Med-Surg II Final Practice Questions

A 20-year-old is brought in by ambulance to the emergency department after being involved in a motorcycle accident. The patient has an open fracture of his tibia. The wound is higlhy contaminated and there is extensive soft tissue damage. How would this patient's fracture likely be graded

Grade III

A 45-year-old man with diabetic nephropathy has ESKD and is starting dialysis "What should the nurse teach the patient about hemodialysis"

Hemodialysis is a treatment option that is usually required three times a week

While assessing a patient the nurse notes that the patients ABI of the right leg is 0.4. How should the nurse best respond to this assessment finding?

Implement interventions relevant to arterial narrowing

Mrs. Fawcett is a 70-year-old woman who has a diagnosis of emphysema and who receives long-term oxygen therapy. She has presented to the emergency department because she states that she is experiencing an exacerbation of her COPD, and she is in visible respiratory distress. How can the nurse best assess Mrs. Fawcett's dyspnea?

Measure her SpO2 by pulse oximetry and assess her respiratory rate

The critical care nurse is caring for a patient who has been experiencing bradycardia after cardiovascular surgery. The nurse knows that the heart rate is determined by myocardial cells with the fastest inherent firing rate. Under normal circumstances where are these cells located

SA node

The cardiac care nurse is reviewing the conduction system of the heart. The nurse is aware that electrical conduction of the heart usually originates in the SA node and then proceeds in what sequence

SA node to AV node to bundle of His to Purkinje Fibers

The nurse caring for a 78-year-old man who has had an outpatient cholecystectomy. The nurse is getting him up for his first walk postoperatively. To decrease the potential for orthostatic hypotension and consequent falls, what should the nurse have the patient do

Stand upright for 2-3 minutes prior to ambulating

A nurse is providing care for a patient who has a rheumatic disorder. The nurse's comprehensive assessment includes the patient's mood, behavior, LOC, and neurologic status. What is this patient's most likely diagnosis

Systemic lupus eryhtematosus (SLE)

The perioperative nurse is preparing to discharge a female patient home from day surgery performed under general anesthesic. What instruction should the nurse give the patient prior to the patient leaving the hospital

The patient should not drive herself home

The nurse is preparing a patient for surgery prior to her hysterectomy without oophorectomy. The nurse is witnessing the patient's signature on a consent form. Which comment by the patient would best indicate informed consent?

The physician is going to remove my uterus and told me about the risk of bleeding

The nurse is caring for a trauma victim in the ED who will require emergency surgery due to injuries. Before the patient leaves the ED for the OR, the patient goes into cardiac arrest. The nurse assists in the successful resuscitation and proceeds to release the patient to the OR staff. When can the ED nurse perform the preoperative assessment

When assisting with resuscitation

A patient has been brought to the ED with abdominal pain and is subsequently diagnosed with appendicitis. The patient is scheduled for an appendectomy but questions the nurse about how his health will be affected by the absence of an appendix. How should the nurse best repsond

Your appendix doesn't play a major role, so you won't notice any difference after you recover from surgery

A nurse works in a walk-in clinic. The nurse recognizes that certain patients are at higher risk for different disorders than other patients. What patient is at a greater risk for the development of hypothyroidism

a 45-year-old female patient who used oral contraceptives

A 37-year-old male is brought to the clinic by his wife because the patient is experiencing loss of motor function and sensation. After initial neurological assessment, the health care provider suspects the patient has a spinal cord tumor and hospitalizes him for diagnostic testing. In preparation for diagnostic studies, the nurse will inform the patient that the most commonly used study to diagnose spinal cord compression from a tumor is what

a MRI scan

A surgical patient has just been admitted to the unit from PACU with patient-controlled analgesia (PCA). The nurse should know that the requirements for safe and effective use of PCA include what?

a clear understanding of the need to self-dose

The public health nurse is administering Mantoux tests to children who are being registered for kindergarten in the community. How should the nurse administer this test

administer intradermal injections into the children's inner forearms

A patient with a total hip replacement is progressing well and expects to be discharged tomorrow. On returning to bed after ambulating, he complains of a new onset of pain at the surgical site. What is the nurse's best action

administer pain medication as ordered

Which nursing action is most appropriate for a client hospitalized with acute pancreatitis?

administering meperidine as ordered to relieve severe pain

The nurse is caring for a patient scheduled for renal angiography following a MVA. What patient preparation should the nurse most likely provide before this test?

administration fo a laxative

A nurse on a medical unit is caring for a patient who has been diagnosed with lymphangitis. When reviewing this patient's medication administration record, the nurse should anticipate which of the following?

an antibiotic

A patient with dysphagia is scheduled for PEG tube insertion and asks the nurse how the tube will stay in place. What is the nurse's best response?

an internal retention disc secures the tube against the stomach wall

You are writing a care plan for a patient who has been diagnosed with angina pectoris. The patient describes herself as being distressed and shocked by her new diagnosis. What nursing diagnosis is most clearly suggested by the woman's statement

anxiety related to cardiac symptoms

When assessing for substances that are known to harm worker's lungs, the occupational health nurse should assess their potential exposure to which of the following

asbestos

A 79-year-old man is admitted to the medical unit with digital gangrene. The man states that his problems first began when he stubbed his toe going to the bathroom in the dark. In addition to this trauma the nurse should suspect that the patient has a history of what health problem?

aterial insufficiency

A nurse is preparing to perform an admission assessment on a patient with COPD. It is most important for the nurse to review which of the following

available diagnostic tests

It is important for the nurse to assist a postsurgical client to sit up and turn his or her head to one side when vomiting in order to

avoid aspiration

A patient with peptic ulcer disease has had metronidazole (flagyl) added to his current medication regimen. What health education related to this medication should the nurse provide

avoid drinking alcohol while taking the drug

The nurse is planning discharge teaching for a patient with a newly inserted permanent pacemaker. What is priority teaching for this patient

avoid exposure to high-voltage electrical generators

A factory worker has approached the occupational health nurse with complaints of numbness and night pain in his dominant hand and wrist. Based on these complaints and nature of worker's tasks in the factory, the nurse suspects carpal tunnel syndrome. The nurse should recommend that the worker:

avoid flexing his wrist repeatedly

The nurse is providing care for an older adult patient whose current medication regimen includes levothyroxine. As a result the nurse should be aware of the heightened risk of adverse effects when administering an IV dose of what medication

benzodiazepine

A patient who has sustained a basal skull fracture is admitted to the neurological unit. The nurse should know that the patient should be observed for:

bleeding from the ears

A 59-year-old patient is being assessed for hypoparathyroidism. The nurse should anticipate that this patient is likely to require what diagnostic test

bone density testing

As an intraoperative nurse, you are the advocate for each other patients who receives care in the surgical setting. How can you best exemplify the principles of patient advocacy?

by maintaining each of your patient's privacy

Which of the following assessment findings indicate to the nurse that a client may have peripheral neurovascular dysfunction

capillary refill of 4-5 seconds pain cool skin

The nurse is caring for a patient who has had a dysrhythmic event. The nurse is aware of the need to assess for signs of diminished cardiac output. What change in status may signal to the nurse a decrease in cardiac output

changes in LOC

Postural drainage has been ordered for a patient who is having difficulty mobilizing her bronchial secretions. Before repositioning the patient and beginning treatment the nurse should perform what health assessment

chest auscultation

A 76-year-old client is visiting the urologist because of an increasingly troublesome need to urinate several times through the night. After checking his prostate (Which was within normal limits), the physician prescribes limiting fluid intake after the evening meal. What is another important intervention to keep the client safe?

decrease salt intake

A nurse who oversees the care that is provided in a long-term care facility is aware that there are numerous age-related changes to every body system. Which of the following phenomena may be a result of age-related changes to the endocrine system

decreased oil production by sebaceous glands

The nurse is caring for a 77-year-old patient with diarrhea. What would be especially important to monitor this patient for?

dehydration

The nurse working on the coronary care unit is caring for a patient with ACS. How can the nurse best meet the patient's psychosocial needs?

directly address the patient's anxieties and fears

A patient suffering a stroke is having a difficult time swallowing. What would the nurse document this finding as?

dysphagia

An asthma nurse educator is working with a group of adolescent asthma patients. What intervention is most likely to prevent asthma exacerbations among these patients

educating patients about recognizing and avoiding asthma triggers

A nurse is providing information on food allergies to a group of teachers. What food items would the nurse inform the teachers are common allergens?

eggs and nuts

A client stops breathing during sleep as a result of repetitive upper airway obstruction. To help decrease the frequency of the apneic episodes, the nurse intervenes by informing the client to

eliminate alcohol ingestion

A client is scheduled to receive a 25% dextrose solution of parenteral nutrition. The nurse does all of the following. Select all that apply.

ensures completion of baseline monitoring of the complete blood count (CBC) and chemistry panel ensures availability of an infusion pump places a 1.5-micron filter on the tubing

A patient who has mandibular structural abnormality has just been admitted to the postsurgical unit from the PACU following surgical remodeling. To ensure the patient's safety, what action should the nurse prioritize?

ensuring that wire cutters or scissors are available at the patient's bedside

A patient was treated in the ED and critical care unit after ingesting bleach. What possible complication of the resulting gastritis should the nurse recognize

esophageal or pyloric obstruction related to scarring

The patient with a brain tumor may be at increased risk for aspiration. The most important nursing intervention includes which of the following

evaluation of gag reflex and ability to swallow

The Family Nurse Practitioner is performing a physical examination of a client. The NP examines the client's anterior, posterior, and lateral chest walls. What is the Nurse Practitioner assessing?

evidence of muscle weakness

The nurse is preparing to suction a patient with an endotracheal tube. What would be the nurse's first step in the suctioning process?

explain the procedure to the patient before beginning and offer reassurance during sucitoning

The perioperative nurse has admitted a patient who has just underwent a tonsillectomy. The nurse's postoperative assessment should prioritize which of the following potential complications of this surgery

hemorrhage

Which of the following is the most common complication associated with peptic ulcer

hemorrhage

A nurse understands that a major concern with type 2 diabetes is

insulin resistance

The treatment of choice for a spinal cord-inured patient with impaired bladder emptying would include which of the following?

intermittent self-catheterization

The patient is concerned about leakage of gastric contents out of the gastric sump tube the nurse has just inserted. What would the nurse do to prevent reflux gastric contents from coming through the blue vent of a gastric sump tube?

keep the vent lumen above the patient's stomach level

A patient is brought to the renal unit from the PACU status post resection of a renal tumor. Which of the following nursing actions should the nurse prioritize in the care of this patient

managing postoperative pain

A patient who is obese has been unable to lose weight successfully using lifestyle modifications and has mentioned the possibility of using weight-loss medications. What should the nurse teach the patient about pharmacologic interventions for the treatment of obesity

medications can be helpful but few people achieve and maintain their desired weight loss with medications alone

A patient who had a recent MI was brought to the ED with bleeding esophageal varices and is presently receiving fluid resuscitation. What first-line pharmacologic therapy does the nurse anticipate administering to control the bleeding from the varices

octreotide

The school nurse is planning a health fair for a group of fifth graders and dental health is one topic that the nurse plans to address. What would be most likely to increase the risk of tooth decay

organic fruit juice

Which of the following is considered the "fifth vital sign"

pain

The nurse is discussing activity management with a patient who is postoperative following thoracotomy. What instructions should the nurse give the patient regarding activity immediately following discharge?

perform shoulder exercises five times daily

A patient was recently exposed to infection microorganisms and many t lymphocytes are now differentiating into killer T cells. This process characterizes what stage of the immune response

proliferation

A patient being treated in the hospital has been experiencing occasional urinary retention. What nursing action should the nurse take to encourage a patient who is having difficulty voiding

provide privacy for the patient

When elevating the function of the GI tract, the nurse needs to understand the role of hormones. Secretin, stimulated by the pH of chyme in the duodenum, is a major GI hormone that does which of the following?

regulates the secretion of gastric acid

A 78-year-old patient with type 2 diabetes is brought to the ED by his daughter. The patient is found to have a blood glucose level of 623 mg/dL. The patient's daughter reports that the patient recently had a GI virus and has been confused for the last 3 hours. A diagnosis of HHNS is made. What nursing action would be the priority?

replacing fluids and electrolytes

The nurse is providing care for a patient who has MS. The nurse recognizes the autoimmune etiology of this disease and the potential benefits of what treatment

stem cell transplantation

A nurse is caring for a patient with a bone tumor. The nurse is providing education to help the patient reduce the risk for pathologic fractures. What should the nurse teach the patient

support the affected extremity with external supports such as splints

While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of the patient's closed chest-drainage system. What should the nurse conclude

the system has an air leak

A 77-year-old man is recovering in the hospital after a recent femoral fracture and has rung his call light. The nurse has entered the room to find the patient in distress, clutching his chest while struggling to say, "I can't breathe." The nurse should take prompt action based on the knowledge that this patient may be experiencing what complication of lower extremity fractures

thromboembolism

A nurse caring for a patient with colorectal cancer is preparing the patient for upcoming surgery. The nurse administer cephalexin (keflex) to the patient and explains what rationale

to reduce intestinal bacteria levels

The nurse is admitting a client from ED with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury?

traction with weights and pulleys

A nurse is providing discharge teaching for a client with COPD. When teaching the client about breathing exercises, what should the nurse include in the teaching?

use diaphragmatic breathing

You are developing a care plan for a patient with Cushing syndrome. What nursing diagnosis would have the highest priority in this care plan

risk for injury related to weakness

Patients with hyperthyroidism are characteristically

sensitive to heat

Maintaining an aseptic environment in the OR is essential to patient safety and infection control. When moving around surgical areas, what distance must the nurse maintain from the sterile field?

1 foot

A nurse is aware that insulin secretion increases 3-5 minutes after a meal and then returns to baseline. If a patient ate breakfast at 7:30AM, the muscle would expect a baseline level by

10:30AM

A client who is suspected of having diabetes is undergoing a postprandial (after meals) glucose test. Which result would the nurse interpret as suggestive of diabetes?

160 mg/dL

A patient arrives in the ED after being burned in a house fire. The patient's burns cover the face and the left forearm. What extent of burns does the patient most likely have?

18%

A 56-year-old man has sought care because the automated blood pressure machine in his pharmacy indicated a blood pressure reading of 146/96 mmHg. He has said to the nurse, "My pressure has never been this high. Will I need to take medication to take medication to reduce it?" Which of the following responses by the nurse would be best?

A single elevated blood pressure doesn't confirm hypertension. You'll need to have your blood pressure reassessed several times before a diagnosis can be made

A young patient is being treated for a femoral fracture suffered in a snowboarding accident. The nurse's most recent assessment reveals that the patient is uncharacteristically confused. What diagnostic test should be performed on this patient?

ABGs

A community health nurse serves a diverse population. What individual would likely face the highest risk for parotitis

An older adult whose medication regimen includes an anticholinergic

A patient with gastritis required hospital treatment for an exacerbation of symptoms and receives a subsequent diagnosis of pernicious anemia due to malabsorption. When planning the patient's continuing care in the home setting, what assessment question is most relevant

Does anyone in your family have experience at giving injections

A patient comes to the ophthalmology clinic for an eye examination. The patient tells the nurse that he often sees "floaters" in his vision. What should the nurse respond to the patient?

This is normal aging process of the eye

The PACU nurse is caring for a patient who has arrived from the OR. During the initial assessment, the nurse observes that the patient's skin has become blue and dusky. The nurse looks, listens and feels for breathing and determines the patient is not breathing. What is the priority intervention?

Treat possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw

The nurse is inserting a nasoenteric tube for a patient with a paralytic ileus. How long does the nurse anticipate the tube will be required?

Until flatus is passed Until peristalsis is resumed Until bowel sound is present Until the patient stops vomitting

The home care nurse is assessing the home environment of a patient who will be discharged from the hospital shortly after his laryngectomy. The nurse should inform the patient that he may need to arrange for the installation of which system in his home

a humidification system

The nurse coming on shift on the medical unit is taking a report on four patients. What patient does the nurse know is at the greatest risk of developing ESKD

a patient with diabetes mellitus and poorly controlled hypertension

The current phase of a patient's treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities the patient is in what phase of burn care

acute

A nurse is caring for a patient admitted with symptoms of an anorectal infection; cultures indicate that the patient has a viral infection. The nurse should anticipate the administration of what drug?

acyclovir

A hospital has been the site of an increased incidence of HAP. What is an important measure for the prevention of HAP?

administration of pneumococcal vaccine to vulnerable individuals

A nurse is emptying an orthopedic surgery patient's closed suction drainage at the end of a shift. The nurse notes that the volume is within expected parameters but that the drainage has a foul odor. What is the nurse's best action?

advance the drain 1-1.5 cm

The nurse is providing care for a patient whose inflammatory bowel disease has necessitated hospital treatment. Which of the following would most likely be included in the patient's medication regimen?

anticholinergic medications 30 minutes before a meal

Deep vein thrombosis and a pulmonary embolism are complications of lower extremity fractures. Two significant diagnostic findings suggestive of a PE are

anxiety and tachycardia

A client is admitted to the hospital after sustaining a closed head injury in a skiing accident. The physician ordered neurologic assessments to be performed every 2 hours. The client's neurologic assessments have been unchanged since admission and the client is complaining of a headache. Which intervention by the nurse is best

assess the client's neurologic status for subtile changes, administer acetaminophen and then reassess the client in 30 minutes

The nurse has assessed a patient's family history for three generations. The presence of which respiratory disease would justify this type of assessment

asthma

The client has just had a central line inserted for parenteral nutrition. The client is awaiting transport to the radiology department for catheter placement verification. The client reports feeling anxious. Respirations are 28 breaths/minute. The first action by the nurse is

auscultate lung sounds

A nurse is providing health promotion education to a patient diagnosed with an esophageal reflux disorder. What practice should the nurse encourage the patient to implement

avoid carbonated drinks

The nurse teaches the patient with GERD which of the following measures to manage his disease?

avoid eating or drinking 2 hours before bedtime

A nurse is creating a care plan for a patient with acute pancreatitis. The care plan includes reduced activity. What rationale for this intervention should be cited in the care plan?

bed rest lowers the metabolic rate and reduces enzyme production

The nurse is reviewing a patient's activities of daily living prior to discharge from total hip replacement. The nurse should identify what activity as posing a potential risk for hip dislocation

bending down to put on socks

As part of a start-of-shift nursing assessment, the nurse is documenting a patient's neurological status according to the Glasgow Coma Scale. What responses will the nurse assess to determine the patient's GCS score?

best motor response best eye opening best verbal response

A patient with an occluded coronary artery is admitted and has an emergency percutaneous transluminal coronary angioplasty (PTCA). The patient is admitted to the cardiac critical care unit after the PTCA. For what complication should the nurse most closely monitor in the patient

bleeding at the insertion site

An older adult patient has symptoms of osteoporosis and is being assess during her annual physical examination. The assessment shows that the patient will require further testing related to a possible exacerbation of her osteoporosis. The nurse should anticipate what diagnostic test

bone densitometry

The mother of two young children has been diagnosed with HIV and expresses fear of dying. How should the nurse best respond to the patient?

can you tell me what concerns you the most about dying

A 72-year-old male with a 100 pack-year and COPD history, has entered your ED with SOB, dyspnea and anxiety. As his BP starts to drop, the focus is on keeping his BP stable while radiology indicates what is causing his condition. Which type of shock is the team trying to avoid

cardiogenic shock

An infusion of nitroglycerine has been ordered by the critical care health care provider in the treatment of a patient who has been admitted to the ICU in a state of shock. The nurse should anticipate that this patient is likely experiencing what type of shock?

cardiogenic shock

The nurse is to administer a cyclic feeding through a gastric tube. It is most important for the nurse to

check residual volume before feeding/ elevate head of bed 45º

A hospitalized client with terminal heart failure is nearing the end of life. The nurse observes which of the following breathing patterns?

cheyne stokes

The nurse is assessing a patient in respiratory failure. What finding is a late indicator of hypoxia

cyanosis

The public health nurse is participating in a health fair and interviews a patient with a history of hypertension, who is currently smoking one pack of cigarettes per day. She denies any of the most common manifestations of CAD. Based on these data, the nurse would expect the focuses of CAD treatment most likely to be which of the following

diet therapy and smoking cessation

The nurse is doing a preoperative assessment of an 87-year-old man who is slated to have a right lung lobe resection to treat lung cancer. What underlying principle should guide the nurse's preoperative assessment of an elderly patient

elderly patients have less physiologic reserve than younger patients

A medical patient developed a new onset of SOB with pulse ox ranging between 70% to 75% and a respiratory rate of 30 to 35 breaths per minute. The patient did not respond to oxygen therapy with nasal prongs and was fitted with a partial rebreathing mask by the respiratory therapist. When maintaining this patient's oxygen delivery system, the nurse should

ensure that the reservoir bag remains inflated at all times

Which of the following is the priority nursing diagnosis for the client in the oliguric phase of acute renal failure?

fluid volume excess

Since the emergence of HIV/AIDS there have been significant changes in epidemiologic trends. Members of what group currently have the greatest risk of contracting HIV?

gay, bisexual and other men who have sex with men

An OR nurse is preparing to assist with a CABG. The OR nurse knows that the vessel most commonly used as a source for CABG is what

greater saphenous vein

A nurse is performing health education with a patient who has a history of frequent serious dental caries. When planning educational interventions the nurse should identify a risk for what nursing diagnosis

imbalanced nutrition: less than body requirements

A patient with a history of dermatitis takes corticosteroids on a regular basis. The nurse should assess the patient for which of the following complications of therapy

immunosuppression

The nurse is caring for a patient with a lower respiratory tract infection. When planning a focused respiratory assessment, the nurse should know that this type of infection most often causes what

impaired gas exchange

A patient has come to the orthopedic clinic for a follow-up appointment 6 weeks after fracturing his ankle. Diagnostic imaging reveals that bone union is not taking place. What factor may have contributed to this complication

inadequate immobilization

A patient's abdominal ultrasound indicated cholelithiasis. When the nurse is reviewing the patient's laboratory studies, what finding is most closely associated with this diagnosis

increased bilirubin

An older adult woman's current medication regimen includes alendronate (fosamax). What outcome would indicate successful therapy

increased bone mass

The nursing care plan for a patient in traction specifies regular assessments for venous thromboembolism (VTE). When assessing a patient's lower limbs, what sign or symptom is suggestive of a DVT

increased warmth of the calf

A medical nurse who is caring for a patient being discharged home after a radical neck dissection has collaborated with the home health nurse to develop a plan of care for this patient. What is a priority psychosocial outcome for a patient who has had a radical neck dissection

indicates acceptance of altered appearance and demonstrates positive self-image

A nurse is providing care for a patient whose neck dissection surgery involved the use of a graft. When assessing the graft the nurse should prioritize data related to what nursing diagnosis

ineffective tissue perfusion

The client has been taking famotidine at home. The nurse prepares a teaching plan for the client indicating that the medication acts primarily to achieve which of the following

inhibit gastric acid secretions

A nurse is aware of the vital role that hormones and the negative feedback mechanism play in the maintenance of homeostasis. Which of the following statements best describes the negative feedback mechanism that controls insulin secretion

insulin is synthesized and released in an inversely proportionate quantity to glucagon

The nurse is taking a health history of a new patient. The patient reports experiencing pain in his left lower leg and foot when walking. This pain is relieved with rest. The nurse notes that the left lower leg is slightly edematous and is hairless. When planning this patient's subsequent care, the nurse should most likely address what health problem

intermittent claudication

A patient with a small bowel obstruction has had a Levin tube inserted and is admitted to a medical unit. The nurse who is caring for this patient is now checking that the wall suction settings are correct and should anticipate which of the following settings.

intermittent low suction

Preoperative education is an important part of the nursing care of patients having coronary artery revascularization. When explaining the pre- and postoperative regimens, the nurse would be sure to include education about which subject

intubation and mechanical ventilation

An emergency department nurse is assessing a 17-year-old soccer player who presented with a knee injury. The patient's description of the injury indicates that his knee was struck medially while his foot was on the ground. The nurse knows that the patient likely has experienced what injury

lateral collateral ligament injury

A 17-year-old high school junior was involved in a motor-vehicle collision and brought to the ED via squad. His left arm was severely traumatized in the accident and he was taken immediately to surgery. He is admitted to the ICU where you practice nursing and the physician has ordered close monitoring for compartment syndrome. What musculoskeletal structure does compartment syndrome affect?

ligament nerve

A patient is undergoing diagnostic testing for osteomalacia. Which of the following lab results is most suggestive of this diagnosis

low serum calcium and low phosphorus level

A client presents to the ED status post seizure. The physician wants to know what the pressure is in the client's head. What test might be ordered on this client?

lumbar puncture

Why is it important for a nurse to provide required information and appropriate explanations of diagnostic procedures to patients with respiratory disorders

manage decreased energy levels

A nurse has performed tracheal suctioning on a patient who experienced increasing dyspnea prior to a procedure. When applying the nursing process, how can the nurse best evaluate the outcomes of this intervetion

measure the patient's oxygen saturation

A patient has sustained a long bone fracture and the nurse is preparing the patient's care plan. Which of the following should the nurse include in the care plan

monitor temperature and pulses of the affected extremity

An OR nurse will be participating in the intraoperative phase of a patient's kidney transplant. What action will the nurse prioritize in this aspect of nursing care?

monitoring the patient's physiologic status

A patient's injury has initiated an immune response that involves inflammation. What are the first cells to arrive at a site of inflammation

neutrophils

A patient has been living with type 2 diabetes for several years and the nurse realizes that the patient is likely to have minimal contact with the health care system. In order to ensure that the patient maintains adequate blood sugar control over the long term, the nurse should recommend which of the following

participation in a support group for persons with diabetes

A nurse is assessing the skin integrity of a patient who has AIDS. When performing this inspection, the nurse should prioritize assessment of what skin surface?

perianal region and oral mucosa

A patient is being assessed for a suspected deficit in intrinsic factor synthesis. What diagnostic or assessment finding is the most likely rationale for this examination of intrinsic factor production?

persistently low hemoglobin and hematocrit

A client is weak and drowsy after a lumbar puncture. The nurse caring for the client knows that what priority nursing intervention should be provided after a lumbar puncture

position the client flat for at least 3 hours

An 80-year-old female patient has been admitted to the hospital and lives with numerous health problems, which include osteoporosis. The patient's medication regimen includes calcitonin nasal spray, vitamin D and calcium supplements, and a biphosphonate that is administered weekly. When administering the patient's biphosphaonate the nurse should

position the patient in high fowlers after giving the drug

A patient with a recent diagnosis of hypothyroidism is being treated for an unrelated injury. When administering medications to the patient, the nurse should know that the patient's diminished thyroid function may have what effect

prolonged duration of effect

A client with oral cancer informs the nurse that he has been experiencing dryness of the mouth. The best action of the nurse is to

provide a humidifier for the client to use while sleeping

As a perioperative nurse, you know that the National Patient Safety Goals have the potential to improve patient outcomes in a wide variety of health care settings. Which of these Goals has the most direct relevance to the OR?

reduce risk of fires

The home care nurse is monitoring a patient discharged home after resolution of a PE. For what potential complication would the home care nurse be most closely monitoring this patient

residual effects of compromised oxygenation

A 16-year-old presents at the emergency department complaining of right lower quadrant pain and is subsequently diagnosed with appendicitis. When planning this patient's nursing care, the nurse should prioritize what nursing diagnosis

risk for infection related to possible rupture of appendix

A patient's brain tumor has been manifested by seizures that have become more frequent and severe in recent days. The patient has been scheduled for neurosurgery, but the nurse is nonetheless making changes to the patient's preoperative nursing care plan. The patient's seizures should cause the nurse to prioritize which of the following nursing diagnoses?

risk for injury related to seizures

A patient with HIV is admitted to the hospital because of chronic severe diarrhea. The nurse caring this patient should expect the physician to order what drug for the management of the patient's diarrhea

sandostatin

A patient has been admitted to the post-surgical unit following a thyroidectomy. To promote comfort and safety, how should the nurse best position the patient

semi-fowlers with the head supported on two pillows

A pneumothorax is a possible complication of COPD. Symptoms will depend on the suddenness of the attack and the size of the air leak. The most common, immediate symptom that should be assessed

sharp, stabbing chest pain

A nurse is assessing an elderly patient with gallstones. The nurse is aware that the patient may not exhibit typical symptoms and that particular symptoms that may be exhibited in the elderly patient may include what

signs and symptoms of septic shock

A patient has been taking prednisone for several weeks after experiencing a hypersensitivity reaction. To prevent adrenal insufficiency, the nurse should ensure that the patient knows to do which of the following

slowly taper down the dose of prednisone as ordered

A nurse is caring for a patient in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values

sodium deficit

The nurse is doing preoperative patient education with a 61-year-old male patient who has a 40-pack per year history of cigarette smoking. The patient will undergo an elective bunionectomy at a time that fits his work schedule in a few months. What would be the best instruction to give to this patient?

stop smoking 4 to 8 weeks before the scheduled surgery to enhance pulmonary function and decrease infection

A patient with kidney stones is scheduled for extracorporeal shock wave lithotripsy (ESWL). What should the nurse include in the patient's post procedure

strain the patients urine following the procedure

A client with respiratory complications of MS is admitted to the med-surg unit. Which equipment is most important for the nurse to keep at the at the client's bedside?

suction machine with catheters

A client with spinal trauma tells the nurse they cannot cough. What nursing intervention should the nurse perform when a client with spinal trauma may not be able to cough

suction the airway

The nurse is providing care for an adult patient who has a diagnosis of COPD. Which of the following principles should the nurse apply when managing this patient's supplementary oxygen?

supplementary oxygen should be used with caution with COPD patients in order to avoid depressing the respiratory drive

The ED nurse is caring for an 11-year-old brought in by ambulance after having been hit by a car. The child's parents are thought to be en route to the hospital but have not yet arrived. No other family members are present and attempts to contact the parents have been unsuccessful. The child needs emergency surgery to save her life. How should the need for informed consent be addressed?

surgery should be done without informed consent

The nurse is teaching a patient that the body needs iodine for the thyroid to function. What food would be the best source of iodine for the body

table salt

The perioperative nurse is constantly assessing the surgical patient for signs and symptoms of complications of surgery. Which symptom should first signal to the nurse the possibility that the patient is developing malignant hyperthermia

tachycardia

Six weeks after an above-the-knee amputation (AKA), a patient returns to the outpatient office for a routine postoperative checkup. During the nurse's assessment, the patient reports symptoms of phantom pain. What should the nurse tell the patient to do to reduce discomfort of the phantom pain

take opioid analgesics as ordered

The nurse is caring for a patient who has just been diagnosed with chronic rhinosinusitis. While being admitted to the clinic the patient asks, "Will this chronic infection hurt my new kidney?" What should the nurse know about chronic rhinosinusitis in patients who have had a transplant

taking immunosuppressive drugs can contribute to chronic rhinosinusitis

A nurse is admitting a new patient who has been admitted with a diagnosis of COPD exacerbation. How can the nurse best help the patient achieve the goal of maintaining effective oxygenation

teach the patient strategies for promoting diaphragmatic breathing

The admitting nurse in a short-stay surgical unit is responsible for numerous aspects of care. What must the nurse verify before the patient is taken to the preoperative holding area

that preoperative teaching was performed

A physician has explained to a patient that he has developed diabetic neuropathy in his right foot. Later that day, the patient asks the nurse what causes diabetic neuropathy. What would be the nurse's best response

the cause is not known for sure but it is thought to involve elevated blood glucose levels over a period of years

A client has been brought to the ED after a fall off a roof. The client has no cord function below the point of injury. The ED nurse knows what about this client?

the client is in spinal shock

A nurse is providing health education to the family of a patient with bronchiectasis. What should the nurse teach the patient's family members

the correct technique for providing postural drainage

A 28-year-old pregnant woman is spilling sugar in her urine. The physician orders a glucose tolerance test, which reveals gestational diabetes. The patient is shocked by the diagnosis, stating that she is conscientious about her health and asks the nurse what causes gestational diabetes. The nurse should explain that gestational diabetes is a result of what etiologic factor

the effects of hormonal changes during pregnancy

A patient has a diagnosis of MS. The nurse is aware that neuromuscular disorders such as MS may lead to a decreased vital capacity. What does vital capacity measure

the maximal volume of air exhaled from the point of maximal inspiration

The nurse is caring for a patient with addison's disease who is scheduled for discharge. When teaching the patient about hormone replacement therapy, the nurse should address what topic?

the need for lifelong steroid replacement

A 24-year-old man has suffered extensive head and neck injuries in a motorcycle accident an d has been admitted to the ICU in apparent neurogenic shock. Which of the following are characteristics of this patient's diagnosis?

the patient has adequate blood volume but is profoundly vasodilated

A patient has been admitted to the ED with a massive GI bleed and the team recognizes that hypovolemic shock is an imminent possibility. What assessment finding would suggest that the patient is deteriorating from a preshock state into shock?

the patient is confused and agitated

While performing a patients ordered wound care for the treatment of a burn, the patient has made a series of sarcastic remarks to the nurse and criticized her technique. How should the nurse best interpret this patient's behavior

the patient may be experiencing anger about his circumstances that he is deflecting toward the nurse

A patient with GERD has a diagnosis of Barrett's esophagus with minor cell changes. Which of the following principles should be intergrated into the patient's subsequent care

the patient will require an upper endoscopy every 6 months to detect malignant changes

A patient with type 1 diabetes has told the nurse that his most recent urine test for ketones was positive. What is the nurse's most plausible conclusion based on this assessment finding

the patient's insulin levels are inadequate

A 50-year old woman has a long history of hospital admissions related to alcohol abuse and consequent liver failure. During this present admission, the patient has been diagnosed with hepatic encephalopathy and prescribed lactulose (cephulac). During morning report, the nurse learns that the previous nurse withheld the patient's latest dose of lactulose because the patient had two loose bowel movements during the shift. How should the nurse interpret the previous nurse's action?

the previous nurse should have administered the lactulose because it is necessary to remove excess ammonia

An ED nurse has just admitted a patient with a nurn. What characteristic of the burn will primarily determine whether the patient experiences a systemic response to this injury

the total body surface area affected by the burn

A patient has just been diagnosed with squamous cell carcinoma of the neck. While the nurse is doing health education, the patient asks "Does this kind of cancer tend to spread to other parts of the body?" What is the nurse's best response

this cancer usually does not spread to distant sites in the body

A patient who underwent a bowel resection to correct diverticula suffered irreparable nerve damage. During the case review, the team is determining if incorrect positioning may have contributed to the patient's nerve damage. What surgical position places the patient at highest risk for nerve damage

trendelenburg

A patient with a decreased level of consciousness is in a recumbent position. How should the nurse best assess the lung fields for a patient in this position

turn the patient to enable assessment of all the patient's lung fields

When caring for a patient in shock, one of the major nursing goals is to reduce the risk that the patient will develop complications from shock. What does this require the nurse to do?

understand the underlying mechanisms of shock, recognize the subtle and more obvious signs and then provide rapid assessment and response

The client is being examined following a head injury sustained in an automobile accident. The client's blood alcohol level is elevated. To provide for safety, the nurse

uses an alcohol screening test to detect alcoholism

For a client with advanced COPD, which nursing action best promotes adequate gas exchange?

using a venturi mask to deliver oxygen as ordred

A nurse is developing a teaching plan for a client with diabetes mellitus. A client with diabetes mellitus should:

wash and inspect the feet daily

The older client asks the nurse how best to maintain strong muscles. The best response by the nurse is

weight-resistance exercises can strengthen muscles

The care team is considering the use of dialysis in a patient whose renal function is progressively declining. Renal replacement therapy is indicated in which of the following situations

when about 80% of the nephrons are no longer functioning

While caring for a patient with an endotracheal tube, the nurse recognizes that suctioning is required how often

when adventitious breath sounds are auscultated