FINAL EXAM - NUR 314

A nurse is working with a patient who takes atorvastatin (Lipitor). The patient's recent laboratory results include a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best?

Ask if the patient eats grapefruit There is a drug-food interaction between statins and grapefruit that can lead to acute kidney failure. This patient has elevated renal laboratory results, indicating some degree of kidney involvement. The nurse would assess if the patient eats grapefruit or drinks grapefruit juice. Dehydration can cause the BUN to be elevated, but the elevation in creatinine is more specific for a kidney injury. The patient does not necessarily need to be admitted. A urinalysis may or may not be ordered.

A patient in the emergency department reports difficulty breathing. The nurse assesses the patient's appearance as depicted below: What action by the nurse is the priority?

Assess blood pressure and pulse This patient has superior vena cava syndrome, in which venous return from the head, neck, and trunk is blocked. Decreased cardiac output can occur. The nurse should assess indicators of cardiac output, including blood pressure and pulse, as the priority. The other actions are also appropriate but are not the priority.

An older adult is on cardiac monitoring after a myocardial infarction. The patient shows frequent dysrhythmias. What action by the nurse is most appropriate?

Assess for any hemodynamic effects of the rhythm. Older patients may have dysrhythmias due to age-related changes in the cardiac conduction system. They may have no significant hemodynamic effects from these changes. The nurse would first assess for the effects of the dysrhythmia before proceeding further. The alarms on a cardiac monitor would never be shut off. The other two actions may or may not be needed.

A nurse assesses an older adult patient who has multiple chronic diseases. The patient's heart rate is 48 beats/min. What action would the nurse take first?

Assess the patient's medications. Pacemaker cells in the conduction system decrease in number as a person ages, resulting in bradycardia. The nurse would check the medication reconciliation for medications that might cause such a drop in heart rate, and then would inform the healthcare provider. Documentation is important, but it is not the priority action. The heart rate is not low enough for atropine or an external pacemaker to be needed.

A patient with acquired Immune deficiency syndrome has been hospitalized with suspected cryptosporidiosis. What physical assessment would be most consistent with this condition?

Assessing mucous membranes Crotosporidiosis can cause extreme loss of fluids and electrolytes, up to 20 L/day. The nurse would assess signs of hydration/dehydration as the priority, including checking the patient's mucous membranes for dryness. The nurse will perform the other assessments as part of a comprehensive assessment

A patient has received a dose of ondansetron (Zofran) for nausea. What action by the nurse is most important?

Assist the patient in getting out of bed. Ondansetron side effects include postural hypotension, vertigo, and bradycardia, all of which increase the patient's risk for injury. The nurse should assist the patient when getting out of bed. Headache and fluid retention are not side effects of this drug.

A patient has frequent hospitalizations for leukemia and is worried about functioning as a parent to four small children. What action by the nurse would be most helpful?

Assist the patient to make sick-day plans for household responsibilities While all options are reasonable choices, the best option is to help the patient make sick-day plans, as that is more comprehensive and inclusive than the other options, which focus on a single item

A nurse is teaching a patient who has cystic fibrosis (CF). Which statement would the nurse include in this patient's teaching?

'Eat a well-balanced. nutritious diet Patients with CF often are malnourished due to vitamin deficiency and pancreatic malfunction. Maintaining nutrition is essential. Daily antibiotics and dally exercise are not essential actions. Genetic screening would not help the patient manage CF better.

A nurse teaches a patient with diabetes mellitus who is experiencing numbness and reduced sensation. Which statement would the nurse include in this patient's teaching to prevent injury?

'Use a bath thermometer to test the water temperature." Patients with diminished sensory perception can easily experience a burn injury when bathwater is too hot. Instead of checking the temperature of the water by feeling it, they should use a thermometer. Examining the feet daily does not prevent injury, although daily foot examinations are important to find problems so they can be addressed. Rotating insulin and checking blood glucose levels will not prevent injury.

A nurse assesses patients at a health fair. Which patients would the nurse counsel to be tested for diabetes? ( Select all that apply.)

- 56-year-old African-American male - 48-year-old woman with a sedentary lifestyle - Male with a body mass index greater than 25 kg/m2 - 28-year-old female who gave birth to a baby weighing 9.2 lbs (4.2 kg) Risk factors for type 2 diabetes include certain ethnic/racial groups (African-Americans, American-Indians, Hispanics), obesity and physical inactivity, and giving birth to large babies. Pancreatic trauma and a 30-Ib (13.6 kg) gestational weight gain are not risk factors.

A nursing student studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in what ways? ( Select all that apply.)

- Accompanied by shortness of breath - Feelings of fear or anxiety - No relief from taking nitroglycerin - Pain occurs without known cause The pain from an MI is often accompanied by shortness of breath and fear or anxiety. It lasts longer than 15 minutes and is not relieved by nitroglycerin. It occurs without a known cause such as exertion.

A patient on interferon therapy is reporting severe skin itching and irritation. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? ( Select all that apply.)

- Apply moisturizers to dry skin. - Bathe the patient using mild soap The nurse can delegate applying unscented moisturizer and using mild soap for bathing. Steroid creams are not used for this condition. Hot water will worsen the irritation. Patient teaching is a nursing function

A patient's family members are concerned that telling the patient about a new finding of cancer will cause extreme emotional distress. They approach the nurse and ask if this can be kept from the patient. What actions by the nurse are most appropriate? ( Select all that apply.)

- Ask the family to describe their concerns more fully. - Consult with a social worker, chaplain, or ethics committee. - Explain the patient's right to know and ask for their assistance. The patient's right of autonomy means that the patient must be fully informed as to his or her diagnosis and treatment options. The nurse cannot ethically keep this information from the patient. The nurse can ask the family to explain their concerns more fully so everyone understands the concerns. A social worker, chaplain, or ethics committee can become involved to assist the nurse, patient, and family. The nurse should explain the patient's right to know and ask the family how best to proceed. The nurse should not abdicate responsibility for this difficult situation by transferring care to another nurse. Simply telling the family that he or she will not keep this secret sets up an adversarial relationship. Explaining this fact along with the concept of autonomy would be acceptable, but this by itself is not.

A nurse is caring for a patient with a history of renal insufficiency who is scheduled for a cardiac catheterization. What actions would the nurse take prior to the catheterization? ( Select all that applv.)

- Assess for allergies to iodine - Administer intravenous fluids - Assess blood urea nitrogen (BUN) and creatinine results. If the patient has kidney disease (as indicated by BUN and creatinine results), fluids may be given 12 to 24 hours before the procedure for renal protection. The patient would be assessed for allergies to iodine including shellfish; the contrast medium used during the catheterization contains iodine. A Foley catheter and central venous catheter not required for the procedure and would on increase the patients risk for infection. Prophylactic antibiotics are not administered prior to a cardiac catheterization.

A nurse is caring for a patient on IV infusion of heparin. What actions does this nurse include in the patient's plan of care? ( Select all that apply.)

- Assess the patient for bleeding. - Monitor the daily activated partial thromboplastin time (aPTT) results. - Use an IV pump for the infusion. Assessing for bleeding, monitoring aPTT, and using an IV pump for the infusion are all important safety measures for heparin to prevent injury from bleeding. The aPTT needs to be 1.5 to 2 times normal in order to demonstrate that the heparin is therapeutic. Weighing the patient is not related.

A patient with a history of prostate cancer is in the clinic and reports new onset of severe loW back pain. What action by the nurse is most important?

- Assess the patient's gait and balance This patient has manifestations of spinal cord compression, which can be seen with prostate cancer. This may affect both gait and balance and urinary function. For patient safety, assessing gait and balance is priority. Documentation should be complete. The patient may or may not have occupational risks for low back pain, but with his history of prostate cancer, this should not be where the nurse starts investigating.

A patient will begin taking streptomycin as part of the medication regimen to treat tuberculosis. Before administering this medication, the nurse will review which laboratory values in the patient's medical record?

- Blood urea nitrogen (BUN) and creatinine Streptomycin can cause significant renal toxicity.

A nurse is caring for a patient with a deep vein thrombosis (DVT). What nursing assessment indicates that a priority outcome has been met?

Oxygen saturation of 98% A critical complication of VT is pulmonary embolism. A normal oxygen saturation indicates that this has not occurred. The other assessments are also positive, but not the priority.

A patient is admitted with fever, myalgia, and a papular rash on the face, palms, and soles of the feet. What action will the nurse take first?

Place the patient on Airborne Precautions. This patient has manifestations of smallpox, a public health emergency, and will be placed on Airborne Precautions first before other care measures are implemented.

A patient who has AIDS is at risk to contract aspergillosis. The nurse will anticipate that which antifungal medication will be ordered prophylactically for this patient?

Posaconazole(Noxafil) Posaconazole is given for prophylactic treatment of Aspergillus and Candida infections.

A hospitalized patient uses a transdermal fentanyl (Duragesic) patch for chronic pain. Which action by the nurse is most important for patient safety?

Remove the old patch when applying the new one The old fentanyl patch would be removed when applying a new patch so that accidental overdose does not occur. The other actions are appropriate, but not as important for safety.

A patient who had surgery has extreme postoperative pain that is worsened when trying to participate in physical therapy. Which intervention for pain management does the nurse include in the patient's care plan?

Round-the-clock analgesia with PRN analgesics Severe pain related to surgery or tissue trauma is best managed with round-the-clock dosing. Breakthrough pain associated with specific procedures is managed with additional medication. An as-needed regimen will not control postoperative pain. A patient-controlled analgesia pump might be a good idea but needs basal (continuous) and bolus (intermittent) settings to accomplish adequate pain control. Pain control needs to be continuous, not just administered prior to therapy.

A nurse reviews laboratory results for a patient with diabetes mellitus who presents with polyuria, lethargy, and a blood glucose of 560 mg/dL (31.1 mmol/L). Which laboratory result would the nurse correlate with the patient's polyuria?

Serum osmolarity: 375 mOsm/kg (375 mmol/kg) Hyperglycemia causes hyperosmolarity of extracellular fluid. This leads to polyuria from an osmotic diuresis. The patient's serum osmolarity is high. The patient's sodium would be expected to be high owing to dehydration. Serum creatinine and urine ketone bodies are not related to the polyuria.

A hospital unit is participating in a bioterrorism drill. A "patient" is admitted with inhalation anthrax. Under what type of precautions does the charge nurse admit the "patient"?

Standard Precautions Only Standard Precautions are needed. No other special precautions are required for the "patient" because inhalation anthrax is not spread person to person.

A nursing student is struggling to understand the process of graft-versus-host disease. What explanation by the nurse instructor is best?

The donor's cells are actually attacking the patient's cells" Graft-versus-host disease is an autoimmune-type process in which the donor cells recognize the patient's cells as foreign and begin attacking them. The other answers are not accurate

The nurse working with oncology patients understands that which age-related change increases the older patient's susceptibility to infection during chemotherapy?

- Decreased immune function As people age, there is an age-related decrease in immune unction, causing the older adult to be more susceptible to infection than other patients. Not all older adults have diminished nutritional stores, cognitive dysfunction, or poor physical reserves.

A patient has Hodgkin's lymphoma, Ann Arbor stage Ib. For what manifestations should the nurse assess the patient? ( Select all that apply.)

- Night sweats - Persistent fever - Weight loss In this stage, the disease is located in a single lymph node region or a single nonlymph node site. The patient displays night sweats, persistent fever, and weight loss. Headache and urinary problems are not related.

After teaching a patient who is prescribed a long-acting beta 2 agonist medication, a nurse assesses the patient's understanding. Which statement indicates that the patient comprehends the teaching?

"I will take this medication every morning to help prevent an acute attack." Long-acting beta 2 agonist medications will help prevent an acute asthma attack because they are long acting. The patient will take this medication every day for best effect. The patient does not have to always keep this medication with him or her because it is not used as a rescue medication. This is not the medication the patient will use during an acute asthma attack because it does not have an immediate onset of action. The patient will not be weaned off this medication because this is likely to be one of his or her daily medications.

A patient with coronary artery disease (CAD) asks the nurse about taking fish oil supplements. What response by the nurse is best?

"The best source is fish, but pills have benefits too." Omega-3 fatty acids have shown benefit in reducing lipid levels, in reducing the incidence of sudden cardiac death, and for stabilizing atherosclerotic plaque. The best source is fish three times a week or some fish oil supplements. The other options are not accurate.

A patient with HIV/AIDS asks the nurse why gabapentin (Neurontin) is part of the drug regimen when the patient does not have a history of seizures. What response by the nurse is best?

"This drug helps treat the pain from nerve irritation." Many classes of medications are used for neuropathic pain, including tricyclic antidepressants and anticonvulsants such as gabapentin. It is not being used to prevent seizures from fungal infections. If the nurse does not know the answer, he or she should find out for the patient.

A patient has been admitted for suspected inhalation anthrax infection. What question by the nurse is most important?

"What is your occupation?" Inhalation anthrax is rare and is an occupational hazard among people who work with animal wool, bone meal, hides, and skin, such as taxidermists and veterinarians. Inhalation anthrax seen in someone without an occupational risk is considered a bioterrorism event and must be reported to authorities immediately. The other questions are appropriate for anyone with an infection.

A patient is being administered the first dose of adalimumab (Humira). What actions by the nurse are most appropriate? ( Select all that apply.)

- Observe the patient for at least 2 hours afterward - Monitor the patient for rales and tachycardia. - Ensure emergency equipment is working and nearby. This drug is a monoclonal antibody to tumor necrosis factor. The first dose should be administered in a place where severe allergic reactions and/or anaphylaxis can be managed. This includes having emergency equipment nearby. The patient should be observed for at least 2 hours after this first dose. Adalimumab does not enter the breast milk, so nursing mothers can continue to breastfeed. Elevated lipids are not associated with this drug.

A nurse assesses a patient who is at risk for neck cancer. Which symptoms would the nurse assess for? ( Select all that apply.)

- Oral mucosa is gray or dark brown -Oral lesions that are over 2 weeks old -Changes in the patients voice quality Symptoms of head and neck cancer Include color changes in the mouth or tongue to gray or dark brown; pain in the mouth, neck, and throat; burning sensation when drinking citrus juices; weight loss; oral lesions or soars that do not heal in 2 weeks; and hoarseness or changes in voice quality.

The nursing student is studying hypersensitivity reactions. Which reactions are correctly matched with their hypersensitivity types? ( Select all that apply.)

- Type I- examples include hay fever and anaphylaxis - Type Ill- immune complex deposits in blood vessel walls - Type IV- examples are poison ivy and transplant rejection Type I reactions are mediated by immunoglobulin E (IgE) and include hay fever, anaphylaxis, and allergic asthma. Type Ill reactions consist of immune complexes that form and deposit in the walls of blood vessels. Type IV reactions include responses to poison ivy exposure, positive tuberculosis tests, and graft rejection. Type I reactions are mediated by immunoglobulin G, not IgM. Type IV hypersensitivity reactions do not involve either antibodies or complement.

A patient with acquired immune deficiency syndrome and esophagitis due to Candida fungus is scheduled for an endoscopy. What actions by the nurse are most appropriate? ( Select all that apply.)

-Assess the patient's mouth and throat. -Ensure that the consent form is on the chart. -Maintain NPO status as prescribed. Oral Candida fungal infections can lead to esophagitis. This is diagnosed with an endoscopy and biopsy. The nurse assesses the patient's mouth and throat beforehand, ensures valid consent is on the chart, and maintains the patient in NPO status as prescribed. A stiff neck and abdominal percussion are not related to this diagnostic procedure.

A nurse works on an oncology unit and delegates personal hygiene to an unlicensed assistive personnel (UAP). What action by the UAP requires intervention from the nurse?

Allowing a very tired patient to skip oral hygiene and sleep Even though patients may be tired, they still need to participate in hygiene to help prevent infection. The other options are all appropriate.

A postoperative patient is reluctant to participate in physical therapy. Which action by the nurse is best?

ASK the palient about pain goals and it they are beina met A comprehensive pain management plan includes the patient's goals for pain control. Adequate pain control is necessary to allow full participation in therary. The first thing the nurse would do is to ask about the patient's pain goals and if they are being met. If not, an adjustment to treatment can be made. If they are being met, the nurse can assess for other factors influencing the patients benavior. Asking the patient why he or she is being uncooperative is not the best response for two reasons. First, why questions tend to put people on the defensive. Second, labeling the behavior is inappropriate. Simply increasing the pain medication may not be advantageous. Simply telling the patient that physical therapy is required does not address the issue.

A nurse assesses a patient who has diabetes mellitus and notes that the patient is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup (* (120 mL) of orange juice, the patient's clinical manifestations have not changed. What action would the nurse take next?

Administer another half-cup (120 mL) of orange juice. This patient is experiencing mild hypoglycemia. For mild hypoglycemic manifestations, the nurse would administer oral glucose in the form of orange juice. If the symptoms do not resolve immediately, the treatment would be repeated. The patient does not need intravenous dextrose, insulin, or glucagon.

A patient has been admitted after sustaining a humerus fracture that occurred when picking up the family cat. What test result would the nurse correlate to this condition?

Bence-Jones protein in urine This patient has possible multiple myeloma. A positive Bence-Jones protein finding would correlate with this condition. The Epstein-Barr virus is a herpesvirus that causes infectious mononucleosis and some cancers. A hemoglobin of 18 mg/dL (180 mol/L) is slightly high for a male and somewhat high for a female; this can be caused by several conditions, and further information would be needed to correlate this value with a specific medical condition. A red blood cell count of 8.2 × 10 6/mm 3 (8.2 x 10 12/L) is also high, but again, more information would be needed to correlate this finding with a specific medical condition.

A patient is receiving interleukins along with chemotherapy. What assessment by the nurse takes priority?

Blood pressure Interleukins can cause capillary leak syndrome and fluid shifting, leading to intravascular volume depletion. Although all assessments are important in caring for patients with cancer, blood pressure and fluid status assessments take priority

The nurse providing direct patient care uses specific practices to reduce the chance of acquiring infection with human immune deficiency virus (HIV) from patients. Which practice is most effective?

Consistent use of Standard Precautions According to The Joint Commission, the most effective preventative measure to avoid HIV exposure is consistent use of Standard Precautions. Double-gloving is not necessary. Labeling charts and armbands in this fashion is a violation of the Health Information Portability and Accountability Act (HIPAA). Wearing a mask within 3 ft (1 m) of the patient is part of Airborne Precautions and is not necessary with every patient contact.

Which action by the nurse Is most helpful to prevent patients from acquiring Infections while hospitalized?

Consistently using appropriate hand hygiene Consistent practice of proper hand hygiene Is the best method to prevent infection, as most healthcare-associated infections are due to staff members contaminated hands. Assessing the patient and monitoring laboratory values will help the nurse catch signs of infection quickly but will not prevent infection from occurring. Teaching visitors not to come to see the patient when they are ill will also help prevent infection, but not to the degree that hand hygiene will

A patient has hemodynamic monitoring after a myocardial infarction. What safety precaution does the nurse implement for this patient?

Ensure that the balloon does not remain wedged If the balloon remains inflated, it can cause pulmonary infarction or rupture. The nurse would ensure that the balloon remains deflated between PAWP readings. Documenting PAWP readings and assessing trends are important nursing actions related to hemodynamic monitoring, but are not specifically related to safety. The patient does not have to be NPO while undergoing hemodynamic monitoring. Positioning may or may not affect readings.

A patient receiving a blood transfusion develops anxiety and low back pain. After stopping the transtusion, what action by the nurse is most important?

Double-checking the patient and blood product identification This patient had a hemolytic transfusion reaction, most commonly caused by blood type or Rh incompatibility. The nurse should double-check all identifying information for both the patient and blood type Documentation occurs after the patient is stable. Bedrest may or may not be needed. Allergies to medications or environmental items are not related.

A hospitalized patient Is placed on Contact Precautions. The patient needs to have a computed tomography (CT) scan. What action by the nurse is most appropriate?

Ensure that the radiology department is aware of the isolation precautions. Patients in isolation will leave their rooms only when necessary, such as for a CT scan that cannot be done portably in the room. The nurse will ensure that the receiving department is aware of the isolation precautions needed to care for the patient. The other options are not needed.

A patient is having a catheter placed in the femoral artery to deliver chemotherapy beads into a liver tumor. What action by the nurse is most important?

Ensuring that informed consent is on the chart This is an invasive procedure requiring informed consent. The nurse should ensure that consent is on the chart. The other actions are also appropriate but not the priority.

A patient is admitted with superior vena cava syndrome. What action by the nurse is most appropriate?

Gently inquire about advance directives. Superior vena cava syndrome is often a late-stage manifestation. After the patient is stabilized and comfortable, the nurse should initiate a conversation about advance directives. Allopurinol is used for tumor lysis syndrome. Potassium levels are important in tumor lysis syndrome, in which cell destruction leads to large quantities of potassium being released into the bloodstream. Surgery is rarely done for superior vena cava syndrome

A nurse reviews laboratory results for a patient with diabetes mellitus who is prescribed an intensified insulin regimen. Fasting blood glucose: 75 mg/dL (4.2 mmol/L) Postprandial blood glucose: 200 mg/dL (11.1 mmol/L) Hemoglobin A 1c level: 5.5% How would the nurse interpret these laboratory findings?

Good control of blood glucose The patient is maintaining blood glucose levels within the defined ranges for goals in an intensified regimen. Because the patient's glycemic control is good, he or she is not at higher risk for ketoacidosis or hyperglycemia and is not showing signs of insulin resistance.

A hospitalized patient has a history of depression for which sertraline (Zoloft) is prescribed. The patient also has a morphine allergy and a history of alcoholism: After surgery, several opioid analgesics are prescribed. Which one would the nurse choose?

Hydromorphone (Dilaudid) Hydromorphone is a good alternative to morphine for moderate to severe pain. The nurse would not choose Lorcet because it contains acetaminophen (Tylenol) and the patient has a history of alcoholism. Tramadol would not be used due to the potential for interactions with the patient's sertraline. Meperidine is rarely used and is often restricted.

A patient having severe allergy symptoms has received several doses of IV antinistamines. What action by the nurse is most important?

Instruct the patient not to get up without help. Antihistamines can cause drowsiness, so for the patient's safety, he or she should be instructed to call for assistance prior to trying to get up. Hyperglycemia and tachycardia are side effects of sympathomimetics. Fluid and sodium retention are side effects of corticosteroids

A patient has a sickle cell crisis with extreme lower extremity pain. What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)?

Keep the lower extremities warm. During a sickle cell crisis, the tissue distal to the occlusion has decreased blood flow and ischemia, leading to pain. Due to decreased blood flow, the patient's legs will be cool or cold. The UAP can attempt to keep the patient's legs warm. Ice and elevation will further decrease perfusion. Elastic bandage wraps are not indicated and may constrict perfusion in the legs.

A nurse teaches a patient who is diagnosed with diabetes mellitus. Which statement would the nurse include in this patient's plan of care to delay the onset of microvascular and macrovascular complications?

Maintain tight glycemic control and prevent hyperglycemia Hyperglycemia is a critical factor in the pathogenesis of long-term diabetic complications. Maintaining tight glycemic control will help delay the onset of complications. Restricting fluid intake is not part of the treatment plan for patients with diabetes. Preventing hypoglycemia and ketosis, although important, is not as important as maintaining daily glycemic cohtrol.

The nurse is caring for a patient with a chest tube after a coronary artery bypass graft. The drainage slows significantly. What action by the nurse is most important?

Notify the provider immediately. If the drainage in the chest tube decreases significantly and dramatically, the tube may be blocked by a clot. This could lead to cardiac tamponade. The nurse would notify the provider immediately. The nurse would not independently increase the suction, reposition the chest tube, or take the tubing apart.