Care Considerations exam 4
After receiving change-of-shift report on a heart failure unit, which patient should the nurse assess first? A. A patient who is cool and clammy, with new-onset confusion and restlessness B. A patient who has crackles bilaterally in the lung bases and is receiving oxygen. C. A patient who had dizziness after receiving the first dose of captopril (Capoten) D. A patient who is receiving IV nesiritide (Natrecor) and has a blood pressure of 100/62
A
Which nursing action should the nurse take first in order to assist a patient with newly diagnosed stage 1 hypertension in making needed dietary changes? A. Collect a detailed diet history. B. Provide a list of low-sodium foods. C. Help the patient make an appointment with a dietitian. D. Teach the patient about foods that are high in potassium.
A
Which assessment finding for a patient who is receiving IV furosemide (Lasix) to treat stage 2 hypertension is most important to report to the health care provider? A. Blood glucose level of 175 mg/dL B. Blood potassium level of 3.0 mEq/L C. Most recent blood pressure (BP) reading of 168/94 mm Hg D. Orthostatic systolic BP decrease of 12 mm Hg
B
Which blood pressure (BP) finding by the nurse indicates that no changes in therapy are needed for a patient with stage 1 hypertension who has a history of diabetes mellitus? A. 102/60 mm Hg B. 128/76 mm Hg C. 139/90 mm Hg D. 136/82 mm Hg
B
When the nurse is monitoring a patient who is undergoing exercise (stress) testing on a treadmill, which assessment finding requires the most rapid action by the nurse? A. Patient complaint of feeling tired B. Pulse change from 87 to 101 beats/minute C. Blood pressure (BP) increase from 134/68 to 150/80 mm Hg D. Newly inverted T waves on the electrocardiogram
D
While doing the admission assessment for a thin 76-year-old patient, the nurse observes pulsation of the abdominal aorta in the epigastric area. Which action should the nurse take? A. Teach the patient about aneurysms. B. Notify the hospital rapid response team. C. Instruct the patient to remain on bed rest. D. Document the finding in the patient chart.
D
When assessing a newly admitted patient, the nurse notes a murmur along the left sternal border. To document more information about the murmur, which action will the nurse take next? A. Find the point of maximal impulse. B. Determine the timing of the murmur. C. Compare the apical and radial pulse rates. D. Palpate the quality of the peripheral pulses.
B
When auscultating over the patients abdominal aorta, the nurse hears a humming sound. The nurse documents this finding as a A. thrill B. bruit C. murmur D. normal finding.
B
A 50-year-old patient who underwent a gastroduodenostomy (Billroth I) earlier today complains of increasing abdominal pain. The patient has no bowel sounds and 200 mL of bright red nasogastric (NG) drainage in the last hour. The highest priority action by the nurse is to A. contact the surgeon. B. irrigate the NG tube. C. monitor the NG drainage. D. administer the prescribed morphine.
A
A 51-year-old male patient has a new diagnosis of Crohns disease after having frequent diarrhea and a weight loss of 10 pounds (4.5 kg) over 2 months. The nurse will plan to teach about A. medication use. B. fluid restriction. C. enteral nutrition. D. activity restrictions.
A
A 51-year-old woman with Crohns disease who is taking infliximab (Remicade) calls the nurse in the outpatient clinic about new symptoms. Which symptom is most important to communicate to the health care provider? A. Fever B. Nausea C. Joint pain D. Headache
A
A 58-year-old woman has just returned to the nursing unit after an esophagogastroduodenoscopy (EGD). Which action by unlicensed assistive personnel (UAP) requires that the registered nurse (RN) intervene? A. Offering the patient a drink of water B. Positioning the patient on the right side C. Checking the vital signs every 30 minutes D. Swabbing the patients mouth with cold water
A
A few days after experiencing a myocardial infarction (MI) and successful percutaneous coronary intervention, the patient states, I just had a little chest pain. As soon as I get out of here, Im going for my vacation as planned. Which reply would be most appropriate for the nurse to make? A. What do you think caused your chest pain? B. Where are you planning to go for your vacation? C. Sometimes plans need to change after a heart attack. D. Recovery from a heart attack takes at least a few weeks.
A
A healthy 28-year-old woman patient who weighs 145 pounds (66 kg) asks the nurse about the minimum daily requirement for protein. How many grams of protein will the nurse recommend? A. 53 B. 66 C. 75 D. 98
A
A patient in the intensive care unit with acute decompensated heart failure (ADHF) complains of severe dyspnea and is anxious, tachypneic, and tachycardic. All of the following medications have been ordered for the patient. The nurses priority action will be to A. give IV morphine sulfate 4 mg. B. give IV diazepam (V alium) 2.5 mg. C. increase nitroglycerin (Tridil) infusion by 5 mcg/min. D. increase dopamine (Intropin) infusion by 2 mcg/kg/min.
A
A patient is being scheduled for endoscopic retrograde cholangiopancreatography (ERCP) as soon as possible. Which actions from the agency policy for ERCP should the nurse take first? A. Place the patient on NPO status. B. Administer sedative medications. C. Ensure the consent form is signed. D. Teach the patient about the procedure.
A
A patient who has recently started taking pravastatin (Pravachol) and niacin (Nicobid) reports the following symptoms to the nurse. Which is most important to communicate to the health care provider? A. Generalized muscle aches and pains B. Dizziness when changing positions quickly C. Nausea when taking the drugs before eating D. Flushing and pruritus after taking the medications
A
During a visit to a 78-year-old with chronic heart failure, the home care nurse finds that the patient has ankle edema, a 2-kg weight gain over the past 2 days, and complains of feeling too tired to get out of bed. Based on these data, the best nursing diagnosis for the patient is A. activity intolerance related to fatigue. B. disturbed body image related to weight gain. C. impaired skin integrity related to ankle edema. D. impaired gas exchange related to dyspnea on exertion.
A
The charge nurse observes a new registered nurse (RN) doing discharge teaching for a patient with hypertension who has a new prescription for enalapril (Vasotec). The charge nurse will need to intervene if the new RN tells the patient to A. increase the dietary intake of high-potassium foods. B. make an appointment with the dietitian for teaching. C. check the blood pressure (BP) with a home BP monitor at least once a day. D. move slowly when moving from lying to sitting to standing.
A
The nurse hears a murmur between the S1 and S2 heart sounds at the patients left fifth intercostal space and midclavicular line. How will the nurse record this information? A. Systolic murmur heard at mitral area B. Systolic murmur heard at Erbs point C. Diastolic murmur heard at aortic area D. Diastolic murmur heard at the point of maximal impulse
A
The nurse is caring for a patient who was admitted to the coronary care unit following an acute myocardial infarction (AMI) and percutaneous coronary intervention the previous day. Teaching for this patient would include A. when cardiac rehabilitation will begin. B. the typical emotional responses to AMI. C. information regarding discharge medications. D. the pathophysiology of coronary artery disease.
A
The nurse is reviewing the laboratory test results for a patient who has recently been diagnosed with hypertension. Which result is most important to communicate to the health care provider? A. Serum creatinine of 2.8 mg/dL B. Serum potassium of 4.5 mEq/L C. Serum hemoglobin of 14.7 g/dL D. Blood glucose level of 96 mg/dL
A
The nurse on the intermediate care unit received change-of-shift report on four patients with hypertension. Which patient should the nurse assess first? A. 43-year-old with a (blood pressure (BP) of 160/92 who is complaining of chest pain B. 52-year-old with a BP of 212/90 who has intermittent claudication C. 50-year-old with a BP of 190/104 who has a creatinine of 1.7 mg/dL D. 48-year-old with a BP of 172/98 whose urine shows microalbuminuria
A
The nurse will anticipate preparing a 71-year-old female patient who is vomiting coffee-ground emesis for A. endoscopy. B. angiography. C. barium studies. D. gastric analysis.
A
The standard policy on the cardiac unit states, Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg. The nurse will need to call the health care provider about the A. postoperative patient with a BP of 116/42. B. newly admitted patient with a BP of 150/87. C. patient with left ventricular failure who has a BP of 110/70. D. patient with a myocardial infarction who has a BP of 140/86.
A
Three days after experiencing a myocardial infarction (MI), a patient who is scheduled for discharge asks for assistance with hygiene activities, saying, I am too nervous to take care of myself. Based on this information, which nursing diagnosis is appropriate? A. Ineffective coping related to anxiety B. Activity intolerance related to weakness C. Denial related to lack of acceptance of the MI D. Disturbed personal identity related to understanding of illness
A
To auscultate for S3 or S4 gallops in the mitral area, the nurse listens with the A. bell of the stethoscope with the patient in the left lateral position. B. diaphragm of the stethoscope with the patient in a supine position. C. bell of the stethoscope with the patient sitting and leaning forward. D. diaphragm of the stethoscope with the patient lying flat on the left side
A
When caring for a patient who has just arrived on the medical-surgical unit after having cardiac catheterization, which nursing intervention should the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? A. Give the scheduled aspirin and lipid-lowering medication. B. Perform the initial assessment of the catheter insertion site. C. Teach the patient about the usual postprocedure plan of care. D. Titrate the heparin infusion according to the agency protocol.
A
Which action should the nurse in the emergency department anticipate for a 23-year-old patient who has had several episodes of bloody diarrhea? A. Obtain a stool specimen for culture. B. Administer antidiarrheal medication. C. Provide teaching about antibiotic therapy. D. Teach about adverse effects of acetaminophen (Tylenol).
A
Which action should the nurse include in the plan of care when caring for a patient admitted with acute decompensated heart failure (ADHF) who is receiving nesiritide (Natrecor)? A. Monitor blood pressure frequently. B. Encourage patient to ambulate in room. C. Titrate nesiritide slowly before stopping. D. Teach patient about home use of the drug.
A
Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires the most immediate action by the nurse? A. Oxygen saturation of 88% B. Weight gain of 1 kg (2.2 lb) C. Heart rate of 106 beats/minute D. Urine output of 50 mL over 2 hours
A
Which finding for a 19-year-old female who is a vegan may indicate the need for cobalamin supplementation? A. Paresthesias B. Ecchymoses C. Dry, scaly skin D. Gingival swelling
A
Which information about a patient who has been receiving thrombolytic therapy for an acute myocardial infarction (AMI) is most important for the nurse to communicate to the health care provider? A. No change in the patients chest pain B. An increase in troponin levels from baseline C. A large bruise at the patients IV insertion site D. A decrease in ST-segment elevation on the electrocardiogram
A
Which information will the nurse include when teaching adults to decrease the risk for cancers of the tongue and buccal mucosa? A. Avoid use of cigarettes and smokeless tobacco. B. Use sunscreen when outside even on cloudy days. C. Complete antibiotic courses used to treat throat infections. D. Use antivirals to treat herpes simplex virus (HSV) infections.
A
Which menu choice by the patient with diverticulosis is best for preventing diverticulitis? A. Navy bean soup and vegetable salad B. Whole grain pasta with tomato sauce C. Baked potato with low-fat sour cream D. Roast beef sandwich on whole wheat bread
A
Which finding by the nurse during abdominal auscultation indicates a need for a focused abdominal assessment? A. Loud gurgles B. High-pitched gurgles C. Absent bowel sounds D. Frequent clicking sounds
C
Which patient statement indicates that the nurses teaching following a gastroduodenostomy has been effective? A. Vitamin supplements may prevent anemia. B. Persistent heartburn is common after surgery. C. I will try to drink more liquids with my meals. D. I will need to choose high carbohydrate foods.
A
A 24-year-old woman with Crohns disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, fecal-smelling urine. What information will the nurse add to a general teaching plan about UTIs in order to individualize the teaching for this patient? A. Bacteria in the perianal area can enter the urethra. B. Fistulas can form between the bowel and bladder. C. Drink adequate fluids to maintain normal hydration. D. Empty the bladder before and after sexual intercourse.
B
A 19-year-old female admitted with anorexia nervosa is 5 ft 6 in (163 cm) tall and weighs 88 pounds (41 kg). Laboratory tests reveal hypokalemia and iron-deficiency anemia. Which nursing diagnosis has the highest priority? A. Risk for activity intolerance related to anemia B. Risk for electrolyte imbalance related to eating patterns C. Ineffective health maintenance related to body image obsession D. Imbalanced nutrition: less than body requirements related to anorexia
B
Which finding in the mouth of a patient who uses smokeless tobacco is suggestive of oral cancer? A. Bleeding during tooth brushing B. Painful blisters at the lip border C. Red, velvety patches on the buccal mucosa D. White, curdlike plaques on the posterior tongu
C
A 25-year-old male patient calls the clinic complaining of diarrhea for 24 hours. Which action should the nurse take first? A. Inform the patient that laboratory testing of blood and stools will be necessary. B. Ask the patient to describe the character of the stools and any associated symptoms. C. Suggest that the patient drink clear liquid fluids with electrolytes, such as Gatorade or Pedialyte. D. Advise the patient to use over-the-counter loperamide (Imodium) to slow gastrointestinal (GI) motility.
B
A 26-year-old patient with a family history of stomach cancer asks the nurse about ways to decrease the risk for developing stomach cancer. The nurse will teach the patient to avoid A. emotionally stressful situations. B. smoked foods such as ham and bacon. C. foods that cause distention or bloating. D. chronic use of H2 blocking medications.
B
A 44-year-old man admitted with a peptic ulcer has a nasogastric (NG) tube in place. When the patient develops sudden, severe upper abdominal pain, diaphoresis, and a firm abdomen, which action should the nurse take? A. Irrigate the NG tube. B. Check the vital signs. C. Give the ordered antacid. D. Elevate the foot of the bed.
B
A 48-year-old woman has a body mass index (BMI) of 31 kg/m2, a normal C-reactive protein level, and low serum transferrin and albumin levels. The nurse will plan patient teaching to increase the patients intake of foods that are high in A. iron. B. protein. C. calories. D. carbohydrate.
B
A 49-year-old man has been admitted with hypotension and dehydration after 3 days of nausea and vomiting. Which order from the health care provider will the nurse implement first? A. Insert a nasogastric (NG) tube. B. Infuse normal saline at 250 mL/hr. C. Administer IV ondansetron (Zofran). D. Provide oral care with moistened swabs.
B
A 53-year-old patient with Stage D heart failure and type 2 diabetes asks the nurse whether heart transplant is a possible therapy. Which response by the nurse is most appropriate? A. Because you have diabetes, you would not be a candidate for a heart transplant. B. The choice of a patient for a heart transplant depends on many different factors. C. Your heart failure has not reached the stage in which heart transplants are needed. D. People who have heart transplants are at risk for multiple complications after surgery.
B
A 58-year-old man with blunt abdominal trauma from a motor vehicle crash undergoes peritoneal lavage. If the lavage returns brown fecal drainage, which action will the nurse plan to take next? A. Auscultate the bowel sounds. B. Prepare the patient for surgery. C. Check the patients oral temperature. D. Obtain information about the accident.
B
A 62- year-old man reports chronic constipation. To promote bowel evacuation, the nurse will suggest that the patient attempt defecation A. in the mid-afternoon. B. after eating breakfast. C. right after getting up in the morning. D. immediately before the first daily meal.
B
A 68-year-old patient with a bleeding duodenal ulcer has a nasogastric (NG) tube in place, and the health care provider orders 30 mL of aluminum hydroxide/magnesium hydroxide (Maalox) to be instilled through the tube every hour. To evaluate the effectiveness of this treatment, the nurse A. monitors arterial blood gas values daily. B. periodically aspirates and tests gastric pH. C. checks each stool for the presence of occult blood. D. measures the volume of residual stomach contents.
B
A 71-year-old male patient tells the nurse that growing old causes constipation so he has been using a suppository for constipation every morning. Which action should the nurse take first? A. Encourage the patient to increase oral fluid intake. B. Assess the patient about risk factors for constipation. C. Suggest that the patient increase intake of high-fiber foods. D. Teach the patient that a daily bowel movement is unnecessary.
B
A family member of a 28-year-old patient who has suffered massive abdominal trauma in an automobile accident asks the nurse why the patient is receiving famotidine (Pepcid). The nurse will explain that the medication will A. decrease nausea and vomiting. B. inhibit development of stress ulcers. C. lower the risk for H. pylori infection. D. prevent aspiration of gastric contents.
B
A patient hospitalized with chronic heart failure eats only about 50% of each meal and reports feeling too tired to eat. Which action should the nurse take first? A. Teach the patient about the importance of good nutrition. B. Serve multiple small feedings of high-calorie, high-protein foods. C. Obtain an order for enteral feedings of liquid nutritional supplements. D. Consult with the health care provider about providing parenteral nutrition (PN).
B
A patient is scheduled for a cardiac catheterization with coronary angiography. Before the test, the nurse informs the patient that A. it will be important to lie completely still during the procedure. B. a flushed feeling may be noted when the contrast dye is injected. C. monitored anesthesia care will be provided during the procedure. D. arterial pressure monitoring will be required for 24 hours after the test.
B
A patient who is recovering from an acute myocardial infarction (AMI) asks the nurse about when sexual intercourse can be resumed. Which response by the nurse is best? A. Most patients are able to enjoy intercourse without any complications. B. Sexual activity uses about as much energy as climbing two flights of stairs. C. The doctor will provide sexual guidelines when your heart is strong enough. D. Holding and cuddling are good ways to maintain intimacy after a heart attack.
B
A patient with a history of hypertension treated with a diuretic and an angiotensin-converting enzyme (ACE) inhibitor arrives in the emergency department complaining of a severe headache and nausea and has a blood pressure (BP) of 238/118 mm Hg. Which question should the nurse ask first? A. Did you take any acetaminophen (Tylenol) today? B. Have you been consistently taking your medications? C. Have there been any recent stressful events in your life? D. Have you recently taken any antihistamine medications?
B
A patient with hypertension who has just started taking atenolol (Tenormin) returns to the health clinic after 2 weeks for a follow-up visit. The blood pressure (BP) is unchanged from the previous visit. Which action should the nurse take first? A. Inform the patient about the reasons for a possible change in drug dosage. B. Question the patient about whether the medication is actually being taken. C. Inform the patient that multiple drugs are often needed to treat hypertension. D. Question the patient regarding any lifestyle changes made to help control BP.
B
A registered nurse (RN) is observing a student nurse who is doing a physical assessment on a patient. The RN will need to intervene immediately if the student nurse A. presses on the skin over the tibia for 10 seconds to check for edema. B. palpates both carotid arteries simultaneously to compare pulse quality. C. documents a murmur heard along the right sternal border as a pulmonic murmur. D. places the patient in the left lateral position to check for the point of maximal impulse.
B
A severely malnourished patient reports that he is Jewish. The nurses initial action to meet his nutritional needs will be to A. have family members bring in food. B. ask the patient about food preferences. C. teach the patient about nutritious Kosher foods. D. order nutrition supplements that are manufactured Kosher.
B
A transesophageal echocardiogram (TEE) is ordered for a patient with possible endocarditis. Which action included in the standard TEE orders will the nurse need to accomplish first? A. Start an IV line. B. Place the patient on NPO status. C. Administer O2 per nasal cannula. D. Give lorazepam (Ativan) 1 mg IV.
B
After change-of-shift report, which patient will the nurse assess first? A. A 40-year-old woman whose parenteral nutrition infusion bag has 30 minutes of solution left B. A 40-year-old man with continuous enteral feedings who has developed pulmonary crackles C. A 30-year-old man with 4+ generalized pitting edema and severe protein-calorie malnutrition D. A 30-year-old woman whose gastrostomy tube is plugged after crushed medications were administered.
B
After receiving change-of-shift report on a heart failure unit, which patient should the nurse assess first? A. Patient who is taking carvedilol (Coreg) and has a heart rate of 58 B. Patient who is taking digoxin and has a potassium level of 3.1 mEq/L C. Patient who is taking isosorbide dinitrate/hydralazine (BiDil) and has a headache D. Patient who is taking captopril (Capoten) and has a frequent nonproductive cough
B
After the nurse teaches the patient about the use of carvedilol (Coreg) in preventing anginal episodes, which statement by a patient indicates that the teaching has been effective? A. Carvedilol will help my heart muscle work harder. B. It is important not to suddenly stop taking the carvedilol. C. I can expect to feel short of breath when taking carvedilol. D. Carvedilol will increase the blood flow to my heart muscle.
B
Diltiazem (Cardizem) is ordered for a patient with newly diagnosed Prinzmetals (variant) angina. When teaching the patient, the nurse will include the information that diltiazem will A. reduce heart palpitations. B. decrease spasm of the coronary arteries. C. increase the force of the heart contractions. D. help prevent plaque from forming in the coronary arteries.
B
The nurse and a licensed practical/vocational nurse (LPN/LVN) are working together to care for a patient who had an esophagectomy 2 days ago. Which action by the LPN/LVN requires that the nurse intervene? A. The LPN/LVN uses soft swabs to provide for oral care. B. The LPN/LVN positions the head of the bed in the flat position. C. The LPN/LVN encourages the patient to use pain medications before coughing. D. The LPN/LVN includes the enteral feeding volume when calculating intake and output.
B
The nurse and unlicensed assistive personnel (UAP) on the telemetry unit are caring for four patients. Which nursing action can be delegated to the UAP? A. Teaching a patient scheduled for exercise electrocardiography about the procedure B. Placing electrodes in the correct position for a patient who is to receive ECG monitoring C. Checking the catheter insertion site for a patient who is recovering from a coronary angiogram D. Monitoring a patient who has just returned to the unit after a transesophageal echocardiogram
B
The nurse determines that teaching regarding cobalamin injections has been effective when the patient with chronic atrophic gastritis states which of the following? A. The cobalamin injections will prevent gastric inflammation. B. The cobalamin injections will prevent me from becoming anemic. C. These injections will increase the hydrochloric acid in my stomach. D. These injections will decrease my risk for developing stomach cancer.
B
The nurse is administering IV fluid boluses and nasogastric irrigation to a patient with acute gastrointestinal (GI) bleeding. Which assessment finding is most important for the nurse to communicate to the health care provider? A. The bowel sounds are hyperactive in all four quadrants. B. The patients lungs have crackles audible to the midchest. C. The nasogastric (NG) suction is returning coffee-ground material. D. The patients blood pressure (BP) has increased to 142/84 mm Hg.
B
The nurse is assessing a 31-year-old female patient with abdominal pain. Th nurse,who notes that there is ecchymosis around the area of umbilicus, will document this finding as A. Cullen sign. B. Rovsing sign. C. McBurney sign. D. Grey-Turners signt.
B
The nurse is assessing a patient who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider? A. Urine output over 8 hours is 250 mL less than the fluid intake. B. The patient cannot move the left arm and leg when asked to do so. C. Tremors are noted in the fingers when the patient extends the arms. D. The patient complains of a headache with pain at level 8/10 (0 to 10 scale).
B
The nurse is assessing an alert and independent 78-year-old woman for malnutrition risk. The most appropriate initial question is which of the following? A. How do you get to the store to buy your food? B. Can you tell me the food that you ate yesterday? C. Do you have any difficulty in preparing or eating food? D. Are you taking any medications that alter your taste for food?
B
The nurse obtains the following information from a patient newly diagnosed with prehypertension. Which finding is most important to address with the patient? A. Low dietary fiber intake B. No regular aerobic exercise C. Weight 5 pounds above ideal weight D. Drinks a beer with dinner on most nights
B
The nurse will determine that teaching a 67-year-old man to irrigate his new colostomy has been effective if the patient A. inserts the irrigation tubing 4 to 6 inches into the stoma. B. hangs the irrigating container 18 inches above the stoma. C. stops the irrigation and removes the irrigating cone if cramping occurs. D. fills the irrigating container with 1000 to 2000 mL of lukewarm tap water.
B
The nurse will suspect that the patient with stable angina is experiencing a side effect of the prescribed metoprolol (Lopressor) if the A. patient is restless and agitated. B. blood pressure is 90/54 mm Hg. C. patient complains about feeling anxious. D. cardiac monitor shows a heart rate of 61 beats/minute.
B
To improve the physical activity level for a mildly obese 71-year-old patient, which action should the nurse plan to take? A. Stress that weight loss is a major benefit of increased exercise. B. Determine what kind of physical activities the patient usually enjoys. C. Tell the patient that older adults should exercise for no more than 20 minutes at a time. D. Teach the patient to include a short warm-up period at the beginning of physical activity.
B
When admitting a patient for a cardiac catheterization and coronary angiogram, which information about the patient is most important for the nurse to communicate to the health care provider? A. The patients pedal pulses are +1. B. The patient is allergic to shellfish. C. The patient had a heart attack a year ago. D. The patient has not eaten anything today.
B
When caring for a patient who is recovering from a sudden cardiac death (SCD) event and has no evidence of an acute myocardial infarction (AMI), the nurse will anticipate teaching the patient that A. sudden cardiac death events rarely reoccur. B. additional diagnostic testing will be required. C. long-term anticoagulation therapy will be needed. D. limited physical activity after discharge will be needed to prevent future events.
B
When evaluating the effectiveness of preoperative teaching with a patient scheduled for coronary artery bypass graft (CABG) surgery using the internal mammary artery, the nurse determines that additional teaching is needed when the patient says which of the following? A. They will circulate my blood with a machine during the surgery. B. I will have small incisions in my leg where they will remove the vein. C. They will use an artery near my heart to go around the area that is blocked. D. I will need to take an aspirin every day after the surgery to keep the graft open.
B
When titrating IV nitroglycerin (Tridil) for a patient with a myocardial infarction (MI), which action will the nurse take to evaluate the effectiveness of the medication? A. Monitor heart rate. B. Ask about chest pain. C. Check blood pressure. D. Observe for dysrhythmias.
B
Which action should the nurse take first when preparing to teach a frail 79-year-old Hispanic man who lives with an adult daughter about ways to improve nutrition? A. Ask the daughter about the patients food preferences. B. Determine who shops for groceries and prepares the meals. C. Question the patient about how many meals per day are eaten. D. Assure the patient that culturally preferred foods will be included.
B
Which action will the nurse in the hypertension clinic take in order to obtain an accurate baseline blood pressure (BP) for a new patient? A. Deflate the BP cuff at a rate of 5 to 10 mm Hg per second. B. Have the patient sit in a chair with the feet flat on the floor. C. Assist the patient to the supine position for BP measurements. D. Obtain two BP readings in the dominant arm and average the results.
B
Which assessment data collected by the nurse who is admitting a patient with chest pain suggest that the pain is caused by an acute myocardial infarction (AMI)? A. The pain increases with deep breathing. B. The pain has lasted longer than 30 minutes. C. The pain is relieved after the patient takes nitroglycerin. D. The pain is reproducible when the patient raises the arms.
B
Which assessment finding by the nurse caring for a patient who has had coronary artery bypass grafting using a right radial artery graft is most important to communicate to the health care provider? A. Complaints of incisional chest pain B. Pallor and weakness of the right hand C. Fine crackles heard at both lung bases D. Redness on both sides of the sternal incision
B
Which information about an 80-year-old man at the senior center is of most concern to the nurse? A. Decreased appetite B. Unintended weight loss C. Difficulty chewing food D. Complaints of indigestion
B
Which information about dietary management should the nurse include when teaching a patient with peptic ulcer disease (PUD)? A. You will need to remain on a bland diet. B. Avoid foods that cause pain after you eat them. C. High-protein foods are least likely to cause you pain. D. You should avoid eating any raw fruits and vegetables.
B
Which information will the nurse include for a patient with newly diagnosed gastroesophageal reflux disease (GERD)? A. Peppermint tea may reduce your symptoms. B. Keep the head of your bed elevated on blocks. C. You should avoid eating between meals to reduce acid secretion. D. Vigorous physical activities may increase the incidence of reflux.
B
Which information will the nurse include in teaching a patient who had a proctocolectomy and ileostomy for ulcerative colitis? A. Restrict fluid intake to prevent constant liquid drainage from the stoma. B. Use care when eating high-fiber foods to avoid obstruction of the ileum. C. Irrigate the ileostomy daily to avoid having to wear a drainage appliance. D. Change the pouch every day to prevent leakage of contents onto the skin.
B
Which item should the nurse offer to the patient who is to restart oral intake after being NPO due to nausea and vomiting? A. Glass of orange juice B. Dish of lemon gelatin C. Cup of coffee with cream D. Bowl of hot chicken broth
B
Which nursing action should be included in the postoperative plan of care for a patient after a laparoscopic esophagectomy? A. Notify the doctor about bloody nasogastric (NG) drainage. B. Elevate the head of the bed to at least 30 degrees. C. Reposition the NG tube if drainage stops. D. Start oral fluids when the patient has active bowel sounds.
B
Which nursing action will the nurse include in the plan of care for a 35-year-old male patient admitted with an exacerbation of inflammatory bowel disease (IBD)? A. Restrict oral fluid intake. B. Monitor stools for blood. C. Ambulate four times daily D. Increase dietary fiber intake
B
Which patient at the cardiovascular clinic requires the most immediate action by the nurse? A. Patient with type 2 diabetes whose current blood glucose level is 145 mg/dL B. Patient with stable angina whose chest pain has recently increased in frequency C. Patient with familial hypercholesterolemia and a total cholesterol of 465 mg/dL D. Patient with chronic hypertension whose blood pressure today is 172/98 mm Hg
B
A 19-year-old female is brought to the emergency department with a knife handle protruding from the abdomen. During the initial assessment of the patient, the nurse should A. remove the knife and assess the wound. B. determine the presence of Rovsing sign. C. check for circulation and tissue perfusion. D. insert a urinary catheter and assess for hematuria.
C
A 20-year-old female is being admitted for electrolyte disorders of unknown etiology. Which assessment finding is most important to report to the health care provider? A. The patient uses laxatives daily. B. The patients knuckles are macerated. C. The patients serum potassium level is 2.9 mEq/L. D. The patient has a history of large weight fluctuations.
C
A 22-year-old female patient with an exacerbation of ulcerative colitis is having 15 to 20 stools daily and has excoriated perianal skin. Which patient behavior indicates that teaching regarding maintenance of skin integrity has been effective? A. The patient uses incontinence briefs to contain loose stools. B. The patient asks for antidiarrheal medication after each stool. C. The patient uses witch hazel compresses to decrease irritation. D. The patient cleans the perianal area with soap after each stool.
C
A 38-year old woman receiving chemotherapy for breast cancer develops a Candida albicans oral infection. The nurse will anticipate the need for A. hydrogen peroxide rinses. B. the use of antiviral agents. C. administration of nystatin (Mycostatin) tablets. D. referral to a dentist for professional tooth cleaning.
C
A 46-year-old female with gastroesophageal reflux disease (GERD) is experiencing increasing discomfort. Which patient statement indicates that additional teaching about GERD is needed? A. I take antacids between meals and at bedtime each night. B. I sleep with the head of the bed elevated on 4-inch blocks. C. I eat small meals during the day and have a bedtime snack. D. I quit smoking several years ago, but I still chew a lot of gum.
C
A 53-year-old male patient with deep partial-thickness burns from a chemical spill in the workplace experiences severe pain followed by nausea during dressing changes. Which action will be most useful in decreasing the patients nausea? A. Keep the patient NPO for 2 hours before and after dressing changes. B. Avoid performing dressing changes close to the patients mealtimes. C. Administer the prescribed morphine sulfate before dressing changes. D. Give the ordered prochlorperazine (Compazine) before dressing changes.
C
A 54-year-old man has just arrived in the recovery area after an upper endoscopy. Which information collected by the nurse is most important to communicate to the health care provider? A. The patient is very drowsy. B. The patient reports a sore throat. C. The oral temperature is 101.6 F. D. The apical pulse is 104 beats/minute.
C
A 57-year-old man with Escherichia coli O157:H7 food poisoning is admitted to the hospital with bloody diarrhea and dehydration. Which order will the nurse question? A. Infuse lactated Ringers solution at 250 mL/hr. B. Monitor blood urea nitrogen and creatinine daily. C. Administer loperamide (Imodium) after each stool. D. Provide a clear liquid diet and progress diet as tolerated.
C
A 58-year-old patient has just been admitted to the emergency department with nausea and vomiting. Which information requires the most rapid intervention by the nurse? A. The patient has been vomiting for 4 days. B. The patient takes antacids 8 to 10 times a day. C. The patient is lethargic and difficult to arouse. D. The patient has undergone a small intestinal resection.
C
A 58-year-old woman who recently has been diagnosed with esophageal cancer tells the nurse, I do not feel ready to die yet. Which response by the nurse is most appropriate? A. You may have quite a few years still left to live. B. Thinking about dying will only make you feel worse. C. Having this new diagnosis must be very hard for you. D. It is important that you be realistic about your prognosis.
C
A 68-year-old male patient with a stroke is unconscious and unresponsive to stimuli. After learning that the patient has a history of gastroesophageal reflux disease (GERD), the nurse will plan to do frequent assessments of the patients A. apical pulse. B. bowel sounds. C. breath sounds. D. abdominal girth.
C
A 71-year-old patient had an abdominal-perineal resection for colon cancer. Which nursing action is most important to include in the plan of care for the day after surgery? A. Teach about a low-residue diet. B. Monitor output from the stoma. C. Assess the perineal drainage and incision. D. Encourage acceptance of the colostomy stoma.
C
A 72-year-old male patient with dehydration caused by an exacerbation of ulcerative colitis is receiving 5% dextrose in normal saline at 125 mL/hour. Which assessment finding by the nurse is most important to report to the health care provider? A. Patient has not voided for the last 4 hours. B. Skin is dry with poor turgor on all extremities. C. Crackles are heard halfway up the posterior chest. D. Patient has had 5 loose stools over the last 6 hours
C
A 76-year-old woman with a body mass index (BMI) of 17 kg/m2 and a low serum albumin level is being admitted by the nurse. Which assessment finding will the nurse expect to find? A. Restlessness B. Hypertension C. Pitting edema D. Food allergies
C
A patient admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI) is restless and anxious. The blood pressure is 86/40 and heart rate is 123. Based on this information, which nursing diagnosis is a priority for the patient? A. Acute pain related to myocardial infarction B. Anxiety related to perceived threat of death C. Stress overload related to acute change in health D. Decreased cardiac output related to cardiogenic shock
C
A patient has recently started on digoxin (Lanoxin) in addition to furosemide (Lasix) and captopril (Capoten) for the management of heart failure. Which assessment finding by the home health nurse is a priority to communicate to the health care provider? A. Presence of 1 to 2+ edema in the feet and ankles B. Palpable liver edge 2 cm below the ribs on the right side C. Serum potassium level 3.0 mEq/L after 1 week of therapy D. Weight increase from 120 pounds to 122 pounds over 3 days
C
A patient is recovering from a myocardial infarction (MI) and develops chest pain on day 3 that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take next? A. Assess the feet for pedal edema. B. Palpate the radial pulses bilaterally. C. Auscultate for a pericardial friction rub. D. Check the heart monitor for dysrhythmias.
C
A patient returned from a laparoscopic Nissen fundoplication for hiatal hernia 4 hours ago. Which assessment finding is most important for the nurse to address immediately? A. The patient is experiencing intermittent waves of nausea. B. The patient complains of 7/10 (0 to 10 scale) abdominal pain. C. The patient has absent breath sounds in the left anterior chest. D. The patient has hypoactive bowel sounds in all four quadrants.
C
A patient who has chronic heart failure tells the nurse, I was fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating! The nurse will document this assessment finding as A. orthopnea. B. pulsus alternans. C. paroxysmal nocturnal dyspnea. D. acute bilateral pleural effusion.
C
A patient who is receiving dobutamine (Dobutrex) for the treatment of acute decompensated heart failure (ADHF) has the following nursing interventions included in the plan of care. Which action will be most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? A. Assess the IV insertion site for signs of extravasation. B. Teach the patient the reasons for remaining on bed rest. C. Monitor the patients blood pressure and heart rate every hour. D. Titrate the rate to keep the systolic blood pressure >90 mm Hg.
C
A patient with ST-segment elevation in three contiguous electrocardiographic (ECG) leads is admitted to the emergency department (ED) and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which question should the nurse ask to determine whether the patient is a candidate for thrombolytic therapy? A. Do you have any allergies? B. Do you take aspirin on a daily basis? C. What time did your chest pain begin? D. Can you rate your chest pain using a 0 to 10 scale?
C
A patient with a history of chronic heart failure is admitted to the emergency department (ED) with severe dyspnea and a dry, hacking cough. Which action should the nurse do first? A. Auscultate the abdomen. B. Check the capillary refill. C. Auscultate the breath sounds. D. Assess the level of orientation.
C
A patient with chronic heart failure who is taking a diuretic and an angiotensin-converting enzyme (ACE) inhibitor and who is on a low-sodium diet tells the home health nurse about a 5-pound weight gain in the last 3 days. The nurses priority action will be to A. have the patient recall the dietary intake for the last 3 days. B. ask the patient about the use of the prescribed medications. C. assess the patient for clinical manifestations of acute heart failure. D. teach the patient about the importance of restricting dietary sodium.
C
A patient with heart failure has a new order for captopril (Capoten) 12.5 mg PO. After administering the first dose and teaching the patient about the drug, which statement by the patient indicates that teaching has been effective? A. I will be sure to take the medication with food. B. I will need to eat more potassium-rich foods in my diet. C. I will call for help when I need to get up to use the bathroom. D. I will expect to feel more short of breath for the next few days.
C
A patients capillary blood glucose level is 120 mg/dL 6 hours after the nurse initiated a parenteral nutrition (PN) infusion. The most appropriate action by the nurse is to A. obtain a venous blood glucose specimen. B. slow the infusion rate of the PN infusion. C. recheck the capillary blood glucose in 4 to 6 hours. D. notify the health care provider of the glucose level.
C
After abdominal surgery, a patient with protein calorie malnutrition is receiving parenteral nutrition (PN). Which is the best indicator that the patient is receiving adequate nutrition? A. Serum albumin level is 3.5 mg/dL. B. Fluid intake and output are balanced. C. Surgical incision is healing normally. D. Blood glucose is less than 110 mg/dL.
C
After the nurse has completed teaching a patient with newly diagnosed eosinophilic esophagitis about the management of the disease, which patient action indicates that the teaching has been effective? A. Patient orders nonfat milk for each meal. B. Patient uses the prescribed corticosteroid inhaler. C. Patient schedules an appointment for allergy testing. D. Patient takes ibuprofen (Advil) to control throat pain.
C
After the nurse has finished teaching a patient about the use of sublingual nitroglycerin (Nitrostat), which patient statement indicates that the teaching has been effective? A. I can expect some nausea as a side effect of nitroglycerin. B. I should only take the nitroglycerin if I start to have chest pain. C. I will call an ambulance if I still have pain after taking 3 nitroglycerin 5 minutes apart. D. Nitroglycerin helps prevent a clot from forming and blocking blood flow to my heart.
C
An older patient has been diagnosed with possible white coat hypertension. Which action will the nurse plan to take next? A. Schedule the patient for regular blood pressure (BP) checks in the clinic. B. Instruct the patient about the need to decrease stress levels. C. Tell the patient how to self-monitor and record BPs at home. D. Inform the patient that ambulatory blood pressure monitoring will be needed.
C
An outpatient who has chronic heart failure returns to the clinic after 2 weeks of therapy with metoprolol (Toprol XL). Which assessment finding is most important for the nurse to report to the health care provider? A. 2+ pedal edema B. Heart rate of 56 beats/minute C. Blood pressure (BP) of 88/42 mm Hg D. Complaints of fatigue
C
At his first postoperative checkup appointment after a gastrojejunostomy (Billroth II), a patient reports that dizziness, weakness, and palpitations occur about 20 minutes after each meal. The nurse will teach the patient to A. increase the amount of fluid with meals. B. eat foods that are higher in carbohydrates. C. lie down for about 30 minutes after eating. D. drink sugared fluids or eat candy after meals.
C
During the administration of the thrombolytic agent to a patient with an acute myocardial infarction (AMI), the nurse should stop the drug infusion if the patient experiences A. bleeding from the gums. B. increase in blood pressure. C. a decrease in level of consciousness. D. a nonsustained episode of ventricular tachycardia.
C
Following an acute myocardial infarction (AMI), a patient ambulates in the hospital hallway. When the nurse is evaluating the patients response to the activity, which assessment data would indicate that the exercise level should be decreased? A. Blood pressure (BP) changes from 118/60 to 126/68 mm Hg. B. Oxygen saturation drops from 99% to 95%. C. Heart rate increases from 66 to 92 beats/minute. D. Respiratory rate goes from 14 to 20 breaths/minute.
C
Four hours after a bowel resection, a 74-year-old male patient with a nasogastric tube to suction complains of nausea and abdominal distention. The first action by the nurse should be to A. auscultate for hypotonic bowel sounds. B. notify the patients health care provider. C. reposition the tube and check for placement. D. remove the tube and replace it with a new one.
C
Heparin is ordered for a patient with a nonST-segment-elevation myocardial infarction (NSTEMI). What is the purpose of the heparin? A. Heparin enhances platelet aggregation. B. Heparin decreases coronary artery plaque size. C. Heparin prevents the development of new clots in the coronary arteries. D. Heparin dissolves clots that are blocking blood flow in the coronary arteries.
C
IV sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to titrate the nitroprusside rate if the patient develops A. ventricular ectopy. B. a dry, hacking cough. C. a systolic BP <90 mm Hg. D. a heart rate <50 beats/minute.
C
In preparation for discharge, the nurse teaches a patient with chronic stable angina how to use the prescribed short-acting and long-acting nitrates. Which patient statement indicates that the teaching has been effective? A. I will check my pulse rate before I take any nitroglycerin tablets. B. I will put the nitroglycerin patch on as soon as I get any chest pain. C. I will stop what I am doing and sit down before I put the nitroglycerin under my tongue. D. I will be sure to remove the nitroglycerin patch before taking any sublingual nitroglycerin.
C
The nurse has received the laboratory results for a patient who developed chest pain 4 hours ago and may be having a myocardial infarction. The most important laboratory result to review will be A. myoglobin. B. low-density lipoprotein (LDL) cholesterol C. troponins T and I D. creatine kinase-MB (CK-MB)
C
The nurse is assessing a patient who had a total gastrectomy 8 hours ago. What information is most important to report to the health care provider? A. Absent bowel sounds B. Complaints of incisional pain C. Temperature 102.1 F (38.9 C) D. Scant nasogastric (NG) tube drainage
C
The nurse is reviewing the laboratory results for newly admitted patients on the cardiovascular unit. Which patient laboratory result is most important to communicate as soon as possible to the health care provider? A. Patient whose triglyceride level is high B. Patient who has very low homocysteine level C. Patient with increase in troponin T and troponin I level D. Patient with elevated high-sensitivity C-reactive protein level
C
Which electrocardiographic (ECG) change is most important for the nurse to report to the health care provider when caring for a patient with chest pain? A. Inverted P wave B. Sinus tachycardia C. ST-segment elevation D. First-degree atrioventricular block
C
The nurse obtains the following data when assessing a patient who experienced an ST-segment-elevation myocardial infarction (STEMI) 2 days previously. Which information is most important to report to the health care provider? A. The troponin level is elevated. B. The patient denies ever having a heart attack. C. Bilateral crackles are auscultated in the mid-lower lobes. D. The patient has occasional premature atrial contractions (PACs).
C
The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide (HydroDIURIL). Appropriate instructions for the patient include A. limit dietary sources of potassium. B. take the hydrochlorothiazide before bedtime. C. notify the health care provider if nausea develops. D. skip the digoxin if the pulse is below 60 beats/minute.
C
The nurse working on the heart failure unit knows that teaching an older female patient with newly diagnosed heart failure is effective when the patient states that A. she will take furosemide (Lasix) every day at bedtime. B. the nitroglycerin patch is applied when any chest pain develops. C. she will call the clinic if her weight goes from 124 to 128 pounds in a week. D. an additional pillow can help her sleep if she is feeling short of breath at night.
C
The registered nurse (RN) is caring for a patient with a hypertensive crisis who is receiving sodium nitroprusside (Nipride). Which nursing action can the nurse delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? A. Titrate nitroprusside to decrease mean arterial pressure (MAP) to 115 mm Hg. B. Evaluate effectiveness of nitroprusside therapy on blood pressure (BP). C. Set up the automatic blood pressure machine to take BP every 15 minutes. D. Assess the patients environment for adverse stimuli that might increase BP.
C
When the nurse is screening patients for possible peripheral arterial disease, indicate where the posterior tibial artery will be palpated. A. 1 B. 2 C. 3 D. 4
C
Which action will the nurse implement for a patient who arrives for a calcium-scoring CT scan? A. Insert an IV catheter. B. Administer oral sedative medications. C. Teach the patient about the procedure. D. Confirm that the patient has been fasting.
C
Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute shortness of breath has heart failure? A. Serum troponin B. Arterial blood gases C. B-type natriuretic peptide D. 12-lead electrocardiogram
C
Which diet choice by the patient with an acute exacerbation of inflammatory bowel disease (IBD) indicates a need for more teaching? A. Scrambled eggs B. White toast and jam C. Oatmeal with cream D. Pancakes with syrup
C
Which information obtained by the nurse who is admitting the patient for magnetic resonance imaging (MRI) will be most important to report to the health care provider before the MRI? A. The patient has an allergy to shellfish. B. The patient has a history of atherosclerosis. C. The patient has a permanent ventricular pacemaker. D. The patient took all the prescribed cardiac medications today.
C
Which nursing intervention will be most effective when assisting the patient with coronary artery disease (CAD) to make appropriate dietary changes? A. Give the patient a list of low-sodium, low-cholesterol foods that should be included in the diet. B. Emphasize the increased risk for heart problems unless the patient makes the dietary changes. C. Help the patient modify favorite high-fat recipes by using monosaturated oils when possible. D. Inform the patient that a diet containing no saturated fat and minimal salt will be necessary.
C
Which patient choice for a snack 2 hours before bedtime indicates that the nurses teaching about gastroesophageal reflux disease (GERD) has been effective? A. Chocolate pudding B. Glass of low-fat milk C. Cherry gelatin with fruit D. Peanut butter and jelly sandwich
C
Which patient should the nurse assess first after receiving change-of-shift report? A. A patient with nausea who has a dose of metoclopramide (Reglan) due B. A patient who is crying after receiving a diagnosis of esophageal cancer C. A patient with esophageal varices who has a blood pressure of 92/58 mm Hg D. A patient admitted yesterday with gastrointestinal (GI) bleeding who has melena
C
Which statement to the nurse from a patient with jaundice indicates a need for teaching? A. I used cough syrup several times a day last week. B. I take a baby aspirin every day to prevent strokes. C. I use acetaminophen (Tylenol) every 4 hours for back pain. D. I need to take an antacid for indigestion several times a week
C
Which topic will the nurse plan to include in discharge teaching for a patient with systolic heart failure and an ejection fraction of 33%? A. Need to begin an aerobic exercise program several times weekly B. Use of salt substitutes to replace table salt when cooking and at the table C. Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors D. Importrance of making an annual appointment with the primary care provide
C
While admitting an 82-year-old with acute decompensated heart failure to the hospital, the nurse learns that the patient lives alone and sometimes confuses the water pill with the heart pill. When planning for the patients discharge the nurse will facilitate a A. consult with a psychologist. B. transfer to a long-term care facility. C. referral to a home health care agency. D. arrangements for around-the-clock care.
C
While assessing a 68-year-old with ascites, the nurse also notes jugular venous distention (JVD) with the head of the patients bed elevated 45 degrees. The nurse knows this finding indicates A. decreased fluid volume. B. jugular vein atherosclerosis. C. increased right atrial pressure. D. incompetent jugular vein valves.
C
A 27-year-old female patient is admitted to the hospital for evaluation of right lower quadrant abdominal pain with nausea and vomiting. Which action should the nurse take? A. Encourage the patient to sip clear liquids. B. Assess the abdomen for rebound tenderness. C. Assist the patient to cough and deep breathe. D. Apply an ice pack to the right lower quadrant.
D
A 42-year-old woman is admitted to the outpatient testing area for an ultrasound of the gallbladder. Which information obtained by the nurse indicates that the ultrasound may need to be rescheduled? A. The patient took a laxative the previous evening. B. The patient had a high-fat meal the previous evening. C. The patient has a permanent gastrostomy tube in place. D. The patient ate a low-fat bagel 4 hours ago for breakfast.
D
A 50-year-old man vomiting blood-streaked fluid is admitted to the hospital with acute gastritis. To determine possible risk factors for gastritis, the nurse will ask the patient about A. the amount of saturated fat in the diet. B. any family history of gastric or colon cancer. C. a history of a large recent weight gain or loss. D. use of nonsteroidal antiinflammatory drugs (NSAIDs).
D
A 56-year-old patient who has no previous history of hypertension or other health problems suddenly develops a blood pressure (BP) of 198/110 mm Hg. After reconfirming the BP, it is appropriate for the nurse to tell the patient that A. a BP recheck should be scheduled in a few weeks. B. dietary sodium and fat content should be decreased. C. there is an immediate danger of a stroke and hospitalization will be required. D. diagnosis of a possible cause, treatment, and ongoing monitoring will be needed.
D
A 60-year-old man who is hospitalized with an abdominal wound infection has only been eating about 50% of meals and states, Nothing on the menu sounds good. Which action by the nurse will be most effective in improving the patients oral intake? A. Order six small meals daily. B. Make a referral to the dietitian. C. Teach the patient about high-calorie foods. D. Have family members bring in favorite foods.
D
A 73-year-old patient is diagnosed with stomach cancer after an unintended 20-pound weight loss. Which nursing action will be included in the plan of care? A. Refer the patient for hospice services. B. Infuse IV fluids through a central line. C. Teach the patient about antiemetic therapy. D. Offer supplemental feedings between meals.
D
A 73-year-old patient with diverticulosis has a large bowel obstruction. The nurse will monitor for A. referred back pain. B. metabolic alkalosis. C. projectile vomiting. D. abdominal distention.
D
A patient who has had chest pain for several hours is admitted with a diagnosis of rule out acute myocardial infarction (AMI). Which laboratory test should the nurse monitor to help determine whether the patient has had an AMI? A. Myoglobin B. Homocysteine C. C-reactive protein D. Cardiac-specific troponin
D
A patient who has just been admitted with pulmonary edema is scheduled to receive the following medications. Which medication should the nurse question before giving? A. Furosemide (Lasix) 60 mg B. Captopril (Capoten) 25 mg C. Digoxin (Lanoxin) 0.125 mg D. Carvedilol (Coreg) 3.125 mg
D
After change-of-shift report, which patient should the nurse assess first? A. 42-year-old who has acute gastritis and ongoing epigastric pain B. 70-year-old with a hiatal hernia who experiences frequent heartburn C. 53-year-old who has dumping syndrome after a recent partial gastrectomy D. 60-year-old with nausea and vomiting who has dry oral mucosa and lethargy
D
After noting a pulse deficit when assessing a 74-year-old patient who has just arrived in the emergency department, the nurse will anticipate that the patient may require A. emergent cardioversion. B. a cardiac catheterization. C. hourly blood pressure (BP) checks. D. electrocardiographic (ECG) monitoring.
D
After receiving change-of-shift report about the following four patients, which patient should the nurse assess first? A. 39-year-old with pericarditis who is complaining of sharp, stabbing chest pain B. 56-year-old with variant angina who is to receive a dose of nifedipine (Procardia) C. 65-year-old who had a myocardial infarction (MI) 4 days ago and is anxious about the planned discharge D. 59-year-old with unstable angina who has just returned to the unit after having a percutaneous coronary intervention (PCI)
D
After several days of antibiotic therapy, an older hospitalized patient develops watery diarrhea. Which action should the nurse take first? A. Notify the health care provider. B. Obtain a stool specimen for analysis. C. Teach the patient about handwashing. D. Place the patient on contact precautions.
D
After the nurse teaches the patient with stage 1 hypertension about diet modifications that should be implemented, which diet choice indicates that the teaching has been effective? A. The patient avoids eating nuts or nut butters. B. The patient restricts intake of chicken and fish. C. The patient has two cups of coffee in the morning. D. The patient has a glass of low-fat milk with each meal.
D
During a physical examination of a 74-year-old patient, the nurse palpates the point of maximal impulse (PMI) in the sixth intercostal space lateral to the left midclavicular line. The most appropriate action for the nurse to take next will be to A. ask the patient about risk factors for atherosclerosis. B. document that the PMI is in the normal anatomic location. C. auscultate both the carotid arteries for the presence of a bruit. D. assess the patient for symptoms of left ventricular hypertrophy.
D
Following an acute myocardial infarction, a previously healthy 63-year-old develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about A. digitalis preparations. B. b-adrenergic blockers. C. calcium channel blockers. D. angiotensin-converting enzyme (ACE) inhibitors.
D
Nadolol (Corgard) is prescribed for a patient with chronic stable angina and left ventricular dysfunction. To determine whether the drug is effective, the nurse will monitor for A. decreased blood pressure and heart rate. B. fewer complaints of having cold hands and feet. C. improvement in the strength of the distal pulses. D. the ability to do daily activities without chest pain.
D
The health care provider prescribes antacids and sucralfate (Carafate) for treatment of a patients peptic ulcer. The nurse will teach the patient to take A. sucralfate at bedtime and antacids before each meal. B. sucralfate and antacids together 30 minutes before meals. C. antacids 30 minutes before each dose of sucralfate is taken. D. antacids after meals and sucralfate 30 minutes before meals.
D
The nurse explaining esomeprazole (Nexium) to a patient with recurring heartburn describes that the medication A. reduces gastroesophageal reflux by increasing the rate of gastric emptying. B. neutralizes stomach acid and provides relief of symptoms in a few minutes. C. coats and protects the lining of the stomach and esophagus from gastric acid. D. treats gastroesophageal reflux disease by decreasing stomach acid production.
D
The nurse is caring for a 70-year-old who uses hydrochlorothiazide (HydroDIURIL) and enalapril (Norvasc), but whose self-monitored blood pressure (BP) continues to be elevated. Which patient information may indicate a need for a change? A. Patient takes a daily multivitamin tablet. B. Patient checks BP daily just after getting up. C. Patient drinks wine three to four times a week. D. Patient uses ibuprofen (Motrin) daily to treat osteoarthritis.
D
The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best indicator that the treatment has been effective? A. Weight loss of 2 pounds in 24 hours B. Hourly urine output greater than 60 mL C. Reduction in patient complaints of chest pain D. Reduced dyspnea with the head of bed at 30 degrees
D
The nurse teaches the patient being evaluated for rhythm disturbances with a Holter monitor to A. connect the recorder to a computer once daily. B. exercise more than usual while the monitor is in place. C. remove the electrodes when taking a shower or tub bath. D. keep a diary of daily activities while the monitor is worn
D
The nurse will anticipate teaching a patient experiencing frequent heartburn about A. a barium swallow. B. radionuclide tests. C. endoscopy procedures. D. proton pump inhibitors.
D
The nurse will plan to teach a patient with Crohns disease who has megaloblastic anemia about the need for A. oral ferrous sulfate tablets. B. regular blood transfusions. C. iron dextran (Imferon) infusions. D. cobalamin (B12) spray or injections.
D
To determine the effects of therapy for a patient who is being treated for heart failure, which laboratory result will the nurse plan to review? A. Troponin B. Homocysteine (Hcy) C. Low-density lipoprotein (LDL) D. B-type natriuretic peptide (BNP)
D
When a 72-year-old patient is diagnosed with achalasia, the nurse will teach the patient that A. lying down after meals is recommended. B. a liquid or blenderized diet will be necessary. C. drinking fluids with meals should be avoided. D. treatment may include endoscopic procedures.
D
When caring for a patient with a history of a total gastrectomy, the nurse will monitor for A. constipation. B. dehydration. C. elevated total serum cholesterol. D. cobalamin (vitamin B12) deficiency.
D
When caring for a patient with acute coronary syndrome who has returned to the coronary care unit after having angioplasty with stent placement, the nurse obtains the following assessment data. Which data indicate the need for immediate action by the nurse? A. Heart rate 102 beats/min B. Pedal pulses 1+ bilaterally C. Blood pressure 103/54 mm Hg D. Chest pain level 7 on a 0 to 10 point scale
D
When developing a teaching plan for a 61-year-old man with the following risk factors for coronary artery disease (CAD), the nurse should focus on the A. family history of coronary artery disease. B. increased risk associated with the patients gender. C. increased risk of cardiovascular disease as people age. D. elevation of the patients low-density lipoprotein (LDL) level.
D
When reviewing the 12-lead electrocardiograph (ECG) for a healthy 79-year-old patient who is having an annual physical examination, what will be of most concern to the nurse? A. The PR interval is 0.21 seconds. B. The QRS duration is 0.13 seconds. C. There is a right bundle-branch block. D. The heart rate (HR) is 42 beats/minute.
D
When teaching the patient with newly diagnosed heart failure about a 2000-mg sodium diet, the nurse explains that foods to be restricted include A. canned and frozen fruits. B. fresh or frozen vegetables. C. eggs and other high-protein foods. D. milk, yogurt, and other milk products.
D
Which assessment should the nurse perform first for a patient who just vomited bright red blood? A. Measuring the quantity of emesis B. Palpating the abdomen for distention C. Auscultating the chest for breath sounds D. Taking the blood pressure (BP) and pulse
D
Which breakfast choice indicates a patients good understanding of information about a diet for celiac disease? A. Oatmeal with nonfat milk B. Whole wheat toast with butter C. Bagel with low-fat cream cheese D. Corn tortilla with scrambled eggs
D
Which information given by a patient admitted with chronic stable angina will help the nurse confirm this diagnosis? A. The patient states that the pain wakes me up at night. B. The patient rates the pain at a level 3 to 5 (0 to 10 scale). C. The patient states that the pain has increased in frequency over the last week. D. The patient states that the pain goes away with one sublingual nitroglycerin tablet.
D
Which information should the nurse include when teaching a patient with newly diagnosed hypertension? A. Increasing physical activity will control blood pressure (BP) for most patients. B. Most patients are able to control BP through dietary changes. C. Annual BP checks are needed to monitor treatment effectiveness. D. Hypertension is usually asymptomatic until target organ damage occurs.
D
Which menu choice indicates that the patient is implementing plans to choose high-calorie, high-protein foods? A. Baked fish with applesauce B. Beef noodle soup and canned corn C. Fresh fruit salad with yogurt topping D. Fried chicken with potatoes and gravy
D
Which patient should the nurse assess first after receiving change-of-shift report? A. 60-year-old patient whose new ileostomy has drained 800 mL over the previous 8 hours B. 50-year-old patient with familial adenomatous polyposis who has occult blood in the stool C. 40-year-old patient with ulcerative colitis who has had six liquid stools in the previous 4 hours D. 30-year-old patient who has abdominal distention and an apical heart rate of 136 beats/minute
D
Which question from the nurse would help determine if a patients abdominal pain might indicate irritable bowel syndrome? A. Have you been passing a lot of gas? B. What foods affect your bowel patterns? C. Do you have any abdominal distention? D. How long have you had abdominal pain?
D
Which statement made by a patient with coronary artery disease after the nurse has completed teaching about therapeutic lifestyle changes (TLC) diet indicates that further teaching is needed? A. I will switch from whole milk to 1% milk. B. I like salmon and I will plan to eat it more often. C. I can have a glass of wine with dinner if I want one. D. I will miss being able to eat peanut butter sandwiches.
D
While assessing a patient who was admitted with heart failure, the nurse notes that the patient has jugular venous distention (JVD) when lying flat in bed. Which action should the nurse take next? A. Document this finding in the patients record. B. Obtain vital signs, including oxygen saturation. C. Have the patient perform the Valsalva maneuver. D. Observe for JVD with the patient upright at 45 degrees.
D