Cumulative Content Review

Following surgery, a client has great difficulty getting out of bed, walking, and coughing/deep breathing. Although patient-controlled analgesia (PCA) is in place, it is rarely used, even when suggested by the nurse. This concerns the nurse. Which statement is the best way to address this concern with the client? "I noticed you use very little pain medication. You must be very brave and strong. But without pain medication, you will get weaker, not stronger." "I noticed you don't use much pain medication. Don't worry about getting addicted." "I noticed you haven't used your pain medication as often as you could, even though it is painful for you to get out of bed and to walk. Many people are reluctant to take pain medication. Tell me what makes you reluctant." "I can understand why you are reluctant to use pain medication with all the side effects that can occur."

"I noticed you haven't used your pain medication as often as you could, even though it is painful for you to get out of bed and to walk. Many people are reluctant to take pain medication. Tell me what makes you reluctant."

The nurse assesses a newborn and observes central cyanosis. What type of congenital heart defect usually results in central cyanosis? A. Shunting of blood from right to left B. Shunting of blood from left to right C. Obstruction of blood flow from the left side of the heart D. Obstruction of blood flow between the left and right sides of the heart

A. Shunting of blood from right to left

The nurse caring for a cardiac patient on telemetry finds the patient unconscious. According to the 2012 AHA Standards of care, the nurse should first: Call for help Start oxygen at 10 L/minute and raise the head of the bed Check the carotid pulse and give 2 rescue breaths Check the telemetry monitor to see if the patient is experiencing an arrhythmia

Call for help

The nurse is planning to administer Propanolol (Inderol)) to a hospitalized client. The nurse must complete which of the following assessments before giving the medication to ensure safe administration? Check the blood pressure and heart rate Check the respiratory rate Check the oxygen saturation level (SaO2) Check heart rate and respiratory rate

Check the blood pressure and heart rate

A nurse assesses a patient for pain. The patient says she has severe arthritis pain and rates it as a "10." Vital signs are 138/80, 16, 80, and 92%. The client is calmly watching television. Which of the following nursing diagnoses is most appropriate at this time? Acute pain Altered sensory perception Anxiety Chronic pain

Chronic pain

A client with no history of cardiovascular disease suddenly calls the nurse into the room and states he now has sharp pains in his chest. Which of the following questions best helps the nurse to discriminate if the pain is due to a cardiac or non-cardiac problem? Have you had this pain before? Can you describe the pain to me? Can you rate the pain on a 1-10 with 10 being the worst? Does the pain get worse when you breathe in?

Does the pain get worse when you breathe in?

A patient who has been NPO with gastric suction and IV fluid replacement for 3 days following surgery develops nausea and vomiting, weakness, and confusion and has a serum sodium level of 125 mEq/L. The nurse reviews the health care provider's postoperative medication and IV orders. Which health care provider order should the nurse question? Administer 3% NS if serum sodium drops to less than 128 mEq/L. IV morphine sulfate 4 mg every 2 hours prn. Infuse 5% dextrose in water at 125 ml/hr. Give IV metoclopramide (Reglan) 10 mg every 6 hours prn nausea.

Infuse 5% dextrose in water at 125 ml/hr.

A patient in diabetic ketoacidosis may have the following symptom: Kussmaul respirations Bradycardia Moist mucouos membranes Hypertension

Kussmaul respirations

A patient with stage I hypertension is likely to report: Chest pain No symptoms Dyspnea on exertion Dizziness and vertigo

No symptoms

you are administering Regular Insulin to a patient before breakfast. How soon is the onset of action? Onset 1.5 hours Onset 2 hours Onset 4 hours Onset ½ hour

Onset ½ hour

Angina results from: Increased viscosity of arterial blood flow Reduction in myocardial oxygenation Hypertensive crisis Necrosis of myocardial tissue

Reduction in myocardial oxygenation

An 8-year-old boy is crying with pain after a tonsillectomy. Which nursing intervention is most appropriate for this patient? Tell him to be a big boy and stop crying. Tell him he may have a popsicle when he stops crying. Tell him you will have to shut the door if he continues to cry. Sit down with him, provide comfort, and read one of his favorite books.

Sit down with him, provide comfort, and read one of his favorite books.

Complications from diabetes typically involve: Liver disease Small vessel disease like eyes, kidneys, and nerves Large vessel disease like aortic aneurysms Mid-size vessel diseases like gastritis and peptic ulcer disease

Small vessel disease like eyes, kidneys, and nerves

A patient with a history of asthma is admitted to the hospital in acute respiratory distress. During assessment of the patient, the nurse would notify the physician immediately upon finding The Choices Were: an SpO2 of 90%. a PFR of 240 ml/min. decreased breath sounds and wheezing. ABG results of pH 7.4, PaCO2 50 mm Hg, and PaO2 84 mm Hg.

decreased breath sounds and wheezing.

A client is admitted to the emergency department with crushing chest pain. A diagnosis of acute coronary syndrome is suspected. The nurse expects that the client's initial treatment will include which medication? A. Aspirin B. Midazolam C. Gabapentin D. Alprazolam

A. Aspirin

When caring for an intubated client receiving mechanical ventilation, the nurse hears the high-pressure alarm. Which action is most appropriate? A. Remove secretions by suctioning. B. Lower the setting of the tidal volume. C. Check that tubing connections are secure. D. Obtain a specimen for arterial blood gases (ABGs).

A. Remove secretions by suctioning.

A client is admitted with dehydration. Which findings should the nurse expect the client to exhibit? Select all that apply. A. Supple skin turgor B. Rapid, thready pulse C. Decreased hematocrit D. Elevated specific gravity E. Adventitious breath sounds

B. Rapid, thready pulse D. Elevated specific gravity

A client receiving morphine is being monitored by the nurse for adverse effects of the drug. Which clinical findings warrant immediate follow up by the nurse? Select all that apply. A.Polyuria B.Sedation C.Bradycardia D.Dilated pupils E.Slow respirations

B.Sedation C.Bradycardia E.Slow respirations

Which is the most important assessment for the nurse to make after a client has a femoropopliteal bypass for peripheral vascular disease? A. Incisional pain B. Popliteal pulse rate C. Degree of hair growth D. Lower extremity color

D. Lower extremity color

On the second day after surgery, a client reports pain in the right calf. What should the nurse do first? A. Apply a warm soak. B. Document the symptom. C. Elevate the leg above the heart. D. Notify the primary healthcare provider.

D. Notify the primary healthcare provider.

A patient is taking hydrochlorothiazide, a potassium-wasting diuretic, for treatment of hypertension. The nurse will teach the patient to report symptoms of adverse effects such as: generalized weakness. facial muscle spasms. frequent loose stools. personality changes.

generalized weakness.

Which of the following is a correct "stress response" by the body: decreased cardiac output decreased metabolic rate decreased oxygen consumption increased blood glucose

increased blood glucose

A 70-year-old patient is recovering from an acute episode of COPD. In planning with the patient to increase his activity tolerance at home, the nurse knows that an appropriate initial exercise goal for the patient is to increase his activity any amount over his current level. walk for 20 minutes a day with his pulse rate less than 120. limit his exercise to activities of daily living to conserve his energy. swim for 10 minutes a day, gradually increasing to 30 minutes a day.

walk for 20 minutes a day with his pulse rate less than 120.

A patient is receiving Humulin N at breakfast at 0700. If he is eating meals as scheduled, you know the highest risk for developing hypoglycemia will be at: 1500 1300 1100 0730

1500

A client's arterial blood gas report indicates that pH is 7.25, Pco 2 is 60 mm Hg, and HCO 3 is 26 mEq/L (26 mmol/L). Which client should the nurse consider is most likely to exhibit these blood gas results? A. A 65-year-old with pulmonary fibrosis B. A 24-year-old with uncontrolled type 1 diabetes C. A 45-year-old who has been vomiting for 3 days D. A 54-year-old who takes sodium bicarbonate for indigestion

A. A 65-year-old with pulmonary fibrosis

Which nursing intervention should the nurse consider to be a priority for clients with fluid overload? A. Ensuring client safety B. Providing drug therapy C. Providing nutritional therapy D. Preventing future fluid overload

A. Ensuring client safety

Severe cancer pain is most effectively treated with analgesics given: Around the clock, with extra doses available as needed In doses at least 4 hours apart As needed by the client Sparingly to avoid side effects

Around the clock, with extra doses available as needed

A client has surgery to replace a prolapsed mitral valve. What should the nurse teach the client? A. The signs and symptoms of pericarditis B. The signs and symptoms of heart failure C. That cardiac surgery will have to be done eventually for the other valves D. That cardiac surgery will have to be done every six months to replace the valve

B. The signs and symptoms of heart failure

A client who is admitted to the hospital and requires a colon resection states, "I want to be a do not resuscitate (DNR)." The nurse questions the client's understanding of a DNR order. Which response by the client best indicates to the nurse an understanding of a DNR order? A."My doctor will know what to do." B."My family can make the decisions for me." C."If something happens to me, I do not want CPR." D."If I have a heart attack, I do not want any medication."

C."If something happens to me, I do not want CPR."

The presence of ketones in the urine of a diabetic patient: Is normal in small amounts Can be an indication of a complication called DKA Indicates that a different oral agent is needed Suggests the smogyi effect

Can be an indication of a complication called DKA

A postoperative client is prescribed acetaminophen (Tylenol) with codeine at discharge. When performing discharge teaching, the nurse should: Warn the patient about signs of addiction Recommend that the patient decrease the number of tablets taken each day Warn patient that some people experience temporary stress incontinence Recommend that the patient increase their fluid and fiber intake

Correct Answer : Recommend that the patient increase their fluid and fiber intake

The nurse is assessing the condition of a patient with left-sided heart failure. If the condition worsens, the nurse will most likely note which of the following assessment finding? Positive Homan's sign Crackles in the lower lobes of the lungs Increasing pedal edema Capillary refill of less than three seconds

Crackles in the lower lobes of the lungs

A nurse is caring for a client with Addison disease. Which information should the nurse include in a teaching plan to encourage this client to modify dietary intake? A. Increased amounts of potassium are needed to replace renal losses. B. Increased protein is needed to heal the adrenal tissue and thus cure the disease. C. Supplemental vitamins are needed to supply energy and assist in regaining the lost weight. D. Extra salt is needed to replace the amount being lost caused by lack of sufficient aldosterone to conserve sodium.

D. Extra salt is needed to replace the amount being lost caused by lack of sufficient aldosterone to conserve sodium.

A fifty year-old male with a history of diabetes is brought into the emergency room with dehydration and confusion. His heart rate is 100, B/P 76/50, serum glucose is 650. His urine is negative for ketones. His admitting diagnosis would most likely be: Diabetes, type I Diabetes, type II HHS Somogyi syndrome

HHS

Which of the following correctly describes the stress response? Stress activates the HPA axis, ACTH is released which stimulates the adrenal cortex to secrete corticosteroids Stress activates the complex feedback loop and the thyroid releases thyroxine. Stress activates the adrenal medulla to secrete insulin. Stress activates the nervous system to produce leukocyte

Stress activates the HPA axis, ACTH is released which stimulates the adrenal cortex to secrete corticosteroids

A 60-year-old homeless man has a cough, late-afternoon fever, and night sweats. The patient's response to a purified protein derivative (PPD) skin test is 15 mm. The nurse recognizes that this response indicates that the patient has a tuberculosis has metastatic tuberculosis. has been exposed to the tuberculosis organism. has been treated for tuberculosis in the past

has been exposed to the tuberculosis organism.

An Advair Diskus (combined fluticasone and salmeterol) dry powder inhaler is prescribed for a patient diagnosed with mild persistent asthma. The patient asks the nurse why she must use two different drugs. The best response by the nurse is: both are bronchodilators that prevent bronchospasm The fluticasone in the Advair is a short acting bronchodilator to use when the patient is feeling short of breath the salmeterol is used to decrease the bronchospasm in the long term, and the fluticasone helps reduce the inflammatory response the salmeterol stimulates the bronchodilator effect of beta-2 receptors and the fluticasone blocks the bronchoconstrictor effect of the parasympathetic nervous system.

the salmeterol is used to decrease the bronchospasm in the long term, and the fluticasone helps reduce the inflammatory response

A nurse concludes that the teaching about sickle cell anemia has been understood when an adolescent with the disorder makes which statement? A. "I'll start to have symptoms when I drink less fluid." B. "I'll start to have symptoms when I have fewer platelets." C. "I'll start to have symptoms when I decrease the iron in my diet." D. "I'll start to have symptoms when I have fewer white blood cells."

A. "I'll start to have symptoms when I drink less fluid."

A client's serum potassium level is below the normal range. Which clinical indicators should the nurse determine are consistent with hypokalemia? Select all that apply. A. Abdominal cramping B. Tall, peaked T wave C. Irregular heart rate D. Muscular weakness E. Decreased bowel sounds F. Hyperactive deep tendon reflexes

A. Abdominal cramping C. Irregular heart rate D. Muscular weakness E. Decreased bowel sounds

The nurse is preparing discharge instructions for a client who was prescribed enalapril for treatment of hypertension. Which instruction is appropriate for the nurse to include in the client's teaching? A. Do not change to a standing position suddenly. B. Lightheadedness is a common adverse effect that need not be reported. C. The medication may cause a sore throat for the first few days. D. Schedule blood tests weekly for the first 2 months.

A. Do not change to a standing position suddenly.

A client who is suspected of having Cushing syndrome is admitted to the hospital. When checking the laboratory reports, which condition should the nurse expect? A. Hypokalemia B. Hypovolemia C. Hypocalcemia D. Hyponatremia

A. Hypokalemia

What interventions should the nurse implement when caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH)? Select all that apply. A. Instituting fall risk precautions B. Restricting fluids to 2 L per day C. Placing the client in high-Fowler position D. Monitoring for and reporting neurologic changes

A. Instituting fall risk precautions D. Monitoring for and reporting neurologic changes

The home health nurse is visiting a client with multiple health problems that include a history of chronic atrial fibrillation. The nurse obtains a radial rate of 136 beats per minute. What should the nurse do first? A. Obtain the other vital signs. B. Recheck the pulse to verify the rate. C. Stay with the client until an ambulance arrives. D. Alert the primary healthcare provider of the client's status.

A. Obtain the other vital signs.

While caring for a client receiving blood transfusion care, the nurse notices that the client is having an acute hemolytic reaction. What is the priority nursing intervention in this situation? A.Stop the blood transfusion immediately. B.Report to the primary healthcare provider. C.Recheck identifying tags and numbers on the client. D.Maintain a patent intravenous (IV) line with saline solution.

A.Stop the blood transfusion immediately.

While waiting to perform x-rays on an injured right hand, according to non-pharmacological pain management practice, pain can be modulated if the nurse: gives PRN ibuprofen. Administers a placebo Applies ice to the right elbow Shuts the door to the patient room

Applies ice to the right elbow

nurse evaluates if a patient-controlled analgesia (PCA) pump is effective by doing which of the following? Monitoring the number of minutes between when the patient presses the button Measuring how much of a loading dose is required to relieve pain Asking the patient, "Is your pain level where you would like it to be right now?" Asking the patient if their pain is a "0."

Asking the patient, "Is your pain level where you would like it to be right now?"

A client has a platelet count of 49,000/mL (40 × 10 9/L). The nurse should instruct the client to avoid which activity? A.Ambulation B.Blowing the nose C.Visiting with children D.The semi-Fowler position

B. Blowing the nose

The nurse is caring for a client with a respiratory tract infection that started with a common cold but has progressed to whooping cough. The client also has coughing fits that last for several minutes. Which organism is responsible for the client's condition? A. Bacillus anthracis B. Bordetella pertussis C. Streptococcus pneumonia D. Mycobacterium tuberculosis

B. Bordetella pertussis

A client presents to the emergency department with symptoms of acute myocardial infarction (MI). Which results will the nurse expect to find upon assessment? A. Decreased breath sounds B. Elevated serum troponin I C. Decreased creatine kinase-MB (CK-MB) D. Elevated brain natriuretic peptide (BNP) level

B. Elevated serum troponin I

A 13-year-old child with type 1 diabetes is receiving 15 units of regular insulin and 20 units of NPH insulin at 7:00 AM each day. At what time does the nurse anticipate a hypoglycemic reaction from the NPH insulin to occur? A. Before noon B. In the afternoon C. Within 30 minutes D. During the evening

B. In the afternoon

A client's parathyroid glands are removed. What clinical manifestation is indicative of the fluid and electrolyte imbalance associated with this surgery? A. Constipation B. Muscle spasms C. Hypoactive reflexes D. Increased specific gravity

B. Muscle spasms

A client who had a myocardial infarction is in the coronary care unit on a cardiac monitor. The nurse observes runs of ventricular tachycardia on the screen. What medication should the nurse prepare to administer? A. Digoxin B. Furosemide C. Amiodarone D. Norepinephrine

C. Amiodarone

The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). The nurse should monitor the results of which laboratory test to evaluate the client for hypoxia? A. Red blood cell count B. Sputum culture C. Arterial blood gas D. Total hemoglobin

C. Arterial blood gas

Surgery is performed on a client. The postoperative arterial blood gas values are pH 7.32, PCO 2 53 mm Hg, and HCO 3 25 mEq/L (25 mmol/L). Which action should the nurse take? A. Obtain a prescription for a diuretic. B. Have the client breathe into a rebreather bag. C. Encourage the client to take deep, cleansing breaths. D. Request a prescription for the administration of sodium bicarbonate.

C. Encourage the client to take deep, cleansing breaths.

A client is admitted with a head injury. The nurse identifies that the client's urinary catheter is draining large amounts of clear, colorless urine. What does the nurse identify as the most likely cause? A. Increased serum glucose B. Deficient renal perfusion C. Inadequate antidiuretic hormone (ADH) secretion D. Excess amounts of intravenous (IV) fluid

C. Inadequate antidiuretic hormone (ADH) secretion

A 16-year-old girl with sickle cell anemia is experiencing a painful episode (vaso-occlusive crisis) and has a patient-controlled analgesia (PCA) pump. She complains of pain (5 on a scale of 1 to 10) in her right elbow. The nurse observes that the pump is "locked out" for another 10 minutes. What action should the nurse implement? A.Turning on the television for diversion B.Calling the primary healthcare provider for another analgesic prescription C.Placing the prescribed as-needed warm, wet compress on the elbow D.Informing her gently that she must wait until the pump reactivates to get more medication

C.Placing the prescribed as-needed warm, wet compress on the elbow

A nurse is assessing a client with a diagnosis of early left ventricular heart failure. Specific to this type of heart failure, what statement by the client would the nurse expect? A. "My ankles are swollen." B. "I am tired at the end of the day." C. "When I eat a large meal, I feel bloated." D. "I have trouble breathing when I walk rapidly."

D. "I have trouble breathing when I walk rapidly."

A client's arterial blood gas report indicates the pH is 7.52, PCO 2 is 32 mm Hg, and HCO 3 is 24 mEq/L. What does the nurse identify as a possible cause of these results? A. Airway obstruction B. Inadequate nutrition C. Prolonged gastric suction D. Excessive mechanical ventilation

D. Excessive mechanical ventilation

The nurse is caring for a client with type 1 diabetes who is developing ketoacidosis. Which arterial blood gas report is indicative of diabetic ketoacidosis? A. PCO 2: 49, HCO 3: 32, pH: 7.50 B. PCO 2: 26, HCO 3: 20, pH: 7.52 C. PCO 2: 54, HCO 3: 28, pH: 7.30 D. PCO 2: 28, HCO 3: 18, pH: 7.28

D. PCO 2: 28, HCO 3: 18, pH: 7.28

In addition to treatment of the underlying cause, which medical intervention should the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)? A. Chest tube insertion B. Aggressive diuretic therapy C. Administration of beta-blockers D. Positive end-expiratory pressure (PEEP)

D. Positive end-expiratory pressure (PEEP)

In the patient with an acute MI, the nurse would expect diagnostic testing to reveal all of the following except: ST elevation Increased CK-MB level Elevated Troponin level Decreased Myoglobin level

Decreased Myoglobin level

Which of the following is NOT included in a routine assessment of a patient's pain? Location of the pain Family history of addiction to pain medications Characteristics of pain Alleviating factors

Family history of addiction to pain medications

Symptoms of diabetic ketoacidosis include: Blood sugar less than 70 Food cravings Cool clammy skin Fruity acetone breath

Fruity acetone breath

A patient with diabetes complains of "burning" pain in his legs. Which of the following medications is most likely to be effective for this type of pain? Gabapentin (Neurontin) The Choices Were: Gabapentin (Neurontin) Acetaminophen (Tylenol) Morphine (Duramorph) Hydrocodone/Acetaminophen (Vicodin)

Gabapentin (Neurontin)

A patient with a history of iron-deficiency anemia is experiencing increased fatigue and dizziness. The nurse would expect the patient's laboratory findings to include: Hct 38% Platelets 300,000 ug/dl Hgb 8.6 g/dl increased iron stores

Hgb 8.6 g/dl

The nurse is checking the blood pressure of a client returning to the clinic for follow-up after recently being diagnosed with hypertension. To ensure accuracy in measurement, the nurse should do all of the following EXCEPT: Seat the client with arm bared, supported, and at heart level Measure the blood pressure after the client has been seated quietly for at least five-to-ten minutes Use a cuff with a bladder that covers approximately 80% of the limb If the measurement is high, have the patient stand and retake it.

If the measurement is high, have the patient stand and retake it.

Both clients and nurses have misconceptions about pain. Which statement reflects a misconception about pain? People can adapt to severe pain. Minor injuries can cause intense pain. The client is the authority about pain. Regular administration of short-term analgesics leads to addiction.

Regular administration of short-term analgesics leads to addiction.

Signs and symptoms of acute respiratory alkalosis include: cardiac dysrhythmias tingling of hands and feet shallow breathing a & b

a & b

A 52-year-old patient has a 40-pack-year history of smoking and has been diagnosed with cancer of the lung. He tells the nurse that he didn't know that anything was wrong until he had a routine chest x-ray. The nurse explains that symptoms of lung cancer occur late in the disease but usually the first thing people notice is fatigue. chest pain. a persistent cough. shortness of breath.

a persistent cough.

While caring for a patient with secondary polycythemia, the nurse recognizes that causes of the disorder can be related to: decreased oxygenation capillary fragility and hemorrhage decreased production of erythropoetin fatty infiltration of the bone marrow

decreased oxygenation

A nurse is obtaining a health history from the newly-admitted client who has chronic pain in the right knee. What should the nurse include in the pain assessment? Select all that apply. A.Pain history, including location, intensity, and quality of pain B.Client's purposeful body movement in arranging the papers on the bedside table C.Pain pattern, including precipitating and alleviating factors D.Vital signs, such as increased blood pressure and heart rate E.The client's family statement about increases in pain with ambulation

A. Pain history, including location, intensity, and quality of pain C.Pain pattern, including precipitating and alleviating factors

A client who had been receiving palliative care for cancer has deteriorated and now needs end-of-life care. The nurse identifies that which types of care will now be removed from the treatment plan? Select all that apply. A.Chemotherapy B.Repositioning C.Regular oral care D.Blood transfusion E.Radiation therapy

A.Chemotherapy D.Blood transfusion E.Radiation therapy

A young child with acute nonlymphoid leukemia is admitted to the pediatric unit with a fever and neutropenia. What are the most appropriate nursing interventions to minimize the complications associated with neutropenia? A.Placing the child in a private room, restricting ill visitors, and using strict hand washing techniques B.Encouraging a well-balanced diet, including iron-rich foods, and helping the child avoid overexertion C.Avoiding rectal temperatures, limiting injections, and applying direct pressure for 5 minutes after venipuncture D.Offering a moist, bland, soft diet; using toothettes rather than a toothbrush; and providing frequent saline mouthwashes

A.Placing the child in a private room, restricting ill visitors, and using strict hand washing techniques

A 3-year-old child with mild iron deficiency anemia is seen by a nurse in the clinic. In addition to weakness and fatigue, what should the nurse expect the child to exhibit? A. Cold, clammy skin B. Increased pulse rate C. Increased blood pressure D. Cyanosis of the nail beds

B. Increased pulse rate

The nurse caring for a patient with cystic fibrosis recognizes that the manifestations of the disease are caused by the pathophysiologic processes of The Choices Were: inflammation and fibrosis of lung tissue. failure of the bronchial goblet cells to produce mucus. altered function of exocrine glands, with abnormally thick, viscous secretions. thickening and fibrosis of the pleural linings of the lungs, causing thoracic wall changes.

altered function of exocrine glands, with abnormally thick, viscous secretions.

A recently admitted patient has a small-cell carcinoma of the lung, which is causing the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse will monitor carefully for: rapid and unexpected weight loss. increased total urinary output. decreased serum sodium level. elevation of serum hematocrit.

decreased serum sodium level.

A patient being treated for TB comes to the clinic after 2 months for a follow-up visit. Sputum smears for AFB are still positive. The nurse asks the patient if he has been taking his medication as prescribed, with the knowledge that directly observed therapy will be necessary if the patient has been noncompliant. a combination product of isoniazid, rifampin, and pyrazinamide (Rifater) is indicated if the patient skips doses. treatment protocols involving twice weekly administration of the drugs are not as effective as daily administration. if the drugs are causing side effects, a regimen including the administration of only isoniazid can be substituted.

directly observed therapy will be necessary if the patient has been noncompliant.

A 68-year-old man has a long history of COPD and is admitted to the hospital with cor pulmonale. The patient says his doctor said his heart was failing and asks whether he is having a heart attack. The nurse explains to the patient that he is not having a heart attack, but his heart has been damaged by having to work harder to pump blood into hs lungs it could be a heart attack and when the heart is damaged it causes respiratory damage too. it is not a heart attack but his heart has gradually weakened over the years, causing respiratory disease. it is probably a heart attack because cor pulmonale means the heart is not getting enough blood and becomes too weak to pump effectively.

he is not having a heart attack, but his heart has been damaged by having to work harder to pump blood into hs lungs

When the nurse discusses foods high in iron with a patient who has iron-deficiency anemia, the patient tells the nurse that she prepares low-cholesterol foods for her family and probably does not eat enough meat to meet her iron requirements. An appropriate goal for the patient would be to increase dietary intake of The Choices Were: eggs and fish nuts and cornmeal milk and cheese legumes and whole-grain cereals

legumes and whole-grain cereals

To prevent laryngeal spasms and respiratory arrest in a patient who is at risk for hypocalcemia, an early sign of hypocalcemia the nurse should assess for is: weak hand grips. confusion. constipation. lip numbness.

lip numbness.

To protect susceptible patients in the hospital from aspiration pneumonia, the nurse should turns and repositions immobile patients every 2 hours. places patients with dysphagia in High Fowler's position while eating monitors for respiratory symptoms in those patients who are immunosuppressed. plans room assignments to prevent patients with infections from being placed with surgical or chronically ill patients.

places patients with dysphagia in High Fowler's position while eating

The nurse teaches a patient with COPD how to perform pursed-lip breathing, explaining that this technique will assist respiration by Multiple Choice | 0.10pts Your Score: 0.10 loosening secretions so that they may be coughed up more easily. promoting maximal inhalation for better oxygenation of the lungs. preventing bronchial collapse and air trapping in the lungs during expiration. slowing the respiratory rate and giving the patient control of respiratory patterns.

preventing bronchial collapse and air trapping in the lungs during expiration.