AL test 5 340

The nurse provides postoperative care one day after a patient undergoes colostomy surgery. The patient's stoma is moist and dark pink, with no obvious drainage. Which action should the nurse take? 1 Document the normal findings 2 Consult the enterostomal therapist 3 Irrigate the ostomy with normal saline 4 Palpate the abdomen around the stoma

1 A colostomy stoma that is moist and dark pink without any drainage on the first postoperative day is normal. These findings should be documented in the patient's medical record. Consulting the enterostomal therapist, irrigating the ostomy, and palpating the abdomen are not necessary, because the colostomy stoma is normal. Text Reference - p. 992

The nurse is aware that which type of anesthesia can be administered without the presence of an anesthesia care provider? 1 Moderate sedation 2 General anesthesia 3 Regional anesthesia 4 Monitored anesthesia care

1 An anesthesia care provider (ACP) is responsible for administering anesthesia. An ACP can be an anesthesiologist, nurse anesthetist, or anesthesiologist assistant. Moderate sedation involves administering sedatives, anxiolytics, or analgesics. It is used for procedures performed outside the operating room and does not require the presence of an ACP. A registered nurse who is educated in moderate sedation and is permitted by institution protocols and state nurse acts can perform this. However, general anesthesia, regional anesthesia, and monitored anesthesia care require the presence of an ACP. Text Reference - p. 341

A patient with pneumococcal pneumonia is prescribed ceftriaxone for 10 days. During a follow-up visit, the patient reports to the nurse, "I stopped the medication after taking it for five days because I felt better." What is the best nursing response? 1 Explain the importance of completing the planned medication therapy. 2 Instruct the patient to obtain a refill to continue the medication for another week. 3 Instruct the patient to save the remaining medication in case the symptoms reoccur. 4 Suggest that the patient give the leftover medications to the pharmacy.

1 Antibiotics should always be taken until the completion of planned therapy even if the symptoms subside. Skipping the medications or not completing the therapy may result in developing resistance to the organism. Antibiotics should not be used for more than the planned therapy. Organisms may develop resistance to antibiotics if used for a longer duration. Antibiotics will lose their effectiveness when stored for a longer time, and they can even be fatal. The nurse will not instruct the patient to save the remaining medication for future use. The patient should not give it back to the pharmacy, because this medication may not be appropriate for others and may contain inadequate doses that do not provide full treatment. Text Reference - p. 230

For which complication does the nurse monitor a postoperative patient for based solely on the postoperative status? 1 Atelectasis 2 Bronchoconstriction 3 Increased compliance 4 Chronic productive cough

1 Atelectasis is the condition in which the alveoli collapse due to insufficient surfactant. The postoperative patient is at risk for atelectasis due to the effects of anesthesia and shallow breathing that often accompanies pain. Bronchoconstriction, increased compliance, and a chronic productive cough are not complications associated with surgery. Text Reference - p. 477

A patient is taking azathioprine 100 mg by mouth daily for the treatment of Crohn's disease. What expected outcome will the drug achieve for this patient? 1 Blocks purine synthesis 2 Inhibits cytokine production 3 Prevents the activation of T cells 4 Inhibits function of cytotoxic T cells

1 Azathioprine is an immunosuppressive drug that belongs to the category of cytotoxic drugs and it acts by blocking purine synthesis. Prednisone acts by inhibiting cytokine production. Belatacept acts by preventing the activation of T cells. Muromonab-CD3 acts by stalling the functions of cytotoxic T cells. Text Reference - p. 222

A diabetic patient is waiting in the preoperative holding area for a hernia operation. The patient asks the nurse if the daily insulin dose should be taken. Which response is the most appropriate? 1 "I will check with the surgeon and let you know." 2 "Take half of the dose of insulin because you are fasting." 3 "Replace the insulin with an oral drug." 4 "Avoid taking insulin, because it may cause hypoglycemia."

1 If a diabetic patient on insulin is due for surgery, it is important to get clear instructions from the surgeon regarding the insulin administration. The surgeon may choose to avoid the dose or give an adjusted dose based on the blood sugar levels. The nurse should not suggest taking a reduced dose, because it may cause a fluctuation in blood sugar levels. The insulin should not be replaced with oral drugs unless advised by the surgeon. The insulin dose may be skipped if the surgeon advises that. Text Reference - p. 322

A computed tomography (CT) scan of the head of a patient reveals that the patient has experienced a hemorrhagic stroke. What is the priority nursing intervention in the emergency department? 1 Maintenance of the patient's airway 2 Positioning to promote cerebral perfusion 3 Control of fluid and electrolyte imbalances 4 Administration of tissue plasminogen activator (tPA)

1 Maintenance of a patent airway is the priority in the acute care of a patient with a hemorrhagic stroke. It supersedes the importance of fluid and electrolyte imbalance and positioning. tPA is contraindicated in hemorrhagic stroke.

A patient with a family history of malignant hyperthermia is being taken into the operating room. While this patient is under general anesthesia, which sign would indicate that the patient is experiencing malignant hyperthermia? 1 Muscle contracture 2 Hypotension 3 Tachycardia 4 Bronchospasm

1 Malignant hyperthermia causes hypermetabolism of skeletal muscle resulting from altered control of intracellular calcium. The early manifestations may include muscle contracture, hyperthermia, hypoxemia, lactic acidosis, and hemodynamic and cardiac alterations. Tachycardia may be seen but is not specific to malignant hyperthermia. Hypotension and bronchospasms are seen in anaphylactic reactions. Text Reference - p. 346

A nurse is providing immediate postoperative care for a patient who has undergone a thymectomy. An anesthesia care provider has prescribed Naloxone. What is the primary reason the medication is being given? 1 To reverse opioid-induced respiratory depression 2 To decrease postoperative pain 3 To reduce the incidence of postoperative infection 4 To maintain normal blood pressures

1 Narcan is the antidote of opioids. It contains naloxone. Opioid overdose induces respiratory depression. Narcan is prescribed to reverse this. Narcan is not useful in reducing postoperative pain or postoperative infection, or in maintaining blood pressure. Text Reference - p. 344

An 82-year-old woman is brought to her health care provider by her daughter with complaints of some confusion. What testing should the nurse suggest for this patient? 1 Urinalysis 2 Sputum culture 3 Red blood cell count 4 White blood cell count

1 The developments of urinary tract infections commonly contribute to atypical manifestations, such as cognitive and behavior changes in older adults. Sputum culture, red blood cell count, and white blood cell count may be done, but the first step would be to assess for a possible urinary tract infection. Text Reference - p. 231

An older adult patient is receiving corticosteroid therapy for rheumatoid arthritis. What is the major concern in adopting this line of treatment? 1 Osteopenia 2 Drug-drug interaction 3 Moon face and weight gain 4 Diabetes and mood swings

1 The major concern is corticosteroid-induced osteopenia, which can add to the problem of decreased bone density related to age and inactivity in older patients. It also increases the risk of pathologic fractures, especially compression fractures of vertebrae. Drug-drug interactions, moon face and weight gain, and diabetes and mood swings are side effects that can be monitored.

Which is the most common manifestation of systemic lupus erythematosus (SLE)? 1 Arthritis 2 Butterfly rash 3 Discoid lesions 4 Lupus nephritis

1 The most common manifestation of SLE is arthritis. It occurs in 90 percent of patients with SLE. Butterfly rash occurs in 50 percent of patients with SLE. Discoid lesions are found in 20 percent of patients. Lupus nephritis is found in 40 percent of patients with SLE. Test-Taking Tip: The most reliable way to ensure that you select the correct response to a multiple-choice question is to recall it. Depend on your learning and memory to furnish the answer to the question. To do this, read the stem, and then stop! Do not look at the response options yet. Try to recall what you know and, based on this, what you would give as the answer. After you have taken a few seconds to do this, then look at all of the choices and select the one that most nearly matches the answer you recalled. It is important that you consider all the choices and not just choose the first option that seems to fit the answer you recall. Remember the distractors. The second choice may look okay, but the fourth choice may be worded in a way that makes it a slightly better choice. If you do not weigh all the choices, you are not maximizing your chances of correctly answering each question. Text Reference - p. 1582

A patient is scheduled for a gastrectomy. During the preoperative evaluation, the patient reports taking ginseng regularly. What should the nurse do? 1 Inform the surgeon. 2 Advise the patient to take vitamin E in addition to the ginseng. 3 Advise the patient to decrease the dose of ginseng. 4 Advise the patient to replace the ginseng with another herbal drug.

1 The priority intervention is to inform the surgeon. The gastrectomy needs to be rescheduled. The next priority is to suggest that the patient discontinue the use of ginseng, because ginseng increases blood pressure before and during surgery. Vitamin E should not be taken, because it can increase bleeding. Decreasing the dose of ginseng will not remove the risk. Use of any herbal product should be discontinued 2 to 3 weeks before surgery, because such medicines may increase the risk of postoperative bleeding.

A patient with acute osteomyelitis asks the nurse how this problem will be treated. Which response by the nurse is most appropriate? 1 "Intravenous (IV) antibiotics usually are required for several weeks." 2 "Oral antibiotics often are required for several months." 3 "Surgery almost always is necessary to remove the dead tissue that is likely to be present." 4 "Drainage of the foot and instillation of antibiotics into the affected area is the usual therapy."

1 The standard treatment for acute osteomyelitis consists of several weeks of IV antibiotic therapy. This is because bone is denser and less vascular than other tissues, and it takes time for the antibiotic therapy to eradicate all of the microorganisms. Oral antibiotics are not effective. Surgery may be used for chronic osteomyelitis, which may include debridement of the devitalized and infected tissue and irrigation of the affected bone with antibiotics. Antibiotics are not commonly injected into the affected area.

A nurse is updating the health history of a patient who has been admitted to the hospital with a stroke. What question should the nurse ask the patient's support person? 1 What was the time of onset of symptoms? 2 How much food did the patient eat the previous night? 3 What was the position of the patient when the symptoms arose? 4 Was the patient wearing tight clothes at the time of the stroke?

1 The time of onset of stroke is important for all types of stroke since it can affect the treatment decisions. Other questions are not relevant. The quantity of food that the person had in the previous night does not contribute to diagnosis or treatment of stroke. Strokes do not happen in a particular position; therefore, questions about the patient's position are not relevant. Wearing tight clothes does not increase the risk of stroke; therefore, the question is not relevant.

A patient being treated for multiple sclerosis complains of flu-like symptoms and reports feeling depressed. The patient also reports having frequent thoughts of committing suicide. Which drug in the patient's prescription may be responsible for these symptoms? 1 β-interferon 2 Natalizumab 3 Mitoxantrone 4 Dalfampridine

1 β-interferon is an immunomodualtor prescribed in the initial treatment of multiple sclerosis. It is known to cause flu-like symptoms, depression, and suicidal ideations. Natalizumab is prescribed for patients with active and aggressive forms of multiple sclerosis. This drug is not part of initial treatment and the major risk factor associated with this drug therapy is progressive multifocal leukoencephalopathy. Mitoxantrone is also prescribed for patients with active and aggressive forms of multiple sclerosis, not in the initial treatment. The risk factors associated with this drug are cardiotoxicity, leukemia, and infertility. Dalfampridine is prescribed to improve walking speed. Text Reference - p. 1430

Nurses have a major role in prevention of urinary tract infections (UTIs). Which guidelines can help prevent hospital-acquired UTIs? Select all that apply. 1 Avoid unnecessary catheritization 2 Wash hands before and after contact with each patient 3 Routine and thorough perineal hygiene for all hospitalized patients 4 Wash around catheter insertion site with betadine daily. 5 Intermittent catheterization every four hours.

1 2 3 The patient should not be catheterized unless absolutely necessary. Hand hygiene is the number one prevention method in spreading infection in the hospital setting. Routine perineal care daily with soap and water is evidenced-based practice to prevent UTI. Betadine should not be applied to the catheter insertion site daily. Intermittent catheterization places the patient at high risk for hospital-acquired UTIs. Text Reference - p. 1068

A patient receiving long-term corticosteroid therapy for rheumatoid arthritis is admitted to the hospital with a wound of the left upper extremity. What should the nurse expect while assessing this patient? Select all that apply. 1 The patient is at risk of hyperglycemia. 2 The wound of this patient will heal slowly. 3 There will be reduced bleeding from the wound. 4 The patient is at a risk of developing bone infection. 5 The symptom of fever may be blunted in this patient.

1 2 5 Persistent hyperglycemia (steroid diabetes) can occur because of altered glucose metabolism. Because the antiinflammatory response is depressed as a result of increased cortisol levels, the wounds of patients receiving long-term corticosteroid therapy tend to heal slowly. Because of the depressed immune system, fever may be blunted in this patient. Corticosteroid therapy does not affect the risk of bleeding from the wound or the risk of bone infection. Text Reference - p. 181

The nurse is examining a patient suspected of having fibromyalgia. Which sites should the nurse assess for tenderness? Select all that apply. 1 Knee 2 First rib 3 Low cervical area 4 Lesser trochanter 5 Medial epicondyle

1 3 In order to identify a patient with fibromyalgia, the nurse should examine 18 identified sites for tenderness. Tenderness in 11 or more of these sites indicates fibromyalgia. These 18 identified tender points include the knee and the low cervical area. Other identified tender points include the second rib, the greater trochanter, and the lateral epicondyle. Text Reference - p. 1591

A nurse is caring for a patient who has undergone a knee joint replacement. What measures should a nurse take to prevent constipation of the patient in the postoperative period? Select all that apply. 1 Advise the patient to drink more than 2500 mL/day of fluids. 2 Instruct the patient to drink cold fluids. 3 Advise the patient to eat more fruits and vegetables. 4 Advise the patient to maintain complete bed rest until recovery. 5 Use stool softeners and laxatives as advised.

1 3 5 Patients often have reduced mobility after a fracture, which may result in constipation. The nurse should implement appropriate measures, such as high fluid intake (more than 2500 mL/day unless contraindicated) and a diet high in bulk and roughage (fruits and vegetables) to prevent constipation. If these measures fail to maintain normal bowel pattern, then laxatives and stool softeners can be used. Constipation can be relieved by drinking warm fluids, not cold ones. Physical activity also helps in bowel activity, so the patient should ambulate as early as the indications and provider prescriptions allow. Text Reference - p. 1519

A patient with behavioral changes is scheduled for neurologic testing. Which findings does the nurse identify as supporting a diagnosis of dementia? Select all that apply. 1 Loss of memory 2 Early awakening from sleep 3 Hyperactive body movements 4 Difficulty with normal conversation 5 Changes developing over the last few days

1 4 Dementia is often diagnosed when two or more brain functions, such as memory loss or language skills, are significantly impaired. Early awakening from sleep is associated with depression. Hyperactive body movements are associated with either dementia or delirium. Behavior changes that developed over the last few days are manifestations of delirium.

A patient has undergone cholecystectomy. What postoperative care should the nurse perform for this patient? Select all that apply. 1 Maintain a low-fat diet. 2 Monitor for any bleeding. 3 Instruct not to do deep breathing. 4 Place patient in shock position. 5 Place the patient in Sims' position.

1, 2, 5 After cholecystectomy, it is important to follow dietary restrictions. A diet low in fat decreases the workload of the liver. Bleeding is a complication after the procedure; hence the nurse should monitor it. It is important to position the patient in Sims' position to facilitate gas pockets moving away from the diaphragm. Encourage deep breathing along with movement and ambulation to help expand the lungs and promote ventilation. The patient need not be put in shock position; it does not contribute to recovery.

A patient has been given spinal anesthesia for knee replacement surgery. The nurse should monitor the patient for which indicators of autonomic nervous system blockade? Select all that apply. 1 Nausea 2 Bradycardia 3 Hypotension 4 Vomiting 5 Hyperglycemia

1,2,3,4 Spinal anesthesia involves administration of an anesthetic agent into the cerebrospinal fluid. It may produce an autonomic, sensory, or motor blockade. The signs of autonomic blockade include nausea, bradycardia, hypotension, and vomiting. Hyperglycemia is not a sign of autonomic blockade.

A nurse is caring for an older adult postoperatively. For which symptoms should a nurse be observant to distinguish delirium from dementia? Select all that apply. 1 Rapid onset of symptoms, often at night 2 Abrupt progression of disease 3 Difficulty in finding proper words 4 Sleeping during the day 5 Accelerated, incoherent speech

1,2,5 Delirium is a temporary state of mental confusion caused by reversible impairment of cerebral oxidative metabolism and multiple neurotransmitter abnormalities. The onset is usually rapid, mostly at night, and with abrupt progression. Decreased oxygen supply to the brain may cause the patient's speech to become accelerated and incoherent. In contrast, dementia has a slow onset and progression. The changes are subtle and progress over many years. As the cognitive decline progresses, and more brain areas are affected, the patient may have difficulty in finding proper words. A patient with dementia may sleep during the day and awaken frequently at night, owing to changes in the sleep-wake cycle. Text Reference - p. 1444

A patient with spinal cord injury has to be catheterized. Which nursing interventions will help to prevent urinary tract infection (UTI)? Select all that apply. 1 Ensure regular and complete drainage of the bladder. 2 Start intermittent catheterization once the patient is stabilized. 3 Empty the urine bag whenever it is 25 percent filled. 4 Maintain the urine drainage bag above the level of the bladder. 5 Cleanse the patient's genitalia using antiseptic before placing the catheter.

1,2,5 UTIs are a common problem in patients with spinal cord injuries. The best method for preventing UTIs is regular and complete bladder drainage. After the patient is stabilized, the best means of managing long-term urinary function should be assessed. Usually the patient is started on an intermittent catheterization program. The other common yet important intervention that a nurse could utilize is to use aseptic methods while inserting the catheter, like cleaning the genitalia using antiseptic. The urine bag should be drained every eight hours or when filled about two thirds. When catheterized for a long period, the urine bag should be kept below the level of the bladder; this will prevent backflow of urine and guard against infections. Text Reference - p. 1481

What should be included in the nursing plan for prevention of skin breakdown in a stroke patient? Select all that apply. 1 Good skin hygiene 2 Minimizing the frequency of position changes 3 Massaging the damaged area 4 Applying emollients to dry skin 5 Administering back rubs with alcohol for a cooling effect

1,4 The skin of a patient with stroke is particularly susceptible to breakdown related to loss of sensation, decreased circulation, and immobility. Therefore the nursing prevention plan for skin breakdown should include pressure relief interventions such as position changes, application of emollients to dry skin, good skin hygiene, and early mobility. Massage to the damaged area may cause additional damage and should be avoided. Back rubs can be very relaxing, but should be done with lotion or oil, not alcohol, which is very drying to the skin.

During a health screening event, which assessment finding would alert the nurse to the possible presence of osteoporosis? 1 The presence of bowed legs 2 A measurable loss of height 3 Poor appetite and aversion to dairy products 4 Development of unstable, wide-gait ambulation

2 A gradual but measurable loss of height and the development of kyphosis or "dowager's hump" are indicative of the presence of osteoporosis, in which the rate of bone resorption is greater than bone deposition. Bowed legs may be caused by abnormal bone development or rickets but is not indicative of osteoporosis. Lack of calcium and Vitamin D intake may cause osteoporosis, but are not indicative of osteoporosis. A wide gait is used to support balance and does not indicate osteoporosis. Text Reference - p. 1554

A male patient complains of fever, dysuria, and cloudy urine. What additional information may indicate that these manifestations may be something other than a urinary tract infection (UTI)? 1 Escherichia coli bacteria in the urine 2 A very tender prostate gland 3 Complaints of chills and rectal pain 4 Complaints of urgency and frequency

2 A tender and swollen prostate is indicative of prostatitis, which is a more serious male reproductive problem, because an acute episode can result in chronic prostatitis and lead to epididymitis or cystitis. E. coli in the urine, chills, rectal pain, urgency, and frequency are all present with a UTI and not specifically indicative of prostatitis. Text Reference - p. 1322

A patient with pneumonia has a fever of over 103° F. What should the nurse do to manage the patient's fever? 1 Administer aspirin (ASA) on a scheduled basis around the clock. 2 Provide acetaminophen every four hours to maintain consistent blood levels. 3 Administer acetaminophen when the patient's oral temperature exceeds 103.5° F. 4 Provide drug interventions if complementary and alternative therapies have failed.

2 Antipyretics should be given around the clock to prevent acute swings in temperature. ASA would not be the drug of choice because of its antiplatelet action and accompanying risk of bleeding. 103.5° F is already a high fever and antipyretics should be given sooner. When treating fever, drug interventions normally are not withheld in lieu of complementary therapies.

A patient with a stroke develops aphasia. What does the nurse suspect to be the reason for the patient's condition? 1 A defect in the vertebral artery 2 A defect in the middle cerebral artery 3 A defect in the anterior cerebral artery 4 A defect in the posterior cerebral artery

2 Aphasia is caused by a defect in the middle cerebral artery. A defect in the vertebral artery may lead to cranial nerve deficits, or coma. Defects in the anterior cerebral artery may cause motor or sensory deficits. A defect in the posterior cerebral artery may result in visual hallucinations or motor deficits. Text Reference - p. 1393

The nurse is conducting a preoperative class for a group of older adults who are scheduled for hip replacement surgery. During the planning meeting for this class, which of the nurse's statements reflects a correct understanding of the older adult surgical patient? 1 "This handout will do the explaining for me during the class." 2 "I will watch the participants for signs of excessive anxiety." 3 "I will make sure the lights are bright so that they can see the materials easily." 4 "Older people are usually able to face surgeries more easily than younger people."

2 Be particularly alert when assessing and caring for the older adult surgical patient. An event that has little effect on a younger adult may be overwhelming to the older patient. Emotional reactions to impending surgery and hospitalization often intensify in the older adult. Help to decrease anxieties and fears, as well as maintain and restore the self-esteem of the older adult during the surgical experience. Simply reading a handout may not be sufficient. Consider that sensory deficits may be present, and bright lights may bother those with eye problems. These and other changes may require more time for the older adult to complete preoperative testing and understand preoperative instructions. Text Reference - p. 329

A patient who is being treated for osteoporosis receives a prescription for a bisphosphonate drug. What instruction should the nurse give to the patient regarding its administration and aftereffects? 1 "You may feel like throwing up and lose your appetite." 2 "You should drink a full glass of water with the medicine." 3 "You should lie down immediately after eating, for 15 minutes." 4 "You should eat a meal within 15 minutes after taking the medicine."

2 Bisphosphonate drugs should be administered correctly to facilitate absorption into the body. The drug should be consumed with a full glass of water. The patient may experience flu-like symptoms such as fever and headache without any loss of appetite or vomiting. After eating, the patient should remain upright for 30 minutes and should not lie down. The medicine should be taken 30 minutes before having food.

What nursing diagnostic statement would be assigned the highest priority in the plan of care for a patient who has ulcerative colitis? 1 Activity intolerance 2 Deficient fluid volume 3 Impaired tissue integrity 4 Risk for impaired skin integrity

2 In ulcerative colitis, fluid is not absorbed from the distal large intestine because of ulceration, bleeding, and, later, scarring and narrowing of the lumen of the bowel. Fluid and electrolytes are also lost in the stool; therefore deficient fluid volume is the priority nursing diagnostic statement. Activity intolerance, impaired tissue integrity, and risk for impaired skin integrity are all possibilities related to ulcerative colitis, but they are not as high of a risk as deficient fluid volume. Text Reference - p. 978

Which similarity is seen in patients with rheumatoid arthritis and those with systemic lupus erythematosus? 1 Both may show symptoms of Reiter's syndrome. 2 Both may show symptoms of Sjogren's syndrome. 3 Both may show symptoms of restless leg syndrome. 4 Both may show symptoms of carpal tunnel syndrome.

2 Sjogren's syndrome may be seen in both rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). Patients with Sjogren's syndrome have decreased lacrimal and salivary secretion leading to dry eyes and mouth. Reiter's syndrome is seen in reactive arthritis. Restless leg syndrome is a clinical manifestation of fibromyalgia. Carpal tunnel syndrome is present in rheumatoid arthritis but absent in SLE.

The nurse is providing care to a postoperative patient on a medical-surgical unit. The patient is experiencing tachypnea and becomes disoriented at times. Which is the priority action by the nurse in this situation? 1 Assessing the current level of pain 2 Activating the rapid response team 3 Documenting the data in the medical record 4 Administering the prescribed antihypertensive medication

2 Tachypnea and disorientation are early and subtle signs of deterioration. The rapid response team (RRT) brings rapid and immediate care to unstable patients in non-critical care units. While assessing pain, documenting the data in the medical record, and administering prescribed medications such as antihypertensive medications are all appropriate actions, they are not the priority nursing actions in this situation.

The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the postanesthesia care unit (PACU). What should the nurse's initial action be upon the patient's arrival? 1 Assess the patient's pain 2 Assess the patient's vital signs 3 Check the rate of the intravenous (IV) infusion 4 Check the health care provider's postoperative prescriptions

2 The highest priority action by the nurse is to assess the physiologic stability of the patient. This is accomplished in part by taking the patient's vital signs. Assessing the patient's pain, checking the rate of the IV infusion, and checking the health care provider's postoperative prescriptions then can take place in rapid sequence.

The health care provider has prescribed intravenous (IV) vancomycin for a patient with pneumonia. Which action should the nurse perform first? 1 Obtain a full set of vital signs 2 Obtain sputum cultures for sensitivity 3 Draw a blood specimen to evaluate the white blood cell count 4 Administer the antibiotic over at least 60 minutes

2 The nurse should ensure that the sputum for culture and sensitivity has been sent to the laboratory before administering the antibiotic. It is important that the organisms be correctly identified (in the culture) before their numbers are affected by the antibiotic; the test also will determine whether the proper antibiotic has been prescribed (sensitivity testing). Vital signs and white blood cell count measurement can be assessed following the obtainment of sputum cultures. Timing of antibiotic administration should be based upon the institution's policy. Text Reference - p. 525

The nurse is providing postoperative care to a patient who underwent surgical repair of a fractured hip two days ago. Which assessment finding indicates the need for immediate nursing action and intervention? 1 Pain at the surgical site 2 Sudden shortness of breath 3 Serosanguineous wound drainage 4 Limited range of motion of the affected leg

2 The sudden onset of shortness of breath could be an indication of fat embolism syndrome, a potentially fatal complication of long bone fractures. Pain at the surgical site, serosanguineous wound drainage, and limited range of motion of the affected leg are all expected findings in a patient who has just undergone repair of a fractured hip. Text Reference - p. 1523

While caring for a postoperative patient with a nasogastric tube, the nurse suspects that the tube is repositioned. What is the priority nursing intervention to prevent complications in the patient? 1 Inserting a new nasogastric tube 2 Notifying the primary health care provider immediately 3 Irrigating the nasogastric tube with normal saline solution 4 Monitoring for the symptoms of edema and inflammation

2 When the nurse suspects repositioning of the nasogastric tube, the primary health care provider should be called as soon as possible, because there is a danger of either perforation of the gastric mucosa or a disruption of the suture line. The nurse should not insert a new tube without the order of the primary health care provider. Irrigating the tube with normal saline solution is helpful in preventing tube clogging. Monitoring for the symptoms of edema and inflammation will put the safety of the patient at risk.

What nursing interventions would be applied first for the patient with acute exacerbation of multiple sclerosis? Select all that apply. 1 Assisting the patient with the grieving process 2 Preventing the complication of pressure ulcers 3 Preventing the complication of urinary tract infections 4 Teaching the patient to build a general resistance to illness 5 Teaching the patient to maintain a good balance between exercise and rest

2 3 A patient experiencing an acute exacerbation of multiple sclerosis may be immobile and confined to bed. The first nursing interventions in this phase are aimed at preventing major complications associated with immobility. Pressure ulcers may occur due to the immobility of the patient while confined to the bed. Immediate care should be taken to prevent this. Urinary tract infections are also common due to the stagnation of urine. Assisting the patient with the grieving process is an important intervention during the diagnostic phase of multiple sclerosis. It is not applicable to a patient with an acute exacerbation of the disease. Teaching the patient to build general resistance to illness is a general intervention for a patient suffering from multiple sclerosis. Teaching the patient to maintain a good balance between exercise and rest is a general intervention for a patient with multiple sclerosis. It is not applicable for patients who are immobile. Text Reference - p. 1432

Which dietary instructions should the nurse provide the caregiver of a postoperative patient with dumping syndrome? Select all that apply. 1 "Avoid giving cheese." 2 "Give the patient eggs and meat." 3 "Avoid giving jelly and jam." 4 "Avoid giving fluids with meals." 5 "Divide the meals into three feedings."

2 3 4 Eggs and meat contain proteins and fat, which help to rebuild body tissues and meet energy demands. Distention and fullness of the stomach can occur if fluids are consumed along with meals. Jelly and jam cause diarrhea and dizziness; these foods should be avoided. Cheese contains proteins and fats and should be provided to the patient. The meals of the patient should be divided into six small feedings to avoid overloading the stomach and intestine during meal times. Text Reference - p. 950

The nurse is reinforcing health teaching about osteoporosis with a patient admitted to the hospital. The nurse discusses several risk factors for osteoporosis, including which of the following? Select all that apply. 1 Obesity 2 Asian descent 3 Smoking 4 Hyperlipidemia 5 Sedentary lifestyle

2 3 5 A small frame, Asian descent, smoking, and a sedentary lifestyle all contribute to the development of osteoporosis. Obesity and hyperlipidemia are not risk factors for osteoporosis.

A nurse is teaching a patient about measures to prevent the recurrence of urinary tract infections. What instructions should the nurse include? Select all that apply. 1 Drink lemon juice daily. 2 Maintain an adequate daily fluid intake. 3 Urinate regularly, approximately every three to four hours during the day. 4 Wipe from back to front after having a bowel movement or urinating. 5 Cleanse the perineal area with warm soapy water after each bowel movement.

2 3 5 It is necessary to maintain an adequate fluid intake and to urinate regularly. Delaying urination when there is an urge to urinate increases the chances of bacterial infection. Cleansing the perineal area with warm soapy water after a bowel movement reduces the risk of infection. It is important to wipe from front to back to avoid the risk of getting fecal matter near the urethra. Acidic foods and drinks like lemon juice, orange juice, and tomatoes irritate the bladder and should be avoided. Text Reference - p. 1069

A nurse is delegating responsibilities to unlicensed assistive personnel for caring for a patient who has suffered from a stroke this morning. What responsibilities will the nurse assign? Select all that apply. 1 Administer scheduled anticoagulant and antiplatelet medications. 2 Perform passive and active range-of-motion exercises. 3 Screen patients for contraindications for tissue plasminogen activator (tPA). 4 Measure and record urine output. 5 Assess the patient's ability to swallow.

2 4 Helping the patient perform exercises and measuring and recording urine output are the responsibilities of unlicensed assistive personnel, because they require less skill. Skilled activities such as administering anticoagulant and antiplatelet medications, screening patients for contraindications for tPA, and assessing the patient's ability to swallow should be performed only by a licensed nurse. Text Reference - p. 1405

When establishing a diagnosis of multiple sclerosis (MS), about what diagnostic studies should the nurse teach the patient? Select all that apply. 1 EEG 2 Computed tomography (CT) scan 3 Carotid duplex scan 4 Evoked response testing 5 Cerebrospinal fluid analysis

2 4 5 There is no definitive diagnostic test for MS. CT scan, evoked response testing, cerebrospinal fluid analysis, and magnetic resonance imaging (MRI) along with the patient's history and physical examination, are used to establish a diagnosis for MS. EEG and carotid duplex scan are not used for diagnosing MS.

An elderly patient is diagnosed with pneumonia. The nurse reviews the patient's laboratory report, which reveals a normal WBC count. What are the likely reasons that the lab result does not correspond to the diagnosis of pneumonia? Select all that apply. 1 The laboratory reports are erroneous. 2 The patient has decreased T-cell function. 3 The patient has decreased humoral antibody response. 4 The blood sample might not have been obtained properly. 5 The patient has increased bone marrow reserve of granulocyte.

2,3 Elderly patients usually show only a minimal elevation in the total WBC count. It may be due to decreased T-cell function and humoral antibody response related to aging. The laboratory reports may not be erroneous, because infections in elderly patients do not manifest as a high WBC count. There may not be any error in obtaining the sample. The elderly patient usually has a decreased bone marrow reserve of granulocyte, due to suppression of bone marrow. Text Reference - p. 618

A patient is diagnosed with delirium using the Confusion Assessment Method (CAM). As a next step, what should the nurse consider to determine the reason for the patient's change in mental status? Select all that apply. 1 Employment history 2 Previous health history 3 Serum electrolyte values 4 Current living arrangements 5 Medications routinely taken

2,3,5 Once delirium has been diagnosed, potential causes should be explored by evaluating health history, serum electrolytes, and the medication record. Employment history and current living arrangements are not identified as essential when determining the cause for delirium. Text Reference - p. 1459

The nurse is teaching a student nurse about postoperative care for a patient that has undergone laparoscopic cholecystectomy. Which statements made by the student nurse indicate the need for further teaching? Select all that apply. 1 "I will monitor for bleeding." 2 "The patient will need to return to the office in 7 to 10 days for removal of stitches." 3 "The patient will use a bedside commode for the first 24 hours after surgery." 4 "I will encourage the patient to practice deep breathing." 5 "I will most likely need to administer narcotics for pain control."

2,3,5 With laparoscopic cholecystectomy, there are small incisions that are covered by small adhesive bandages that can be removed in about five days. The stitches dissolve over time. Patients who have undergone laparoscopic cholecystectomy can usually walk to the bathroom, so there is no need for a bedside commode. Postoperative pain can usually be controlled with over-the-counter pain relievers. A cholecystectomy may result in changes in prothrombin time and may cause bleeding. Therefore, the nurse should monitor for bleeding. Deep breathing exercises should be encouraged to prevent postoperative pneumonia and to help relieve the patient's discomfort. Text Reference - p. 1040

A female patient is one-day postoperative following an abdominal hysterectomy. Which intervention should the nurse perform to prevent deep vein thrombosis (DVT)? 1 Place the patient in a high-Fowler's position 2 Provide pillows to place under the patient's knees 3 Encourage the patient to change positions frequently 4 Teach the patient deep breathing and coughing exercises

3

What action is most beneficial to a patient with a right-brain stroke? 1 Wear shoes when out of bed 2 Arrange food on the left side 3 Remove clutter and obstacles 4 Give directions non-verbally

3 A right-brain stroke survivor is at a higher risk for injury due to mobility issues. Therefore, all clutter and obstacles should be removed and proper lighting should be provided. Patients should wear nonslip and skid-resistant socks when out of bed to prevent falls. A right-brain stroke patient will tend to neglect the left side of the body; food should not be placed on the left side. All directions for activities should be given verbally to facilitate comprehension. Text Reference - p. 1406

The new patient has a diagnosis of frontal lobe dementia. What functional difficulties should the nurse expect in this patient? 1 The lack of reflexes 2 Endocrine problems 3 Higher cognitive function abnormalities 4 Respiratory, vasomotor, and cardiac dysfunction

3 Because the frontal lobe is responsible for higher cognitive function, this patient may have difficulty with memory retention, voluntary eye movements, voluntary motor movement, and expressive speech. The lack of reflexes would occur if the patient had problems with the reflex arcs in the spinal cord. Endocrine problems would be evident if the hypothalamus or pituitary gland were affected. Respiratory, vasomotor, and cardiac dysfunction would occur if there were a problem in the medulla. Text Reference - p. 1338

The nurse would determine that a postoperative patient is not receiving the beneficial effects of enoxaparin after noting what during a routine shift assessment? 1 Generalized weakness and fatigue 2 Crackles bilaterally in the lung bases 3 Pain and swelling in the lower extremity 4 Abdominal pain with decreased bowel sounds

3 Enoxaparin is a low-molecular weight heparin used to prevent the development of deep vein thromboses (DVTs) in the postoperative period. Pain and swelling in the lower extremity can indicate development of DVT and therefore may signal ineffective medication therapy. Generalized weakness, fatigue, abdominal pain, and crackles in the bases of the lungs would not necessitate the use of enoxaparin. Text Reference - p. 854

A patient with bacterial meningitis has developed delirium and hallucinations. What would be the cause of these symptoms? 1 Nuchal rigidity 2 Cranial nerve irritation 3 Increased intracranial pressure 4 Residual neurologic dysfunction

3 Increased intracranial pressure can cause altered mental status such as delirium and hallucinations. Nuchal rigidity (neck stiffness) is a clinical sign of bacterial meningitis. Cranial nerve irritation occurs due to neurologic dysfunction and increased intracranial pressure. Residual neurologic dysfunction is a complication of bacterial meningitis but it is not a cause of altered mental states. Text Reference - p. 1382

A patient is diagnosed with multiple sclerosis (MS) and is prescribed interferon. What should the nurse include in medication teaching? 1 The medication should be taken before meals on an empty stomach. 2 The medication is given during exacerbation of symptoms to promote remission. 3 The medication often causes patients to experience flu-like symptoms. 4 The medication alters carbohydrate metabolism and elevates serum glucose levels.

3 Interferon is an immunomodulator medication that treats the disease process and prevents relapses. The medication often causes flu-like symptoms, achiness, and headache, which are treated effectively with mild analgesics such as acetaminophen or ibuprofen. The medication is administered subcutaneously every other day. Exacerbations of MS are treated with corticosteroid medications. Corticosteroids alter carbohydrate metabolism and elevate serum glucose levels.

While evaluating a patient the nurse suspects primary open-angle glaucoma if which classic symptom is present? 1 Vacillating pupil 2 Constant tearing 3 Decreased peripheral vision 4 Colored halos around lights

3 Primary open-angle glaucoma develops slowly and without symptoms. The gradual loss of peripheral vision is one of the diagnostic criteria for primary open-angle glaucoma, which manifests as tunnel vision late in POAG. Vacillating pupils and constant tearing are not directly associated with any form of glaucoma. Colored halos around lights are seen in acute-angle closure glaucoma, which is less common than POAG. Acute-angle closure glaucoma is an ocular emergency requiring immediate intervention, because intraocular pressure increases rapidly and may cause optic nerve damage and blindness.

When administering eye drops to a patient with glaucoma, which nursing measure is most appropriate to minimize systemic effects of the medication? 1 Apply pressure to each eyeball for a few seconds after administration. 2 Have the patient close the eyes and move them back and forth several times. 3 Have the patient put pressure on the inner canthus of the eye after administration. 4 Have the patient try to blink out excess medication immediately after administration.

3 Systemic absorption can be minimized by applying pressure to the inner canthus of the eye. Applying pressure to each eyeball, having the patient close the eyes and move them back and forth, and having the patient try to blink out excess medication will not minimize systemic effects of the medication. Text Reference - p. 401

Which measure is a priority for a nurse to include in the plan of care for a patient who has multiple sclerosis? 1 Referring the patient for genetic counseling 2 Teaching the patient about medications used during acute exacerbations 3 Assisting the patient in identifying the factors that precipitate exacerbations 4 Instructing the patient in the proper technique for self-administration of an enema

3 The cause of multiple sclerosis is unknown, although fatigue, stress, or events such as pregnancy or acute illness can bring on an exacerbation. Identifying and avoiding such activities or factors may prevent exacerbations. Multiple sclerosis does not have a genetic link. Teaching the patient about medications and the proper technique for the self-administration of an enema is important but not as high of a priority as preventing exacerbations of the disease and complications. Text Reference - p. 1429

When reviewing the preoperative forms, the nurse notices that the informed consent form is not signed. What is the best action for the nurse to take? 1 Have the patient sign a consent form. 2 Have the family sign the form for the patient. 3 Notify the health care provider to obtain consent for surgery. 4 Teach the patient about the surgery and get verbal permission.

3 The informed consent for the surgery must be obtained by the health care provider. The nurse can witness the signature on the consent form and verify that the patient (or caregiver if patient is a minor, unconscious, or mentally incompetent to sign) understands the informed consent. Verbal consents are not enough. The state's nurse practice act and agency policies must be followed. Text Reference - p. 326

Which postoperative care, given by the nurse to the patient after a total hip replacement surgery, indicates an effective intervention? 1 Allowing the patient to sit on chairs without arms 2 Allowing the patient to cross legs at the knees or ankles 3 Allowing the patient to use a pillow between the legs for the first six weeks after surgery 4 Allowing the patient to perform daily activities such as putting on shoes and socks

3 The nurse should allow the patient to use a pillow between the legs for the first six weeks after surgery. It should be used when lying on the nonoperative side or when in a supine position to maintain the joint in abduction and prevent dislocation of the new joint. Sitting on chairs without arms will lead to a sudden flexing of the body more than 90°, resulting in destabilization of the prosthesis. Crossing of the legs at the knees or ankles affects healing of the soft tissue of the hip joint, leading to predisposition of the joint. Performing daily activities such as putting on shoes and socks that require flexing the body more than 90°, will lead to damage of the soft tissue. Therefore, it should be avoided till at least six weeks after the surgery. Text Reference - p. 1526

A registered nurse is teaching a student nurse about tissue plasminogen activator (tPA) administration in a patient with ischemic stroke. Which statement made by the student nurse indicates a need for further teaching? 1 "tPA is administered intravenously (IV)." 2 "tPA is administered by intraarterial infusion." 3 "tPA should be administered within 12 hours of the onset of a stroke." 4 "tPA requires blood pressure monitoring during and 24 hours after the treatment."

3 When tPA is administered to patients with an acute onset of ischemic stroke, it is administered intravenously (IV) and should be provided 3 to 4.5 hours from the onset of a stroke, not 12 hours. When administered by intraarterial infusion, tPA is delivered directly to the clot and can be administered up to 6 hours after the onset of stroke symptoms. It is important to monitor blood pressure during the treatment and for 24 hours after the fibrinolytic treatment. If blood pressure is not controlled, it can alter the fibrinolytic treatment. Text Reference - p. 1398

Which clinical manifestations of inflammatory bowel disease are common to both patients with ulcerative colitis (UC) and Crohn's disease? Select all that apply. 1 Restricted to rectum 2 Strictures are common 3 Diarrhea stools 4 Cramping abdominal pain 5 Lesions that penetrate the intestine

3,4 Clinical manifestations of UC and Crohn's disease include diarrhea, cramping abdominal pain, and nutritional disorders. Intestinal lesions associated with UC usually are restricted to the rectum before moving into the colon. Lesions that penetrate the intestine or cause strictures are characteristic of Crohn's disease.

A patient with significant right-sided pneumonia is receiving respiratory therapy. Which position is best suited for this patient? 1 Prone position 2 Tripod position 3 Supine position 4 Side-lying position

4 A patient with a medical condition involving only one lung requires focused intervention. A lateral or side-lying position is used for patients whose condition involves only one lung, because it allows for improved ventilation to perfusion that matches with the affected lung. This position also optimizes pulmonary blood flow and ventilation to the dependent lung areas. When a patient is in the prone position, air-filled, non-atelectatic alveoli in the ventral (anterior) portion of the lung become dependent, and perfusion may be better matched to ventilation. However, not all patients respond well to prone positioning and there is no reliable way of predicting who will respond. Tripod positioning helps to increase chest and lung expansion and decrease the effort needed to breathe for patients with chronic obstructive pulmonary disease, not patients with conditions affecting only one lung. The supine position changes the pleural pressure and predisposes the patient to atelectasis. Text Reference - p. 1662

A patient is admitted to the hospital for elective surgery. The patient is taking nonsteroidal antiinflammatory drugs (NSAIDs) for knee pain. The nurse recognizes that NSAID use will have what effect on a postoperative patient? 1 It may increase the risk of infections. 2 It may cause atelectasis postoperatively. 3 It may cause clotting of blood in the deep veins of legs. 4 It may increase risk of postoperative bleeding.

4 Although pain killers are required for surgical patients, the use of NSAIDS should be stopped before surgery, because these drugs are associated with increased postoperative bleeding. NSAIDS do not increase the risk of infections. NSAIDS do not cause atelectasis postoperatively. NSAIDS do not increase blood clotting. Text Reference - p. 320

A patient presenting with pneumonia scores 5 on the CURB-65 scale. What action should the nurse take? 1 Advise no treatment. 2 Advise treating at home. 3 Consider hospital admission. 4 Consider admission to an intensive care unit.

4 CURB-65 is used in addition to clinical judgment in determining the severity of pneumonia and the need for advanced medical care. A patient scoring 5 on the CURB-65 scale means the condition is severe and needs advanced medical care. Hence, the nurse should consider admission to an intensive care unit. If the patient has symptoms of pneumonia, advising no treatment is not an option. Treating at home is advised when the score on CURB-65 scale is 0. Hospital admission is considered when the score on the CURB-65 scale is 1 to 2.

The registered nurse is teaching a student nurse about the proper way to communicate with a patient who has aphasia due to a stroke. Which statement made by the student nurse indicates a need for further learning? 1 "I will speak in a normal tone with the patient." 2 "I will frame questions in a "Yes" or "No" format." 3 "I will not pretend to understand the patient, if I do not." 4 "I will try to force communication with the patient if the patient is upset."

4 Communication should not be forced if the patient is upset because anxiety worsens aphasia. Communication with the patient should be in a normal tone of voice because the patient should not feel as if they are spoken to like a child. Questions should be framed in a "Yes" or "No" format, to make communication easier for the patient. The nurse should not pretend to understand the patient. Instead, the patient should be encouraged to use nonverbal modes of communication.

In which programs should the nurse instruct a patient with Crohn's disease to participate during an exacerbation of the disease? 1 Aerobic exercise 2 Weight reduction 3 Smoking cessation 4 Stress management

4 Exacerbation of Crohn's disease may be partly related to stress and involves symptoms that are psychologically stressful. For this reason, stress management may be helpful. Aerobic exercise, smoking cessation, and weight reduction are all part a healthy lifestyle that may support reduction of stress; however, a formal stress-management program is still the best intervention for a patient with Crohn's disease during an exacerbation. Text Reference - p. 978

The patient in the intensive care unit is receiving gentamicin for pneumonia from Pseudomonas. What assessment results should the nurse report to the health care provider? 1 Decreased weight 2 Increased appetite 3 Increased urinary output 4 Elevated creatinine level

4 Gentamicin can be toxic to the kidneys and the auditory system. The elevated creatinine level must be reported to the health care provider, because it probably indicates renal damage. Other factors that may occur with renal damage would include increased weight and decreased urinary output. Many medications have the side effect of anorexia. Text Reference - p. 1057

The nurse is caring for a patient with rheumatoid arthritis who is receiving nonsteroidal antiinflammatory drugs (NSAIDs). Which intervention included in the care plan will help the nurse provide safe and effective care? 1 Provide a potassium-rich diet 2 Administer vitamin C supplements 3 Teach deep breathing and Kegel exercises 4 Monitor for symptoms of gastrointestinal distress

4 NSAIDs decrease mucus production and increase the risk of bleeding and gastrointestinal distress in patients. The nurse should check a patient with rheumatoid arthritis for symptoms of gastrointestinal distress in order to provide safe and effective care. NSAIDs do not cause potassium deficiency, so the nurse would not need to provide a potassium-rich diet to the patient. NSAIDs do not decrease the absorption of vitamin C supplements, nor do they cause vitamin C deficiency. NSAIDs do not cause respiratory distress and do not cause pelvic muscle weakness, so the nurse will not teach deep breathing and Kegel exercises to the patient.

The nurse is providing postoperative care for a bariatric surgery patient who has difficulty breathing and has abdominal pressure. Which priority nursing intervention would be beneficial in this situation? 1 Performing jaw-thrust maneuver 2 Assisting the patient to walk a short distance 3 Administering a low dose of heparin to the patient 4 Placing the patient's head at a 35 to 40 degree angle

4 Placing the patient's head at a 35 to 40 degree angle will reduce pressure on the abdomen and help in lung expansion, improving breathing. The jaw-thrust maneuver is performed to reduce the risk of pulmonary aspiration and to promote airway opening in a sedated patient. After a bariatric surgery, the patient is encouraged to walk for short distances three to four times a day to prevent complications such as deep venous thrombosis. A low dose of an anticoagulant, such as heparin, will help prevent deep venous thrombosis.

Prevention of vision loss resulting from chronic open angle glaucoma is accomplished best by which intervention? 1 Tobacco smoking cessation 2 Yearly ophthalmic examination 3 Eating a diet high in green leafy vegetables and lysine 4 Strict adherence to prescribed eye drop medication schedule

4 Strict adherence to prescribed medication regimen to treat glaucoma will keep the intraoptic pressure at safe levels to avoid optic nerve damage. Tobacco cessation is healthy but will not treat glaucoma. Yearly eye examinations are important but will measure only any damage done if the patient does not follow treatment. A diet high in lutein, found in green leafy vegetables, is thought to improve eye health. Lysine is an amino acid that has some antiviral properties. Text Reference - p. 401

The nurse is caring for a patient in the initial postoperative period after having an ileostomy. What is a priority nursing action for this patient? 1 Using opaque pouches for the patient 2 Limiting sodium in the patient's diet 3 Offering high-fiber food to the patient 4 Using transparent pouches for the patient

4 The nurse should use transparent pouches in the initial postoperative period of a patient who has undergone ileostomy to aid in the assessment of stoma viability. The nurse should give additional sodium in patient's diet to prevent sodium deficiency. The nurse can use opaque pouches a few days after an ileostomy. Offering high-fiber food during the initial postoperative period of ileostomy leads to diarrhea. Text Reference - p. 993

The nurse is caring for a 73-year-old patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient complains of shortness of breath, slight chest pain, and that "something is wrong." Temperature is 98.4° F, blood pressure 130/88, respirations 36/minute, and oxygen saturation 91% on room air. What action should the nurse take first? 1 Notify the health care provider 2 Administer a nitroglycerin tablet sublingually 3 Conduct a thorough assessment of the chest pain 4 Sit the patient up in bed as tolerated and apply oxygen

4 The patient's clinical picture is most likely pulmonary embolus, and the first action the nurse should take is to assist with the patient's respirations. For this reason, the nurse should sit the patient up as tolerated and apply oxygen before notifying the health care provider. The nitroglycerin tablet would not be helpful and the oxygenation status is a bigger problem than the slight chest pain at this time. Text Reference - p. 553

A patient with ulcerative colitis has been prescribed sulfasalazine. What instructions should the nurse give to the patient regarding the medication? 1 The function of the patient's liver enzymes will be monitored. 2 This medication should not be used, if patient is pregnant. 3 The medication may cause irregular values on a complete blood count (CBC). 4 The medication may cause a yellowish orange discoloration of skin and urine.

4 When the patient is treated with sulfasalazine, the patient should be informed that this medication may cause the skin and urine to become yellowish orange in color. This medication does not require monitoring of liver enzymes, may be prescribed for pregnant women, and will not significantly alter a CBC. Text Reference - p. 978

What behavior is exhibited by a patient who has suffered a right-brain stroke? 1 Very cautious 2 Accomplishes tasks quickly 3 Difficulty with words 4 Impulsive and impatient

4 A patient who has suffered a stroke on the right side of the brain will behave impulsively and act impatiently. A left-brain stroke survivor is aware of the deficiency and failure in mental functioning, and is very cautious. After a stroke, a patient will be much slower while undertaking actions. Survivors of left-brain damage will experience communication problems and have difficulty with words. Text Reference - p. 1407

Five minutes after the patient receives preoperative sedative medication by intramuscular (IM) injection, he or she asks to get up to go to the bathroom to urinate. What is the most appropriate action by the nurse? 1 Request a second nurse to help transport the patient to the bathroom. 2 Insert a Foley catheter in preparation for surgery. 3 Ask the patient to try to hold it because the patient will have a catheter soon. 4 Offer the patient a urinal and provide privacy.

4 The prime issue after administration of a sedative or opioid analgesic medication is safety. Providing the patient with a urinal and providing privacy allows the patient to stay in bed, but also allows the patient to void. Because these medications affect the central nervous system, the patient is at risk for falls and should not be allowed out of bed, even with assistance. A Foley catheter is not indicated at this time, and it is not reasonable to ask the patient to wait until the surgery is underway.

A nurse assesses the blood pressure (BP) of a patient who had a stroke and finds it to be 166/96 mm Hg. What is the priority action by the nurse? Select all that apply. 1 Call the health care provider immediately. 2 Start intravenous antihypertensive drugs. 3 Start oral antihypertensive drugs. 4 Ensure adequate fluid intake. 5 Consider this as a protective response.

4 5 Elevated BP is common immediately after a stroke. It is important to provide adequate fluid intake during acute care to maintain hydration. Elevation of BP is a protective response to maintain cerebral perfusion. Therefore, it is not necessary to call the health care provider. Antihypertensives should be started only if there is a marked increase in BP (systolic greater than 220 mm Hg or diastolic greater than 120 mm Hg). Text Reference - p. 1397

While caring for a postoperative patient with urinary retention, the primary health care provider orders the nurse to monitor and record urine output every hour. The weight of the person is 70 kg. What should be the minimum acceptable urine output after five hours? Record your answer using a whole number. ____________ mL/hr

The total urine output should be 0.5 mL/kg/hr. Because the weight of the patient is 70 kg, 70 × 0.5 = 35 mL/hr. The urine output for 1 hour is 35 mL/hr and for 5 hours 175 mL/hr. Text Reference - p. 1095

A patient is recovering from a stroke and needs help with improving muscle strength, gait training, and transfer training. The nurse should refer the patient to what health care professional? A Pastoral caregiver B Speech therapist C Physical therapist D Occupational therapist

c A physical therapist helps the patient improve strength and endurance, and provides gait training and transfer training. Pastoral care offers spiritual support to the patient and family. A speech therapist focuses on the management of speech disorders. An occupational therapist helps the patient improve motor-sensory coordination, cognitive-perceptual skills, and the ability to perform activities of daily living.