med-surg 2 in class review

When is it appropriate to start CPR?

no palpable pulse

acute MI definition

not relieved by position change or nitro, lasts INDEFINITELY (longer than 30 mins)

Post-op monitoring of respiratory status, what should they be doing

High CO2 = Deep breathe! blowing off excess CO2 that way

IgG vs. IgM

IgG: (gone) past infection IgM: current infection

Decorticate vs. Decerberate posturing (Be able to identify what it looks like)

(decorticate is two cs curled in)

While doing an admission assessment, the nurse notes clubbing of the patient's fingers. Based on this finding, the nurse will question the patient about which disease process? A. Endocarditis B. Acute kidney injury C. Myocardial infarction D. Chronic thrombophlebitis

A. Endocarditis Clubbing of the fingers is a loss of the normal angle between the base of the nail and the skin. This finding can be found in endocarditis, congenital defects, and/or prolonged oxygen deficiency. Clinical manifestations of acute kidney injury, myocardial infarction, and chronic thrombophlebitis will not include clubbing of the fingers.

The nursing management of a patient in sickle cell crisis includes (select all that apply): A. monitoring CBC B. blood transfusion if required and iron chelation C. optimal pain management and oxygen therapy D. rest as needed and DVT prophylaxis E. administration of IV iron and diet high in iron content

A, B, C, D

When caring for a patient with infective endocarditis, the nurse will assess the patient for which vascular manifestations (select all that apply)? A. Osler's nodes B. Janeway's lesions C. Splinter hemorrhages D. Subcutaneous nodules E. Erythema marginatum lesions

A. Osler's nodes B. Janeway's lesions C. Splinter hemorrhages Osler's nodes, Janeway's lesions, and splinter hemorrhages are all vascular manifestations of infective endocarditis. Subcutaneous nodules and erythema marginatum lesions occur with rheumatic fever.

A patient with a new ileostomy asks how much drainage to expect. The nurse explains that after the bowel adjusts to the ileostomy, the usual drainage will be about _____ cups daily. a. 2 b. 3 c. 4 d. 5

ANS: A After the proximal small bowel adapts to reabsorb more fluid, the average amount of ileostomy drainage is about 500 mL daily. One cup is about 240 mL.

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

ANS: A Ambulation will improve peristalsis and help the patient eliminate flatus and reduce gas pain. A mineral oil retention enema is helpful for constipation with hard stool. A return-flow enema might be used to relieve persistent gas pains. Morphine will further reduce peristalsis. Promethazine is used as an antiemetic rather than to decrease gas pains or distention.

An appropriate nursing intervention for a patient with non-Hodgkin's lymphoma whose platelet count drops to 18,000/µL during chemotherapy is to a. check all stools for occult blood. b. encourage fluids to 3000 mL/day. c. provide oral hygiene every 2 hours. d. check the temperature every 4 hours.

ANS: A Because the patient is at risk for spontaneous bleeding, the nurse should check stools for occult blood. A low platelet count does not require an increased fluid intake. Oral hygiene is important, but it is not necessary to provide oral care every 2 hours. The low platelet count does not increase risk for infection, so frequent temperature monitoring is not indicated.

A patient with bacterial pneumonia has rhonchi and thick sputum. What is the nurse's most appropriate action to promote airway clearance? a. Assist the patient to splint the chest when coughing. b. Teach the patient about the need for fluid restrictions. c. Encourage the patient to wear the nasal oxygen cannula. d. Instruct the patient on the pursed lip breathing technique.

ANS: A Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal oxygen will improve gas exchange, but will not improve airway clearance. Pursed lip breathing is used to improve gas exchange in patients with COPD, but will not improve airway clearance

Which menu choice indicates that the patient understands the nurse's teaching about best dietary choices for iron-deficiency anemia? a. Omelet and whole wheat toast b. Cantaloupe and cottage cheese c. Strawberry and banana fruit plate d. Cornmeal muffin and orange juice

ANS: A Eggs and whole grain breads are high in iron. The other choices are appropriate for other nutritional deficiencies but are not the best choice for a patient with iron-deficiency anemia.

6. Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate? a. "I will call my health care provider if my stools turn black." b. "I will take a stool softener if I feel constipated occasionally." c. "I should take the iron with orange juice about an hour before eating." d. "I should increase my fluid and fiber intake while I am taking iron tablets."

ANS: A It is normal for the stools to appear black when a patient is taking iron, and the patient should not call the doctor about this. The other patient statements are correct.

When teaching patients who are at risk for Bell's palsy because of previous herpes simplex infection, which information should the nurse include? a. "Call the doctor if pain or herpes lesions occur near the ear." b. "Treatment of herpes with antiviral agents prevents Bell's palsy." c. "You may be able to prevent Bell's palsy by doing facial exercises regularly." d. "Medications to treat Bell's palsy work only if started before paralysis onset."

ANS: A Pain or herpes lesions near the ear may indicate the onset of Bell's palsy and rapid corticosteroid treatment may reduce the duration of Bell's palsy symptoms. Antiviral therapy for herpes simplex does not reduce the risk for Bell's palsy. Corticosteroid therapy will be most effective in reducing symptoms if started before paralysis is complete but will still be somewhat effective when started later. Facial exercises do not prevent Bell's palsy.

The nurse determines that additional instruction is needed for a 60-year-old patient with chronic syndrome of inappropriate antidiuretic hormone (SIADH) when the patient says which of the following? a. "I need to shop for foods low in sodium and avoid adding salt to food." b. "I should weigh myself daily and report any sudden weight loss or gain." c. "I need to limit my fluid intake to no more than 1 quart of liquids a day." d. "I will eat foods high in potassium because diuretics cause potassium loss."

ANS: A Patients with SIADH are at risk for hyponatremia, and a sodium supplement may be prescribed. The other patient statements are correct and indicate successful teaching has occurred

A patient with a head injury has admission vital signs of blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse? a. Blood pressure 156/60, pulse 55, respirations 12 b. Blood pressure 130/72, pulse 90, respirations 32 c. Blood pressure 148/78, pulse 112, respirations 28 d. Blood pressure 110/70, pulse 120, respirations 30

ANS: A Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad and indicate that the intracranial pressure (ICP) has increased, and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process.DIF: Cognitive Level: Application REF: 1429-1430

There is one opening in the schedule at the dermatology clinic, and 4 patients are seeking appointments today. Which patient will the nurse schedule for the available opening? a. 38-year old with a 7-mm nevus on the face that has recently become darker b. 62-year-old with multiple small, soft, pedunculated papules in both axillary areas c. 42-year-old with complaints of itching after using topical fluorouracil on the nose d. 50-year-old with concerns about skin redness after having a chemical peel 3 days ago

ANS: A The description of the lesion is consistent with possible malignant melanoma. This patient should be assessed as soon as possible by the health care provider. Itching is common after using topical fluorouracil and redness is an expected finding a few days after a chemical peel. Skin tags are common, benign lesions after midlife

The health care provider diagnoses impetigo in a patient who has crusty vesicopustular lesions on the lower face. Which instructions should the nurse include in the teaching plan? a. Clean the infected areas with soap and water. b. Apply alcohol-based cleansers on the lesions. c. Avoid use of antibiotic ointments on the lesions. d. Use petroleum jelly (Vaseline) to soften crusty areas.

ANS: A The treatment for impetigo includes softening of the crusts with warm saline soaks and then soap-and-water removal. Alcohol-based cleansers and use of petroleum jelly are not recommended for impetigo. Antibiotic ointments, such as mupirocin (Bactroban), may be applied to the lesions

A patient with atopic dermatitis has been using a high-potency topical corticosteroid ointment for several weeks. The nurse should assess for which adverse effect? a. Thinning of the affected skin b. Alopecia of the affected areas c. Reddish-brown discoloration of the skin d. Dryness and scaling in the areas of treatment

ANS: A Thinning of the skin indicates that atrophy, a possible adverse effect of topical corticosteroids, is occurring. The health care provider should be notified so that the medication can be changed or tapered. Alopecia, red-brown discoloration, and dryness/scaling of the skin are not adverse effects of topical corticosteroid use

The nurse is reviewing the laboratory results for newly admitted patients on thecardiovascular unit. Which laboratory result is most important to communicate as soon as possible to the health care provider? a. High troponin I level b. Increased triglyceride level c. Very low homocysteine level d. Elevated high-sensitivity C-reactive protein level

ANS: A The elevation in troponin I indicates that the patient has had an acute myocardial infarction.Further assessment and interventions are indicated. The other laboratory results are indicative ofincreased risk for coronary artery disease but are not associated with acute cardiac problems thatneed immediate intervention.

A nurse is teaching a patient with contact dermatitis of the arms and legs about ways to decrease pruritus. Which information should the nurse include in the teaching plan (select all that apply)? a. Cool, wet cloths or dressings can be used to reduce itching. b. Take cool or tepid baths several times daily to decrease itching. c. Add oil to your bath water to aid in moisturizing the affected skin. d. Rub yourself dry with a towel after bathing to prevent skin maceration. e. Use of an over-the-counter (OTC) antihistamine can reduce scratching.

ANS: A, B, E Cool or tepid baths, cool dressings, and OTC antihistamines all help reduce pruritus and scratching. Adding oil to bath water is not recommended because of the increased risk for falls. The patient should use the towel to pat (not rub) the skin dry

The nurse assesses a patient who is receiving interleukin-2. Which finding should the nurse report immediately to the health care provider? a. Generalized muscle aches b. Crackles heard at the lung bases c. Complaints of nausea and anorexia d. Oral temperature of 100.6° F (38.1° C)

ANS: B Capillary leak syndrome and acute pulmonary edema are possible toxic effects ofinterleukin-2. The patient may need oxygen and the nurse should rapidly notify the health careprovider. The other findings are common side effects of interleukin-2.DIF: Cognitive Level: Analyze (analysis) REF: 257TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

The nurse identifies the nursing diagnosis of decreased cardiac output related to valvular insufficiency for the patient with infective endocarditis (IE) based on which assessment finding(s)? a. Fever, chills, and diaphoresis b. Urine output less than 30 mL/hr c. Petechiae on the inside of the mouth and conjunctiva d. Increase in heart rate of 15 beats/minute with walking

ANS: B Decreased renal perfusion caused by inadequate cardiac output will lead to decreased urine output. Petechiae, fever, chills, and diaphoresis are symptoms of IE, but are not caused by decreased cardiac output. An increase in pulse rate of 15 beats/minute is normal with exercise.

Which assessment information will the nurse collect to determine whether a patient is developing postconcussion syndrome? a. Muscle resistance b. Short-term memory c. Glasgow coma scale d. Pupil reaction to light

ANS: B Decreased short-term memory is one indication of postconcussion syndrome. The other data may be assessed but are not indications of postconcussion syndrome.DIF: Cognitive Level: Application REF: 1440

The nurse determines that demeclocycline (Declomycin) is effective for a patient with syndrome of inappropriate antidiuretic hormone (SIADH) based on finding that the patient's a. weight has increased. b. urinary output is increased. c. peripheral edema is decreased. d. urine specific gravity is increased.

ANS: B Demeclocycline blocks the action of antidiuretic hormone (ADH) on the renal tubules and increases urine output. An increase in weight or an increase in urine specific gravity indicates that the SIADH is not corrected. Peripheral edema does not occur with SIADH. A sudden weight gain without edema is a common clinical manifestation of this disorder

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

ANS: B Fistulas between the bowel and bladder occur in Crohn's disease and can lead to UTI. Teaching for UTI prevention in general includes good hygiene, adequate fluid intake, and voiding before and after intercourse.

A patient arrives at an urgent care center with a deep puncture wound after stepping on a nail that was lying on the ground. The patient reports having had a tetanus booster 7 years ago. The nurse will anticipate a. IV infusion of tetanus immune globulin (TIG). b. administration of the tetanus-diphtheria (Td) booster. c. intradermal injection of an immune globulin test dose. d. initiation of the tetanus-diphtheria immunization series.

ANS: B If the patient has not been immunized within 5 years, administration of the Td booster is indicated because the wound is deep. Immune globulin administration is given by the IM route if the patient has no previous immunization. Administration of a series of immunization is not indicated. TIG is not indicated for this patient, and a test dose is not needed for immune globulin.

A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of a. iron. b. folic acid. c. cobalamin (vitamin B12). d. ascorbic acid (vitamin C).

ANS: B Methotrexate use can lead to folic acid deficiency. Supplementation with oral folic acid supplements is the usual treatment. The other nutrients would not correct folic acid deficiency, although they would be used to treat other types of anemia.

The nurse is interviewing a patient with contact dermatitis. Which finding indicates a need for patient teaching? a. The patient applies corticosteroid cream to pruritic areas. b. The patient uses Neosporin ointment on minor cuts or abrasions. c. The patient adds oilated oatmeal (Aveeno) to the bath water every day. d. The patient takes diphenhydramine (Benadryl) at night if itching occurs.

ANS: B Neosporin can cause contact dermatitis. The other medications are being used appropriately by the patient

It is important for the nurse providing care for a patient with sickle cell crisis to a. limit the patient's intake of oral and IV fluids. b. evaluate the effectiveness of opioid analgesics. c. encourage the patient to ambulate as much as tolerated. d. teach the patient about high-protein, high-calorie foods.

ANS: B Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control. Fluid intake should be increased to reduce blood viscosity and improve perfusion. Rest is usually ordered to decrease metabolic requirements. Patients are instructed about the need for dietary folic acid, but high-protein, high-calorie diets are not emphasized.

A 58-yr-old 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.

ANS: B Return of brown drainage and fecal material suggests perforation of the bowel and the need for immediate surgery. Auscultation of bowel sounds, checking the temperature, and obtaining information about the accident are appropriate actions, but the priority is to prepare to send the patient for emergency surgery.

A patient with a head injury opens the eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to remove a painful stimulus. The nurse records the patient's Glasgow Coma Scale score as a. 9. b. 11. c. 13. d. 15.

ANS: B The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor response.DIF: Cognitive Level: Application REF: 1434

When planning care for a patient hospitalized with a streptococcal infective endocarditis (IE), which intervention is a priority for the nurse to include? a. Monitor labs for streptococcal antibodies. b. Arrange for placement of a long-term IV catheter. c. Teach the importance of completing all oral antibiotics. d. Encourage the patient to begin regular aerobic exercise.

ANS: B Treatment for IE involves 4 to 6 weeks of IV antibiotic therapy in order to eradicate the bacteria, which will require a long-term IV catheter such as a peripherally inserted central catheter (PICC) line. Rest periods and limiting physical activity to a moderate level are recommended during the treatment for IE. Oral antibiotics are not effective in eradicating the infective bacteria that cause IE. Blood cultures, rather than antibody levels, are used to monitor the effectiveness of antibiotic therapy.

Which admission order written by the health care provider for a patient admitted with infective endocarditis (IE) and a fever would be a priority for the nurse to implement? a. Administer ceftriaxone (Rocephin) 1 g IV. b. Order blood cultures drawn from two sites. c. Give acetaminophen (Tylenol) PRN for fever. d. Arrange for a transesophageal echocardiogram.

ANS: B Treatment of the IE with antibiotics should be started as quickly as possible, but it is essential to obtain blood cultures before initiating antibiotic therapy to obtain accurate sensitivity results. The echocardiogram and acetaminophen administration also should be implemented rapidly, but the blood cultures (and then administration of the antibiotic) have the highest priority.

The nurse has received the laboratory results for a patient who developed chest pain 4 hours ago and may be having a myocardial infarction. The laboratory test result most helpful in indicating myocardial damage will be a. myoglobin. b. troponins T and I. c. homocysteine (Hcy) d. creatine kinase-MB (CK-MB).

ANS: B Cardiac troponins start to elevate 4 to 6 hours after myocardial injury and are highly specific tomyocardium. They are the preferred diagnostic marker for myocardial infarction. Myoglobin risesin response to myocardial injury within 30 to 60 minutes. It is rapidly cleared from the body, thuslimiting its use in the diagnosis of myocardial infarction. Low-density lipoprotein cholesterol isuseful in assessing cardiovascular risk but is not helpful in determining whether a patient is havingan acute myocardial infarction. Creatine kinase (CK-MB) is specific to myocardial injury andinfarction and increases 4 to 6 hours after the infarction occurs. It is often trended with troponinlevels. Homocysteine (Hcy) is an amino acid that is produced during protein catabolism. ElevatedHcy levels can be either hereditary or acquired from dietary deficiencies of vitamin B6, cobalamin(vitamin B12), or folate. Elevated levels of Hcy have been linked to a higher risk of CVD,peripheral vascular disease, and stroke.

During the assessment of a 25-year-old patient with infective endocarditis (IE), the nurse would expect to find a. substernal chest pressure. b. a new regurgitant murmur. c. a pruritic rash on the chest. d. involuntary muscle movement.

ANS: B New regurgitant murmurs occur in IE because vegetations on the valves prevent valve closure. Substernal chest discomfort, rashes, and involuntary muscle movement are clinical manifestations of other cardiac disorders such as angina and rheumatic fever.

The nurse teaches a patient who is scheduled for a prostate needle biopsy about the procedure. Which statement, if made by the patient, indicates that teaching was effective? a. "The biopsy will remove the cancer in my prostate gland." b. "The biopsy will determine how much longer I have to live." c. "The biopsy will help decide the treatment for my enlarged prostate." d. "The biopsy will indicate whether the cancer has spread to other organs."

ANS: C A biopsy is used to determine whether the prostate enlargement is benign or malignant anddetermines the type of treatment that will be needed. A biopsy does not give informationabout metastasis, life expectancy, or the impact of cancer on the patient's life.

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?"

ANS: C A complete description of the pain provides clues about the cause of the problem. Although the nurse should ask whether the patient is pregnant to determine whether the patient might have an ectopic pregnancy and before any radiology studies are done, this information is not the most useful in determining the cause of the pain. The usual diet and elimination patterns are less helpful in determining the reason for the patient's symptoms.

A patient with a large stomach tumor attached to the liver is scheduled for a debulking procedure. Which information should the nurse teach the patient about the outcome of this procedure? a. Pain will be relieved by cutting sensory nerves in the stomach. b. Relief of pressure in the stomach will promote better nutrition. c. Decreasing the tumor size will improve the effects of other therapy. d. Tumor growth will be controlled by the removal of malignant tissue.

ANS: C A debulking surgery reduces the size of the tumor and makes radiation and chemotherapy more effective. Debulking surgeries do not control tumor growth. The tumor is debulked because it is attached to the liver, a vital organ (not to relieve pressure on the stomach).Debulking does not sever the sensory nerves, although pain may be lessened by the reduction in pressure on the abdominal organs.

During discharge teaching with a 68-year-old patient who had a mitral valve replacement with a mechanical valve, the nurse instructs the patient on the a. use of daily aspirin for anticoagulation. b. correct method for taking the radial pulse. c. need for frequent laboratory blood testing. d. need to avoid any physical activity for 1 month.

ANS: C Anticoagulation with warfarin (Coumadin) is needed for a patient with mechanical valves to prevent clotting on the valve. This will require frequent international normalized ratio (INR) testing. Daily aspirin use will not be effective in reducing the risk for clots on the valve. Monitoring of the radial pulse is not necessary after valve replacement. Patients should resume activities of daily living as tolerated.

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.

ANS: C Because C. difficile is highly contagious, the patient should be placed in a private room, and contact precautions should be used. There is no need to restrict dairy products for this type of diarrhea. Metronidazole (Flagyl) is frequently used to treat C. difficile infections. Improper food handling and storage do not cause C. difficile.

A 52-year-old patient has a new diagnosis of pernicious anemia. The nurse determines that the patient understands the teaching about the disorder when the patient states, a. "I need to start eating more red meat and liver." b. will stop having a glass of wine with dinner." c. could choose nasal spray rather than injections of vitamin B12." d. will need to take a proton pump inhibitor like omeprazole (Prilosec)."

ANS: C Because pernicious anemia prevents the absorption of vitamin B12, this patient requires injections or intranasal administration of cobalamin. Alcohol use does not cause cobalamin deficiency. Proton pump inhibitors decrease the absorption of vitamin B12. Eating more foods rich in vitamin B12 is not helpful because the lack of intrinsic factor prevents absorption of the vitamin.

The nurse instructs a patient about application of corticosteroid cream to an area of contact dermatitis on the right leg. Which patient action indicates that further teaching is needed? a. The patient takes a tepid bath before applying the cream. b. The patient spreads the cream using a downward motion. c. The patient applies a thick layer of the cream to the affected skin. d. The patient covers the area with a dressing after applying the cream.

ANS: C Creams and ointments should be applied in a thin layer to avoid wasting the medication. The other actions by the patient indicate that the teaching has been successful

When caring for a patient with infective endocarditis of the tricuspid valve, the nurse should monitor the patient for the development of a. flank pain. b. splenomegaly. c. shortness of breath. d. mental status changes.

ANS: C Embolization from the tricuspid valve would cause symptoms of pulmonary embolus. Flank pain, changes in mental status, and splenomegaly would be associated with embolization from the left-sided valves.

Which instruction will the nurse plan to include in discharge teaching for the patient admitted with a sickle cell crisis? a. Take a daily multivitamin with iron. b. Limit fluids to 2 to 3 quarts per day. c. Avoid exposure to crowds when possible. d. Drink only two caffeinated beverages daily.

ANS: C Exposure to crowds increases the patient's risk for infection, the most common cause of sickle cell crisis. There is no restriction on caffeine use. Iron supplementation is generally not recommended. A high-fluid intake is recommended

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

ANS: C Frequent deep breathing and coughing are needed after chest surgery to prevent atelectasis. To promote gas exchange, patients after pneumonectomy are positioned on the surgical side. Early mobilization decreases the risk for postoperative complications such as pneumonia and deep vein thrombosis. In a pneumonectomy, chest tubes may or may not be placed in the space from which the lung was removed. If a chest tube is used, it is clamped and only released by the surgeon to adjust the volume of serosanguineous fluid that will fill the space vacated by the lung. If the cavity overfills, it could compress the remaining lung and compromise the cardiovascular and pulmonary function. Daily chest x-rays can be used to assess the volume and space

A 21-year-old woman is scheduled for percutaneous transluminal balloon valvuloplasty to treat mitral stenosis. Which information should the nurse include when explaining the advantages of valvuloplasty over valve replacement to the patient? a. Biologic valves will require immunosuppressive drugs after surgery. b. Mechanical mitral valves need to be replaced sooner than biologic valves. c. Lifelong anticoagulant therapy will be needed after mechanical valve replacement. d. Ongoing cardiac care by a health care provider is not necessary after valvuloplasty.

ANS: C Long-term anticoagulation therapy is needed after mechanical valve replacement, and this would restrict decisions about career and childbearing in this patient. Mechanical valves are durable and last longer than biologic valves. All valve repair procedures are palliative, not curative, and require lifelong health care. Biologic valves do not activate the immune system, and immunosuppressive therapy is not needed.

The community health nurse is developing a program to decrease the incidence of meningitis in adolescents and young adults. Which nursing action is most important? a. Vaccinate 11- and 12-year-old children against Haemophilus influenzae. b. Emphasize the importance of hand washing to prevent spread of infection. c. Immunize adolescents and college freshman against Neisseria meningitides. d. Encourage adolescents and young adults to avoid crowded areas in the winter.

ANS: C The Neisseria meningitides vaccination is recommended for children ages 11 and 12, unvaccinated teens entering high school, and college freshmen. Hand washing may help decrease the spread of bacteria, but it is not as effective as immunization. Vaccination with Haemophilus influenzae is for infants and toddlers. Because adolescents and young adults are in school or the workplace, avoiding crowds is not realistic.DIF: Cognitive Level: Application REF: 1453-1455

A patient who is scheduled for a breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct? a. "Benign tumors do not cause damage to other tissues." b. "Benign tumors are likely to recur in the same location." c. "Malignant tumors may spread to other tissues or organs." d. "Malignant cells reproduce more rapidly than normal cells."

ANS: C The major difference between benign and malignant tumors is that malignant tumors invadeadjacent tissues and spread to distant tissues and benign tumors do not metastasize. The otherstatements are inaccurate. Both types of tumors may cause damage to adjacent tissues.Malignant cells do not reproduce more rapidly than normal cells. Benign tumors do notusually recur.

The nurse teaches a postmenopausal patient with stage III breast cancer about the expected outcomes of cancer treatment. Which patient statement indicates that the teaching has been effective? a. "After cancer has not recurred for 5 years, it is considered cured." b. "The cancer will be cured if the entire tumor is surgically removed." c. "I will need follow-up examinations for many years after treatment before I can be considered cured." d. "Cancer is never cured, but the tumor can be controlled with surgery, chemotherapy, and radiation."

ANS: C The risk of recurrence varies by the type of cancer. Some cancers are considered cured after a shorter time span or after surgery, but stage III breast cancer will require additional therapies and ongoing follow-up.

The nurse is caring for a patient with left-sided lung cancer. Which finding would be most important for the nurse to report to the health care provider? a. Hematocrit of 32% b. Pain with deep inspiration c. Serum sodium of 126 mEq/L d. Decreased breath sounds on left side

ANS: C The syndrome of inappropriate antidiuretic hormone (and the resulting hyponatremia) is anoncologic metabolic emergency and requires rapid treatment to prevent complications such asseizures and coma. The other findings also require intervention but are common in patientswith lung cancer and not immediately life threatening.

A patient with metastatic cancer of the colon experiences severe vomiting after each administration of chemotherapy. Which action, if taken by the nurse, is appropriate? a. Have the patient eat large meals when nausea is not present. b. Offer dry crackers and carbonated fluids during chemotherapy. c. Administer prescribed antiemetics 1 hour before the treatments. d. Give the patient a glass of a citrus fruit beverage during treatments.

ANS: C Treatment with antiemetics before chemotherapy may help prevent nausea. The patient should eat small, frequent meals. Offering food and beverages during chemotherapy is likely to cause nausea. The acidity of citrus fruits may be further irritating to the stomach.

The nurse will plan discharge teaching about the need for prophylactic antibiotics when having dental procedures for which patient? a. Patient admitted with a large acute myocardial infarction. b. Patient being discharged after an exacerbation of heart failure. c. Patient who had a mitral valve replacement with a mechanical valve. d. Patient being treated for rheumatic fever after a streptococcal infection.

ANS: C Current American Heart Association guidelines recommend the use of prophylactic antibiotics before dental procedures for patients with prosthetic valves to prevent infective endocarditis (IE). The other patients are not at risk for IE.

A patient who has non-Hodgkin's lymphoma is receiving combination treatment with rituximab (Rituxan) and chemotherapy. Which patient assessment finding requires the most rapid action by the nurse? a. Anorexia b. Vomiting c. Oral ulcers d. Lip swelling

ANS: D Lip swelling in angioedema may indicate a hypersensitivity reaction to the rituximab. The nurse should stop the infusion and further assess for anaphylaxis. The other findings may occur with chemotherapy, but are not immediately life threatening.

When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient? a. Emergency pericardiocentesis b. Stabilization of the chest wall with tape c. Administration of an inhaled bronchodilator d. Insertion of a chest tube with a chest drainage system

ANS: D The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patient's clinical manifestations are not consistent with these problems

After several days of antibiotic therapy, an older hospitalized patient develops watery diarrhea. Which action should the nurse take first? a. Notify the health care provider. b. Obtain a stool specimen for analysis. c. Teach the patient about handwashing. d. Place the patient on contact precautions.

ANS: D The patient's history and new onset diarrhea suggest a C. difficile infection, which requires implementation of contact precautions to prevent spread of the infection to other patients. The other actions are also appropriate but can be accomplished after contact precautions are implemented.

A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurse's first action should be to a. administer oxygen therapy at a high flow rate. b. obtain a urine specimen to send to the laboratory. c. notify the health care provider about the symptoms. d. disconnect the transfusion and infuse normal saline.

ANS: D The patient's symptoms indicate a possible acute hemolytic reaction caused by the transfusion. The first action should be to disconnect the transfusion and infuse normal saline. The other actions also are needed but are not the highest priority.

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. The nurse should 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.

ANS: D The stoma appearance indicates good circulation to the stoma. There is no indication that surgical intervention is needed or that frequent stoma monitoring is required. Swelling of the stoma is normal for 2 to 3 weeks after surgery, and an ice pack is not needed.

The health care provider prescribes topical 5-FU for a patient with actinic keratosis on the left cheek. The nurse should include which statement in the patient's instructions? a. "5-FU will shrink the lesion so that less scarring occurs once the lesion is excised." b. "You may develop nausea and anorexia, but good nutrition is important during treatment." c. "You will need to avoid crowds because of the risk for infection caused by chemotherapy." d. "Your cheek area will be painful and develop eroded areas that will take weeks to heal."

ANS: D Topical 5-FU causes an initial reaction of erythema, itching, and erosion that lasts 4 weeks after application of the medication is stopped. The medication is topical, so there are no systemic effects such as increased infection risk, anorexia, or nausea

Which action could the nurse delegate to unlicensed assistive personnel (UAP) trained as electrocardiogram (ECG) technicians working on the cardiac unit? a. Select the best lead for monitoring a patient with an admission diagnosis of Dressler syndrome. b. Obtain a list of herbal medications used at home while admitting a new patient with pericarditis. c. Teach about the need to monitor the weight daily for a patient who has hypertrophic cardiomyopathy. d. Check the heart monitor for changes in rhythm while a patient who had a valve replacement ambulates.

ANS: D Under the supervision of registered nurses (RNs), UAP check the patient's cardiac monitor and obtain information about changes in heart rate and rhythm with exercise. Teaching and obtaining information about home medications (prescribed or complementary) and selecting the best leads for monitoring patients require more critical thinking and should be done by the RN.

The nurse obtains a health history from a 65-year-old patient with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse is most appropriate? a. "Do you have a history of a heart attack?" b. "Is there a family history of endocarditis?" c. "Have you had any recent immunizations?" d. "Have you had dental work done recently?"

ANS: D Dental procedures place the patient with a prosthetic mitral valve at risk for infective endocarditis (IE). Myocardial infarction (MI), immunizations, and a family history of endocarditis are not risk factors for IE.

Which action should the nurse take when caring for a patient who is receiving chemotherapy and complains of problems with concentration? a. Teach the patient to rest the brain by avoiding new activities. b. Teach that "chemo-brain" is a short-term effect of chemotherapy. c. Report patient symptoms immediately to the health care provider. d. Suggest use of a daily planner and encourage adequate rest and sleep.

ANS: D Use of tools to enhance memory and concentration such as a daily planner and adequate rest are helpful for patients who develop "chemo-brain" while receiving chemotherapy. Patients should be encouraged to exercise the brain through new activities. Chemo-brain may be short or long term. There is no urgent need to report common chemotherapy side effects to the provider.

When preparing to defibrillate a patient, in which order will the nurse perform the following steps? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Turn the defibrillator on. b. Deliver the electrical charge. c. Select the appropriate energy level. d. Place the hands-free, multifunction defibrillator pads on the patient's chest. e. Check the location of other staff and call out "all clear."

ANS:A, C, D, E, B This order will result in rapid defibrillation without endangering hospital staff.DIF: Cognitive Level: Analyze (analysis)

The nurse recognizes that teaching a patient following a laparoscopic cholecystectomy has been effective when the patient makes which statement? a. "I can expect yellow-green drainage from the incision for a few days." b. "I can remove the bandages on my incisions tomorrow and take a shower." c. "I should plan to limit my activities and not return to work for 4 to 6 weeks." d. "I will need to maintain a low-fat diet for life because I no longer have a gallbladder."

B After a laparoscopic cholecystectomy, the patient will have Band-Aids in place over the incisions. Patients are discharged the same (or next) day and have few restrictions on activities of daily living. Drainage from the incisions would be abnormal, and the patient should be instructed to call the health care provider if this occurs. A low-fat diet may be recommended for a few weeks after surgery but will not be a lifelong requirement.

Which assessment information will be most important for the nurse to report to the health care provider about a patient with acute cholecystitis? a. The patient's urine is bright yellow. b. The patient's stools are tan colored. c. The patient has increased pain after eating. d. The patient complains of chronic heartburn.

B Tan or gray stools indicate biliary obstruction, which requires rapid intervention to resolve. The other data are not unusual for a patient with this diagnosis, although the nurse would also report the other assessment information to the health care provider.

The nurse evaluates that administration of hepatitis B vaccine to a healthy patient has been effective when the patient's blood specimen reveals a. HBsAg. b. anti-HBs. c. anti-HBc IgG. d. anti-HBc IgM.

B The presence of surface antibody to HBV (anti-HBs) is a marker of a positive response to the vaccine.The other laboratory values indicate current infection with HBV.

The nurse is providing care for a patient who has been admitted to the hospital with a head injury and who requires regular neurologic and vital sign assessment. Which assessments will be components of the patient's score on the Glasgow Coma Scale (GCS) (select all that apply)? A. Judgment B. Eye opening C. Abstract reasoning D. Best verbal response E. Best motor response F. Cranial nerve function

B,D,E The three dimensions of the GCS are eye opening, best verbal response, and best motor response. Judgment, abstract reasoning, and cranial nerve function are not components of the GCS.

The nurse performs discharge teaching for a 68-year-old man who is newly diagnosed with infective endocarditis with a history of IV substance abuse. Which statement by the patient indicates to the nurse that teaching was successful? A."I will need antibiotics before having any invasive procedure or surgery." B. "I will inform my dentist about my hospitalization for infective endocarditis." C."I should not be alarmed if I have difficulty breathing or pink-tinged sputum." D. "An elevated temperature is expected and can be managed by taking acetaminophen."

B. "I will inform my dentist about my hospitalization for infective endocarditis."Patients with infective endocarditis should inform their dental providers of their health history. Antibiotic prophylaxis is recommended for patients with a history of infective endocarditis who have certain dental procedures performed. Antibiotics are not indicated before genitourinary or gastrointestinal procedures unless an infection is present. Patients should immediately report the presence of fever or clinical manifestations indicating heart failure to their health care provider.

The patient had a history of rheumatic fever and has been diagnosed with mitral valve stenosis. The patient is planning to have a biologic valve replacement. What protective mechanisms should the nurse teach the patient about using after the valve replacement? A. Long-term anticoagulation therapy B. Antibiotic prophylaxis for dental care C. Exercise plan to increase cardiac tolerance D. Take β-adrenergic blockers to control palpitations.

B. Antibiotic prophylaxis for dental careThe patient will need to use antibiotic prophylaxis for dental care to prevent endocarditis. Long-term anticoagulation therapy is not used with biologic valve replacement unless the patient has atrial fibrillation. An exercise plan to increase cardiac tolerance is needed for a patient with heart failure. Taking β-adrenergic blockers to control palpitations is prescribed for mitral valve prolapse, not valve replacement.

The nurse conducts a complete physical assessment on a patient admitted with infective endocarditis. Which finding is significant? A. Respiratory rate of 18 and heart rate of 90 B. Regurgitant murmur at the mitral valve area C. Heart rate of 94 and capillary refill time of 2 seconds D. Point of maximal impulse palpable in fourth intercostal space

B. Regurgitant murmur at the mitral valve areaA regurgitant murmur of the aortic or mitral valves would indicate valvular disease, which is a complication of endocarditis. All the other findings are within normal limits.

The nurse is aware that a major difference between Hodgkin's lymphoma and non-Hodgkin's lymphoma is: A. Hodgkin's lymphoma only occurs in young adults B. Hodgkin's lymphoma is considered potentially curable C. non-Hodgkin's lymphoma can manifest in multiple organs D. non-Hodgkin's lymphoma is treated only with radiation therapy

C

To prepare a patient with ascites for paracentesis, the nurse a. places the patient on NPO status. b. assists the patient to lie flat in bed. c. asks the patient to empty the bladder. d. positions the patient on the right side.

C The patient should empty the bladder to decrease the risk of bladder perforation during the procedure. The patient would be positioned in Fowler's position and would not be able to lie flat without compromising breathing. Because no sedation is required for paracentesis, the patient does not need to be NPO.

Which laboratory test result will the nurse monitor when evaluating the effects of therapy for a patient who has acute pancreatitis? a. Calcium b. Bilirubin c. Amylase d. Potassium

C Amylase is elevated in acute pancreatitis. Although changes in the other values may occur, they would not be useful in evaluating whether the prescribed therapies have been effective.

A 50-year-old patient sustained a large, open wound. The patient indicates his last tetanus booster was 3 years earlier. What action do you anticipate? A. Administer tetanus and diphtheria toxoid (Td) booster. B. Administer tetanus immune globulin (TIg). C. Clean the wound with soap and water. D. Clean the wound with hydrogen peroxide.

C. Clean the wound with soap and water. Immediate, thorough cleansing of all wounds with soap and water is important in the prevention of tetanus. After the adult is immunized, a booster is given every 10 years. If an open wound occurs, a booster is given if the last one was 5 or more years earlier. Immune globulin is used if immunization was never provided. Hydrogen peroxide is not ordinarily used for wound cleansing.

The nurse will ask a patient being admitted with acute pancreatitis specifically about ahistory of a. diabetes mellitus. b. high-protein diet. c. cigarette smoking. d. alcohol consumption.

D Alcohol use is one of the most common risk factors for pancreatitis in the United States. Cigarette smoking, diabetes, and high-protein diets are not risk factors.

A young adult contracts hepatitis from contaminated food. During the acute (icteric)phase of the patient's illness, the nurse would expect serologic testing to reveal a. antibody to hepatitis D (anti-HDV). b. hepatitis B surface antigen (HBsAg). c. anti-hepatitis A virus immunoglobulin G (anti-HAV IgG). d. anti-hepatitis A virus immunoglobulin M (anti-HAV IgM).

D Hepatitis A is transmitted through the oral-fecal route, and antibody to HAV IgM appears during the acute phase of hepatitis A. The patient would not have antigen for hepatitis B or antibody for hepatitis D. Anti-HAV IgG would indicate past infection and lifelong immunity.

Which action will be included in the care for a patient who has recently been diagnosed with asymptomatic nonalcoholic fatty liver disease (NAFLD)? a. Teach symptoms of variceal bleeding. b. Draw blood for hepatitis serology testing. c. Discuss the need to increase caloric intake. d. Review the patient's current medication list.

D Some medications can increase the risk for NAFLD, and they should be eliminated. NAFLD is not associated with hepatitis, weight loss is usually indicated, and variceal bleeding would not be a concern in a patient with asymptomatic NAFLD.

A patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care? a. Restrict daily dietary protein intake. b. Reposition the patient every 4 hours. c. Perform passive range of motion twice daily. d. Place the patient on a pressure-relief mattress.

D The pressure-relieving mattress will decrease the risk for skin breakdown for this patient. Adequate dietary protein intake is necessary in patients with ascites to improve oncotic pressure. Repositioning thepatient every 4 hours will not be adequate to maintain skin integrity. Passive range of motion will not takethe pressure off areas such as the sacrum that are vulnerable to breakdown.

When providing nutritional counseling for patients at risk for coronary artery disease (CAD), which foods would the nurse encourage patients to include in their diet (select all that apply.)?Select all that apply. a. Tofu b. Walnuts c. Tuna fish d. Whole milk e. Orange juice

a. Tofu b. Walnuts c. Tuna fish

biggest risk factor for pancreatitis:

alcohol abuse

#1 complication of chest trauma:

atelectasis which leads to pneumonia

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) rectal suppository

b.

Which nursing intervention is likely to be most effective when assisting the patient with coronary artery disease to make appropriate dietary changes? a. Inform the patient about a diet containing no saturated fat and minimal salt. b. Help the patient modify favorite high-fat recipes by using monounsaturated oils. c. Emphasize the increased risk for heart problems unless the patient makes the dietary changes. d. Give the patient a list of low-sodium, low-cholesterol foods that should be included in the diet.

b. Help the patient modify favorite high-fat recipes by using monounsaturated oils Lifestyle changes are more likely to be successful when consideration is given to the patient's values and preferences. The highest percentage of calories from fat should come from monounsaturated or polyunsaturated fats.

The nurse is admitting a patient who has chest pain. Which assessment data suggest that the pain is caused by an acute myocardial infarction (AMI)---[A blockage of blood flow to the heart muscle]? a. The pain increases with deep breathing. b. The pain has lasted longer than 30 minutes. c. The pain is relieved after the patient takes nitroglycerin. d. The pain is reproducible when the patient raises the arms.

b. The pain has lasted longer than 30 minutes. Chest pain that lasts for 20 minutes or more is characteristic of AMI.

After reviewing information shown in the accompanying figure from the medical records of a 43-yr-old patient, which risk factor modification for coronary artery disease should the nurse include in patient teaching? a. Importance of daily physical activity b. Effect of weight loss on blood pressure c. Dietary changes to improve lipid levels d. Cardiac risk associated with previous tobacco use

c. Dietary changes to improve lipid levels The patient has an elevated low-density lipoprotein cholesterol and low high-density lipoprotein cholesterol, which will increase the risk of coronary artery disease.

node involvement of Hodgkin's

cervical, axillary, inguinal

pt throwing PVCs what do you do

check patient, then anticipate ordering EKG, **electrolytes (order of BNP or CMP... K and Mg out of whack)**

prevention of PE

compression stockings

Which statement made by a patient with coronary artery disease after the nurse has completed teaching about the therapeutic lifestyle changes (TLC) diet indicates that further teaching is needed? a. "I will switch from whole milk to 1% milk." b. "I like salmon and I will plan to eat it more often." c. "I can have a glass of wine with dinner if I want one." d. "I will miss being able to eat peanut butter sandwiches."

d. "I will miss being able to eat peanut butter sandwiches."

When evaluating a patient's knowledge regarding a low-sodium, low-fat cardiac diet, the nurse recognizes additional teaching is needed when the patient selects which food? a. Baked flounder b. Angel food cake c. Baked potato with margarine d. Canned chicken noodle soup

d. Canned chicken noodle soup

AAA and age ranges for screening, risk factors

male patients who are smokers: 65-75

A male patient who has coronary artery disease (CAD) has serum lipid values of low-density lipoprotein (LDL) cholesterol of 98 mg/dL and high-density lipoprotein (HDL) cholesterol of 47 mg/dL. What should the nurse include in patient teaching? a. Consume a diet low in fats. b. Reduce total caloric intake. c. Increase intake of olive oil. d. The lipid levels are normal.

d. The lipid levels are normal.

labs to look at for acute MI

elevated troponin

CP care in the ER

first ASSESS!!!! Interventions at the end!!!!

expected findings with lung cancer

hemoptysis cough diminished lungs dyspnea

prevention of chest trauma complications

incentive spirometer, deep breathe, splinting

3 palliative care measures

laminectomy colostomy de-bulking

S/S of malignant skin cancers

skin lesion is changing/ growing

Pt teaching for smokers

stop smoking