Exam 4

The nurse is caring for a patient with an obstructed common bile duct. What condition should the nurse expect? a. Melena b. Steatorrhea c. Decreased serum cholesterol level d. Increased serum indirect bilirubin level

b. Steatorrhea

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. Absent bowel sounds

The nurse is providing preoperative teaching for a patient scheduled for an abdominal-perineal resection. Which information will the nurse include? a. The patient will need to remain on bedrest for three days after surgery. b. An additional surgery in 8 to 12 weeks will be done to create an ileal-anal reservoir. c. IV antibiotics will be started at least 24 hours before surgery to reduce the bowel bacteria. d. The site where the stoma will be located will be marked on the abdomen preoperatively.

d. The site where the stoma will be located will be marked on the abdomen preoperatively.

Which information will the nurse provide for a patient with achalasia? a. A liquid diet will be necessary. b. Avoid drinking fluids with meals. c. Lying down after meals is recommended. d. Treatment may include endoscopic procedures.

d. Treatment may include endoscopic procedures.

The child most likely to receive propranolol to manage tremors is one diagnosed with which disorder? a. Attention-deficit/hyperactivity disorder (ADHD) b. Posttraumatic stress disorder (PTSD) c. A motor disorder d. Separation anxiety

c. A motor disorder

Which patient statement indicates that the nurse's teaching about sulfasalazine (Azulfidine) for ulcerative colitis has been effective? a. "I should apply sunscreen before going outdoors." b. "The medication will be tapered if I need surgery." c. "I will need to avoid contact with people who are sick." d. "The medication prevents the infections that cause diarrhea.

a. "I should apply sunscreen before going outdoors."

A 40-yr-old obese woman reports that she wants to lose weight. Which question should the nurse ask first? a. "What factors led to your obesity?" b. "Which types of food do you like best?" c. "How long have you been overweight?" d. "What physical activities do you enjoy?"

a. "What factors led to your obesity?"

A patient with a new ileostomy asks how much it will drain. How many cups of drainage per day should the nurse explain for the patient to expect? a. 2 b. 3 c. 4 d. 5

a. 2

Which patient should the nurse assess first after receiving change-of-shift report? a. A 30-yr-old patient who has a distended abdomen and tachycardia b. A 60-yr-old patient whose ileostomy has drained 800 mL over 8 hours c. A 40-yr-old patient with ulcerative colitis who had six liquid stools in 4 hours d. A 50-yr-old patient with familial adenomatous polyposis who has occult blood in the stool

a. A 30-yr-old patient who has a distended abdomen and tachycardia

Which patient should the nurse assess first after receiving change-of-shift report? a. A patient with esophageal varices who has a rapid heart rate b. A patient with a history of gastrointestinal bleeding who has melena c. A patient with nausea who has a dose of metoclopramide (Reglan) due d. A patient who is crying after receiving a diagnosis of esophageal cancer

a. A patient with esophageal varices who has a rapid heart rate

A patient diagnosed with schizophrenia is acutely disturbed and violent. After several doses of haloperidol, the patient is calm. Two hours later the nurse sees the patient's head rotated to one side in a stiff position; the lower jaw is thrust forward, and the patient is drooling. Which effect is the patient demonstrating? a. Acute dystonic reaction b. Tardive dyskinesia c. Waxy flexibility d. Akathisia

a. Acute dystonic reaction

What should the nurse admitting a patient with acute diverticulitis plan for initial care? a. Administer IV fluids. b. Prepare for colonoscopy. c. Encourage a high-fiber diet. d. Give stool softeners and enemas.

a. Administer IV fluids.

An acutely violent patient diagnosed with schizophrenia receives several doses of haloperidol. Two hours later the nurse notices the patient's head rotated to one side in a stiffly fixed position; the lower jaw is thrust forward, and the patient is drooling. Which intervention by the nurse is indicated? a. Administer diphenhydramine 50 mg IM from the PRN medication administration record. b. Reassure the patient that the symptoms will subside. Practice relaxation exercises with the patient. c. Give trihexyphenidyl 5 mg orally at the next regularly scheduled medication administration time. d. Administer atropine sulfate 2 mg subcutaneously from the PRN medication administration record

a. Administer diphenhydramine 50 mg IM from the PRN medication administration record.

Which information will the nurse include when teaching adults to decrease the risk for cancers of the tongue and buccal mucosa? a. Use sunscreen even on cloudy days. b. Avoid cigarettes and smokeless tobacco. c. Complete antibiotic courses used to treat throat infections. d. Use antivirals to treat herpes simplex virus (HSV) infections.

b. Avoid cigarettes and smokeless tobacco.

A patient presenting with delusions of persecution about being poisoned has refused all hospital meals for 3 days. Which intervention is most likely to be acceptable to the patient? a. Allow the patient to have supervised access to food vending machines. b. Allow the patient to telephone a local restaurant to deliver meals. c. Offer to taste each portion on the tray for the patient. d. Begin tube feedings or total parenteral nutrition.

a. Allow the patient to have supervised access to food vending machines.

An 11-year-old child, who has been diagnosed with oppositional defiant disorder (ODD), becomes angry over the rules at a residential treatment program and begins shouting at the nurse. What is the best method to defuse the situation? a. Assign the child to a short time-out. b. Administer an antipsychotic medication. c. Place the child in a therapeutic hold. d. Call a staff member to seclude the child

a. Assign the child to a short time-out.

A patient who was admitted the previous day with pneumonia reports a sharp pain of 7 (on 0 to 10 scale) "whenever I take a deep breath." Which action will the nurse take next? a. Auscultate for breath sounds. b. Administer as-needed morphine. c. Have the patient cough forcefully. d. Notify the patient's health care provider.

a. Auscultate for breath sounds.

Which finding would prompt the nurse to carefully assess an 8-year-old child for development of a psychiatric disorder? a. Being raised by a parent with chronic major depressive disorder b. Moving to three new homes over a 2-year period c. Not being promoted to the next grade d. Having an imaginary friend

a. Being raised by a parent with chronic major depressive disorder

When teaching a patient about testing to diagnose metabolic syndrome, which topic would the nurse include? a. Blood glucose test b. Cardiac enzyme tests c. Postural blood pressures d. Resting electrocardiogram

a. Blood glucose test

A child diagnosed with attention-deficit/hyperactivity disorder (ADHD) is going to begin medication therapy. The nurse should plan to teach the family about which classification of medications? a. Central nervous system stimulants and nonstimulants b. Monoamine oxidase inhibitors (MAOIs) c. Antipsychotic medications d. Anxiolytic medications

a. Central nervous system stimulants and nonstimulants

A patient calls the clinic to report a new onset of severe diarrhea. What should the nurse anticipate that the patient will need to do? a. Collect a stool specimen. b. Prepare for colonoscopy. c. Schedule a barium enema. d. Have blood cultures drawn

a. Collect a stool specimen.

A 12-year-old child has been the neighborhood bully for several years. The parents say, "We can't believe anything our child says." Recently, the child shot a dog with a pellet gun and set fire to a trash bin outside a store. The child's behaviors are most consistent with which disorder? a. Conduct disorder (CD) b. Defiance of authority c. Anxiety over separation from a parent d. Attention-deficit/hyperactivity disorder (ADHD)

a. Conduct disorder (CD)

The nurse is assessing a patient with abdominal pain. How will the nurse document ecchymosis around the area of umbilicus? a. Cullen sign b. Rovsing sign c. McBurney sign d. Grey-Turner's sign

a. Cullen sign

The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Document the amount of drainage every 8 hours. b. Obtain samples of drainage for culture from the system. c. Assess patient pain level associated with the chest tube. d. Check the water-seal chamber for the correct fluid level

a. Document the amount of drainage every 8 hours.

The nurse will be teaching self-management to patients after gastric bypass surgery. Which information will the nurse plan to include? a. Drink fluids between meals but not with meals. b. Choose high-fat foods for at least 30% of intake. c. Developing flabby skin can be prevented by exercise. d. Choose foods high in fiber to promote bowel function

a. Drink fluids between meals but not with meals.

Which nursing action will be included in the plan of care for a 25-yr-old male patient with a new diagnosis of irritable bowel syndrome (IBS)? a. Encourage the patient to express concerns and ask questions about IBS. b. Suggest that the patient increase the intake of milk and other dairy products. c. Teach the patient to avoid using nonsteroidal antiinflammatory drugs (NSAIDs). d. Teach the patient about the use of alosetron (Lotronex) to reduce IBS symptoms.

a. Encourage the patient to express concerns and ask questions about IBS.

What diagnostic test should the nurse anticipate for an older patient who is vomiting "coffee-ground" emesis? a. Endoscopy b. Angiography c. Barium studies d. Gastric analysis

a. Endoscopy

A patient with Crohn's 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. Fever

A young woman with Crohn's 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. Fistulas can form between the bowel and bladder. b. Bacteria in the perianal area can enter the urethra. c. Drink adequate fluids to maintain normal hydration. d. Empty the bladder before and after sexual intercourse.

a. Fistulas can form between the bowel and bladder.

The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect? a. Increased tactile fremitus b. Dry, nonproductive cough c. Hyperresonance to percussion d. A grating sound on auscultation

a. Increased tactile fremitus

A patient is awaiting surgery for acute peritonitis. Which action will the nurse plan to include in the preoperative care? a. Position patient with the knees flexed. b. Avoid use of opioids or sedative drugs. c. Offer frequent small sips of clear liquids. d. Assist patient to breathe deeply and cough

a. Position patient with the knees flexed.

After having frequent diarrhea and a weight loss of 10 lb (4.5 kg) over 2 months, a patient has a new diagnosis of Crohn's disease. What should the nurse plan to teach the patient? a. Medication use b. Fluid restriction c. Enteral nutrition d. Activity restrictions

a. Medication use

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. Navy bean soup and vegetable salad

A patient diagnosed with schizophrenia begins to talk about "cracklomers" in the local shopping mall. The term "cracklomers" should be documented using what term? a. Neologism b. Concrete thinking c. Thought insertion d. An idea of reference

a. Neologism

The family members of a patient newly diagnosed with schizophrenia state that they do not understand what has caused the illness. The nurse's response should be based on which models? (Select all that apply.) a. Neurobiological b. Environmental c. Family theory d. Genetic e. Stress

a. Neurobiological d. Genetic e. Stress

A woman receiving chemotherapy for breast cancer develops a Candida albicans oral infection. Which intervention should the nurse anticipate? a. Nystatin tablets b. Antiviral agents c. Referral to a dentist d. Hydrogen peroxide rinses ANS: A

a. Nystatin tablets

The nurse is caring for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider? a. O2 saturation is 88%. b. Blood pressure is 155/90 mm Hg. c. Respiratory rate is 24 breaths/min when lying flat. d. Pain level is 5 (on 0 to 10 scale) with a deep breath.

a. O2 saturation is 88%.

The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment could be used to evaluate the effectiveness of the therapies? a. Observe for distended neck veins. b. Auscultate for crackles in the lungs. c. Palpate for heaves or thrills over the heart. d. Monitor for elevated white blood cell count.

a. Observe for distended neck veins.

Which action should the nurse in the emergency department anticipate for a young adult patient who has had several acute episodes of bloody diarrhea? a. Obtain a stool specimen for culture. b. Administer antidiarrheal medication. c. Provide teaching about antibiotic therapy. d. Teach the adverse effects of acetaminophen (Tylenol

a. Obtain a stool specimen for culture.

A 58-yr-old patient 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 pitcher of water b. Positioning the patient on the right side c. Checking the vital signs every 30 minutes d. Swabbing the patient's mouth with a wet cloth

a. Offering the patient a pitcher of water

A patient is being scheduled for endoscopic retrograde cholangiopancreatography (ERCP) as soon as possible. Which prescribed action 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. Place the patient on NPO status.

The family of a patient diagnosed with schizophrenia is unfamiliar with the illness and their role in recovery. Which type of therapy should the nurse recommend? a. Psychoeducational b. Psychoanalytic c. Transactional d. Family

a. Psychoeducational

A parent diagnosed with schizophrenia and her 13-year-old child live in a homeless shelter. The child has formed a trusting relationship with a shelter volunteer. The child says, "My three friends and I got an A on our school science project." The nurse can assess that the child is demonstrating what characteristic? a. Resiliency b. Shy temperament c. Early posttraumatic stress disorder d. Uses intellectualization to deal with problems

a. Resiliency

Which health promotion information should the nurse include when teaching a patient with a 42 pack-year history of cigarette smoking? (Select all that apply.) a. Resources for support in smoking cessation b. Reasons for annual sputum cytology testing c. Erlotinib (Tarceva) therapy to prevent tumor risk d. Computed tomography (CT) screening for cancer e. Importance of obtaining a yearly influenza vaccination

a. Resources for support in smoking cessation d. Computed tomography (CT) screening for cancer e. Importance of obtaining a yearly influenza vaccination

A patient diagnosed with schizophrenia is hospitalized after arguing with coworkers and threatening to harm them. The patient is aloof and suspicious and says, "Two staff members I saw talking were plotting to assault me." Based on data gathered at this point, which nursing diagnoses relate? (Select all that apply.) a. Risk for other-directed violence b. Disturbed thought processes c. Risk for loneliness d. Spiritual distress e. Social isolation

a. Risk for other-directed violence b. Disturbed thought processes

When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol was prescribed. The patient now says, "I stopped taking those pills. I didn't like how it made me feel." What likely side effects did the patient experience? a. Sedation and muscle stiffness b. Sweating, nausea, and diarrhea c. Mild fever, sore throat, and skin rash d. Headache, watery eyes, and runny nose

a. Sedation and muscle stiffness

Which prescribed intervention for a patient with chronic short bowel syndrome should the nurse question? a. Senna 1 tablet daily b. Ferrous sulfate 325 mg daily c. Psyllium (Metamucil) 3 times daily d. Diphenoxylate with atropine (Lomotil) PRN loose stool

a. Senna 1 tablet daily

The nurse receives the following information about a patient who is scheduled for a colonoscopy. Which information should be communicated to the health care provider before sending the patient for the procedure? a. The patient declined to drink the prescribed laxative solution. b. The patient has had an allergic reaction to shellfish and iodine. c. The patient has a permanent pacemaker to prevent bradycardia. d. The patient is worried about discomfort during the examination.

a. The patient declined to drink the prescribed laxative solution.

Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has no symptoms of TB and has never had a positive TB skin test before. Which information should the occupational health nurse plan to teach the staff nurse? a. Use and side effects of isoniazid b. Standard four-drug therapy for TB c. Need for annual repeat TB skin testing d. Bacille Calmette-Guérin (BCG) vaccine

a. Use and side effects of isoniazid

A nurse works with a patient diagnosed with schizophrenia regarding the importance of medication management. The patient repeatedly says, "I don't like taking pills." Which treatment strategy should the nurse discuss with the patient and health care provider? a. Use of long-acting antipsychotic injections b. Addition of a benzodiazepine, such as lorazepam c. Adjunctive use of an antidepressant, such as amitriptyline d. Inpatient hospitalization because of the high risk for exacerbation of symptoms

a. Use of long-acting antipsychotic injections

A community mental health nurse wants to establish a relationship with a very withdrawn patient diagnosed with schizophrenia. The patient lives at home with a supportive family. Select the nurse's best plan. a. Visit daily for 4 days, then visit every other day for 1 week; stay with the patient for 20 minutes; accept silence; state when the nurse will return. b. Arrange to spend 1 hour each day with the patient; focus on asking questions about what the patient is thinking or experiencing; avoid silences. c. Visit twice daily; sit beside the patient with a hand on the patient's arm; leave if the patient does not respond within 10 minutes. d. Visit every other day; remind the patient of the nurse's identity; encourage the patient to talk while the nurse works on reports

a. Visit daily for 4 days, then visit every other day for 1 week; stay with the patient for 20 minutes; accept silence; state when the nurse will return.

The nurse is coaching a community group for persons who are overweight. Which participant behavior is an example of the best exercise plan for weight loss? a. Walking for 40 minutes 6 or 7 days/week b. Lifting weights with friends 3 times/week c. Playing soccer for an hour on the weekend d. Running for 10 to 15 minutes 3 times/week

a. Walking for 40 minutes 6 or 7 days/week

Which finding by the nurse most specifically indicates that a patient is not able to effectively clear the airway? a. Weak cough effort b. Profuse green sputum c. Respiratory rate of 28 breaths/min d. Resting pulse oximetry (SpO2) of 85%

a. Weak cough effort

What assessment findings mark the prodromal stage of schizophrenia? a. Withdrawal, magical thinking, poor concentration, and perceptual disturbances b. Auditory hallucinations, ideas of reference, thought insertion, and broadcasting c. Stereotyped behavior, echopraxia, echolalia, and waxy flexibility d. Loose associations, concrete thinking, and echolalia neologisms

a. Withdrawal, magical thinking, poor concentration, and perceptual disturbances

An older adult is receiving standard multidrug therapy for tuberculosis (TB). Which finding should the nurse report to the health care provider? a. Yellow-tinged sclera b. Orange-colored sputum c. Thickening of the fingernails d. Difficulty hearing high-pitched voices

a. Yellow-tinged sclera

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 pain." d. "You should avoid eating any raw fruits and vegetables."

b. "Avoid foods that cause pain after you eat them."

The nurse is assessing an alert and independent older adult patient for malnutrition risk. Which is the most appropriate initial question? 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. "Can you tell me the food that you ate yesterday?"

A patient with newly diagnosed lung cancer tells the nurse, "I don't think I'm going to live to see my next birthday." Which is the best initial response by the nurse? a. "Are you ready to talk with family members about dying?" b. "Can you tell me what makes you think you will die so soon?" c. "Do you think that an antidepressant medication would be helpful?" d. "Would you like to talk to the hospital chaplain about your feelings?"

b. "Can you tell me what makes you think you will die so soon?"

A person diagnosed with schizophrenia has had difficulty keeping a job because of severe paranoia. Today the person shouts, "They're all plotting to destroy me." Select the nurse's most therapeutic response. a. "Everyone here is trying to help you. No one wants to harm you." b. "Feeling that people want to destroy you must be very frightening." c. "That is not true. People here are trying to help if you will let them." d. "Staff members are health care professionals who are qualified to help you."

b. "Feeling that people want to destroy you must be very frightening."

The nurse is admitting a 67-yr-old patient with new-onset steatorrhea. Which question is most important for the nurse to ask? a. "How much milk do you usually drink?" b. "Have you noticed a recent weight loss?" c. "What time of day do your bowels move?" d. "Do you eat meat or other animal products?"

b. "Have you noticed a recent weight loss?"

A patient who has gastroesophageal reflux disease (GERD) is experiencing increasing discomfort. Which patient statement to the nurse indicates that additional teaching about GERD is needed? a. "I quit smoking years ago, but I chew gum." b. "I eat small meals and have a bedtime snack." c. "I take antacids between meals and at bedtime each night." d. "I sleep with the head of the bed elevated on 4-inch blocks.

b. "I eat small meals and have a bedtime snack."

The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement by the patient indicates a good understanding of the instructions? a. "I will call my health care provider if I still feel tired after a week." b. "I will continue to do deep breathing and coughing exercises at home." c. "I will schedule two appointments for the pneumonia and influenza vaccines." d. "I will cancel my follow-up chest x-ray appointment if I feel better next week."

b. "I will continue to do deep breathing and coughing exercises at home."

A young adult patient is hospitalized with massive abdominal trauma from a motor vehicle crash. The patient asks the nurse about the purpose of receiving famotidine (Pepcid). What should the nurse explain about the action of the medication? a. "It decreases nausea and vomiting." b. "It inhibits development of stress ulcers." c. "It lowers the risk for H. pylori infection." d. "It prevents aspiration of gastric contents."

b. "It inhibits development of stress ulcers."

Which information will the nurse provide 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. "Keep the head of your bed elevated on blocks."

Which information will the nurse include when teaching a patient with peptic ulcer disease about the effect of ranitidine (Zantac)? a. "Ranitidine absorbs the excess gastric acid." b. "Ranitidine decreases gastric acid secretion." c. "Ranitidine constricts the blood vessels near the ulcer." d. "Ranitidine covers the ulcer with a protective material."

b. "Ranitidine decreases gastric acid secretion."

After bariatric surgery, a patient who is being discharged tells the nurse, "I prefer to be independent. I am not interested in any support groups." Which response by the nurse is best? a. "I hope you change your mind so that I can suggest a group for you." b. "Tell me what types of resources you think you might use after this surgery." c. "Support groups have been found to lead to more successful weight loss after surgery." d. "Because there are many lifestyle changes after surgery, we recommend support groups."

b. "Tell me what types of resources you think you might use after this surgery."

Which statement by a patient with chronic atrophic gastritis indicates that the nurse's teaching regarding cobalamin injections has been effective? 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 cobalamin injections will prevent me from becoming anemic."

Which statement by the nurse is most likely to help a 22-yr-old patient with extreme obesity in losing weight on a 1000-calorie diet? a. "It will be necessary to change lifestyle habits permanently to maintain weight loss." b. "You are likely to notice changes in how you feel after a few weeks of diet and exercise." c. "You will decrease your risk for future health problems such as diabetes by losing weight now." d. "Most of the weight that you lose during the first weeks of dieting is water weight rather than fat."

b. "You are likely to notice changes in how you feel after a few weeks of diet and exercise."

After the nurse teaches a patient about the recommended amounts of foods from animal and plant sources, which menu selections indicate that the initial instructions about diet have been understood? a. 3 oz of lean beef, 2 oz of low-fat cheese, and a sliced tomato b. 3 oz of roasted pork, a cup of broccoli, and a cup of carrot sticks c. Cup of tossed salad and nonfat dressing topped with a chicken breast d. Half cup of tuna mixed with nonfat mayonnaise and a half cup of celery

b. 3 oz of roasted pork, a cup of broccoli, and a cup of carrot sticks

After change-of-shift report, which patient should the nurse assess first? a. A 40-yr-old male patient with celiac disease who has frequent frothy diarrhea b. A 30-yr-old female patient with a femoral hernia who has abdominal pain and vomiting c. A 30-yr-old male patient with ulcerative colitis who has severe perianal skin breakdown d. A 40-yr-old female patient with a colostomy bag that is pulling away from the adhesive wafer

b. A 30-yr-old female patient with a femoral hernia who has abdominal pain and vomiting

The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first? a. A 77-yr-old patient with tuberculosis (TB) who has four medications due b. A 46-yr-old patient on bed rest who reports sudden onset of shortness of breath c. A 35-yr-old patient with pneumonia who has a temperature of 100.2° F (37.8° C) d. A 23-yr-old patient with cystic fibrosis who has pulmonary function testing scheduled

b. A 46-yr-old patient on bed rest who reports sudden onset of shortness of breath

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

b. A surgical face mask is applied before visiting the patient.

An hour after a left thoracotomy, a patient reports incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action should the nurse take? a. Clamp the chest tube in two places. b. Administer the prescribed morphine. c. Milk the chest tube to remove any clots. d. Assist the patient with incentive spirometry

b. Administer the prescribed morphine.

An older patient reports chronic constipation. To promote bowel evacuation, when should the nurse suggest that the patient attempt defecation? a. In the mid-afternoon b. After eating breakfast c. Right after awakening in the morning d. Immediately before the first daily meal

b. After eating breakfast

A newly admitted patient diagnosed with schizophrenia is hypervigilant and constantly scans the environment. The patient states, "I saw two doctors talking in the hall. They were plotting to kill me." The nurse may correctly assess this as what classic behavior? a. Echolalia b. An idea of reference c. A delusion of infidelity d. An auditory hallucination

b. An idea of reference

After a total proctocolectomy and permanent ileostomy, the patient tells the nurse, "I cannot manage all this. I don't want to look at the stoma." What action should the nurse take? a. Reassure the patient that ileostomy care will become easier. b. Ask the patient about the concerns with stoma management. c. Postpone any teaching until the patient adjusts to the ileostomy. d. Develop a detailed written list of ostomy care tasks for the patient

b. Ask the patient about the concerns with stoma management.

Which nursing action is appropriate when coaching obese adults enrolled in a behavior modification program? a. Having the adults write down the caloric intake of each meal b. Asking the adults about situations that tend to increase appetite c. Suggesting that the adults plan rewards, such as sugarless candy, for achieving their goals d. Encouraging the adults to eat small amounts frequently rather than having

b. Asking the adults about situations that tend to increase appetite

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

b. Blood cultures from two sites

Which care activity for a patient with a paralytic ileus is appropriate for the registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)? a. Auscultating for bowel sounds b. Brushing the teeth and tongue c. Assessing the nares for irritation d. Irrigating the nasogastric (NG) tube

b. Brushing the teeth and tongue

Which information will the nurse include when teaching a patient how to avoid chronic constipation? (Select all that apply.) a. Stimulant and saline laxatives can be used regularly. b. Bulk-forming laxatives are an excellent source of fiber. c. Walking or cycling frequently will help bowel motility. d. A good time for a bowel movement may be after breakfast. e. Some over-the-counter (OTC) medications cause constipation

b. Bulk-forming laxatives are an excellent source of fiber. c. Walking or cycling frequently will help bowel motility. d. A good time for a bowel movement may be after breakfast. e. Some over-the-counter (OTC) medications cause constipation

Which assessment action will help the nurse determine if an obese patient has metabolic syndrome? a. Take the patient's apical pulse. b. Check the patient's blood pressure. c. Ask the patient about dietary intake. d. Dipstick the patient's urine for protein

b. Check the patient's blood pressure.

A patient 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. Check the vital signs.

What should the nurse preparing for the annual physical exam of a 45-yr-old man plan to teach the patient about? a. Endoscopy b. Colonoscopy c. Computerized tomography screening d. Carcinoembryonic antigen (CEA) testing

b. Colonoscopy

A patient who underwent a gastroduodenostomy (Billroth I) 12 hours ago reports increasing abdominal pain. The patient has no bowel sounds and 200 mL of bright red nasogastric (NG) drainage in the past hour. What is the highest priority action by the nurse? a. Monitor drainage. b. Contact the surgeon. c. Irrigate the NG tube. d. Give prescribed morphine

b. Contact the surgeon.

A patient who has a right-sided chest tube after a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is appropriate? a. Adjust the dial on the wall regulator. b. Continue to monitor the collection device. c. Document the presence of a large air leak. d. Notify the surgeon of a possible pneumothorax.

b. Continue to monitor the collection device.

A patient's care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating? a. Aloofness, haughtiness, suspicion b. Darting eyes, tilted head, mumbling to self c. Elevated mood, hyperactivity, distractibility d. Performing rituals, avoiding open place

b. Darting eyes, tilted head, mumbling to self

A patient being admitted with an acute exacerbation of ulcerative colitis reports crampy abdominal pain and passing 15 bloody stools a day. What should the nurse include in the plan of care? a. Administer IV metoclopramide (Reglan). b. Discontinue the patient's oral food intake. c. Administer cobalamin (vitamin B12) injections. d. Teach the patient about total colectomy surgery.

b. Discontinue the patient's oral food intake.

Which item should the nurse offer to the patient restarting 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. Dish of lemon gelatin

Which nursing action should be included in the postoperative plan of care for a patient after a laparoscopic esophagectomy? a. Reposition the NG tube if drainage stops. b. Elevate the head of the bed to at least 30 degrees. c. Start oral fluids when the patient has active bowel sounds. d. Notify the doctor for any bloody nasogastric (NG) drainage

b. Elevate the head of the bed to at least 30 degrees.

A patient reports gas pains and abdominal distention 2 days after a small bowel resection. Which nursing action should the nurse take? a. Administer morphine sulfate. b. Encourage the patient to ambulate. c. Offer the prescribed promethazine. d. Instill a mineral oil retention enema

b. Encourage the patient to ambulate.

When assessing a 2-year-old diagnosed with autism spectrum disorder, what should a nurse expects? a. Hyperactivity and attention deficits b. Failure to develop interpersonal social skills c. History of disobedience and destructive acts d. High levels of anxiety when separated from a parent

b. Failure to develop interpersonal social skills

The health care provider prescribes medication for a child diagnosed with attention-deficit/hyperactivity disorder (ADHD). What is the desired behavior for which the nurse should monitor? a. Increased expressiveness in communicating with others. b. Improved ability for cooperative play with other children. c. Ability to identify anxiety and implement self-control strategies. d. Improved socialization skills with other children and authority figures

b. Improved ability for cooperative play with other children.

A 49-yr-old man has been admitted with hypotension and dehydration after 3 days of nausea and vomiting. Which prescribed action 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. Infuse normal saline at 250 mL/hr.

A 5-year-old child diagnosed with attention-deficit/hyperactivity disorder (ADHD) bounces out of a chair in the waiting room, runs across the room, and begins to slap another child. What is the nurse's best action? a. Call for emergency assistance from another staff member. b. Instruct the parents to take the child home immediately. c. Direct this child to stop, and then comfort the other child. d. Take the child into another room with toys to act out feelings.

b. Instruct the parents to take the child home immediately.

Which information will the nurse plan to teach a patient who has lactose intolerance? a. Ice cream is relatively low in lactose. b. Live-culture yogurt is usually tolerated. c. Heating milk will break down the lactose. d. Nonfat milk is tolerated better than whole milk

b. Live-culture yogurt is usually tolerated.

An adult with a body mass index (BMI) of 22 kg/m2 is being admitted to the hospital for elective knee surgery. Which assessment finding should the nurse report to the health care provider? a. Tympany on percussion of the abdomen b. Liver edge 3 cm below the costal margin c. Bowel sounds of 20/min in each quadrant d. Aortic pulsations visible in the epigastric area

b. Liver edge 3 cm below the costal margin

Which adult should the nurse plan to teach about risks associated with obesity? a. Man who has a BMI of 18 kg/m2 b. Man with a 42 in waist and 44 in hips c. Woman who has a body mass index (BMI) of 24 kg/m2 d. Woman with a waist circumference of 34 inches (86 cm)

b. Man with a 42 in waist and 44 in hips

Which nursing action will the nurse include in the plan of care for a patient admitted with an exacerbation of inflammatory bowel disease (IBD)? a. Restrict oral fluid intake. b. Monitor stools for blood. c. Ambulate six times daily. d. Increase dietary fiber intake.

b. Monitor stools for blood.

A patient preparing to undergo a colon resection for cancer of the colon asks about the elevated carcinoembryonic antigen (CEA) test result. What should the nurse explain as the reason for the test? a. Identify any metastasis of the cancer. b. Monitor the tumor status after surgery. c. Confirm the diagnosis of a specific type of cancer. d. Determine the need for postoperative chemotherapy

b. Monitor the tumor status after surgery.

What are the primary distinguishing factors between the behavior of children diagnosed with oppositional defiant disorder (ODD) and those diagnosed with conduct disorder (CD)? The child diagnosed with: (Select all that apply.) a. ODD relives traumatic events by acting them out. b. ODD tests limits and disobeys authority figures. c. ODD has difficulty separating from the parents. d. CD uses stereotypical or repetitive language. e. CD often violates the rights of others.

b. ODD tests limits and disobeys authority figures. e. CD often violates the rights of others.

A nurse prepares the plan of care for a 15-year-old adolescent diagnosed with moderate intellectual developmental disorder (IDD) is believed capable of ultimately functioning at a second-grade level. What are the highest outcomes realistic for this person to demonstrate within 5 years? (Select all that apply.) a. Live unaided in an apartment. b. Obtain employment in a local sheltered workshop. c. Correctly use public buses to travel in the community. d. Independently perform his or her own personal hygiene. e. Complete high school or earn a general equivalency diploma (GED).

b. Obtain employment in a local sheltered workshop. c. Correctly use public buses to travel in the community. d. Independently perform his or her own personal hygiene.

A patient diagnosed with schizophrenia has taken a first-generation antipsychotic medication for a year. Hallucinations are less intrusive, but the patient continues to have apathy, poverty of thought, and social isolation. The nurse expects a change to which medication? a. Haloperidol b. Olanzapine c. Chlorpromazine d. Diphenhydramine

b. Olanzapine

A patient diagnosed with schizophrenia is demonstration catatonia. The patient has little spontaneous movement and waxy flexibility. Which patient needs are of priority importance? a. Psychosocial b. Physiological c. Self-actualization d. Safety and security

b. Physiological

Which action should the nurse plan to prevent aspiration in a high-risk patient? a. Turn and reposition an immobile patient at least every 2 hours. b. Place a patient with altered consciousness in a side-lying position. c. Insert a nasogastric tube for feeding a patient with high-calorie needs. d. Monitor respiratory symptoms in a patient who is immunosuppressed

b. Place a patient with altered consciousness in a side-lying position.

Which symptoms are expected for a patient diagnosed with schizophrenia who has disorganization? a. Extremes of motor activity, from excitement to stupor b. Socially withdrawal and ineffective communication c. Severe anxiety with ritualistic behavior d. Highly suspicious, delusional behavior

b. Socially withdrawal and ineffective communication

Which is the correct technique for the nurse to palpate the liver during a head-to-toe physical assessment? a. Place one hand on top of the other and use the upper fingers to apply pressure and the bottom fingers to feel for the liver edge. b. Place one hand on the patient's back and press upward and inward with the other hand below the patient's right costal margin. c. Press slowly and firmly over the right costal margin with one hand and withdraw the fingers quickly after the liver edge is felt. d. Place one hand under the patient's lower ribs and press the left lower rib cage forward, palpating below the costal margin with the other hand

b. Place one hand on the patient's back and press upward and inward with the other hand below the patient's right costal margin.

What action should the nurse take after assisting with a needle biopsy of the liver at a patient's bedside? a. Elevate the head of the bed to facilitate breathing. b. Place the patient on the right side with the bed flat. c. Check the patient's postbiopsy coagulation studies. d. Position a sandbag over the liver to provide pressure

b. Place the patient on the right side with the bed flat.

An experienced nurse instructs a new nurse about how to care for a patient with dyspnea caused by a pulmonary fungal infection. Which action by the new nurse indicates a need for further teaching? a. Listening to the patient's lung sounds several times during the shift b. Placing the patient on droplet precautions in a private hospital room c. Monitoring patient serology results to identify the infecting organism d. Titrating the O2 flowrate as prescribed to keep the O2 saturation over 90%

b. Placing the patient on droplet precautions in a private hospital room

A patient 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 patient's oral temperature. d. Obtain information about the accident.

b. Prepare the patient for surgery.

A 74-yr-old male patient tells the nurse that growing old causes constipation, so he has been using a suppository to prevent constipation every morning. Which action should the nurse take first? a. Encourage the patient to increase oral fluid intake. b. Question 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. Question the patient about risk factors for constipation.

A 19-yr-old patient has familial adenomatous polyposis (FAP). Which action will the nurse in the gastrointestinal clinic include in the plan of care? a. Obtain blood samples for DNA analysis. b. Schedule the patient for yearly colonoscopy. c. Provide preoperative teaching about total colectomy. d. Discuss lifestyle modifications to decrease cancer risk.

b. Schedule the patient for yearly colonoscopy.

A patient with a family history of stomach cancer asks the nurse about ways to decrease the risk for developing stomach cancer. What should the nurse 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. Smoked foods such as ham and bacon

A patient has taken trifluoperazine 30 mg/day orally for 3 years. The clinic nurse notes that the patient grimaces and constantly smacks both lips. The patient's neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect? a. Agranulocytosis b. Tardive dyskinesia c. Tourette syndrome d. Anticholinergic effects

b. Tardive dyskinesia

Which information will the nurse prioritize in planning preoperative teaching for a patient undergoing a Roux-en-Y gastric bypass? a. Educating the patient about the nasogastric (NG) tube b. Teaching the patient on coughing and breathing techniques c. Discussing necessary postoperative modifications in lifestyle d. Demonstrating passive range-of-motion exercises for the legs

b. Teaching the patient on coughing and breathing techniques

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. Hemoglobin (Hgb) 10.8 g/dL b. Temperature 102.1° F (38.9° C) c. Absent bowel sounds in all quadrants d. Scant nasogastric (NG) tube drainage

b. Temperature 102.1° F (38.9° C)

The nurse and a licensed practical/vocational nurse (LPN/VN) are working together to care for a patient who had an esophagectomy 2 days ago. Which action by the LPN/VN requires that the nurse intervene? a. The LPN/VN uses soft swabs to provide oral care. b. The LPN/VN positions the head of the bed in the flat position. c. The LPN/VN includes the enteral feeding volume when calculating intake. d. The LPN/VN encourages the patient to use pain medications before coughing.

b. The LPN/VN positions the head of the bed in the flat position.

A nurse at the mental health clinic plans a series of psychoeducational groups for persons diagnosed with schizophrenia. Which two topics would take priority? (Select all that apply.) a. How to complete an application for employment? b. The importance of correctly taking your medication. c. How to dress when attending community events? d. How to give and receive compliments? e. Ways to quit smoking.

b. The importance of correctly taking your medication. e. Ways to quit smoking.

Which information obtained by the nurse interviewing a 30-yr-old male patient is most important to communicate to the health care provider? a. The patient has a history of constipation. b. The patient has noticed blood in the stools c. The patient had an appendectomy at age 27. d. The patient smokes a pack/day of cigarettes

b. The patient has noticed blood in the stools

Which finding for a patient who has been taking orlistat (Xenical) is most important to report to the health care provider? a. The patient has frequent liquid stools. b. The patient is pale and has many bruises. c. The patient feels very bloated after meals. d. The patient is having a weight loss plateau.

b. The patient is pale and has many bruises.

A 22-yr-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 uses witch hazel compresses to soothe irritation. c. The patient asks for antidiarrheal medication after each stool. d. The patient cleans the perianal area with soap after each stool

b. The patient uses witch hazel compresses to soothe irritation.

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 patient's lungs have crackles audible to the midchest. c. The nasogastric (NG) suction is returning coffee-ground material. d. The patient's blood pressure (BP) has increased to 142/84 mm Hg

b. The patient's lungs have crackles audible to the midchest.

A 33-yr-old male patient with a gunshot wound to the abdomen undergoes surgery, and a colostomy is formed as shown in the accompanying figure. Which information will be included in patient teaching? a. Stool will be expelled from both stomas. b. This type of colostomy is usually temporary. c. Soft, formed stool can be expected as drainage. d. Irrigations can regulate drainage from the stomas

b. This type of colostomy is usually temporary.

A critically ill patient with sepsis is frequently incontinent of watery stools. What action by the nurse will prevent complications associated with ongoing incontinence? a. Apply incontinence briefs. b. Use a fecal management system. c. Insert a rectal tube with a drainage bag. d. Assist the patient to a commode frequently

b. Use a fecal management system.

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. Use care when eating high-fiber foods to avoid obstruction of the ileum.

A nurse observes a patient standing immobile, facing the wall with one arm extended in a salute. The patient remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon? a. Echolalia b. Waxy flexibility c. Depersonalization d. Thought withdrawal

b. Waxy flexibility

A patient diagnosed with schizophrenia begins a new prescription for lurasidone HCl. The patient is 5 feet 6 inches tall and currently weighs 204 pounds. Which topic is most important for the nurse to include in the teaching plan related to this medication? a. How to recognize tardive dyskinesia? b. Weight management strategies. c. Ways to manage constipation. d. Sleep hygiene measures.

b. Weight management strategies.

A patient diagnosed with schizophrenia is stuporous, demonstrates little spontaneous movement, and has waxy flexibility. The patient's activities of daily living are severely compromised. An appropriate outcome is that the patient will: a. demonstrate increased interest in the environment by the end of week 1. b. perform self-care activities with coaching by the end of day 3. c. gradually take the initiative for self-care by the end of week 2 d. voluntarily accept tube feeding by day 2.

b. perform self-care activities with coaching by the end of day 3.

Which breakfast choice indicates a patient's good understanding of information about a diet for celiac disease? a. Wheat toast with butter b. Oatmeal with nonfat milk c. Bagel with low-fat cream cheese d. Corn tortilla with scrambled eggs

d. Corn tortilla with scrambled eggs

A 26-yr-old woman is being evaluated for vomiting and abdominal pain. Which question from the nurse will be most useful in determining the cause of the patient's symptoms? a. "What type of foods do you eat?" b. "Is it possible that you are pregnant?" c. "Can you tell me more about the pain?" d. "What is your usual elimination pattern?"

c. "Can you tell me more about the pain?"

A 58-yr-old woman who was recently 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. "Having this new diagnosis must be very hard for you."

A newly admitted patient diagnosed with schizophrenia says, "The voices are bothering me. They yell and tell me I'm bad. I have got to get away from them." Select the nurse's most helpful reply. a. "Do you hear the voices often?" b. "Do you have a plan for getting away from the voices?" c. "I will stay with you. Focus on what we are talking about, not the voices." d. "Forget about the voices. Ask some other patients to sit and talk with you."

c. "I will stay with you. Focus on what we are talking about, not the voices."

The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective? a. "I will take the bus instead of driving." b. "I will stay indoors whenever possible." c. "My spouse will sleep in another room." d. "I will keep the windows closed at home."

c. "My spouse will sleep in another room."

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

c. "Tell me what you know about the treatments available."

The parent of a child diagnosed with Tourette's disorder says to the nurse, "I think my child is faking the tics because they come and go." Which response by the nurse is accurate? a. "Perhaps your child was misdiagnosed." b. "Your observation indicates the medication is effective." c. "Tics often change frequency or severity. That does not mean they aren't real." d. "This finding is unexpected. How have you been administering your child's medication?

c. "Tics often change frequency or severity. That does not mean they aren't real."

Which patient statement indicates that the nurse's postoperative teaching after a gastroduodenostomy has been effective? a. "I will drink more liquids with my meals." b. "I should choose high carbohydrate foods." c. "Vitamin supplements may prevent anemia." d. "Persistent heartburn is common after surgery."

c. "Vitamin supplements may prevent anemia."

The nurse monitors a patient in the emergency department after chest tube placement for a hemopneumothorax. Which assessment finding is of most concern? a. A large air leak in the water-seal chamber b. Report of pain with each deep inspiration c. 400 mL of blood in the collection chamber d. Subcutaneous emphysema at the insertion site

c. 400 mL of blood in the collection chamber

After change-of-shift report, which patient should the nurse assess first? a. A 42-yr-old patient who has acute gastritis and ongoing epigastric pain b. A 70-yr-old patient with a hiatal hernia who experiences frequent heartburn c. A 60-yr-old patient with nausea and vomiting who is lethargic with dry mucosa d. A 53-yr-old patient who has dumping syndrome after a recent partial gastrectomy

c. A 60-yr-old patient with nausea and vomiting who is lethargic with dry mucosa

After change-of-shift report, which patient should the nurse assess first? a. A 40-yr-old with a pleural effusion who reports severe stabbing chest pain b. A 72-yr-old with cor pulmonale who has 4+ bilateral edema in his legs and feet c. A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter insertion d. A 28-yr-old with a history of a lung transplant 1 month ago and a fever of 101° F (38.3° C)

c. A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter insertion

Which prescribed action will the nurse implement first for a patient who has vomited 1100 mL of blood? a. Give an IV H2 receptor antagonist. b. Draw blood for type and crossmatch. c. Administer 1 L of lactated Ringer's solution. d. Insert a nasogastric (NG) tube and connect to suctio

c. Administer 1 L of lactated Ringer's solution.

An adult with E. coli O157:H7 food poisoning is admitted to the hospital with bloody diarrhea and dehydration. Which prescribed action will the nurse question? a. Infuse lactated Ringer's 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. Administer loperamide (Imodium) after each stool.

A 53-yr-old male patient with deep partial-thickness burns from a chemical spill in the workplace has severe pain followed by nausea during dressing changes. Which action will be most useful in decreasing the patient's nausea? a. Keep the patient NPO for 2 hours before dressing changes. b. Give the prescribed prochlorperazine before dressing changes. c. Administer prescribed morphine sulfate before dressing changes. d. Avoid performing dressing changes close to the patient's mealtimes

c. Administer prescribed morphine sulfate before dressing changes.

A patient has peptic ulcer disease that has been associated with Helicobacter pylori. About which medications will the nurse plan to teach the patient? a. Sucralfate (Carafate), nystatin, and bismuth (Pepto-Bismol) b. Metoclopramide (Reglan), bethanechol (Urecholine), and promethazine c. Amoxicillin (Amoxil), clarithromycin (Biaxin), and omeprazole (Prilosec) d. Famotidine (Pepcid), magnesium hydroxide (Mylanta), and pantoprazole (Protonix)

c. Amoxicillin (Amoxil), clarithromycin (Biaxin), and omeprazole (Prilosec)

A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan? a. Purpose of antibiotic therapy b. Ways to limit oral fluid intake c. Appropriate use of cough suppressants d. Safety concerns with home O2 therapy

c. Appropriate use of cough suppressants

A patient diagnosed with active tuberculosis (TB) is homeless and has a history of chronic alcohol use. Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen? a. Repeat warnings about the high risk for infecting others several times. b. Give the patient written instructions about how to take the medications. c. Arrange for a daily meal and drug administration at a community center. d. Arrange for the patient's friend to administer the medication on schedule.

c. Arrange for a daily meal and drug administration at a community center.

To evaluate an obese patient for adverse effects of lorcaserin (Belviq), which action will the nurse take? a. Take the apical pulse rate. b. Check sclera for jaundice. c. Ask about bowel movements. d. Assess for agitation or restlessness.

c. Ask about bowel movements.

A 25-yr-old male patient calls the clinic reporting diarrhea for 24 hours. Which action should the nurse take first? a. Inform the patient that testing of blood and stools will be needed. b. Suggest that the patient drink clear liquid fluids with electrolytes. c. Ask the patient to describe the stools and any associated symptoms. d. Advise the patient to use over-the-counter antidiarrheal medication

c. Ask the patient to describe the stools and any associated symptoms

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

c. Ask the patient whether medications have been taken as directed.

After successfully losing a pound per week for several months, a patient at the clinic has not lost any weight for the past month. What action should the nurse take first? a. Review the diet and exercise guidelines with the patient. b. Instruct the patient to weigh and record weights weekly. c. Ask the patient whether there have been any changes in exercise or diet patterns. d. Discuss the possibility that the patient has reached a temporary weight loss plateau.

c. Ask the patient whether there have been any changes in exercise or diet patterns.

A 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. Assess the perineal drainage and incision.

Shortly after a 15-year-old's parents announce a plan to divorce, the adolescent stops participating in sports, sits alone at lunch, and avoids former friends. The adolescent says, "All the other kids have families. If my parents loved me, then they would stay together." Which nursing intervention is most appropriate? a. Develop a plan for activities of daily living. b. Communicate disbelief relative to the adolescent's feelings. c. Assist the adolescent to differentiate reality from perceptions. d. Assess and document the adolescent's level of depression daily

c. Assist the adolescent to differentiate reality from perceptions.

A young adult has been admitted to the emergency department with nausea and vomiting. Which action could the RN delegate to unlicensed assistive personnel (UAP)? a. Auscultate the bowel sounds. b. Assess for signs of dehydration. c. Assist the patient with oral care. d. Ask the patient about the nausea

c. Assist the patient with oral care.

A patient is being admitted for bariatric surgery. Which nursing action can the nurse delegate to unlicensed assistive personnel (UAP)? a. Demonstrate use of the incentive spirometer. b. Plan methods for turning the patient after surgery. c. Assist with IV insertion by holding adipose tissue out of the way. d. Develop strategies to provide privacy and decrease embarrassment.

c. Assist with IV insertion by holding adipose tissue out of the way.

A nurse prepares to lead a discussion at a community health center regarding children's health. The nurse wants to use current terminology when teaching about these issues. Which terms are appropriate for the nurse to use? (Select all that apply.) a. Mental retardation b. Asperger's disorder c. Autism spectrum disorder d. Pervasive developmental disorder e. Intellectual development disorder

c. Autism spectrum disorder e. Intellectual development disorder

A 68-yr-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), what should the nurse plan to assess more frequently than is routine? a. Apical pulse b. Bowel sounds c. Breath sounds d. Abdominal girth

c. Breath sounds

A 19-yr-old woman is brought to the emergency department with a knife handle protruding from her abdomen. What should the nurse do during the initial assessment of the patient? 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. Check for circulation and tissue perfusion

Four hours after a bowel resection, a 74-yr-old male patient with a nasogastric tube to suction reports nausea and abdominal distention. What should be the nurse's first action? a. Auscultate for hypotonic bowel sounds. b. Notify the patient's health care provider. c. Check for tube placement and reposition it. d. Remove the tube and replace it with a new one

c. Check for tube placement and reposition it.

Which patient choice for a snack 3 hours before bedtime indicates that the nurse's 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. Cherry gelatin with fruit

A 15-year-old adolescent has run away from home six times. After the adolescent was arrested for prostitution, the parents told the court, "We can't manage our teenager." The adolescent is physically abusive to the mother and defiant with the father. The adolescent's problem is most consistent with criteria for which disorder? a. Attention-deficit/hyperactivity disorder (ADHD) b. Childhood depression c. Conduct disorder (CD) d. Autism spectrum disorder (ASD)

c. Conduct disorder (CD)

A 72-yr-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. Skin is dry with tenting and poor turgor. b. Patient has not voided for the last 2 hours. c. Crackles are heard halfway up the posterior chest. d. Patient has had 5 loose stools over the previous 6 hours.

c. Crackles are heard halfway up the posterior chest.

A patient diagnosed with schizophrenia says, "My coworkers are out to get me. I also saw two doctors plotting to overdose me." What term identifies how this patient is perceiving the environment? a. Disorganized b. Unpredictable c. Dangerous d. Bizarre

c. Dangerous

Which activity in the care of a patient with a new colostomy could the nurse delegate to unlicensed assistive personnel (UAP)? a. Document the appearance of the stoma. b. Place a pouching system over the ostomy. c. Drain and measure the output from the ostomy. d. Check the skin around the stoma for breakdown

c. Drain and measure the output from the ostomy.

The nurse is caring for a patient on the first postoperative day after a Roux-en-Y gastric bypass procedure. Which assessment finding should be reported immediately to the provider? a. Bilateral crackles audible at both lung bases b. Redness, irritation, and skin breakdown in skinfolds c. Emesis of bile-colored fluid past the nasogastric (NG) tube d. Use of patient-controlled analgesia (PCA) several times an hour for pain

c. Emesis of bile-colored fluid past the nasogastric (NG) tube

A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which response by the nurse reflects accurate knowledge about the medication and the patient's illness? a. Ask the patient about any visual changes in red-green color discrimination. b. Question the patient about experiencing shortness of breath, hives, or itching. c. Explain that orange discolored urine and tears are normal while taking this medication. d. Advise the patient to stop the drug and report the symptoms to the health care provider.

c. Explain that orange discolored urine and tears are normal while taking this medication.

An adolescent diagnosed with generalized anxiety disorder says, "My parents focus all their attention on my brother instead of me. He's perfect in their eyes." Which type of therapy might promote the greatest change in this adolescent's behavior? a. Bibliotherapy b. Play therapy c. Family therapy d. Behavior modification therapy

c. Family therapy

The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy. Which information should the nurse include about the patient's postoperative care? a. Bed rest for the first 24 hours b. Positioning only on the right side c. Frequent use of an incentive spirometer d. Chest tube placement to continuous suction

c. Frequent use of an incentive spirometer

A patient with bacterial pneumonia has coarse crackles and thick sputum. Which action should the nurse plan to promote airway clearance? a. Restrict oral fluids during the day. b. Encourage pursed-lip breathing technique. c. Help the patient to splint the chest when coughing. d. Encourage the patient to wear the nasal O2 cannula.

c. Help the patient to splint the chest when coughing.

Which behavior indicates that the treatment plan for a child diagnosed with autism spectrum disorder was effective? a. Plays with one toy for 90 minutes. b. Repeats words spoken by a parent. c. Holds the parent's hand while walking. d. Spins around and claps hands while walking

c. Holds the parent's hand while walking.

A patient is admitted to the emergency department with severe abdominal pain and rebound tenderness. Vital signs include temperature 102° F (38.3° C), pulse 120 beats/min, respirations 32 breaths/min, and blood pressure (BP) 82/54 mm Hg. Which prescribed intervention should the nurse implement first? a. Administer IV ketorolac 15 mg for pain relief. b. Send a blood sample for a complete blood count (CBC). c. Infuse a liter of lactated Ringer's solution over 30 minutes. d. Send the patient for an abdominal computed tomography (CT) scan

c. Infuse a liter of lactated Ringer's solution over 30 minutes.

A patient in the emergency department has just been diagnosed with peritonitis from a ruptured diverticulum. Which prescribed intervention will the nurse implement first? a. Send the patient for a CT scan. b. Insert a urinary catheter to drainage. c. Infuse metronidazole (Flagyl) 500 mg IV. d. Place a nasogastric tube to intermittent low suction.

c. Infuse metronidazole (Flagyl) 500 mg IV.

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. What should the nurse teach the patient to do? 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. Lie down for about 30 minutes after eating.

What information will the nurse include in teaching for a 35-yr-old woman who is overweight and starting a weight-loss plan? a. Weigh yourself at the same time every morning and evening. b. Stick to a 600- to 800-calorie diet for the most rapid weight loss. c. Low carbohydrate diets lead to rapid weight loss but are difficult to maintain. d. Weighing all foods on a scale is necessary to choose appropriate portion sizes

c. Low carbohydrate diets lead to rapid weight loss but are difficult to maintain.

A 76-yr-old patient with obstipation has a fecal impaction and is incontinent of liquid stool. Which action should the nurse take first? a. Administer bulk-forming laxatives. b. Assist the patient to sit on the toilet. c. Manually remove the impacted stool. d. Increase the patient's oral fluid intake.

c. Manually remove the impacted stool.

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

c. Medicate the patient with prescribed morphine.

A nurse will prepare teaching materials regarding which medication for the parents of a child diagnosed with enuresis? a. Haloperidol b. Desmopressin c. Methylphenidate d. Carbamazepine

c. Methylphenidate

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. Oatmeal with cream

A patient has a chest wall contusion as a result of being struck in the chest with a baseball bat. Which initial assessment finding is of most concern to the emergency department nurse? a. Report of chest wall pain b. Heart rate of 110 beats/min c. Paradoxical chest movement d. Large bruised area on the chest

c. Paradoxical chest movement

Which finding indicates to the nurse that the administered nifedipine (Procardia) was effective for a patient who has idiopathic pulmonary arterial hypertension (IPAH)? a. Heart rate is between 60 and 100 beats/min. b. Patient's chest x-ray indicates clear lung fields. c. Patient reports a decrease in exertional dyspnea. d. Blood pressure (BP) is less than 140/90 mm Hg.

c. Patient reports a decrease in exertional dyspnea.

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. Patient schedules an appointment for allergy testing.

Which action will the nurse include in the plan of care for a patient who is being admitted with Clostridium difficile? a. Teach the patient about proper food storage. b. Order a diet without dairy products for the patient. c. Place the patient in a private room on contact isolation. d. Teach the patient about why antibiotics will not be used.

c. Place the patient in a private room on contact isolation.

A patient diagnosed with schizophrenia has auditory hallucinations, delusions of grandeur, poor personal hygiene, and motor agitation. Which assessment finding would the nurse regard as a negative symptom of schizophrenia? a. Auditory hallucinations b. Delusions of grandeur c. Poor personal hygiene d. Motor agitation

c. Poor personal hygiene

Which action should the nurse take to prepare a patient with a pleural effusion for a thoracentesis? a. Remind the patient not to eat or drink 6 hours. b. Start a peripheral IV line to administer sedation. c. Position the patient sitting up on the side of the bed. d. Obtain a collection device to hold 3 liters of pleural fluid.

c. Position the patient sitting up on the side of the bed.

A patient diagnosed with schizophrenia has taken fluphenazine 5 mg orally twice daily for 3 weeks. The nurse now assesses a shuffling, propulsive gait; a masklike face; and drooling. Which term applies to these symptoms? a. Neuroleptic malignant syndrome b. Hepatocellular effects c. Pseudoparkinsonism d. Akathisia

c. Pseudoparkinsonism

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 patches on the buccal mucosa d. Curdlike plaques on the posterior tongue

c. Red patches on the buccal mucosa

An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action recommended by the nurse is intended to prevent lung disease? a. Treat workers with pulmonary fibrosis. b. Teach about symptoms of lung disease. c. Require the use of protective equipment. d. Monitor workers for coughing and wheezing.

c. Require the use of protective equipment.

While interviewing a young adult patient, the nurse learns that the patient has a family history of familial adenomatous polyposis (FAP). What area of patient knowledge should the nurse plan to assess? a. Preventing noninfectious hepatitis b. Treating inflammatory bowel disease c. Risk for developing colorectal cancer d. Using antacids and proton pump inhibitors

c. Risk for developing colorectal cancer

When a 5-year-old child is disruptive, the nurse says, "You must take a time-out." The expectation is that the child will demonstrate what behavior? a. Go to a quiet room until called for the next meal. b. Slowly count to 20 before returning to the group activity. c. Sit on the edge of the activity until able to regain self-control. d. Sit quietly on the lap of a staff member until able to apologize for the behavior.

c. Sit on the edge of the activity until able to regain self-control.

A desired outcome for a 12-year-old diagnosed with oppositional defiant disorder (ODD) is to improve relationships with other children. Which treatment modality should the nurse suggest for the plan of care? a. Bibliotherapy b. Music therapy c. Social skills groups d. Behavior modification

c. Social skills groups

A young adult 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. Assist the patient to cough and deep breathe. b. Palpate the abdomen for rebound tenderness. c. Suggest the patient lie on the side, flexing the right leg. d. Encourage the patient to sip clear, noncarbonated liquids.

c. Suggest the patient lie on the side, flexing the right leg.

After a patient has had a hemorrhoidectomy at an outpatient surgical center, which instructions will the nurse include in discharge teaching? a. Maintain a low-residue diet until the surgical area is healed. b. Use ice packs on the perianal area to relieve pain and swelling. c. Take prescribed pain medications before you expect a bowel movement. d. Delay having a bowel movement for several days until you are well healed

c. Take prescribed pain medications before you expect a bowel movement.

The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take? a. Teach about the reason for the blood tests. b. Schedule an appointment for a chest x-ray. c. Teach the patient about providing specimens for 3 consecutive days. d. Instruct the patient to collect several separate sputum specimens today

c. Teach the patient about providing specimens for 3 consecutive days.

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

c. Teaching patients about the need for adult pertussis immunizations

The nurse is caring for a patient with idiopathic pulmonary arterial hypertension (IPAH). Which assessment information requires the most immediate action by the nurse? a. The O2 saturation is 90%. b. The blood pressure is 98/56 mm Hg. c. The epoprostenol (Flolan) infusion is disconnected. d. The international normalized ratio (INR) is prolonged

c. The epoprostenol (Flolan) infusion is disconnected.

A patient 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 101.4° F. d. The apical pulse is 100 beats/min

c. The oral temperature is 101.4° F.

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 reports 7/10 (0 to 10 scale) abdominal pain. b. The patient is experiencing intermittent waves of nausea. c. The patient has no breath sounds in the left anterior chest. d. The patient has hypoactive bowel sounds in all four quadrants.

c. The patient has no breath sounds in the left anterior chest.

A 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 had a small intestinal resection.

c. The patient is lethargic and difficult to arouse.

A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment is effective? a. Bronchial breath sounds are heard at the right base. b. The patient coughs up small amounts of green mucus. c. The patient's white blood cell (WBC) count is 6000/µL. d. Increased tactile fremitus is palpable over the right chest

c. The patient's white blood cell (WBC) count is 6000/µL.

Which information about an 80-yr-old male patient at the senior center is of most concern to the nurse? a. Decreased appetite b. Occasional indigestion c. Unintended weight loss d. Difficulty chewing food

c. Unintended weight loss

A patient vomiting blood-streaked fluid is admitted to the hospital with acute gastritis. What should the nurse ask the patient about to determine possible risk factors for gastritis? a. The amount of saturated fat in the diet b. A family history of gastric or colon cancer c. Use of nonsteroidal antiinflammatory drugs d. A history of a large recent weight gain or loss

c. Use of nonsteroidal antiinflammatory drugs

Four months after bariatric surgery, a patient tells the nurse, "My skin is hanging off me. I think I might want to surgery to remove the skinfolds." Which response by the nurse is most appropriate? a. "The important thing is that you are improving your health." b. "The skinfolds show everyone how much weight you have lost." c. "Perhaps you should talk to a counselor about your body image." d. "Cosmetic surgery may be possible once your weight has stabilized."

d. "Cosmetic surgery may be possible once your weight has stabilized."

The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is important for the nurse to ask before the skin test? a. "Do you take any over-the-counter (OTC) medications?" b. "Do you have any family members with a history of TB?" c. "How long has it been since you moved to the United States?" d. "Did you receive the bacille Calmette-Guérin (BCG) vaccine for TB?"

d. "Did you receive the bacille Calmette-Guérin (BCG) vaccine for TB?"

Which question from the nurse would help determine if a patient's abdominal pain might indicate irritable bowel syndrome (IBS)? 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. "How long have you had abdominal pain?"

A patient diagnosed with schizophrenia tells the nurse, "I eat skiller. Tend to end. Easter. It blows away. Get it?" Select the nurse's best response. a. "Nothing you are saying is clear." b. "Your thoughts are very disconnected." c. "Try to organize your thoughts, and then tell me again." d. "I am having difficulty understanding what you are saying."

d. "I am having difficulty understanding what you are saying."

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 take an antacid for indigestion several times a week" d. "I use acetaminophen (Tylenol) every 4 hours for pain."

d. "I use acetaminophen (Tylenol) every 4 hours for pain."

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

d. "I will call the health care provider right away if I develop a fever."

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

d. "I will use the incentive spirometer every hour or two during the day."

How should the nurse explain esomeprazole (Nexium) to a patient with recurring heartburn? a. "It reduces gastroesophageal reflux by increasing the rate of gastric emptying." b. "It neutralizes stomach acid and provides relief of symptoms in a few minutes." c. "It coats and protects the lining of the stomach and esophagus from gastric acid." d. "It treats gastroesophageal reflux disease by decreasing stomach acid production."

d. "It treats gastroesophageal reflux disease by decreasing stomach acid production."

A 4-year-old child cries and screams from the time the parents leave the child at preschool until the child is picked up 4 hours later. The child is calm and relaxed when the parents are present. The parents ask, "What should we do?" What is the nurse's best recommendation? a. "Send a picture of yourself to school to keep with the child." b. "Arrange with the teacher to let the child call home at playtime." c. "Talk with the school about withdrawing the child until maturity increases." d. "Talk with your health care provider about a referral to a mental health professional."

d. "Talk with your health care provider about a referral to a mental health professional."

tells the nurse, "The voice is telling me to do things." Select the nurse's priority assessment question. a. "How long has the voice been directing your behavior?" b. "Do the messages from the voice frighten you?" c. "Do you recognize the voice speaking to you?" d. "What is the voice telling you to do?"

d. "What is the voice telling you to do?"

A nurse sits with a patient diagnosed with schizophrenia. The patient starts to laugh uncontrollably, although the nurse has not said anything funny. Select the nurse's best response. a. "Why are you laughing?" b. "Please share the joke with me." c. "I don't think I said anything funny." d. "You are laughing. Tell me what's happening."

d. "You are laughing. Tell me what's happening."

Which patient diagnosed with schizophrenia would be expected to have the lowest level of overall functioning? a. 39 years old; paranoid ideation since age 35 years b. 32 years old; isolated episodes of catatonia since age 24 years; stable for 3 years c. 19 years old; diagnosed with schizophreniform disorder 6 months ago d. 40 years old; frequent relapses since age 18; often does not take medication as prescribed

d. 40 years old; frequent relapses since age 18; often does not take medication as prescribed

A nurse assesses the four children below. Which assessment findings should prompt the nurse to refer the child for further evaluation? a. A 4-year-old who stuttered for 3 weeks after the birth of a sibling. b. A 9-month-old who does not eat vegetables and likes to be rocked. c. A 3-month-old who cries after feeding until burped and sucks a thumb. d. A 3-year-old who is mute, passive toward adults, and twirls while walking

d. A 3-year-old who is mute, passive toward adults, and twirls while walking

What is a likely finding in the nurse's assessment of a patient who has a large bowel obstruction? a. Referred back pain b. Metabolic alkalosis c. Projectile vomiting d. Abdominal distention

d. Abdominal distention

The health care provider prescribes antacids and sucralfate (Carafate) for treatment of a patient's peptic ulcer. What should the nurse 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. Antacids after meals and sucralfate 30 minutes before meals

A 40-yr-old male patient has had a herniorrhaphy to repair an incarcerated inguinal hernia. Which patient teaching will the nurse provide before discharge? a. Soak in Sitz baths several times each day. b. Cough 5 times each hour for the next 48 hours. c. Avoid using acetaminophen (Tylenol) for pain. d. Apply a scrotal support and ice to reduce swelling

d. Apply a scrotal support and ice to reduce swelling

A health care provider considers which antipsychotic medication to prescribe for a patient diagnosed with schizophrenia who has auditory hallucinations and poor social functioning. The patient is also overweight. Which drug should the nurse advocate? a. Clozapine b. Ziprasidone c. Olanzapine d. Aripiprazole

d. Aripiprazole

A patient diagnosed with schizophrenia says, "High heat. Last time here. Did you get a coat?" What type of verbalization is evident? a. Neologism b. Idea of reference c. Thought broadcasting d. Associative looseness

d. Associative looseness

A 5-year-old child moves and talks constantly. The child awakens before the parents every morning. The child attends kindergarten, but the teacher reports difficulty handling the behavior. What is this child's most likely problem? a. Tic disorder b. Oppositional defiant disorder (ODD) c. Intellectual development disorder (IDD) d. Attention-deficit/hyperactivity disorder (ADHD)

d. Attention-deficit/hyperactivity disorder (ADHD)

Patients diagnosed with schizophrenia who are suspicious and withdrawn generally present with what additional characteristic? a. Universally fear sexual involvement with therapists. b. Are socially disabled by the positive symptoms of schizophrenia. c. Exhibit a high degree of hostility as evidenced by rejecting behavior. d. Avoid relationships because they become anxious with emotional closeness.

d. Avoid relationships because they become anxious with emotional closeness.

The emergency department nurse notes tachycardia and absent breath sounds over the right thorax of a patient who has just arrived after an automobile accident. For which intervention will the nurse prepare the patient? a. Emergency pericardiocentesis b. Stabilization of the chest wall c. Bronchodilator administration d. Chest tube connected to suction

d. Chest tube connected to suction

.What should the nurse plan to teach about to a patient with Crohn's disease who has megaloblastic anemia? a. Iron dextran infusions b. Oral ferrous sulfate tablets c. Routine blood transfusions d. Cobalamin (B12) supplements

d. Cobalamin (B12) supplements

What condition should the nurse anticipate when caring for a patient with a history of a total gastrectomy? a. Constipation b. Dehydration c. Elevated total serum cholesterol d. Cobalamin (vitamin B12) deficiency

d. Cobalamin (vitamin B12) deficiency

A nurse assesses a 3-year-old diagnosed with autism spectrum disorder. Which finding is most associated with the child's disorder? a. Has occasional toileting accidents. b. Is unable to read children's books. c. Cries when separated from a parent. d. Continuously rocks in place for 30 minutes.

d. Continuously rocks in place for 30 minutes.

A patient diagnosed with schizophrenia anxiously says, "I can see the left side of my body merging with the wall, then my face appears and disappears in the mirror." What phenomena is the patient describing? a. Derealization b. Concrete thinking c. Abstract thinking d. Depersonalization

d. Depersonalization

A patient is transferred from the recovery room to a surgical unit after a transverse colostomy. The nurse observes the stoma to be deep pink with edema and a small amount of sanguineous drainage. What action should the nurse take? a. Place ice packs around the stoma. b. Notify the surgeon about the stoma. c. Monitor the stoma every 30 minutes. d. Document stoma assessment findings.

d. Document stoma assessment findings.

A patient with a possible pulmonary embolism reports chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, and respirations of 42 breaths/min. Which action should the nurse take first? a. Administer anticoagulant drug therapy. b. Notify the patient's health care provider. c. Prepare patient for a spiral computed tomography (CT). d. Elevate the head of the bed to a semi-Fowler's position.

d. Elevate the head of the bed to a semi-Fowler's position.

A parent diagnosed with schizophrenia and 13-year-old child live in a homeless shelter. The child has formed a trusting relationship with a volunteer. The teen says, "I have three good friends at school. We talk and sit together at lunch." What is the nurse's best suggestion to the treatment team? a. Suggest foster home placement. b. Seek assistance from an intimate partner violence program. c. Make referrals for existing and emerging developmental problems. d. Encourage healthy characteristics and existing environmental supports.

d. Encourage healthy characteristics and existing environmental supports.

A 15-year-old adolescent is referred to a residential program after an arrest for theft and running away from home. At the program, the adolescent refuses to participate in scheduled activities and pushes a staff member, causing a fall. Which approach by the nursing staff would be most therapeutic? a. Neutrally permit refusals. b. Coax to gain compliance. c. Offer rewards in advance. d. Establish firm limits.

d. Establish firm limits.

A patient diagnosed with schizophrenia demonstrates paranoid thinking. The patient angrily tells a nurse, "You are mean and nasty. No one trusts you or wants to be around you." What is the likely motivation behind this behavior? a. Attempting to manipulate the nurse by using negative comments b. The prelude to disorganization and catatonia in the near future c. Jealousy of the nurse's position of power in the relationship d. Identifying another person's shortcomings in order to preserve his or her own self-esteem

d. Identifying another person's shortcomings in order to preserve his or her own self-esteem

A patient with pneumonia has a fever of 101.4° F (38.6° C), a nonproductive cough, and an O2 saturation of 88%. The patient is weak and needs assistance to get out of bed. Which patient problem should the nurse assign as the priority? a. Fatigue b. Hyperthermia c. Impaired mobility d. Impaired gas exchange

d. Impaired gas exchange

A patient who has chronic constipation asks the nurse about the use of psyllium (Metamucil). Which information will the nurse include in the response? a. Fiber-containing laxatives may reduce the absorption of fat-soluble vitamins. b. Dietary sources of fiber should be eliminated to prevent excessive gas formation. c. Use of this type of laxative to prevent constipation does not cause adverse effects. d. Large amounts of fluid should be taken to prevent impaction or bowel obstruction.

d. Large amounts of fluid should be taken to prevent impaction or bowel obstruction.

An 80-yr-old patient who is hospitalized with peptic ulcer disease develops new-onset auditory hallucinations. Which prescribed medication will the nurse discuss with the health care provider before administration? a. Sucralfate (Carafate) b. Aluminum hydroxide c. Omeprazole (Prilosec) d. Metoclopramide (Reglan)

d. Metoclopramide (Reglan)

A patient who takes a nonsteroidal antiinflammatory drug (NSAID) daily for the management of severe rheumatoid arthritis has recently developed melena. What should the nurse anticipate teaching the patient? a. Substitution of acetaminophen (Tylenol) for the NSAID b. Use of enteric-coated NSAIDs to reduce gastric irritation c. Reasons for using corticosteroids to treat the rheumatoid arthritis d. Misoprostol (Cytotec) to protect the gastrointestinal (GI) mucos

d. Misoprostol (Cytotec) to protect the gastrointestinal (GI) mucos

A patient receiving risperidone reports severe muscle stiffness at 10:30 am. By noon, the patient is diaphoretic, drooling, and has difficulty swallowing. By 4:00 pm, vital signs are body temperature, 102.8° F; pulse, 110 beats/min; respirations, 26 breaths per minute; and blood pressure, 150/90 mm Hg. Select the nurse's best analysis and action. a. Agranulocytosis. Institute reverse isolation. b. Tardive dyskinesia. Withhold the next dose of medication. c. Cholestatic jaundice. Begin a high-protein, low-fat diet. d. Neuroleptic malignant syndrome. Immediately notify the health care provider.

d. Neuroleptic malignant syndrome. Immediately notify the health care provider.

A 73-yr-old patient is diagnosed with stomach cancer after an unintended 20-lb 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. Offer supplemental feedings between meals

A patient diagnosed with schizophrenia says, "Everyone has skin lice that jump on you and contaminate your blood." Which problem is evident? a. Poverty of content b. Concrete thinking c. Neologisms d. Paranoia

d. Paranoia

A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and severe pleuritic chest pain. Which prescribed medication should the nurse give first? a. Codeine b. Guaifenesin c. Acetaminophen (Tylenol) d. Piperacillin/tazobactam (Zosyn)

d. Piperacillin/tazobactam (Zosyn)

The nurse is caring for a patient who develops watery diarrhea and a fever after prolonged omeprazole (Prilosec) therapy. In which order will the nurse take actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Contact the health care provider. b. Assess blood pressure and heart rate. c. Give the PRN acetaminophen (Tylenol). d. Place the patient on contact precautions

d. Place the patient on contact precautions b. Assess blood pressure and heart rate. a. Contact the health care provider c. Give the PRN acetaminophen (Tylenol).

After several days of antibiotic therapy for pneumonia, 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 hand washing. d. Place the patient on contact precautions.

d. Place the patient on contact precautions.

When group therapy is to be used as a treatment modality, the nurse should suggest placing a 9-year-old in a group that focuses on what? a. Play activities exclusively. b. Group discussion exclusively. c. Talk focused on a specific issue. d. Play and then talk about the play activity.

d. Play and then talk about the play activity.

What should the nurse anticipate teaching a patient with a new report of heartburn? a. A barium swallow b. Radionuclide tests c. Endoscopy procedures d. Proton pump inhibitors

d. Proton pump inhibitors

A patient diagnosed with schizophrenia has been stable for a year; however, the family now reports the patient is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating. The patient says, "Demons are in the basement and they can come through the floor." The nurse can correctly assess this information as what? a. Need for psychoeducation b. Medication nonadherence c. Chronic deterioration d. Relapse

d. Relapse

A patient is hospitalized with active tuberculosis (TB). Which assessment finding indicates to the nurse that prescribed airborne precautions are likely to be discontinued? a. Chest x-ray shows no upper lobe infiltrates. b. TB medications have been taken for 6 months. c. Mantoux testing shows an induration of 10 mm. d. Sputum smears for acid-fast bacilli are negative.

d. Sputum smears for acid-fast bacilli are negative.

After sleeve gastrectomy, a 42-yr-old male patient returns to the surgical nursing unit with a nasogastric tube to low, intermittent suction and a patient-controlled analgesia (PCA) machine for pain control. Which nursing action should be included in the postoperative plan of care? a. Offer sips of fruit juices at frequent intervals. b. Irrigate the nasogastric (NG) tube frequently. c. Remind the patient that PCA use may slow the return of bowel function. d. Support the surgical incision during patient coughing and turning in bed.

d. Support the surgical incision during patient coughing and turning in bed.

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. Taking the blood pressure (BP) and pulse

A patient is admitted to the emergency department with an open stab wound to the left chest. What action should the nurse take? a. Keep the head of the patient's bed positioned flat. b. Cover the wound tightly with an occlusive dressing. c. Position the patient so that the left chest is dependent. d. Tape a nonporous dressing on three sides over the wound.

d. Tape a nonporous dressing on three sides over the wound.

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

d. Teach about the need for prolonged antibiotic therapy after discharge from the hospital

A patient 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. The patient ate a low-fat bagel 4 hours ago for breakfast

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

d. The patient is being treated with antiretrovirals for HIV infection

The nurse supervises unlicensed assistive personnel (UAP) providing care for a patient who has right lower lobe pneumonia. Which action by the UAP requires the nurse to intervene? a. UAP assists the patient to ambulate to the bathroom. b. UAP helps splint the patient's chest during coughing. c. UAP transfers the patient to a bedside chair for meals. d. UAP lowers the head of the patient's bed to 15 degrees.

d. UAP lowers the head of the patient's bed to 15 degrees.