Medsurg Exam

When caring for a patient who has just arrived on the telemetry unit after having cardiac catheterization, which nursing intervention should the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Give the scheduled aspirin and lipid-lowering medication. b. Perform the initial assessment of the catheter insertion site. c. Teach the patient about the usual postprocedure plan of care. d. Titrate the heparin infusion according to the agency protocol.

A Administration of oral medications is within the scope of practice for LPNs/LVNs. The initial assessment of the patient, patient teaching, and titration of IV anticoagulant medications should be done by the registered nurse (RN).

When admitting a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI) to the intensive care unit, which action should the nurse perform first? a. Attach the heart monitor. b. Assess the peripheral pulses. c. Obtain the blood pressure. d. Auscultate the breath sounds.

A Because dysrhythmias are the most common complication of myocardial infarction (MI), the first action should be to place the patient on a heart monitor. The other actions are also important and should be accomplished as quickly as possible.

To auscultate for S3 or S4 gallops in the mitral area, the nurse listens with the a. bell of the stethoscope with the patient in the left lateral position. b. diaphragm of the stethoscope with the patient in a supine position. c. bell of the stethoscope with the patient sitting and leaning forward. d. diaphragm of the stethoscope with the patient lying flat on the left side.

A Gallop rhythms generate low-pitched sounds and are most easily heard with the bell of the stethoscope. Sounds associated with the mitral valve are accentuated by turning the patient to the left side, which brings the heart closer to the chest wall. The diaphragm of the stethoscope is best to use for the higher-pitched sounds such as S1 and S2.

A patient has elevated blood urea nitrogen (BUN) and serum creatinine levels. Which bowel preparation order would the nurse question for this patient who is scheduled for a renal arteriogram?a.Fleet enema b.Tap-water enema c.Senna/docusate (Senokot-S) d.Bisacodyl (Dulcolax) tablets

A High-phosphate enemas, such as Fleet enemas, should be avoided in patients with elevated BUN and creatinine because phosphate cannot be excreted by patients with renal failure. The other medications for bowel evacuation are more appropriate

What glomerular filtration rate (GFR) would the nurse estimate for a 30-year-old patient with a creatinine clearance result of 60 mL/min? a.60 mL/min b.90 mL/min c.120 mL/min d.180 mL/min

A The creatinine clearance approximates the GFR. The other responses are not accurate.

Which information will the nurse include in teaching a female patient who has peripheral arterial disease, type 2 diabetes, and sensory neuropathy of the feet and legs? a. Choose flat-soled leather shoes. b. Set heating pads on a low temperature. c. Use callus remover for corns or calluses. d. Soak feet in warm water for an hour each day.

A The patient is taught to avoid high heels and that leather shoes are preferred. The feet should be washed, but not soaked, in warm water daily. Heating pad use should be avoided. Commercial callus and corn removers should be avoided. The patient should see a specialist to treat these problems

During a visit to a 78-year-old with chronic heart failure, the home care nurse finds that the patient has ankle edema, a 2-kg weight gain over the past 2 days, and complains of "feeling too tired to get out of bed." Based on these data, the best nursing diagnosis for the patient is a. Activity intolerance related to fatigue. b. Disturbed body image related to weight gain. c. Impaired skin integrity related to ankle edema. d. Impaired gas exchange related to dyspnea on exertion.

A The patient's statement supports the diagnosis of activity intolerance. There are no data to support the other diagnoses, although the nurse will need to assess for other patient problems.

A 58-year-old woman has just returned to the nursing unit after an esophagogastroduodenoscopy (EGD). Which action by unlicensed assistive personnel (UAP) requires that the registered nurse (RN) intervene? a. Offering the patient a drink of water b. Positioning the patient on the right side c. Checking the vital signs every 30 minutes d. Swabbing the patient's mouth with cold water

A (Immediately after EGD, the patient will have a decreased gag reflex and is at risk for aspiration. Assessment for return of the gag reflex should be done by the RN. The other actions by the UAP are appropriate.)

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

A (The liver is normally not palpable below the costal margin. The nurse needs to push inward below the right costal margin while lifting the patient's back slightly with the left hand. The other methods will not allow palpation of the liver.)

A patient is being scheduled for endoscopic retrograde cholangiopancreatography (ERCP) as soon as possible. Which actions from the agency policy for ERCP should the nurse take first? a. Place the patient on NPO status. b. Administer sedative medications. c. Ensure the consent form is signed. d. Teach the patient about the procedure.

A (The patient will need to be NPO for 8 hours before the ERCP is done, so the nurse's initial action should be to place the patient on NPO status. The other actions can be done after the patient is NPO.)

The nurse is caring for a patient who has undergone bariatric surgery. Which nursing interventions will be beneficial to this patient? Select all that apply. a. Assisting the patient to walk in the evening after the surgery b. Administering carbohydrate-rich foods c. Maintaining the patient in the semi-Fowler's position d. Being prepared to perform a head-tilt maneuvere. Maintaining the patient on large quantities of liquid intake

A C DTo prevent complications, the patient is typically assisted to walk the evening after the surgery. The nurse should place the patient's head at a 35- to 40-degree angle while assisting the patient into the semi-Fowler's position. This intervention promotes maximum chest expansion and prevents breathlessness by relaxing the patient's abdominal muscles and stabilizing the patient's airways. Anesthetics administered during surgery are stored in adipose tissues. The adipocytes release anesthetics into the blood stream after surgery, increasing the risk of resedation. Therefore, the nurse should be prepared to perform a head-tilt maneuver to prevent respiration depression that may be caused by resedation. Foods rich in carbohydrates increase the risk of diarrhea. Excess liquid intake promotes anastomosis leaks and increases the patient's pain.

Which finding indicates to the nurse that lactulose is effective for an older adult who has advanced cirrhosis? a. The patient is alert and oriented b. The patient denies nausea or anorexia c. The patient's bilirubin level decreases d. The patient has at least one stool daily

A. the patient is alert and oriented, the purpose of this med is to lower ammonia levels and prevent encephalopathy.

When admitting a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI) to the intensive care unit, which action should the nurse perform first? a. Attach the heart monitor. b. Assess the peripheral pulses. c. Obtain the blood pressure. d. Auscultate the breath sounds.

A. Because dysrhythmias are the most common complication of myocardial infarction (MI), the first action should be to place the patient on a heart monitor. The other actions are also important and should be accomplished as quickly as possible.

A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication? a. Digoxin (Lanoxin) 0.25 mg/day b. Metoprolol (Lopressor) 12.5 mg/day c. Ibuprofen (Motrin) 400 mg every 6 hours d. Lantus insulin 24 U subcutaneously every evening

A. Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse will also need to do more assessment regarding the other medications, but they are not of as much concern with the potassium level.

The nurse on the intermediate care unit received change-of-shift report on four patients with hypertension. Which patient should the nurse assess first? a. 48-yr-old with a blood pressure of 160/92 mm Hg who reports chest pain b. 52-yr-old with a blood pressure of 198/90 mm Hg who has intermittent claudication c. 50-yr-old with a blood pressure of 190/104 mm Hg who has a creatinine of 1.7 mg/dL d. 43-yr-old with a blood pressure of 172/98 mm Hg whose urine shows microalbuminuria

A. The patient with chest pain may be experiencing acute myocardial infarction and rapid assessment and intervention are needed. The symptoms of the other patients also show target organ damage but are not indicative of acute processes.

Which nursing actions will the nurse take to assess for possible malnutrition in an older adultpatient? (Select all that apply.) a. Assess for depression. b. Review laboratory results. c. Determine food preferences. d. Inspect teeth and oral mucosa. e. Ask about transportation needs.

A. Assess for depression. B. Review laboratory results. D. Inspect teeth and oral mucosa. E. Ask about transportation needs.

Twelve hours after undergoing a gastroduodenostomy (bilroth I), a patient complains of increasing abdominal pain. The patient has absent bowel sounds and 200ml of bright red nasogastric drainage in the last hour. The most appropriate action the nurse at this is to a. Notify the surgeon b. Irrigate the NG tube c. Administer the prescribed morphine d. Continue to monitor the NG drainage

A: Notify a surgeon, this finding indicates possible post-operative hemorrhage, and immediate action must be taken whether it be surgery or blood transfusion

The health care provider prescribes the following therapies for a patient who has been admitted with dehydration and hypotension after 3 days of nausea and vomiting. Which order will the nurse implement first? a. Infuse normal saline at 250 ml/hr b. Administer IV ondansetron (Zofran) c. Provide oral care with moistened swabs d. Insert a 16 gauge nasogastric tube

A: because the patient has severe dehydration, rehydration with IV fluids is the priority.

The nurse is assessing an alert and independent 78-year-old woman for malnutrition risk. The most appropriate initial question is which of the following? a."How do you get to the store to buy your food?" b. "Can you tell me the food that you ate yesterday?" c. "Do you have any difficulty in preparing or eating food?" d. "Are you taking any medications that alter your taste for food?"

B (This question is the most open-ended, and will provide the best overall information about the patient's daily intake and risk for poor nutrition. The other questions may be asked, depending on the patient's response to the first question.)

After an acute myocardial infarction (AMI), a patient ambulates in the hospital hallway. When the nurse evaluates the patient's response to the activity, which data would indicate that the exercise level should be decreased? a. O2 saturation drops from 99% to 95%. b. Heart rate increases from 66 to 98 beats/min. c. Respiratory rate goes from 14 to 20 breaths/min. d. Blood pressure (BP) changes from 118/60 to 126/68 mm Hg.

B A change in heart rate of more than 20 beats over the resting heart rate indicates that the patient should stop and rest. The increases in BP and respiratory rate, and the slight decrease in O2 saturation, are normal responses to exercise.

A 40-yr-old patient with suspected acromegaly is seen at the clinic. To assist in making the diagnosis, which question should the nurse ask? a. "Have you had a recent head injury?" b. "Do you have to wear larger shoes now?" c. "Is there a family history of acromegaly?" d. "Are you experiencing tremors or anxiety?"

B Acromegaly causes an enlargement of the hands and feet. Head injury and family history are not risk factors for acromegaly. Tremors and anxiety are not clinical manifestations of acromegaly.

When developing a teaching plan for a 61-yr-old patient with multiple risk factors for coronary artery disease (CAD), the nurse should focus primarily on the a. family history of coronary artery disease. b. elevated low-density lipoprotein (LDL) level. c. increased risk associated with the patient's gender. d. increased risk of cardiovascular disease as people age.

B Because family history, gender, and age are nonmodifiable risk factors, the nurse should focus on the patient's LDL level. Decreases in LDL will help reduce the patient's risk for developing CAD

How will the nurse assess for flank tenderness in a 30-year-old female patient with suspected pyelonephritis? a.Palpate along both sides of the lumbar vertebral column. b.Strike a flat hand covering the costovertebral angle (CVA). c.Push fingers upward into the two lowest intercostal spaces. d.Percuss between the iliac crest and ribs along the midaxillary line

B Checking for flank pain is best performed by percussion of the CVA and asking about pain. The other techniques would not assess for flank pain.

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. 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 Chest pain that lasts for 20 minutes or more is characteristic of AMI. Changes in pain that occur with raising the arms or with deep breathing are more typical of musculoskeletal pain or pericarditis. Stable angina is usually relieved when the patient takes nitroglycerin.

Which information about a patient who is scheduled for an oral glucose tolerance test should be reported to the health care provider before starting the test? a. The patient reports having occasional orthostatic dizziness. b. The patient takes oral corticosteroids for rheumatoid arthritis. c. The patient has had a 10-lb weight gain in the last month. d. The patient drank several glasses of water an hour previously.

B Corticosteroids can affect blood glucose results. The other information will be provided to thehealth care provider but will not affect the test results.

The nurse caring for a patient after cystoscopy plans that the patient a.learns to request narcotics for pain. b.understands to expect blood-tinged urine. c.restricts activity to bed rest for a 4 to 6 hours. d.remains NPO for 8 hours to prevent vomiting.

B Pink-tinged urine and urinary frequency are expected after cystoscopy. Burning on urination is common, but pain that requires opioids for relief is not expected. A good fluid intake is encouraged after this procedure. Bed rest is not required following cystoscopy.

A patient who is recovering from an acute myocardial infarction (AMI) asks the nurse when sexual intercourse can be resumed. Which response by the nurse is best? a. "Most patients are able to enjoy intercourse without any complications." b. "Sexual activity uses about as much energy as climbing two flights of stairs." c. "The doctor will provide sexual guidelines when your heart is strong enough." d. "Holding and cuddling are good ways to maintain intimacy after a heart attack."

B Sexual activity places about as much physical stress on the cardiovascular system as most moderate-energy activities such as climbing two flights of stairs. The other responses do not directly address the patient's question or may not be accurate for this patient.

Which assessment finding by the nurse caring for a patient who has had coronary artery bypass grafting using a right radial artery graft is most important to communicate to the health care provider? a. Complaints of incisional chest pain b. Pallor and weakness of the right hand c. Fine crackles heard at both lung bases d. Redness on both sides of the sternal incision

B The changes in the right hand indicate compromised blood flow, which requires immediate evaluation and actions such as prescribed calcium channel blockers or surgery. The other changes are expected or require nursing interventions.

When admitting a patient for a cardiac catheterization and coronary angiogram, which information about the patient is most important for the nurse to communicate to the health care provider? a. The patient's pedal pulses are +1. b. The patient is allergic to shellfish. c. The patient had a heart attack a year ago. d. The patient has not eaten anything today

B The contrast dye used for the procedure is iodine based, so patients who have shellfish allergies will require treatment with medications such as corticosteroids and antihistamines before the angiogram. The other information is also communicated to the health care provider but will not require a change in the usual precardiac catheterization orders or medications.

Which electrocardiographic (ECG) change is most important for the nurse to report to the health care provider when caring for a patient with chest pain? a. Inverted P wave b. ST-segment elevation c. Sinus tachycardia d. First-degree atrioventricular block

B The patient is likely to be experiencing an ST-segment-elevation myocardial infarction. Immediate therapy with percutaneous coronary intervention or thrombolytic medication is indicated to minimize myocardial damage. The other ECG changes may also suggest a need for therapy but not as rapidly

Which nursing action will be included in the plan of care for a patient with Graves' disease who has exophthalmos? a. Place cold packs on the eyes to relieve pain and swelling. b. Elevate the head of the patient's bed to reduce periorbital fluid. c. Apply alternating eye patches to protect the corneas from irritation. d. Teach the patient to blink every few seconds to lubricate the corneas.

B The patient should sit upright as much as possible to promote fluid drainage from the periorbital area. With exophthalmos, the patient is unable to close the eyes completely to blink. Lubrication of the eyes, rather than eye patches, will protect the eyes from developing corneal scarring. The swelling of the eye is not caused by excessive blood flow to the eye, so cold packs will not be helpful.

When caring for a patient with acute coronary syndrome who has returned to the coronary care unit after having angioplasty with stent placement, the nurse obtains the following assessment data. Which data indicate the need for immediate action by the nurse? a. Heart rate 102 beats/min b. Report of severe chest pain c. Pedal pulses 1+ bilaterally d. Blood pressure 103/54 mm Hg

B The patient's chest pain indicates that restenosis of the coronary artery may be occurring and requires immediate actions, such as administration of oxygen and nitroglycerin, by the nurse. The other information indicates a need for ongoing assessments by the nurse.

A patient who had a subtotal thyroidectomy earlier today develops laryngeal stridor and a cramp in the right hand upon returning to the surgical nursing unit. Which collaborative action will the nurse anticipate next? a. Suction the patient's airway. b. Administer IV calcium gluconate. c. Plan for emergency tracheostomy. d. Prepare for endotracheal intubation.

B The patient's clinical manifestations of stridor and cramping are consistent with tetany caused by hypocalcemia resulting from damage to the parathyroid glands during surgery. Endotracheal intubation or tracheostomy may be needed if the calcium does not resolve the stridor. Suctioning will not correct the stridor.

The nurse and unlicensed assistive personnel (UAP) on the telemetry unit are caring for four patients. Which nursing action can be delegated to the UAP? a. Teaching a patient scheduled for exercise electrocardiography about the procedure b. Placing electrodes in the correct position for a patient who is to receive ECG monitoring c. Checking the catheter insertion site for a patient who is recovering from a coronary angiogram d. Monitoring a patient who has just returned to the unit after a transesophageal echocardiogram

B UAP can be educated in standardized lead placement for ECG monitoring. Assessment of patients who have had procedures where airway maintenance (transesophageal echocardiography) or bleeding (coronary angiogram) is a concern must be done by the registered nurse (RN). Patient teaching requires RN level education and scope of practice.

When evaluating the effectiveness of preoperative teaching with a patient scheduled for coronary artery bypass graft (CABG) surgery using the internal mammary artery, the nurse determines that additional teaching is needed when the patient says which of the following? a. "They will circulate my blood with a machine during surgery." b. "I will have incisions in my leg where they will remove the vein." c. "They will use an artery near my heart to go around the area that is blocked." d. "I will need to take an aspirin every day after the surgery to keep the graft open."

B When the internal mammary artery is used there is no need to have a saphenous vein removed from the leg. The other statements by the patient are accurate and indicate that the teaching has been effective.

The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first? a. A 23-yr-old patient with cystic fibrosis who has pulmonary function testing scheduled b. A 46-yr-old patient on bed rest who is complaining of sudden onset of shortness of breath c. A 77-yr-old patient with tuberculosis (TB) who has four medications due in 15 minutes d. A 35-yr-old patient who was admitted with pneumonia and has a temperature of 100.2° F (37.8° C)

B. Patients on bed rest who are immobile are at high risk for deep vein thrombosis (DVT). Sudden onset of shortness of breath in a patient with a DVT suggests a pulmonary embolism and requires immediate assessment and action such as O2 administration. The other patients should also be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration.

A young adult patient tells the health care provider about experiencing cold, numb fingers when running during the winter, and Raynaud's phenomenon is suspected. The nurse will anticipate teaching the patient about tests for a. hyperglycemia. b. autoimmune disorders. c. hyperlipidemia. d. coronary artery disease.

B. Secondary Raynaud's phenomenon may occur in conjunction with autoimmune diseases such as rheumatoid arthritis. Patients should be screened for autoimmune disorders. Raynaud's phenomenon is not associated with hyperlipidemia, hyperglycemia, or coronary artery disease.

The nurse manager of a medical/surgical unit wants to improve the alertness of nurses who work the night shift. Which action will be the most helpful? a. Arrange for older staff members to work most night shifts. b. Provide a sleeping area for staff to use for napping at night. c. Post reminders about the relationship of sleep and alertness. d. Schedule nursing staff to rotate day and night shifts monthly.

B. Short on-site naps will improve alertness. Rotating shifts causes the most disruption in sleep habits. Reminding staff members about the impact of lack of sleep on alertness will not improve sleep or alertness. It is not feasible to schedule nurses based on their ages

The emergency department nurse is evaluating the effectiveness of therapy for a patient who has received treatment during an asthma attack. Which assessment finding is the best indicator that the therapy has been effective? a. No wheezes are audible. b. O2 saturation is >90%. c. Accessory muscle use has decreased. d. Respiratory rate is 16 breaths/minute

B. The goal for treatment of an asthma attack is to keep the O2 saturation above 90%. The other patient data may occur when the patient is too fatigued to continue with the increased work of breathing required in an asthma attack.

After receiving change-of-shift report, which of these patients admitted with heart failure should the nurse assess first? a. A patient who is receiving IV nesiritide (Natrecor) and has a blood pressure (BP) of 100/56 b. A patient who is cool and clammy, with new-onset confusion and restlessness c. A patient who had dizziness after receiving the first dose of captopril (Capoten) d. A patient who has crackles in both posterior lung bases and is receiving oxygen

B. The patient who has "wet-cold" clinical manifestations of heart failure is perfusing inadequately and needs rapid assessment and changes in management. The other patients also should be assessed as quickly as possible, but do not have indications of severe decreases in tissue perfusion.

Using the illustrated technique, the nurse is assessing for which finding in a patient with chronic obstructive pulmonary disease (COPD)? a. Hyperresonance b. Reduced excursion c. Tripod positioning d. Accessory muscle use

B. The technique for palpation for chest excursion is shown in the illustrated technique. Reduced chest movement would be noted on palpation of a patient's chest with COPD. Hyperresonance would be assessed through percussion. Accessory muscle use and tripod positioning would be assessed by inspection.

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

B. When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and can more easily be located and removed. The patient does not usually require sedation for the procedure, and there are no restrictions on oral intake because the patient is not sedated or unconscious. Usually only 1000 to 1200 mL of pleural fluid is removed at one time. Rapid removal of a large volume can result in hypotension, hypoxemia, or pulmonary edema.

A patient with new-onset confusion and hyponatremia is being admitted. When making room assignments, the charge nurse should take which action? a. Assign the patient to a semi-private room. b. Assign the patient to a room near the nurse's station. c. Place the patient in a room nearest to the water fountain. d. Place the patient on telemetry to monitor for peaked T waves..

B. The patient should be placed near the nurse's station if confused for the staff to closely monitor the patient. To help improve serum sodium levels, water intake is restricted. Therefore a confused patient should not be placed near a water fountain. Peaked T waves are a sign of hyperkalemia, not hyponatremia. A confused patient could be distracting and disruptive for another patient in a semiprivate room.

Which of these assessment findings in a patient with a hiatal hernia who returned from a laparoscopic Nissen fundoplication 4 hours ago is most important for the nurse to address immediately? a. The patient is experiencing intermittent waves of nausea b. The patient has absent breath sounds throughout the left lung c. The patient has decreased bowel sounds in all four quadrants d. The patient complains of 6/10 on the abdominal pain

B: absent breath sounds throughout the left lung; indicates a pneumothorax

Which action can the nurse delegate to the unlicensed assistive personnel (UAP) who are working in the orthopedic clinic? a. Grade leg muscle strength for a patient with back pain b. Obtain blood sample for uric acid from a patient with gout c. Perform straight-leg raise testing for a patient with sciatica d. Check for knee joint crepitation before arthroscopic surgery

B: obtain blood sample which are common skills performed by UAP in the clinic settings

A patient with acute osteomyelitis of the left femur is hospitalized for regional antibiotic irrigation. Which intervention will the nurse include in the initial plan of care? a. Quadriceps-setting exercises b. Immobilization of the left leg c. Positioning the left leg in flexion d. Assisted weight-bearing ambulation

B: reduces the risk for pathologic fracture; flexion should be avoided to prevent contractures;

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: the patient's stools are tan colored; this indicates biliary obstruction which requires rapid intervention to resolve.

After assisting with a needle biopsy of the liver at a patient's bedside, the nurse should a. put pressure on the biopsy site using a sandbag. b. elevate the head of the bed to facilitate breathing. c. place the patient on the right side with the bed flat. d. check the patient's postbiopsy coagulation studies.

C (After a biopsy, the patient lies on the right side with the bed flat to splint the biopsy site. Coagulation studies are checked before the biopsy. A sandbag does not exert adequate pressure to splint the site.)

Following an acute myocardial infarction (AMI), a patient ambulates in the hospital hallway. When the nurse is evaluating the patient's response to the activity, which assessment data would indicate that the exercise level should be decreased? a. Blood pressure (BP) changes from 118/60 to 126/68 mm Hg. b. Oxygen saturation drops from 99% to 95%. c. Heart rate increases from 66 to 92 beats/minute. d. Respiratory rate goes from 14 to 20 breaths/minute.

C A change in heart rate of more than 20 beats over the resting heart rate indicates that the patient should stop and rest. The increases in BP and respiratory rate, and the slight decrease in oxygen saturation, are normal responses to exercise.

A male patient in the clinic provides a urine sample that is red-orange in color. Which action should the nurse take first? a.Notify the patient's health care provider. b.Teach correct midstream urine collection. c.Ask the patient about current medications. d.Question the patient about urinary tract infection (UTI) risk factors.

C A red-orange color in the urine is normal with some over-the-counter (OTC) medications such as phenazopyridine (Pyridium). The color would not be expected with urinary tract infection, is not a sign that poor technique was used in obtaining the specimen, and does not need to be communicated to the health care provider until further assessment is done.

The nurse reviews a patient's glycosylated hemoglobin (A1C) results to evaluate a. fasting preprandial glucose levels. b. glucose levels 2 hours after a meal. c. glucose control over the past 90 days. d. hypoglycemic episodes in the past 3 months.

C Glycosylated hemoglobin testing measures glucose control over the last 3 months. Glucosetesting before/after a meal or random testing may reveal impaired glucose tolerance andindicate prediabetes, but it is not done on patients who already have a diagnosis of diabetes.There is no test to evaluate for hypoglycemic episodes in the past.

Heparin is ordered for a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI). What is the purpose of the heparin?a. Heparin enhances platelet aggregation at the plaque site. b. Heparin decreases the size of the coronary artery plaque. c. Heparin prevents the development of new clots in the coronary arteries. d. Heparin dissolves clots that are blocking blood flow in the coronary arteries.

C Heparin helps prevent the conversion of fibrinogen to fibrin and decreases coronary artery thrombosis. It does not change coronary artery plaque, dissolve already formed clots, or enhance platelet aggregation.

A patient passing bloody urine is scheduled for a cystoscopy with cystogram. Which description of the procedure by the nurse is accurate? a."Your doctor will place a catheter into an artery in your groin and inject a dye that will visualize the blood supply to the kidneys." b."Your doctor will insert a lighted tube into the bladder, and little catheters will be inserted through the tube into your kidney." c."Your doctor will insert a lighted tube into the bladder through your urethra, inspect the bladder, and instill a dye that will outline your bladder on x-ray." d."Your doctor will inject a radioactive solution into a vein in your arm and the distribution of the isotope in your kidneys and bladder will be

C In a cystoscope and cystogram procedure, a cystoscope is inserted into the bladder for direct visualization, and then contrast solution is injected through the scope so that x-rays can be taken. The response beginning, "Your doctor will place a catheter" describes a renal arteriogram procedure. The response beginning, "Your doctor will inject a radioactive solution" describes a nuclear scan. The response beginning, "Your doctor will insert a lighted tube into the bladder, and little catheters will be inserted" describes a retrograde pyelogram

Which information obtained by the nurse who is admitting the patient for magnetic resonance imaging (MRI) will be most important to report to the health care provider before the MRI? a. The patient has an allergy to shellfish. b. The patient has a history of atherosclerosis. c. The patient has a permanent ventricular pacemaker. d. The patient took all the prescribed cardiac medications today

C MRI is contraindicated for patients with implanted metallic devices such as pacemakers. The other information also will be reported to the health care provider but does not impact on whether or not the patient can have an MRI.

The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin and hydrochlorothiazide. Appropriate instructions for the patient include a. Limit dietary sources of potassium b. Take the hydrochlorthiazide before bedtime c. Notify the HCP if nausea develops d. Skip the digoxin if the pulse is below 60 beats/minute

C Nausea is an indication of digoxin toxicity and should be reported so that the provided can assess the patient for toxicity and adjust the digoxin dose, if necessary. The patient will need to include potassium-containing foods in the diet to avoid hypokalemia. Patient should be taught to check their pulse daily before taking the digoxin and if the pulse is less than 60, to call their provider before taking the digoxin. Diureteics should be taken early in the morning to avoid sleep disruption.

A patient who has chronic heart failure tells the nurse, I was fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating! The nurse will document this assessment finding as a. Orthopnea b. Pulsus alternans c. Paroxysmal nocturnal dyspnea d. Acute bilateral pleural effusion

C Paroxysmal nocturnal dyspnea is caused by the reabsorption of fluid from dependent body ares when the patient is sleeping and is characterized by waking up suddenly with the feeling of suffocation. Pulsus alternans is the alternation of strong and weak peripheral pulses during palpation. Orthopnea indicates that the patient is unable to lie flat because of dyspnea. Pleural effusions develop over a longer time period.

Diltiazem (Cardizem) is ordered for a patient with newly diagnosed Prinzmetal's (variant) angina. When teaching the patient, the nurse will include the information that diltiazem will a. reduce heart palpitations. b. prevent coronary artery plaque. c. decrease coronary artery spasms. d. increase contractile force of the heart.

C Prinzmetal's angina is caused by coronary artery spasm. Calcium channel blockers (e.g., diltiazem, amlodipine [Norvasc]) are a first-line therapy for this type of angina. Lipid-lowering drugs help reduce atherosclerosis (i.e., plaque formation), and -adrenergic blockers decrease sympathetic stimulation of the heart (i.e., palpitations). Medications or activities that increase myocardial contractility will increase the incidence of angina by increasing O2 demand.

After reviewing a patient's history, vital signs, physical assessment, and laboratory data, which information shown in the accompanying figure is most important for the nurse to communicate to the health care provider? a. Hyperglycemia b. Q waves on ECG c. Bilateral crackles d. Elevated troponin

C Pulmonary congestion suggests that the patient may be developing heart failure, a complication of myocardial infarction (MI). Hyperglycemia is common after MI because of the inflammatory process that occurs with tissue necrosis. Troponin levels will be elevated for several days after MI. Q waves often develop with ST-segment-elevation MI.

A patient is being admitted with a diagnosis of Cushing syndrome. Which findings will the nurse expect during the assessment? a. Chronically low blood pressure b. Bronzed appearance of the skin c. Purplish streaks on the abdomen d. Decreased axillary and pubic hair

C Purplish-red striae on the abdomen are a common clinical manifestation of Cushing syndrome. Hypotension and bronzed-appearing skin are manifestations of Addison's disease. Decreased axillary and pubic hair occur with androgen deficiency.

The nurse working on the heart failure unit knows that teaching an older female patient with newly diagnosed heart failure is effective when the patient states that a. She will take furosemide (Lasix) every day at bedtime. b. The nitroglycerin patch is applied when any chest pain develops. c. She will call the clinic if her weight goes from 124 to 128 pounds in a week. d. An additional pillow can help her sleep if she is feeling short of breath at night.

C Teaching for a patient with heart failure includes information about the need to weigh daily & notify the HCP about an increase of 3 pounds in 2 days of 3 to 5 pounds in a week. Nitroglycerin patches are used primarily to reduce preload (not to prevent chest pain) in patients with heart failure and should be used daily, not on an as needed basis. Diuretics should be taken earlier in the day to avoid nocturia and sleep disturbances. The patient should call the clinic if increased orthopnea develops, rather than just compensating by further elevating the HOB.

When titrating IV nitroglycerin for a patient with a myocardial infarction (MI), which action will the nurse take to evaluate the effectiveness of the drug? a. Monitor heart rate. c. Check blood pressure. b. Ask about chest pain. d. Observe for dysrhythmias.

C The goal of IV nitroglycerin administration in MI is relief of chest pain by improving the balance between myocardial oxygen supply and demand. The nurse will also monitor heart rate and blood pressure and observe for dysrhythmias, but these parameters will not indicate whether the medication is effective.

A patient with a history of chronic heart failure is admitted to the ED with severe dyspnea and a dry, hacking cough. Which action should the nurse do first? a. Auscultate the abdomen b. Check capillary refill c. Auscultate the breath sounds d. Assess level of orientation

C This patient's severe dyspnea and cough indicate that acute decompensated heart failure is occurring. ADHF usually manifests as pulmonary edema, which should be detected and treated immediately to prevent ongoing volume status and also should accomplished rapidly, but detection (and treatment) of pulmonary complications is the priority.

A patient with ST-segment elevation in three contiguous electrocardiographic leads is admitted to the emergency department and diagnosed as having an ST-segment-elevation myocardial infarction. Which question should the nurse ask to determine whether the patient is a candidate for thrombolytic therapy? a. "Do you have any allergies?" b. "Do you take aspirin on a daily basis?" c. "What time did your chest pain begin?" d. "Can you rate your chest pain using a 0 to 10 scale?"

C Thrombolytic therapy should be started within 6 hours of the onset of the myocardial infarction, so the time at which the chest pain started is a major determinant of the appropriateness of this treatment. The other information is not a factor in the decision about thrombolytic therapy.

A patient is scheduled for transsphenoidal hypophysectomy to treat a pituitary adenoma. During preoperative teaching, the nurse instructs the patient about the need to: a. cough and deep breathe every 2 hours postoperatively. b. remain on bed rest for the first 48 hours after the surgery. c. avoid brushing teeth for at least 10 days after the surgery. d. be positioned flat with sandbags at the head postoperatively

C To avoid disruption of the suture line, the patient should avoid brushing the teeth for 10 days after surgery. It is not necessary to remain on bed rest after this surgery. Coughing is discouraged because it may cause leakage of cerebrospinal fluid (CSF) from the suture line. The head of the bed should be elevated 30 degrees to reduce pressure on the sella turcica and decrease the risk for headaches

A 54-year-old man has just arrived in the recovery area after an upper endoscopy. Which information collected by the nurse is most important to communicate to the health care provider? a. The patient is very drowsy. b. The patient reports a sore throat. c. The oral temperature is 101.6° F. d. The apical pulse is 104 beats/minute

C (A temperature elevation may indicate that a perforation has occurred. The other assessment data are normal immediately after the procedure.)

Which statement to the nurse from a patient with jaundice indicates a need for teaching? a. "I used cough syrup several times a day last week." b. "I take a baby aspirin every day to prevent strokes." c. "I use acetaminophen (Tylenol) every 4 hours for back pain." d. "I need to take an antacid for indigestion several times a week"

C (Chronic use of high doses of acetaminophen can be hepatotoxic and may have caused the patient's jaundice. The other patient statements require further assessment by the nurse, but do not indicate a need for patient education.)

In caring for a patient admitted with poorly controlled hypertension, which laboratory test result should the nurse understand as indicating the presence of target organ damage? A BUN of 15 mg/dL B Serum uric acid of 3.8 mg/dL C Serum creatinine of 2.6 mg/dL D Serum potassium of 3.5 mEq/L

C Serum creatinine of 2.6 mg/dLThe normal serum creatinine level is 0.6-1.3 mg/dL. This elevated level indicates target organ damage to the kidneys. The other lab results are within normal limits.

Which patient is most likely to be in the fibrous stage of development of coronary artery disease (CAD)? a. Age 40, thrombus adhered to the coronary artery wall b. Age 50, rapid onset of disease with hypercholesterolemia c. Age 32, thickened coronary arterial walls with narrowed vessel lumen d. Age 19, elevated LDL cholesterol, lipid--filled smooth muscle cells

C. Age 32, thickened coronary arterial walls with narrowed vessel lumenThe fibrous plaque stage has progressive changes that can be seen by age 30. Collagen covers the fatty streak and forms a fibrous plaque in the artery. The thrombus adheres to the arterial wall in the complicated lesion stage. Rapid onset of CAD with hypercholesterolemia may be r/t familial hypercholesterolemia, not a stage of CAD development. The fatty streak stage is the earliest stage of atherosclerosis and can be seen by age 15.

The nurse performing an assessment of a patient who has chronic peripheral artery disease (PAD) of the legs and an ulcer on the right second toe would expect to find a. dilated superficial veins. b. swollen, dry, scaly ankles. c. prolonged capillary refill in all the toes. d. serosanguineous drainage from the ulcer

C. Capillary refill is prolonged in PAD because of the slower and decreased blood flow to the periphery. The other listed clinical manifestations are consistent with chronic venous disease

The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. When auscultating the patient's lungs, which finding would the nurse most likely hear? a. Continuous rumbling, snoring, or rattling sounds mainly on expiration b. Continuous high-pitched musical sounds on inspiration and expiration c. Discontinuous, high-pitched sounds of short duration during inspiration d. A series of long-duration, discontinuous, low-pitched sounds during inspiration

C. Fine crackles are likely to be heard in the early phase of heart failure. Fine crackles are discontinuous, high-pitched sounds of short duration heard on inspiration. Course crackles area series of long-duration, discontinuous, low-pitched sounds during inspiration. Wheezes are continuous high-pitched musical sounds on inspiration and expiration.

Which information is most important for the nurse to include when teaching a patient with newly diagnosed hypertension? a. Most people are able to control BP through dietary changes. b. Annual BP checks are needed to monitor treatment effectiveness. c. Hypertension is usually asymptomatic until target organ damage occurs. d. Increasing physical activity alone controls blood pressure (BP) for most people.

C. Hypertension is usually asymptomatic until target organ damage has occurred. Lifestyle changes (e.g., physical activity, dietary changes) are used to help manage BP, but drugs are needed for most patients. Home BP monitoring should be taught to the patient and findings checked by the health care provider frequently when starting treatment for hypertension and then every 3 months when stable.

Which information obtained by the nurse about an older adult who complains of occasional insomnia indicates a need for patient teaching (select all that apply)? a. Drinks a cup of coffee every morning with breakfast b. Has a snack every evening 1 hour before going to bed c. Likes to read or watch television in bed on most evenings d. Usually takes a warm bath just before bedtime every night

C. Reading and watching television in bed may contribute to insomnia.

Which of the following instructions given to a patient who is about to undergo Holter monitoring is most appropriate? A) "You may remove the monitor only to shower or bathe." B) "You should connect the monitor whenever you feel symptoms." C) "You should refrain from exercising while wearing this monitor." D) "You will need to keep a diary of all your activities and symptoms."

D "You will need to keep a diary of all your activities and symptoms."A Holter monitor is worn for at least 24 hours while a patient continues with usual activity and keeps a diary of activities and symptoms. The patient should not take a bath or shower while wearing this monitor.

Which nursing action is essential for a patient immediately after a renal biopsy? a.Check blood glucose to assess for hyperglycemia or hypoglycemia. b.Insert a urinary catheter and test urine for gross or microscopic hematuria. c.Monitor the blood urea nitrogen (BUN) and creatinine to assess renal function. d.Apply a pressure dressing and keep the patient on the affected side for 30 minutes.

D A pressure dressing is applied and the patient is kept on the affected side for 30 to 60 minutes to put pressure on the biopsy side and decrease the risk for bleeding. The blood glucose and BUN/creatinine will not be affected by the biopsy. Although monitoring for hematuria is needed, there is no need for catheterization.

After receiving change-of-shift report about the following four patients on the cardiac care unit, which patient should the nurse assess first? a. A 39-yr-old patient with pericarditis who is complaining of sharp, stabbing chest pain b. A 56-yr-old patient with variant angina who is scheduled to receive nifedipine (Procardia) c. A 65-yr-old patient who had a myocardial infarction (MI) 4 days ago and is anxious about today's planned discharge d. A 59-yr-old patient with unstable angina who has just returned after a percutaneous coronary intervention (PCI)

D After PCI, the patient is at risk for hemorrhage from the arterial access site. The nurse should assess the patient's blood pressure, pulses, and the access site immediately. The other patients should also be assessed as quickly as possible, but assessment of this patient has the highest priority.

Which information from a patient helps the nurse confirm the previous diagnosis of chronic stable angina? a. "The pain wakes me up at night." b. "The pain is level 3 to 5 (0 to 10 scale)." c. "The pain has gotten worse over the last week." d. "The pain goes away after a nitroglycerin tablet."

D Chronic stable angina is typically relieved by rest or nitroglycerin administration. The level of pain is not a consistent indicator of the type of angina. Pain occurring at rest or with increased frequency is typical of unstable angina.

To assess whether there is any improvement in a patient's dysuria, which question will the nurse ask? a."Do you have to urinate at night?" b."Do you have blood in your urine?" c."Do you have to urinate frequently?" d."Do you have pain when you urinate?"

D Dysuria is painful urination. The alternate responses are used to assess other urinary tract symptoms: hematuria, nocturia, and frequency.

When the nurse is monitoring a patient who is undergoing exercise (stress) testing on a treadmill, which assessment finding requires the most rapid action by the nurse? a. Patient complaint of feeling tired b. Pulse change from 87 to 101 beats/minute c. Blood pressure (BP) increase from 134/68 to 150/80 mm Hg d. Newly inverted T waves on the electrocardiogram

D ECG changes associated with coronary ischemia (such as T-wave inversions and ST segment depression) indicate that the myocardium is not getting adequate oxygen delivery and that the exercise test should be terminated immediately. Increases in BP and heart rate (HR) are normal responses to aerobic exercise. Feeling tired is also normal as the intensity of exercise increases during the stress testing.

A 32-year-old patient who is employed as a hairdresser and has a 15 pack-year history of cigarette smoking is scheduled for an annual physical examination. The nurse will plan to teach the patient about the increased risk for a.renal failure. b.kidney stones. c.pyelonephritis. d.bladder cancer.

D Exposure to the chemicals involved with working as a hairdresser and in smoking both increase the risk of bladder cancer, and the nurse should assess whether the patient understands this risk. The patient is not at increased risk for renal failure, pyelonephritis, or kidney stones

After the nurse has finished teaching a patient about the use of sublingual nitroglycerin (Nitrostat), which patient statement indicates that the teaching has been effective? a. "I can expect nausea as a side effect of nitroglycerin." b. "I should only take nitroglycerin when I have chest pain." c. "Nitroglycerin helps prevent a clot from forming and blocking blood flow to my heart." d. "I will call an ambulance if I still have pain after taking three nitroglycerin 5 minutes apart."

D The emergency response system (ERS) should be activated when chest pain or other symptoms are not completely relieved after three sublingual nitroglycerin tablets taken 5 minutes apart. Nitroglycerin can be taken to prevent chest pain or other symptoms from developing (e.g., before intercourse). Gastric upset (e.g., nausea) is not an expected side effect of nitroglycerin. Nitroglycerin does not impact the underlying pathophysiology of coronary artery atherosclerosis.

When reviewing the 12-lead electrocardiograph (ECG) for a healthy 79-year-old patient who is having an annual physical examination, what will be of most concern to the nurse? a. The PR interval is 0.21 seconds. b. The QRS duration is 0.13 seconds. c. There is a right bundle-branch block. d. The heart rate (HR) is 42 beats/minute

D The resting HR does not change with aging, so the decrease in HR requires further investigation. Bundle-branch block and slight increases in PR interval or QRS duration are common in older individuals because of increases in conduction time through the AV node, bundle of His, and bundle branches.DIF:

A 42-year-old woman is admitted to the outpatient testing area for an ultrasound of the gallbladder. Which information obtained by the nurse indicates that the ultrasound may need to be rescheduled? a. The patient took a laxative the previous evening. b. The patient had a high-fat meal the previous evening. c. The patient has a permanent gastrostomy tube in place. d. The patient ate a low-fat bagel 4 hours ago for breakfast.

D (Food intake can cause the gallbladder to contract and result in a suboptimal study. The patient should be NPO for 8 to 12 hours before the test. A high-fat meal the previous evening, laxative use, or a gastrostomy tube will not affect the results of the study.)

The nurse receives the following information about a 51-year-old woman who is scheduled for a colonoscopy. Which information should be communicated to the health care provider before sending the patient for the procedure? a. The patient has a permanent pacemaker to prevent bradycardia. b. The patient is worried about discomfort during the examination. c. The patient has had an allergic reaction to shellfish and iodine in the past. d. The patient refused to drink the ordered polyethylene glycol (GoLYTELY).

D (If the patient has had inadequate bowel preparation, the colon cannot be visualized and the procedure should be rescheduled. Because contrast solution is not used during colonoscopy, the iodine allergy is not pertinent. A pacemaker is a contraindication to magnetic resonance imaging (MRI), but not to colonoscopy. The nurse should instruct the patient about the sedation used during the examination to decrease the patient's anxiety about discomfort.)

A serum potassium level of 3.2 mEq/L reported for a patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (lasix) due. Which action should the nurse take? a. Withhold both drugs b. Administer the furosemide c. Administer both drugs d. Administer the spironolactone

D. administer the spironolactone, it is a potassium sparing diuretic and will help increase the patient's potassium level.

A patient admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI) is restless and anxious. The blood pressure is 86/40 mm Hg, and heart rate is 132 beats/min. Based on this information, which nursing diagnosis is a priority for the patient? a. Acute pain related to myocardial infarction b. Anxiety related to perceived threat of death c. Stress overload related to acute change in health d. Decreased cardiac output related to cardiogenic shock

D. All the nursing diagnoses may be appropriate for this patient, but the hypotension and tachycardia indicate decreased cardiac output and shock from the damaged myocardium. This will result in decreased perfusion to all vital organs (e.g., brain, kidney, heart) and is a priority.

A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

D. The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO3.

The laboratory has just called with the arterial blood gas (ABG) results on four patients. Which result is most important for the nurse to report immediately to the health care provider? a. pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97% b. pH 7.35, PaO2 85 mm Hg, PaCO2 45 mm Hg, and O2 sat 95% c. pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98% d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%

D. These ABGs indicate uncompensated respiratory acidosis and should be reported to the health care provider. The other values are normal or close to normal

A patient who has had chest pain for several hours is admitted with a diagnosis of rule out acute myocardial infarction (AMI). Which laboratory test should the nurse monitor to best determine whether the patient has had an AMI? a. Myoglobin b. C-reactive protein c. Homocysteine d. Cardiac-specific troponin

D. Troponin levels increase about 4 to 6 hours after the onset of myocardial infarction (MI) and are highly specific indicators for MI. Myoglobin is released within 2 hours of MI, but it lacks specificity and its use is limited. The other laboratory data are useful in determining the patient's risk for developing coronary artery disease but are not helpful in determining whether an acute MI is in progress.

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

D. The patient's history and symptoms suggest possible tension pneumothorax, a medical emergency. The other patients also require assessment as soon as possible, but tension pneumothorax will require immediate treatment to avoid death from inadequate cardiac output or hypoxemia.

A 47-year old female 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

D: document stoma assessment findings, the stomas 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.

Which information will the nurses include when teaching a patient with newly diagnosed gastroesophageal reflux disease? a. Peppermint tea may be helpful in reducing your symptoms b. You should avoid eating between meals to reduce acid secretion c. Vigorous physical activities may increase the incidence of reflux d. It will be helpful to keep the head of your bed elevated on blocks

D: keep the head of your bed elevated it will reduce the incidence of reflux while the patient is sleeping

This bariatric surgical procedure involves creating a stoma and gastric pouch that is reversible, and no malabsorption occurs. What surgical procedure is this? a. Vertical gastric banding b. Biliopancreatic diversion c. Roux-en Y gastric d. Adjustable gastric banding

D: with adjustable gastric banding the stomach size is limited by an inflatable band place around the fundus of the stomach. The band is connected to a subcutaneous port and can be inflated or deflated to change the stoma size to meet the patient's needs as weight is lost.

A patient has chronic venous insufficiency (CVI). What important information below will the nurse provide to the patient about how to alleviate signs and symptoms associated with the disease? Select all that apply: A. Elevate the lower extremities below heart level frequently B. Application of compression stockings C. Limit long periods of standing and sitting D. Use the knee-flexed position while lying in bed

The answers are B and C. A is incorrect: elevate the lower extremities ABOVE heart level, not BELOW. This helps return blood to the heart and decrease swelling/pain.D is incorrect: Avoid crossing the legs (or the knee-flexed position) because this impedes blood flow.Limit long periods of standing and sitting (this limits blood return to the heart and increases swelling). The application of compression stockings is very beneficial in peripheral venous disease because it helps blood return to the heart and prevents the stasis of blood in the lower extremities.

A patient with a history of recurrent urinary tract infections has been scheduled for a cystoscopy. What teaching point should the nurse emphasize before the procedure?a."You might have pink-tinged urine and burning after your cystoscopy." b."You'll need to refrain from eating or drinking after midnight the day before the test." c."The morning of the test, you will drink some water that contains a contrast solution."

a. "You might have pink-tinged urine and burning after your cystoscopy."

The nurse is caring for a patient after a right kidney biopsy. Which position would be the most appropriate for this patient immediately after the procedure? a. Right lateral side-lying position b.Reverse Trendelenburg position c.Supine with lower extremities elevated d.High Fowler's position with arms supported

a. Right lateral side-lying position

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.

a. Assist the patient to splint the chest when coughing.

The nurse is caring for a patient after a parathyroidectomy. The nurse would prepare to administer IV calcium gluconate if the patient exhibits which clinical manifestations? a. Facial muscle spasms and laryngospasms b. Tingling in the hands and around the mouth c. Decreased muscle tone and muscle weakness d. Shortened QT interval on the electrocardiogram

a. Facial muscle spasms and laryngospasms

A patient who is experiencing an asthma attack develops bradycardia and a decrease in wheezing. Which action should the nurse take first? a. Notify the health care provider. b. Document changes in respiratory status. c. Encourage the patient to cough and deep breathe. d. Administer IV methylprednisolone (Solu-Medrol).

a. Notify the health care provider.

Which statement by the patient with type 2 diabetes is accurate? a. "I will limit my alcohol intake to one drink" b. "I am not allowed to eat any sweets because of my diabetes" c. "I cannot exercise because I take a blood glucose lowering medication" d. "the amount of fat in my diet is not important. Only carbohydrates raise my blood sugar"

a. "I will limit my alcohol intake to one drink"

An abnormal finding by the nurse during an endocrine assessment would be : Select all that apply a. blood pressure 100/70 b. excessive facial hair on a woman c. soft, formed stool every other day d. 3-lb weight gain over last 6 months e. hyper-pigmented coloration in lower legs

b. excessive facial hair on a woman e. hyper-pigmented coloration in lower legs

Which finding from a patient's right knee arthrocentesis will be of concern to the nurse? a. Cloudy fluid b. Scant thin fluid c. Pale yellow fluid d. Straw-colored fluid

a. The presence of purulent fluid suggests possible joint infection

The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective? a. "I will avoid being outdoors whenever possible." b. "My husband will be sleeping in the guest bedroom." c. "I will take the bus instead of driving to visit my friends." d. "I will keep the windows closed at home to contain the germs."

b. "My husband will be sleeping in the guest bedroom."

The nurse is admitting a patient diagnosed with an acute exacerbation of chronic obstructive pulmonary disease (COPD).What is the best way for the nurse to determine the appropriate oxygen flow rate? a. Minimize oxygen use to avoid oxygen dependency. b. Maintain the pulse oximetry level at 90% or greater. c. Administer oxygen according to the patient's level of dyspnea. d. Avoid administration of oxygen at a rate of more than 2 L/minute.

b. Maintain the pulse oximetry level at 90% or greater.

A nurse is caring for a patient with a history of chronic obstructive pulmonary disease (COPD) admitted for pneumonia. What laboratory finding would be consistent with decreased kidney function in this patient? a.Serum uric acid of 5.2 mg/dL b.Urine specific gravity of 1.040 c.Serum creatinine 2.3 of mg/dL d.Blood urea nitrogen (BUN) of 10 mg/dL

c. Serum creatinine 2.3 of mg/dL

A patient with chronic obstructive pulmonary disease (COPD) has poor gas exchange. Which action by the nurse would be most appropriate? a. Have the patient rest in bed with the head elevated to 15 to 20 degrees. b. Ask the patient to rest in bed in a high-Fowler's position with the knees flexed. c. Encourage the patient to sit up at the bedside in a chair and lean slightly forward. d. Place the patient in the Trendelenburg position with several pillows behind the head.

c. Encourage the patient to sit up at the bedside in a chair and lean slightly forward.

What is the priority action for the nurse to take if the patient with type 2 diabetes complains of blurred vision and irritability? a. call the physician b. administer insulin as ordered c. check the patient's blood glucose level d. assess for other neurologic symptoms

c. check the patient's blood glucose level

Which hormone level would the nurse expect to be elevated in response to a low serum cortisol level? a. Growth hormone (GH) b. Follicle-stimulating hormone (FSH) c. Thyroid-stimulating hormone (TSH) d. Adrenocorticotropic hormone (ACTH)

d. Adrenocorticotropic hormone (ACTH)

A client who is admitted to the hospital with liver cancer and ascites is scheduled for a paracentesis. Which nursing intervention would be included in client's plan of care? a. Cleansing the intestinal tract in preparation b. Marking the anesthetic insertion site c. Discussing the operating room setup d. Having the client void before the procedure

d. Having the client void before the procedure

The nurse identifies a risk for urinary calculi in a patient who relates a past health history that includes a. hyperaldosteronism. b. serotonin deficiency. c. adrenal insufficiency. d. hyperparathyroidism

d. hyperparathyroidism.

On reading the urinalysis results of a dehydrated patient, the nurse would expect to find a. a pH of 8.4 b. RBCs of 4/hpf. c. color: yellow, cloudy. d. specific gravity of 1.035.

d. specific gravity of 1.035.