Excelsior College Lifespan 1 Exams

A charge nurse is instructing a student nurse on the use of erythropoietin for managing anemia in patients who object to blood transfusions. Which statement demonstrates that the student nurse understands this medication? 1. "Synthetic erythropoietin stimulates erythropoiesis. The patient will have serial CBCs and the dosage will be titrated to the hemoglobin." 2. "Synthetic erythropoietin stimulates bone marrow production of erythropoietin so that the adrenals don't work as hard." 3. "Synthetic erythropoietin increases the production of all blood components and effectively treats blood dyscrasias." 4. "Synthetic erythropoietin is most effective in treating the anemia associated with kidney failure."

1. "Synthetic erythropoietin stimulates erythropoiesis. The patient will have serial CBCs and the dosage will be titrated to the hemoglobin." *1) Synthetic erythropoietin stimulates erythropoiesis. The patient will have serial complete blood counts (CBCs) completed. As the hemoglobin rises, the dose will be titrated to achieve therapeutic levels. Synthetic erythropoietin should no longer be administered once hemoglobin levels reach 12 g/dL.

A patient is in sickle cell crisis. Which laboratory values should the RN report to the health care provider? (Select all that apply.) 1. Hemoglobin of 7.3 g/dL 2. Bilirubin of 2.2 mg/dL 3. White blood cell (WBC) count of 12,580 4. Platelet count of 220,000 5.Partial thromboplastin time (PTT) of 13.2 seconds

*1) Sickle cell does result in anemia, so hemoglobin would be lower than 12 to 16 g/dL. *2) Bilirubin would be elevated above the normal of 0 to1 mg/dL. *3) WBCs would be elevated above the normal of 4500 to 10,000/mm3.

A patient presents at a hematology clinic for a blood transfusion and asks, "Can I catch anything from a blood transfusion?" The nurse would base the response on knowledge that which of the following diseases may be transmitted via blood transfusion? Answers: 1. Hepatitis A 2. Hepatitis B 3. Hepatitis C 4. Cytomegalovirus (CMV) 5. Human Immunodeficiency Virus (HIV)

*2) Hepatitis B may be transmitted via blood transfusions. There is a greater risk from pooled blood products and from the blood of paid donors than from volunteer donors. A screening test detects most cases of hepatitis B. *3) Hepatitis C may be transmitted via blood transfusions. There is a greater risk from pooled blood products and from the blood of paid donors than from volunteer donors. A screening test detects most cases of hepatitis C. *4) Cytomegalovirus may be transmitted via blood transfusions. Transmittal risk is greater for premature newborns with CMV antibody-negative mothers and for immunocompromised recipients who are CMV negative (e.g., those with acute leukemia, organ, or tissue transplant recipients). Blood products rendered "leukocyte reduced" help reduce transmission of virus. *5) Human Immunodeficiency Virus may be transmitted via blood transfusions. Donated blood is screened for antibodies to HIV.Transmittal risk is estimated at 1:1.5 million per transfusion. People with high-risk behaviors (multiple sex partners, anal sex, IV/injection drug use) and people with signs and symptoms that suggest AIDS should not donate blood.

A patient receiving a vinca alkaloid to manage cancer reports feeling very clumsy and having trouble using buttons on clothing to the home health RN. Which statement is the RN's best response? 1. "Are you weak and dizzy when you try to stand up?" 2. "This is normal and will go away when your therapy is complete." 3. "Have you noticed any change in your bowel movements?" 4. "There is no reason to worry about a minor side effect of the medication."

1. "Are you weak and dizzy when you try to stand up?"

Respiratory Problems Which statement by the patient indicates to the RN that more teaching is needed about montelukast, a leukotriene receptor antagonist? Answers: 1. "I'll have to have blood drawn regularly to check my kidney function." 2. "I can't take this med with St John's wort without talking to my provider." 3. "This medicine is used for maintenance every day to prevent asthma." 4. "If I drink black or green tea with this medicine, it will make me more nervous."

1. "I'll have to have blood drawn regularly to check my kidney function." *1) This is incorrect. The medication affects liver function.

Abnormal Cellular Growth Which is the most appropriate action for the RN to take when a patient is experiencing nausea related to chemotherapy? Answers: 1. Administer prescribed antiemetics prior to chemotherapy. 2. Suggest foods that look and taste appealing. 3. Provide small, frequent meals. 4. Limit fluid intake prior to chemotherapy.

1. Administer prescribed antiemetics prior to chemotherapy. 1)This is the single most important action.

Which outcome is most appropriate for the nursing diagnosis Activity intolerance for the patient with chronic obstructive pulmonary disease (COPD)? The patient will: 1. Ambulate 100 feet without experiencing dyspnea 2. Drink at least 2,500 mL of water each day. 3. Shower immediately after waking up in the morning. 4. Demonstrate pursed-lip breathing.

1. Ambulate 100 feet without experiencing dyspnea

Abnormal Cellular Growth In planning a presentation for a support group of clients with cancer, the RN should include which information about metastasis? Selected Answer: 1. Cancer cells can enter blood vessels and go to other parts of the body. Answers: 1. Cancer cells can enter blood vessels and go to other parts of the body. 2. Chemotherapy combinations are designed to prevent metastasis. 3. The lymphatic system promotes tumor growth. 4. X-ray therapy cannot be used after metastasis occurs.

1. Cancer cells can enter blood vessels and go to other parts of the body. *1) Cancer cells traveling in the bloodstream is one of the primary mechanisms of metastasis.

Cardiovascular Problems An RN is teaching the parents of a school-age child about dietary modifications to reduce the child's risk of hypertension. Which food choices should be limited? (Select all that apply.) Answers: 1. Canned soups 2. Fresh fruits 3. Lunch meats 4. Boiled eggs 5. Potato chips.

1. Canned soups 3. Lunch meats 5. Potato chips

Which assessment finding in the client diagnosed with COPD would support a nursing diagnosis of Impaired gas exchange? 1. Coarse crackles in bilateral upper and bilateral lower lobes. 2. Capillary refill of less than 3 seconds on index finger. 3. Use of pursed lip breathing and three-point positioning. 4. Decrease in oxygen saturation when sleeping.

1. Coarse crackles in bilateral upper and bilateral lower lobes.

Respiratory Problems An RN is assessing a patient with emphysema. Which assessment findings would the RN anticipate in the patient with cor pulmonale? (Select all that apply.) Selected Answers: Answers: 1. Dependent edema 2. Distended neck veins 3. Hepatic tenderness 4. Loss of nail bed angle 5. Presence of barrel chest

1. Dependent edema 2. Distended neck veins 3. Hepatic tenderness Response Feedback: *1) Cor pulmonale, one of the complications of emphysema, is right-sided heart failure brought on by long-term high blood pressure in the pulmonary arteries. This high pressure in the pulmonary arteries and right ventricle lead to back up of blood in the venous system, resulting in dependent edema, distended neck veins, or pain in the region of the liver. *2) See 1). *3) See 1)

A patient receiving a blood transfusion begins to complain of low back pain, nausea, and difficulty breathing. What should be the RN's first action? 1. Discontinue the transfusion. 2. Assess the patient's vital signs. 3. Notify the health care provider. 4. Administer Benadryl 25 mg IV.

1. Discontinue the transfusion. *1) The symptoms described above indicate that the patient is experiencing an acute hemolytic reaction, which is the most dangerous and life-threatening of transfusion reactions. During a severe transfusion reaction, the nurse should immediately discontinue the transfusion.

An RN administering vincristine (Oncovin) to a patient with head and neck cancer should monitor the patient for which possible side effects? Answers: 1. Hair loss, numbness, and decreased reflexes 2. Nausea, vomiting, and hemorrhagic cystitis 3. Weakness, ataxic gait, and diarrhea 4. Hypercalcemia, constipation, and fluid retention

1. Hair loss, numbness, and decreased reflexes *1) Neuropathy and alopecia are expected side effects of vincristine chemotherapy.

Respiratory Problems Which manifestation in a patient receiving oxygen therapy at 60% for more than 24 hours alerts the RN to the possibility of oxygen toxicity? Answers: 1. Increased dyspnea 2. Decreased rate and depth of respiration 3. Wheezing on inhalation and exhalation 4. Increased excretion of thick, white, frothy sputum

1. Increased dyspnea *1) Oxygen toxicity damages the alveolar membrane, stimulating the formation of a hyaline membrane and impairing gas exchange. Clients become increasingly more dyspneic and hypoxic.

Which intervention by the patient with sickle cell anemia indicates to the RN the need for more teaching? 1. The patient avoids crowds. 2. The patient restricts fluids. 3. The patient dresses warmly. 4. The patient exercises moderately.

2. The patient restricts fluids. *2) A patient with sickle cell anemia should be encouraged to maintain fluid intake. Dehydration is a common complication.

Cardiovascular Problems During morning assessment, the RN auscultates an extra heart sound that is high pitched and blowing, during the systolic phase. Which condition would the RN most likely suspect? Answers: 1. Mitral regurgitation 2. Congestive heart failure 3. Aortic stenosis 4. Dilated cardiomyopathy

1. Mitral regurgitation *1) Mitral valve prolapse (MVP) often presents with an extra heart sound, referred to as a mitral click. This is often the first and only sign of MVP. The systolic click is an early sign that a valve leaflet is ballooning into the left atrium. A murmur may also be heard.

Respiratory Problems Which interventions should the RN include in the plan of nursing care for a patient with chronic obstructive pulmonary disease (COPD)? (Select all that apply.) Answers: 1. Monitor pulse oximetry and arterial blood gases. 2. Monitor patterns of respirations and breath sounds. 3. Monitor cardiovascular status by assessing cardiac enzymes. 4. Monitor for gastrointestinal discomfort by abdominal palpation. 5. Monitor sputum for color, consistency, and amount.

1. Monitor pulse oximetry and arterial blood gases. 2. Monitor patterns of respirations and breath sounds. 3. Monitor cardiovascular status by assessing cardiac enzymes. 5. Monitor sputum for color, consistency, and amount. Response Feedback: *1) Monitoring pulse oximetry and arterial blood gases is important to ensure appropriate oxygenation for the patient with COPD. *2) Monitoring patterns of respiration and breath sounds is essential to identify changes in condition that may indicate complications, such as bronchospasm or improvements based on nursing interventions. *4) Abdominal palpation is appropriate for use in this situation. *5) Monitoring sputum can indicate the presence of infection.

A patient presents to the emergency department (ED) with reports of numb feet, weakness, and dizziness when standing. The patient's hemoglobin is 9.0 g/dL and hematocrit is 23.1%. What other assessment findings would the RN suspect? (Select all that apply.) 1. Pale conjunctiva 2. Fatigue 3. Tachycardia 4. Splenomegaly 5. Hyperreflexia

1. Pale conjunctiva 2. Fatigue 3. Tachycardia *1) Based on the symptoms described above and the patient's lab results, the patient is anemic. Common symptoms of anemia include weakness, fatigue, malaise, jaundice, pica, brittle nails, pale skin, pale mucosa, beefy (or smooth red and sore) tongue, tachycardia, palpitations, dizziness, and GI symptoms. *2) See 1). *3) See 1).

An RN is caring for a surgical patient who is 2 days post-colectomy. A chest X ray shows atelectasis. Lab results show an arterial blood gas of pH 7.30, PaCO2 45, and a plasma bicarbonate of 32. The RN interprets this data as indicating which of the following conditions? Answers: 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

1. Respiratory acidosis *1) Respiratory acidosis is a clinical disorder in which the pH is less than 7.35 and the PaCO2 is greater than 42 mm Hg and a compensatory increase in the plasma HCO3 occurs. This patient is hypoventilating.

Respiratory Problems Which measures should the RN implement in the plan of care for a child with asthma? (Select all that apply.) Answers: 1. Schedule the child for allergy skin testing. 2. Educate the child and parent on how to use a metered dose inhaler (MDI) 3. Have the child complete peak flow rate monitoring monthly. 4. Encourage the child to drink fluids, but avoid milk and milk products. 5. Administer the child's cough suppressants as ordered by the physician.

1. Schedule the child for allergy skin testing. 2. Educate the child and parent on how to use a metered dose inhaler (MDI) 4. Encourage the child to drink fluids, but avoid milk and milk products. *1) Therapy for children with asthma involves planning for skin testing and hyposensitization to identified allergens that may cause an asthma attack. *2) MDIs and nebulizers are used to treat children with asthma when they are having bronchospasm. *4) Children with asthma should not drink milk because it can cause thick mucus and difficulty swallowing.

An 89-year-old patient has been admitted to the emergency department (ED) for fatigue, weakness, dyspnea, and altered mental status. The patient has a history of congestive heart failure and type 1 diabetes. The RN notices that the patient is very pale. What lab result might point to the cause of these symptoms? Answers: 1. Serum ferritin 2. Blood glucose 3. Urinalysis 4. Liver enzymes

1. Serum ferritin *1) Iron deficiency is the predominant cause of anemia in the older people and best explain the symptoms.

In which position should the RN place the patient undergoing a thoracentesis? Answers: 1. Sitting on the edge of the bed with arms and head resting on the over-the-bed table 2. In a dorsal recumbent position with the lower extremities slightly elevated 3. On the affected side with the head of the bed lowered 4. Prone with a small pillow under the head and neck

1. Sitting on the edge of the bed with arms and head resting on the over-the-bed table *1) Thoracentesis is best performed on a patient who is seated with head and arms on the bedside table. If this is not possible, the health care provider will direct what position can be used.

A patient with secondary immune hemolytic anemia wants to complete four marathons per year. Which information should the RN provide to the patient? Selected Answer: 1. Stamina will improve as the hemoglobin increases after completing the corticosteroid regime. 2. The patient has a chronic condition, so activities must be approached cautiously, as the ability to heal, resist infections, and maintain stamina will diminish. 3. After the bone marrow transplant, the patient can resume the prior exercise routine. 4. The splenectomy, transfusions, and medications will prevent the patient from resuming a high level of activity.

1. Stamina will improve as the hemoglobin increases after completing the corticosteroid regime. *1) Corticosteroids may effect a remission but it is rarely permanent

The RN is teaching the patient with asthma how to administer 2 puffs of a metered-dose inhaler beta 2 agonist. What is the correct order of steps that the patient will need to take? Place in the correct order A. Check heart rate. B. Take a slow, deep breath using the spacer. C. Hold breath for several seconds after puff. D. Exhale with mouth open. E. Wait 2 minutes before administering second puff.

1. The patient needs to check their pulse first, as this medication can increase heart rate or cause an irregular heart rate. 2. The patient should exhale with their mouth open. The patient should then take a slow deep breath using the spacer. 3. The patient needs to hold their breath for several seconds after administering the medication. 4. The patient should wait 2 minutes between doses of the same medication to allow for absorption of the first dose.

The charge nurse is making patient assignments. Which patient should the RN assign to the licensed practical nurse (LPN)? 1. The patient who had a bronchoscopy 4 hours ago and has stable vital signs. 2. The patient with pneumonia who has a pulse oximetry reading of 90%. 3. The patient with a pulmonary contusion that has a constant cough and new confusion. 4. The patient with a chest tube who has jugular venous distention and a blood pressure of 96/60.

1. The patient who had a bronchoscopy 4 hours ago and has stable vital signs.

Which expected outcome is most appropriate for the RN to include in the home care plan for a patient with a new colostomy? Answers: 1. The patient will demonstrate colostomy care. 2. The patient will clean the colostomy site with sterile H2O. 3. The patient will check the colostomy bag daily. 4 The patient will irrigate the colostomy 2 times a day.

1. The patient will demonstrate colostomy care. *1) A return demonstration is the best way to ensure that the patient knows self-care techniques.

The RN administers the prescribed sedation to the intubated patient with acute respiratory distress syndrome (ARDS). What is the primary rationale for this intervention? 1. To decrease oxygen consumption. 2. To promote lung volume expansion. 3. To prevent mechanical ventilator malfunction. 4. To reduce the production of secretions.

1. To decrease oxygen consumption.

An RN teaches pursed-lip breathing exercises to patients with emphysema. What is the purpose of pursed-lip breathing? Answers: 1. To prolong exhalation and increase airway pressure during expiration 2. To shorten exhalation and increase airway pressure during inspiration 3. To shorten exhalation and decrease airway pressure during expiration 4. To prolong exhalation and increase airway pressure during inspiration

1. To prolong exhalation and increase airway pressure during expiration *1) Pursed-lip breathing slows (prolongs) exhalation and builds the patient's ability to control rate and depth of respiration.

Which patient would the RN identify as being at increased risk for aspiration? 1. The patient in a side lying position following an endoscopy. 2. The patient with a non functioning nasogastric tube. 3. The patient with an endotracheal tube with a cuff pressure of 25 cm H2O. 4. The patient with a tube feeding with the head of the bed at a 45 degree angle.

2. The patient with a non functioning nasogastric tube.

Cardiovascular Problems An RN is caring for a patient with a history of chronic obstructive pulmonary disease (COPD). The patient has oxygen therapy at 2 L/min, per nasal cannula, and reports increasing dyspnea with activity, and dry cough with occasional hemoptysis. How should the RN revise the plan of care?. Answers: 1.Auscultate the lungs more frequently to assess for crackles. 2. Increase oxygen to 6 L/minute by nasal cannula. 3. Administer furosemide (Lasix) to decrease blood pressure. 4. Assess blood pressure for increase in systolic pressure.

1.Auscultate the lungs more frequently to assess for crackles. *1) Cor pulmonale is a complication of pulmonary hypertension caused by COPD.

A patient has received a blood transfusion secondary to blood loss from a head laceration caused by a fall. Which statement by the patient indicates to the RN understanding of the discharge instructions? 1. "I hope all this new blood will stop the dizziness I had before I fell." 2. "I know I need to call you if I start feeling funny for the next day or two." 3. "I sure wish I would start breathing better now, rather than in a day or two." 4."I know I won't be able to donate blood any more since I have someone else's blood mixed with mine.

2. "I know I need to call you if I start feeling funny for the next day or two." *2) Delayed transfusion reactions can include febrile, non-hemolytic reaction and acute hemolytic reaction. Chills, fever, muscle stiffness, low back pain, nausea, chest tightness, dyspnea, and anxiety can all by symptoms of a significant problem and warrant a call to a provider/medical facility.

Which statement made by the patient following a bone marrow biopsy indicates to the RN that more discharge teaching is necessary? 1. "I may see some bruising in the area of the biopsy." 2. "I will take some aspirin to help manage the pain." 3. "I can take a nice warm tub bath to relieve the ache in my hip." 4. "I can remove the dressing after 24 hours."

2. "I will take some aspirin to help manage the pain."

Cardiovascular Problems A patient has a new diagnosis of hypertension. The physician has written an order to start hydrachlorothiazide (HTCZ) 12.5 mg by mouth every day. Which statement by the patient to the RN indicates that further teaching is needed about the medication? Selected Answer: 1. "I will include foods with potassium in my diet." Answers: 1. "I will include foods with potassium in my diet." 2. "I will take the medication on an empty stomach." 3. "I will use sunblock when in direct sunlight." 4. "I will make sure I change positions slowly."

2. "I will take the medication on an empty stomach." *2) Patients are encouraged to take the medication with food to avoid GI upset.

Which patient statement indicates to the RN a need for further education about the primary prevention of cancer? 1. "I will call my primary care provider to schedule a mammography." 2. "I will try to eat more fruits and vegetables." 3. "I will be sure to apply sunscreen when playing golf." 4. "I will join a smoking cessation class tomorrow."

2. "I will try to eat more fruits and vegetables."

The nurse recognizes that teaching for thalassemia major has been effective when the parent of the patient makes which statement? 1. "My child's bone marrow is being understimulated." 2. "In time, my child's skin may take on a yellow color." 3. "I am glad my child's heart isn't affected." 4. "My child's risk for diabetes is the same as anyone else."

2. "In time, my child's skin may take on a yellow color." *2) Skin will become bronze-colored, due to hemosiderosis and jaundice.

Respiratory Problems Which situation indicates that a chest tube drainage system is working properly? Answers: 1. The chest tubing remains clamped. 2. There is fluid in the suction chamber. 3. The set-up is elevated above the level of the mattress. 4. There are no fluid fluctuations in the water-seal chamber.

2. There is fluid in the suction chamber. *2) The presence of fluid in the suction chamber indicates that the chest tube drainage system is being effective

Cardiovascular Problems An older patient recovering from a myocardial infarction is being discharged from the acute care setting. The charge RN should assign the patient to which staff member? Answers: 1. An LPN/LVN with 10 years of experience in cardiac rehabilitation 2. An RN with 2 months of experience in an extended care facility and 1 year of experience in pediatrics 3. Unlicensed assistive personnel (UAP) with 4 years of experience in the intensive care unit 4. An LPN/LVN with 5 years of experience in a medical surgical unit

2. An RN with 2 months of experience in an extended care facility and 1 year of experience in pediatrics *2) The RN will need to ensure that discharge planning and discharge teaching needs have been met. Assessment, teaching, and evaluation should not be delegated.

Which nursing interventions would the RN implement for a patient with a nursing diagnosis of Risk for Bleeding related to thrombocytopenia? Select all that apply. 1. Measure temperature using a rectal thermometer. 2. Apply pressure for 5 minutes to injections sites. 3. Encourage a diet high in fiber. 4. Administer aspirin to manage fever. 5. Assess neurological status with vital signs.

2. Apply pressure for 5 minutes to injections sites. 3. Encourage a diet high in fiber. 5. Assess neurological status with vital signs.

Cardiovascular Problems A patient with heart failure has a classification of II, according to the New York Heart Association. The RN determines which of the following activities to be possible for the patient to perform and still remain symptom free? Selected Answer: 4. Completing a 5-course meal Answers: 1. Completing a 5K marathon 2. Completing a 5-minute nap 3. Completing a 5-minute walk 4 Completing a 5-course meal.

2. Completing a 5-minute nap *2) This can be performed at rest.

The RN admits a patient with sickle-cell disease in vaso-occlusive crisis. What is the priority nursing intervention for this patient? 1. Maintain adequate hydration. 2. Keep the environment warm. 3. Administer pain medication. 4. Transfuse packed red blood cells.

3. Administer pain medication.

Which nursing interventions should the RN implement to prevent atelectasis? Select all that apply. 1. Limit the use of opioids to manage pain. 2. Encourage early ambulation. 3. Change patient position frequently. 4. Obtain order for daily chest x-ray. 5. Assist with coughing and deep breathing exercises.

2. Encourage early ambulation. 3. Change patient position frequently. 5. Assist with coughing and deep breathing exercises.

A patient with thyroid cancer is preparing for a thyroidectomy. What interventions would the RN select to help reduce the effects of hyperthyroidism that the patient is experiencing? (Select all that apply.) Answers: 1. Encourage the patient to drink carbonated beverages. Abnormal Cellular Growth A patient with thyroid cancer is preparing for a thyroidectomy. What interventions would the RN select to help reduce the effects of hyperthyroidism that the patient is experiencing? (Select all that apply.) Answers: 1. Encourage the patient to drink carbonated beverages. 2. Encourage the patient to read a book of their choice. 3. Encourage the patient to have a family gathering. 4. Encourage the patient to practice yoga exercises. 5. Encourage the patient to plan time for meditation.

2. Encourage the patient to read a book of their choice. 4. Encourage the patient to practice yoga exercises. 5. Encourage the patient to plan time for meditation. *2) This choice can help the patient perform a quiet relaxing activity. *4) This choice can help the patient relax while practicing exercise which helps to reduce stress. *5) This choice can help the patient relax while using relaxation techniques to also help reduce stress.

Which outcome should the RN select for the nursing diagnosis of Deficient fluid volume in a patient diagnosed with disseminated intravascular coagulation (DIC)? The patient will: 1. Have capillary refill less than 3 seconds in both great toes. 2. Have a urine output of 0.5 mL/kg per hour or more.. 3. Have an oxygen saturation of 95% or greater. 4. Have clear breath sounds in upper and lower lobes.

2. Have a urine output of 0.5 mL/kg per hour or more..

Which clinical manifestation should the nurse expect to find as the most common symptom in a patient with cancer of the bladder? Answers: 1. Polyuria with urgency 2. Hematuria without dysuria 3. Nocturia without urgency 4. Pyuria with dysuria

2. Hematuria without dysuria *2) Hematuria (blood in the urine) without dysuria (painful urination) is the most common symptom of bladder cancer.

When planning care for a patient immediately following a modified radical mastectomy, the RN should give priority to which nursing diagnosis statement? Answers: 1. Self-Care Deficit related to partial immobility 2. Ineffective Breathing Pattern related to fear and pain 3. Knowledge Deficit: Follow-Up Care 4. Risk for Sexual Dysfunction related to loss of a body part

2. Ineffective Breathing Pattern related to fear and pain *2) The patient's pain and breathing difficulty should be the RN's first priority.

The nurse is obtaining the health history of a patient who is suspected of having melanoma. Which health history data is the least significant risk factor for this patient's diagnosis? 1. The patient works outdoors. 2. The patient is over the age of 50. 3. The patient smokes one pack of cigarettes daily. 4. The patient has a family history of pancreatic cancer.

3. The patient smokes one pack of cigarettes daily. *3) Smoking is not a documented risk factor for melanoma.

The patient who has had bariatric surgery is experiencing fatigue and paresthesias of the feet. Which medication will the nurse administer to manage these symptoms? 1. Corticosteroids 2. Folic acid 3. Vitamin B12 4. Ferrous sulfate

3. Vitamin B12

Respiratory Problems A pediatric patient with a chest tube has a nursing diagnosis statement of Fear related to inability to breathe without effort. Which intervention would the RN implement to promote effective deep breathing for this patient? Answers: 1. Request a respiratory consult to teach the child effective deep breathing exercises. 2. Play a game of follow-the-leader with the child, thereby teaching them how to deep-breathe. 3. Teach the parents effective deep breathing exercises so they can make the child deep-breathe. 4. Tell the child to take one deep breath every hour, in order to avoid too much effort.

2. Play a game of follow-the-leader with the child, thereby teaching them how to deep-breathe. *2) Through playing a game with the child, the nurse can collaborate and allow the child to have fun while meeting the goal. The child will concentrate on following what the nurse does, rather than focusing on the difficulty with breathing. Games work well with this age group.

Which instruction should the RN give to an older patient with severe stomatitis from chemotherapy? Answers: 1. Keep dentures in place during the day. 2. Rinse mouth with baking soda in water. 3. Clean teeth with a stiff brush after each meal. 4. Dilute commercial mouthwash with saline before using.

2. Rinse mouth with baking soda in water. *2) This soothing technique will promote healing without posing other problems for the patient.

Which information should the RN provide when educating a patient with chronic obstructive pulmonary disease (COPD) that is prescribed two metered dose inhalers, salmeterol and fluticasone? 1. Exhale through the device after administering the medication. 2. Rinse the mouth after administering each medication. 3. Wait at least one minute between each medication. 4. Self-administer the bronchodilator last.

2. Rinse the mouth after administering each medication.

In planning care for a young adult patient with glioma, the RN should instruct the family that the patient is prone to developing which problem? Answers: 1. Constipation 2. Seizures 3. Pathologic fractures 4. Urinary tract infections.

2. Seizures *2) Glioma, a common type of brain tumor, is very likely to cause seizures.

Which etiology would the RN identify for the nursing diagnosis Imbalanced nutrition: less than body requirements in a patient with pneumonia? 1. Elevated body temperature. 2. Shortness of breath. 3. Retained secretions. 4. Insensible fluid loss.

2. Shortness of breath.

Which patient risk factors may indicate that the RN should assign feeding responsibilities to a licensed practical nurse (LPN)? Answers: 1. Abdominal fullness with reports of anorexia 2. Vomiting with a decreased level of consciousness 3. Shortness of breath in a patient with surgical pain 4. Decreased food consumption for a malnourished patien

2. Vomiting with a decreased level of consciousness *2) This patient requires the attention of a nurse trained at the level of LPN/LVN or above.

A patient with a chronic cough has a bronchoscopy. Which intervention will be included in the nursing plans of care after the procedure? Answers: 1.Elevate the head of bed (HOB) to 80 to 90 degrees. 2.Give the patient nothing by mouth until the gag reflex returns. 3. Place the patient on bed rest for at least 4 hours post-bronchoscopy. 4. Notify the health care provider about blood-tinged mucus.

2.Give the patient nothing by mouth until the gag reflex returns. *2) Because a local anesthetic is used to suppress the gag/cough reflexes during bronchoscopy, the nurse should monitor for the return of these reflexes before allowing the patient to take oral fluids or food.

An RN is completing a health evaluation on a patient with a new diagnosis of Hodgkin lymphoma. The patient states, "I am going to die. Everyone I know that gets cancer does not last long." Which response by the RN would be most appropriate? 1. "Pray to God. He is the only one that knows what is going to happen in the future." 2. "Speak to your physician. He knows exactly how many years you may have left to live." 3. "This type of cancer has a high cure rate and responds well to chemotherapy and radiation." 4. "If you have all the lesions removed, you have a better chance of survival."

3. "This type of cancer has a high cure rate and responds well to chemotherapy and radiation." *3) Hodgkin lymphoma has a high cure rate; the 5-year survival rate is 88%. The goal of treatment of Hodgkin lymphoma is cure. Treatment of Hodgkin lymphoma commonly involves a short course (2 to 4 months) of chemotherapy, followed by radiation therapy to the specific involved area.

A patient with a family history of stroke is getting their yearly physical at the health care provider's office. The provider has ordered some laboratory tests. As the RN is completing venipuncture to obtain the specimen, the patient asks "The doctor ordered a new test called a C-reactive protein (CRP). What is that for?" What is the RN's best response? Answers: 1. "The test can evaluate if you have any active infections in your body." 2."The test can evaluate if you have a risk for developing cancer." 3. "The test is a marker used to evaluate your risk for cardiac issues." 4. "The test can evaluate how well you metabolize cholesterol."

3. "The test is a marker used to evaluate your risk for cardiac issues." *3) CRP is a known inflammatory marker for cardiovascular risk, including acute coronary events and stroke.

The RN notes that the patient's ankle-brachial index (ABI) result in the left leg is 0.39. Which finding does this data reflect? Answers: 1. Venous thromboembolism, causing venous dilation 2. Cardiomyopathy, causing decreased cardiac output 3. Atherosclerosis, causing arterial narrowing 4. Normal finding for ABI

3. Atherosclerosis, causing arterial narrowing *3) ABI compares arm blood pressure to leg blood pressure. 0.39 is a low (abnormal) result which indicates peripheral artery disease. Peripheral artery disease is a narrowing of the arteries in the patient's legs, often times caused by atherosclerosis.

Which meal choice would indicate to the RN that the patient with iron deficiency anemia understands the discharge teaching provided by the nutritionist concerning recommended changes in diet? 1. Tuna salad sandwich on white bread and milk. 2. Egg white omelet, bacon, and orange juice. 3. Grilled calves liver, steamed broccoli and spinach salad. 4. Roast chicken, mashed potatoes and gravy.

3. Grilled calves liver, steamed broccoli and spinach salad.

Which nursing intervention is a priority to prevent tumor lysis syndrome in a patient receiving chemotherapy for lymphoma? 1. Monitor blood urea nitrogen (BUN) and creatinine daily. 2. Administer corticosteroids. 3. Hydrate before and after the chemotherapy. 4. Maintain normal nutritional intake of calcium

3. Hydrate before and after the chemotherapy.

Abnormal Cellular Growth Which instruction should the RN include in the teaching plan of a patient who develops diarrhea as a side effect of an antineoplastic drug? Answers: 1. Drink more fluids during meals. 2. Increase the intake of high-fiber foods such as vegetables. 3. Increase the intake of high-potassium foods such as bananas. 4. Eat carbohydrates such as crackers throughout the day.

3. Increase the intake of high-potassium foods such as bananas. *3) Low bulk foods like bananas are indicated for treatment of diarrhea. There is a risk for hypokalemia in patients with diarrhea.

Abnormal Cellular Growth Which information does the RN need to know in developing a teaching plan for a patient with a sigmoid colostomy? Answers: 1. The drainage will be liquid. 2. The drainage has no odor. 3. Irrigation may not be necessary to establish regularity. 4. Digestive enzymes are present in the drainage.

3. Irrigation may not be necessary to establish regularity. *3) Regularity may be achieved with irrigation or by allowing natural evacuation.

Abnormal Cellular Growth Which is an appropriate intervention for a patient with lung cancer who develops superior vena cava syndrome? Answers: 1. Position patient in Trendelenberg position. 2. Assess patient for dysphagia. 3. Monitor neurological status. 4. Apply compression stockings.

3. Monitor neurological status. *3) The patient's neurological status can be compromised by increased intracranial pressure and lack of oxygen as a result of superior vena cava syndrome.

Cardiovascular Problems While assessing a child's radial pulse, the RN notes a pattern of one strong beat followed by one weak beat. The RN knows this indicates which cardiac condition? Answers: 1. Cardiac insufficiency 2. Aortic stenosis 3. Myocardial weakness 4. Ineffective heart action

3. Myocardial weakness *3) Myocardial weakness has a pulsus alternans, which is a pulse of one strong beat and one weak beat.

The RN observes the assistive personnel (AP) removing the nasal cannula from the patient with chronic obstructive pulmonary disease (COPD) while ambulating the patient to the bathroom. Which action should the RN take? 1. Praise the AP since this prevents the patient from tripping on the oxygen tubing. 2. Explain to the AP in front of the patient that oxygen must be left in place at all times. 3. Place the oxygen on the patient and speak to the AP in private concerning their actions. 4. Discuss the action of the AP with the charge nurse so appropriate action can be taken.

3. Place the oxygen on the patient and speak to the AP in private concerning their actions.

Abnormal Cellular Growth Which lab data is of most concern for the patient undergoing radiation therapy? Answers: 1. Hemoglobin 12 g/dL 2. RBC 4.9 X 106/mm3 3. Platelets 100,000/mm3 4. WBC 9,000/mm3

3. Platelets 100,000/mm3 *3) This value is too low, placing the patient at risk for bleeding and infection.

Abnormal Cellular Growth Which is the primary goal for postoperative management of a patient who had a left lower lobectomy for treatment of cancer? Selected Answer: Answers: 1. Prevent dehydration. 2. Prevent infection. 3. Promote optimal ventilation. 4. Promote adequate venous return.

3. Promote optimal ventilation. *3) Because the lobectomy has removed a section of the lung, respiratory complications are the most likely to occur. Nursing measures to promote optimal ventilation, including positioning, breathing exercises, and removal of excess secretions may be used to acheive this goal.

Which is an appropriate discharge instruction for the RN to give to a total laryngectomy for cancer of the larynx? Selected Answer: Answers: 1. The RN demonstrates how to irrigate the airway. 2. The RN demonstrates how to protect the vocal cords. 3. The RN demonstrates alternative communication methods. 4. The RN demonstrates a technique to tightly cover the stoma.

3. The RN demonstrates alternative communication methods. *3) The patient who has had a laryngectomy must learn alternative communication methods immediately. Possibilities include writing, lip speaking, and using a communication board. Eventually the patient may learn to speak using the esophagus or a mechanical device called an electric larnyx.

The RN is caring for a patient who is 1 day postoperative for surgery that created bilateral arterial bypass grafts in the lower extremities to manage peripheral artery disease. Which assessment finding should the RN report to the surgeon immediately? Answers: 1. The patient had his legs crossed for approximately 15 minutes while lying in bed. 2. The pedal and posterior tibial pulses are 2+ and regular bilaterally. 3. The left foot is cold to the touch and dusky in appearance. 4. The patient reports incisional pain of 5 on a scale of 10 before pain medication administration.

3. The left foot is cold to the touch and dusky in appearance. *3) The primary goal during the postoperative period is to maintain adequate circulation. The patient's left foot is cold and dusky in appearance. These assessment findings indicate poor circulation and possible occlusion. This finding should be reported to the surgeon immediately.

A patient is on chemotherapy. The RN is teaching the patient about neutropenia. Which statement by the patient indicates they understood the teaching? 1. "I will have to use a soft-bristled toothbrush when brushing my teeth." 2. "I can give an infection to others because my body can't fight off infection." 3. "Eating fresh fruit and vegetables will help improve the neutropenia." 4. "I will call my health care provider if I have an increased temperature."

4. "I will call my health care provider if I have an increased temperature." *4) If neutropenia is accompanied by increased temperature, the patient is considered to have an infection and is usually is admitted to the hospital.

Which statement by a patient with pernicious anemia indicates an understanding of the RN's teaching plan about the therapeutic regimen? 1. "I will increase my intake of meats." 2. "I will be able to stop therapy when my red blood cell count is normal." 3. "I will take multivitamins and iron tablets daily." 4. "I will need to have vitamin B12 injections on a monthly basis."

4. "I will need to have vitamin B12 injections on a monthly basis." *4) Pernicious anemia is linked with a deficiency of vitamin B12

The patient's spouse was found crying in the hospital waiting room. She stated, "Why did my husband have to get bronchiectasis? Where did he catch it?" What is the RN's best response? Answers: 1. "It is his fault for smoking cigarettes all those years." 2. "It's a communicable disease that is passed through the air." 3. "I'm not sure; you will need to speak to the health care provider." 4. "It is an inflammatory process that causes damage to the lungs."

4. "It is an inflammatory process that causes damage to the lungs." *4) This is a therapeutic response; the RN is providing the spouse with information about the illness.

Which information should be included in the discharge plan for a patient receiving an angiotensin converting enzyme (ACE) inhibitor for blood pressure control? Answers: 1."You may experience an increased appetite." 2. "You may experience dehydration." 3. "You may experience constipation." 4. "You may experience cough."

4. "You may experience cough." *4) A cough is the most common side effect of an ACE inhibitor. It usually resolves within 1 to 4 days after therapy is begun, and the patient should be urged to continue taking the medication with this knowledge.

Which outcome would be identified by the RN for the nursing diagnosis Ineffective Breathing Pattern in a patient diagnosed with chronic obstructive pulmonary disease (COPD)? The patient will: 1. Maintain an oxygen saturation of 95% or greater on room air. 2. Have clear breath sounds in both upper and both lower lobes. 3. Ambulate 100 feet without dyspnea. 4. Demonstrate pursed-lip breathing.

4. Demonstrate pursed-lip breathing.

While caring for a patient admitted with sepsis, the RN observes petechiae of the oral mucosa, bleeding from the IV site, and hematuria. The RN would suspect which problem? 1. Thalassemia 2. Factor V Leiden defect 3. Acute myeloid leukemia 4. Disseminated intravascular coagulation

4. Disseminated intravascular coagulation *4) The above clinical manifestations are all consistent with disseminated intravascular coagulation (DIC) which causes thrombus formation in microcirculation, consumption of platelets and clotting factors, and bleeding. Sepsis is one trigger for DIC.

Which data collected by the RN during the health history of an adolescent supports the medical diagnosis of Hodgkin's lymphoma? 1. Frequent nose bleeds. 2. Edema of the face. 3. Pain in the neck. 4. Drenching night sweats.

4. Drenching night sweats.

Abnormal Cellular Growth An RN is developing a care plan for a family with a nursing diagnosis of anticipatory grieving related to a diagnosis of advanced ovarian cancer in the mother. The RN should consider which intervention to be of primary importance? Answers: 1. Discuss treatment modalities. 2. Refer the family to social services. 3. Request that a member of the clergy visit. 4. Establish a trusting relationship.

4. Establish a trusting relationship. *4) This is the first step in developing the care plan.

Respiratory Problems A patient with acute shortness of breath is admitted to the hospital. Which action should the RN take during the initial assessment of the patient? Answers: 1. Complete a full physical examination to determine the systemic effect of the respiratory distress. 2. Obtain a comprehensive health history to determine the extent of any prior respiratory problems. 3. Delay the physical assessment and ask family members about any history of respiratory problems. 4. Perform a focused respiratory system assessment and ask specific questions about this episode of respiratory distress.

4. Perform a focused respiratory system assessment and ask specific questions about this episode of respiratory distress. *4) A focused physical assessment should be done rapidly to help determine the cause of the distress and suggest treatment

Respiratory Problems Which assessment finding indicates to the RN that the treatment plan for a patient with an exacerbation of asthma is effective? Answers: 1. Pulse oximeter reading of 85% 2. Pulse rate of 110 beats per minute 3. Productive cough with rapid breathing 4. Respiration rate of 18 breaths per minute

4. Respiration rate of 18 breaths per minute *4) A respiration rate of 18 is within the normal range and indicates improvement.

The RN assesses a patient admitted to the Emergency Department following a motor vehicle accident. The RN notes a paradoxical chest rise, multiple bruises across the chest and torso, crepitus and tachypnea. Which intervention will the patient need first? 1. Application of a chest binder. 2. Administration of analgesics 3. Insertion of a chest tube. 4. Stabilization of the airway.

4. Stabilization of the airway.

Which food should the RN encourage to decrease a patient's risk of developing colorectal cancer? Answers: 1. Broiled meat 2. Fresh dairy 3. Grilled fish 4. Steamed vegetables

4. Steamed vegetables *4) Fruits and vegetables (especially cruciferous vegetables) are recommended to decrease the risk of colorectal cancer. Steaming preserves nutritive qualities and does not introduce carcinogens.

Hematologic Problems Which assessment finding would the RN observe in a patient who has a platelet count of 20,000/mm3? Answers: 1. This is a normal platelet count with no observable clinical manifestations. 2. There may be petechiae without noticeable bleeding, except after surgery. 3. There may be spontaneous bleeding or gastrointestinal hemorrhage. 4. There may be gingival bleeding, or excessive bleeding after surgery.

4. There may be gingival bleeding, or excessive bleeding after surgery. *4) This is the correct answer for a platelet count of 20,000/mm3.

A medication for a patient is prescribed as 0.5 mg/kg and is supplied in a solution of 5 mg/mL by mouth. The patient weighs 168 lb. What volume of medication should be administered, in milliliters (mL)?

Correct Answer:7.5 Response Feedback: Weight: 168lbs/2.2kg = 76 kg Dosage: 76 kg x .5 mg = 38 mg Volume: 38 mg/5ml = 7.5 mL

An RN is administering cyclophosphamide to a patient with acute lymphocytic leukemia. The health care provider orders 2 mg/kg/day. The patient weighs 110 lb. The medication is available in 50 mg tablets. How many milligram (mg) tablets will the RN administer per day? (Provide your answer rounded to the nearest whole number in the input box below.)

Correct Answer: 2 First, convert the patient's weight from pounds to kilograms by dividing weight in pounds by 2.2 110/2.2 = 50 kg The order is for 2 mg per kg per day, therefore: 2 mg X 50 kg = 100 mg/day Since the medication is available in 50 mg tablets, the patient would get 2 tablets per day.

Hematologic Problems The physician prescribes 1 dose Vitamin K, 10 mg to be administered intravenously. Vitamin K is available as 2 mg/1 mL. How many milliliters (mL) of Vitamin K will the RN administer? (Provide your answer to the nearest whole number in the input box below.)

Correct Answer:5 Response Feedback: Desired/Have x vehicle = amount to administer. Therefore, 10mg/2mg x 1 mL = 5 mL

expected blood gas changes include a low bicarbonate level (less than 22 mEq/L) and a low pH (less than 7.35). The cardinal feature of metabolic acidosis is a decrease in the serum bicarbonate level.

In diagnosing metabolic acidosis

drain at regular intervals with a catheter

Indiana pouch

is a clinical disturbance characterized by a high pH (decreased H+ concentration) and a high plasma bicarbonate concentration. It can be produced by a gain of bicarbonate or a loss of H+.

Metabolic alkalosis

is a clinical disorder in which the pH is less than 7.35 and the PaCO2 is greater than 42 mm Hg and a compensatory increase in the plasma HCO3 occurs. This patient is hypoventilating.

Respiratory acidosis

is a clinical condition in which the arterial pH is greater than 7.45 and the PaCO2 is less than 38 mm Hg. As with respiratory acidosis, acute and chronic conditions can occur.

Respiratory alkalosis

After a pediatric patient has had a bone marrow biopsy and aspiration, which findings would the RN instruct the parents to monitor and report? 1. Nausea and vomiting 2. Temperature and pain 3. Headache and chills 4. Hypotension and cramps

Temperature and pain *2) The procedure is painful and the parents are instructed to monitor the child's temperature 12 hours after and 24 hours after the procedure to detect infection.

apply a protective skin barrier

cutaneous ureterostomy

1. A patient who has chest tubes attached to a Pleur-evac water-seal drainage system is being transported to X ray. Which is the most appropriate action for the nurse to take during transit? a. clamping the tubes during transport b. clamping the tubes during transport c. maintain the patency of the chest tubes and hang the Pleur-evac from an IV pole d. maintain the patency of the chest tubes and keep the Pleur-evac below the chest level

d. maintain the patency of the chest tubes and keep the Pleur-evac below the chest level

assess for a healthy pink or red stoma

ileal conduit