature of 101.2 F

A patient with intracranial pressure monitoring has a pressure of 12 mmHg. The nurse understands that this pressure reflects: A.) A severe decrease in cerebral perfusion pressure B.) An alteration in the production of cerebrospinal fluid C.) The loss of autoregulatory control of intracranial pressure D.) A normal balance between brain tissue, blood, and cerebrospinal fluid

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

A patient with pneumonia has a fever of 101.4 F, a nonproductive cough, and an oxygen saturation of 88%. The patient complains of weakness, fatigue and needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as the highest priority? A.) Hyperthermia related to infectious illness B.) Impaired transfer ability related to weakness C.) Ineffective airway clearance related to thick secretions D.) Impaired gas exchange related to respiratory congestion

A patient with severe chronic obstructive pulmonary disease (COPD) tells the nurse, "I wish I were dead! I'm just a burden on everybody." Based on this information, which nursing diagnosis is most appropriate? A.) Complicated grieving related to expectation of death B.) Ineffective coping related to unknown outcome of illness C.) Deficient knowledge related to lack of education about COPD D.) Chronic low self-esteem related to increased physical dependence

A patient with suspected meningitis is scheduled for a lumbar puncture. Before the procedure, the nurse will plan to: A.) Enforce NPO status for 4 hours B.) Transfer the patient to radiology C.) Administer a sedative medication D.) Help the patient to a lateral position

A preoperative nurse is caring for a client who is having a colon resection. Which of the following actions should the nurse take? A.) Encourage the client to void after preoperative medication administration B.) Administer antibiotics 2 hr prior to surgical incision C.) Remove hair using a manual razor D.) Remove nail polish on fingers and toes

A priority nursing intervention to assist a preoperative patient in coping with fear of postoperative pain would be to: A.) Inform the patient that pain medication will be available B.) Teach the patient to use guided imagery to help manage pain C.) Describe the type of pain expected with the patient's particular surgery D.) Explain the pain management plan, including the use of a pain rating scale

A young adult patient with cystic fibrosis (CF) is admitted to the hospital with increased dyspnea. Which intervention should the nurse include in the plan of care? A.) Schedule a sweat chloride test B.) Arrange for a hospice nurse visit. C.) Place the patient on a low-sodium diet D.) Perform chest physiotherapy every 4 hours

After change of shift, the nurse is assigned to care for the following patients. Which patient should the nurse assess first? A.) A 68 year old patient on a ventilator for whom a sterile sputum specimen must be sent to the laboratory B.) A 57 year old patient with chronic obstructive pulmonary disease (COPD) and a pulse oximetry reading from the previous shift of 90% saturation C.) A 72 year old patient with pneumonia who needs to be started on IV antibiotics D.) A 51 year old patient with asthma who reports shortness of breath after using a bronchodilator inhaler

After change-of-shift report, which patient should the nurse assess first? A.) 72-year-old with cor pulmonale who has 4+ bilateral edema in his legs and feet B.) 28-year-old with a history of a lung transplant and a temperature of 101 F C.) 40-year-old with a pleural effusion who is complaining of severe stabbing chest pain D.) 64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion

After extubation of a patient, which finding would the nurse report to a health care provider immediately? A.) Respiratory rate of 25 breaths/min B.) Patient has difficulty speaking C.) Oxygen saturation of 93% D.) Crowing noise during inspiration

After having a craniectomy and left anterior fossae incision, a 64-year-old patient has a nursing diagnosis of impaired physical mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is to: A.) Cluster nursing activities to allow longer rest periods B.) Turn and reposition the patient side to side every 2 hours C.) Position the bed flat and log roll to reposition the patient D.) Perform range-of-motion (ROM) exercises every 4 hours

After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first? A.) A 20-year-old patient whose cranial x-ray shows a linear skull fracture B.) A 30-year-old patient who has an initial Glasgow Coma Scale score of 13 C.) A 40-year-old patient who lost consciousness for a few seconds after a fall D.) A 50-year-old patient whose right pupil is 10 mm and unresponsive to light

After the nurse receives the change-of-shift report at 7:00 AM, which client must the nurse assess first? A.) A 23 year old client with a migraine headache who reports severe nausea associated with retching B.) A 45 year old client who is scheduled for a craniotomy in 30 minutes and needs preoperative teaching C.) A 59 year old client with Parkinson disease who will need a swallowing assessment before breakfast D.) A 63 year old client with Multiple Sclerosis (MS) who has an oral temperature of 101.8 F and flank pain

After the respiratory therapist performs suctioning on a patient who is intubated, the unlicensed assistive personnel (UAP) measures vital signs for the patient. Which vital sign value should the UAP report to the RN immediately? A.) Heart rate of 98 beats/min B.) Respiratory rate of 24 breaths/min C.) Blood pressure of 168/90 mm Hg D.) Tympanic temperature of 101.4 F

After thyroid surgery, the nurse suspects damage or removal of the parathyroid glands when the patient develops A.) Muscle weakness and weight loss. B.) Hyperthermia and severe tachycardia. C.) Hypertension and difficulty swallowing. D.) Laryngospasms and tingling in the hands and feet.

All cells in the body are believing to have intracellular receptors for: A.) Insulin B.) Glucagon C.) Growth hormone D.) Thyroid hormone

An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen? A.) Arrange for a friend to administer the medication on schedule B.) Give the patient written instructions about how to take the medications C.) Teach the patient about the high risk for infecting others unless treatment is followed D.) Arrange for a daily noon meal at a community center where the drug will be administered

An appropriate nursing intervention for a patient with pneumonia with the nursing diagnosis of ineffective airway clearance related to thick secretions and fatigue would be: A.) Perform postural drainage every hour B.) Provide analgesics as ordered to promote patient comfort C.) Administer oxygen as prescribed to maintain optimal O2 levels D.) Teach the patient how to cough effectively to bring secretions to the mouth

An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action is best for the nurse to take next? A.) Milk the chest tube gently to remove any clots B.) Clamp the chest tube momentarily to check for the origin of the air leak C.) Assist the patient to deep breathe, cough, and use the incentive spirometer D.) Set up the patient controlled analgesia (PCA) and administer the loading dose of morphine

As the nurse prepares a patient the morning of surgery, the patient refuses to remove a wedding ring, saying, "I have never taken it off since the day I was married." Which response by the nurse is best? A.) Have the patient sign a release and leave the ring on B.) Tape the wedding ring securely to the patient's finger C.) Tell the patient that the hospital is not liable for loss of the ring D.) Suggest that the patient give the ring to a family member to keep

Drugs and diseases that impair the function of the extrapyramidal systems that may cause: A.) Sensations of pain and temperature B.) Regulation of the autonomic nervous system C.) Integration of somatic and special sensory inputs D.) Automatic movements associated with skeletal muscle activity

In a patient with a disease that affects the myelin sheath of nerves, such as multiple sclerosis, the glial cells affected are the: A.) Microglia B.) Astrocytes C.) Ependymal cells D.) Oligodendrocytes

Information provided by the patient that would help differentiate a hemorrhagic stroke from a thrombotic stroke includes: A.) Sensory disturbance B.) A history of hypertension C.) Presence of motor weakness D.) Sudden onset of severe headache

Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness (LOC). Which nursing diagnosis do they determine has the highest priority for the patient? A.) Impaired physical mobility related to weakness B.) Disturbed sensory perception related to brain injury C.) Risk for impaired skin integrity related to immobility D.) Risk for aspiration related to inability to protect airway

Of the following patients, the nurse recognizes that the one with the highest risk for stroke is a(n): A.) Obese 45-year old Native American B.) 35-year-old Asian American woman who smokes C.) 32-year-old white woman taking oral contraceptives D.) 65-year-old African American man with hypertension

Postural drainage with percussion and vibration is ordered twice daily for a patient with chronic bronchitis. Which intervention should the nurse include in the plan of care? A.) Schedule the procedure 1 hour after the patient eats B.) Maintain the patient in the lateral position for 20 minutes C.) Perform percussion before assisting the patient to the drainage position D.) Give the ordered albuterol (Proventil) before the patient receives the therapy

The RN clinical instructor is discussing a patient's oxygen-hemoglobin dissociation curve with a student. The student states that the patient's oral body temperature is elevated at 100.8 F. Which statement by the student indicated correct understanding of this patient's curve shift? A.) "When a patient's body temperature is elevated, there is no change in the oxygen-hemoglobin dissociation curve" B.) "When a patient's body temperature is elevated, there is a shift to the left because the oxygen tension level is lower" C.) "When a patient's body temperature is elevated, there is no shift in the curve because the patient is using less oxygen" D.) "When the patient's body temperature is elevated, there is a shift to the right so that hemoglobin will dissociate oxygen faster"

The laboratory has just called with the arterial blood gas (ABG) results on four patients. Which result is most important for the nurse to report immediately to the health care provider? A.) pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97% B.) pH 7.35, PaO2 85 mm Hg, PaCO2 45 mm Hg, and O2 sat 95% C.) pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98% D.) pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%

The nurse admits a patient who has a diagnosis of an acute asthma attack. Which statement indicates that the patient may need teaching regarding medication use? A.) "I have not had any acute asthma attacks during the last year." B.) "I became short of breath an hour before coming to the hospital." C.) "I've been taking Tylenol 650 mg every 6 hours for chest-wall pain." D.) "I've been using my albuterol inhaler more frequently over the last 4 days."

The nurse analyzes the results of a patient's arterial blood gases (ABGs). Which finding would require immediate action? A.) The bicarbonate level (HCO3-) is 31 mEq/L B.) The arterial oxygen saturation (SaO2) is 92% C.) The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg D.) The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg

The nurse assess a patient on the second postoperative day after abdominal surgery to repair a perforated duodenal ulcer. Which finding is most important for the nurse to report to the surgeon? A.) Tympanic temperature 99.2 F B.) Fine crackles audible at both lung bases C.) Redness and swelling along the suture line D.) 200 mL sanguineous fluid in the wound drain

The nurse assesses that the oxygen saturation is 89% in an unconscious patient who was transferred from surgery to the postanesthesia care unit (PACU) 15 minutes ago. Which action should the nurse take first? A.) Elevate the patient's head B.) Suction the patient's mouth C.) Increase the oxygen flow rate D.) Perform the jaw-thrust maneuver

The nurse completes an admission assessment on a patient with asthma. Which information given by patient is most indicative of a need for a change in therapy? A.) The patient uses albuterol (Proventil) before any aerobic exercise B.) The patient says that the asthma symptoms are worse every spring C.) The patient's heart rate increases after using the albuterol (Proventil) inhaler D.) The patients only medications are albuterol (Proventil) and salmeterol (Serevent)

The nurse completes discharge teaching for a patient who has had a lung transplant. The nurse evaluates that the teaching has been effective if the patient makes which statement? A.) "I will make an appointment to see the doctor every year." B.) "I will stop taking the prednisone if I experience a dry cough." C.) "I will not worry if I feel a little short of breath with exercise." D.) "I will call the health care provider right away if I develop a fever."

The nurse develops a teaching plan to help increase activity tolerance at home for an older adult with severe chronic obstructive pulmonary disease (COPD). Which instructions would be most appropriate for the nurse to include in the plan of care? A.) Stop exercising when short of breath B.) Walk until pulse rate exceeds 130 beats/minute C.) Limit exercise to activities of daily living (ADLs) D.) Walk 15 to 20 minutes daily at least 3 times/week

The nurse interviews a patient scheduled to undergo general anesthesia for a hernia repair. Which information is most important to communicate to the surgeon and anesthesiologist before surgery? A.) The patient drinks 3 or 4 cups of coffee every morning before going to work B.) The patient takes a baby aspirin daily but stopped taking aspirin 10 days ago C.) The patient drank 4 ounces of apple juice 3 hours before coming to the hospital D.) The patient's father died after receiving general anesthesia for abdominal surgery

The nurse is caring for a patient who has acute pharyngitis caused by Candida albicans. Which action is appropriate for the nurse to include in the plan of care? A.) Avoid giving patient warm liquids to drink B.) Assess patient for allergies to penicillin antibiotics C.) Teach the patient about the need to sleep in a warm, dry environment D.) Teach patient to swish and swallow prescribed oral nystatin (Mycostatin)

The nurse is caring for a patient who was admitted the previous day with a basilar skull fracture after a motor vehicle crash. Which assessment finding is most important to report to the health care provider? A.) Complaint of severe headache B.) Large contusion behind left ear C.) Bilateral periorbital ecchymosis D.) Temperature of 101.4 F (38.6 C)

The nurse is instructing a senior nursing student on the techniques for palpation of the thyroid gland. What precaution would the nurse be sure to include when instructing the nurse about thyroid palpation? A.) Always stand to the side of the patient B.) Instruct the patient now to swallow C.) Palpate using one hand and then the other D.) Always palpate the thyroid gland gently

The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is most important for the nurse to ask before the skin test? A.) Is there any family history of TB B.) How long have you lived in the United States C.) Do you take any over the counter medications D.) Have you received the bacille Calmette-Gurin (BCG) vaccine for TB

The nurse obtains a health history from a patient who is scheduled for elective hip surgery in 1 week. The patient reports use of garlic and ginkgo biloba. Which action by the nurse is most appropriate? A.) Ascertain that there will be no interactions with anesthetic agents B.) Teach the patient that these products may be continued preoperatively C.) Advise the patient to stop the use of all herbs and supplements at this time D.) Discuss the herb and supplement use with the patient's health care provider

The nurse palpates the posterior chest while the patient says "99" and notes absent fremitus. Which action should the nurse take next? A.) Palpate the anterior chest and observe for barrel chest B.) Encourage the patient to turn, cough, and deep breathe C.) Review the chest x-ray report for evidence of pneumonia D.) Auscultate anterior and posterior breath sounds bilaterally

The nurse performing a focused assessment of left posterior temporal lobe functions will assess the patient for: A.) Sensation on the left side of the body B.) Voluntary movements on the right side C.) Reasoning and problem-solving abilities D.) Understanding written and oral language

The nurse plans to teach a patient how to manage allergic rhinitis. Which information should the nurse include in the teaching plan? A.) Hand washing is the primary way to prevent spreading the condition to others B.) Use or oral antihistamines for 2 weeks before the allergy season may prevent reactions C.) Corticosteroid nasal sprays will reduce inflammation, but systemic effects limit their use D.) Identification and avoidance of environmental triggers are the best way to avoid symptoms

The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient? A.) Supine with the head of the bed elevated 30 degrees B.) In a high-Fowler's position with the left arm extended C.) On the right side with the left arm extended above the head D.) Sitting upright with the arms supported on an over bed table

The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective? A.) "I am going to buy a rib binder to wear during the day." B.) "I can take shallow breaths to prevent my chest from hurting." C.) "I should plan on taking the pain pills only at bedtime so I can sleep." D.) "I will use the incentive spirometer every hour or two during the day."

The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed? A.) UAP splint the patient's chest during coughing B.) UAP assist the patient to ambulate to the bathroom C.) UAP help the patient to a bedside chair for meals D.) UAP lower the head of the patient's bed to 15 degrees

The nurse teaches a patient about discharge instructions after a rhinoplasty. Which statement, if made by the patient, indicates that the teaching was successful? A.) I can take 800 mg ibuprofen for pain control B.) I will safely remove and reapply nasal packing daily C.) My nose will look normal after 24 hours when the swelling goes away D.) I will keep my head elevated for 48 hours to minimize swelling and pain

The nurse teaches a patient who has asthma about peak flow meter use. Which action by the patient indicates that teaching was successful? A.) The patient inhales rapidly through the peak flow meter mouthpiece B.) The patient takes montelukast (Singulair) for peak flows in the red zone C.) The patient calls the health care provider when the peak flow is in the green zone D.) The patient uses albuterol (Proventil) metered dose inhaler (MDI) for peak flows in the yellow zone

The nurse teaches a patient who to administer formoterol (Perforomist) through a nebulizer. Which action by the nurse indicates good understanding of the teaching? A.) The patient attaches a spacer before using the inhaler B.) The patient coughs vigorously after using the inhaler C.) The patient activates the inhaler at the onset of expiration D.) The patient removes the facial mask when misting has ceased

The nurse will anticipate teaching a patient with a possible seizure disorder about which test? A.) Cerebral angiography B.) Evoked potential studies C.) Electromyography (EMG) D.) Electroencephalography (EEG)

The outpatient surgery nurse reviews the complete blood cell (CBC) count results for a patient who is scheduled for surgery in a few days. The results are white blood cell (WBC) count 10.2 × 103/µL; hemoglobin 15 g/dL; hematocrit 45%; platelets 150 × 103/µL. Which action should the nurse take? A.) Call the surgeon and anesthesiologist immediately B.) Ask the patient about any symptoms of a recent infection C.) Discuss the possibility of blood transfusion with the patient D.) Send the patient to the holding area when the operating room calls

The priority nursing assessment for a 72-year-old patient being admitted with a brainstem infarction is: A.) Reflex reaction time B.) Pupil reaction to light C.) Level of consciousness D.) Respiratory rate and rhythm

Using the illustrated technique, the nurse is assessing for which finding in a patient with chronic obstructive pulmonary disease (COPD)? A.) Hyperresonance B.) Tripod positioning C.) Accessory muscle use D.) Reduced chest expansion

When assessing a 22 year old patient who required emergency surgery and multiple transfusions 3 days ago, the nurse finds that the patient looks anxious and has labored respirations at a rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate? A.) Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes B.) Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs C.) Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation D.) Switch the patient to a nonrebreather mask at 95% to 100% fraction of inspired oxygen (FIO2) and call the health care provider to discuss the patient's status

When assessing a 53-year-old patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider? A.) The patient exhibits nuchal rigidity B.) The patient has a positive Kernig's sign C.) The patient's temperature is 101 F (38.3 C) D.) The patients blood pressure is 88/42 mm Hg.

When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent bowel sounds over the right leg. For which intervention will the nurse prepare the patient? A.) Emergency pericardiocentesis B.) Stabilization of the chest wall with tape C.) Administration of an inhaled bronchodilator D.) Insertion of a chest tube with a chest drainage system

When assessing the respiratory system of an older patient, which finding indicates that the nurse should take immediate action? A.) Weak cough effort B.) Barrel shaped chest C.) Dry mucous membranes D.) Bilateral crackles at lung bases

When caring for a patient who has received a general anesthetic, the circulating nurse notes red, raised wheals on the patient's arms. Which action should the nurse take immediately? A.) Apply lotion to the affected nurses B.) Cover the arms with sterile drapes C.) Recheck the patient's arms in 30 minutes D.) Notify the anesthesia care practitioner (ACP) immediately

When scrubbing at the scrub sink, the nurse should: A.) Scrub from elbows to hands B.) Scrub without mechanical friction C.) Scrub fro a minimum of 10 minutes D.) Hold the hands higher than the elbows

When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral atherosclerosis: A.) To monitor and record the blood pressure daily B.) That Plavix will dissolve clots in the cerebral arteries C.) That Plavix will reduce cerebral artery plaque formation D.) To call the health care provider if stools are bloody or tarry

Which action best describes how the scrub nurse maintains aseptic technique during surgery? A.) Uses waterproof shoe covers B.) Wears personal protective equipment C.) Insists that all operating room (OR) staff perform a surgical scrub D.) Changes gloves after touching the upper arm of the surgeon's gown

Which action will the nurse take immediately after surgery for a patient who received ketamine (Ketalar) as an anesthetic agent? A.) Administer higher doses of analgesic agents B.) Ensure that atropine is available in case of bradycardia C.) Question the order for benzodiazepines to be adminstered D.) Provide a quiet environment in the postanesthesia care unit

Which assessment finding of the respiratory system does the nurse interpret as abnormal? A.) Inspiratory chest expansion of 1 inch B.) Symmetric chest expansion and contraction C.) Resonance (to percussion) over the lung bases D.) Bronchial breath sounds in the lower lung fields

Which guideline would be a part of teaching patients how to use a metered-dose inhaler (MDI)? A.) After activating the MDI, breathe in as quickly as you can B.) Estimate the amount of remaining medicine in the MDI by floating the canister in water. C.) Disassemble the plastic canister from the inhaler and rinse both pieces under running water every week D.) To determine how long the canister will last, divide the total number of puffs in the canister by puffs needed per day

Which information will the nurse include in the asthma teaching plan for a patient being discharged? A.) Use the inhaled corticosteroid when shortness of breath occurs B.) Inhale slowly and deeply when using a dry powder inhaler (DPI) C.) Hold your breath for 5 seconds after using a bronchodilator inhaler D.) Tremors are an expected side effect of rapidly acting bronchodilators

Which intervention for a patient with a pulmonary embolus would the RN assign to the LPN/LVn on the patient care team? A.) Evaluating the patient's reports of chest pain B.) Monitoring laboratory values for changes in oxygenation C.) Assessing for symptoms of respiratory failure D.) Auscultating the lungs for crackles

Which intervention will the nurse include in the plan of care for a patient who is diagnosed with a lung abscess? A.) Teach the patient to avoid the use of over-the-counter expectorants B.) Assist the patient with chest physiotherapy and postural drainage C.) Notify the health care provider immediately about any bloody or foul smelling sputum D.) Teach about the need for prolonged antibiotic therapy after discharge from the hospital

Which statement by a 50 year old female patient indicates to the nurse that further assessment of thyroid function may be necessary? A.) I notice my breasts are tender lately B.) I am so thirsty that I drink all day long C.) I get up several times at night to urinate D.) I feel a lump in my throat when I swallow

While in the recovery room, a patient with a total laryngectomy is suctioned and has bloody mucus with some clots. Which nursing interventions would apply? A.) Notify the physician immediately B.) Place the patient in the prone position to facilitate drainage C.) Instill 3 mL of normal saline into the tracheostomy tube to loosen secretions D.) Continue your assessment of the patient, including O2 saturation, respiratory rate, and breath sounds

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