3010 finale

A nurse is caring for a patient who has been admitted to the hospital with diverticulitis. Which of the following would be appropriate nursing diagnosis for this patient? SATA A) Acute Pain Related to Increased Peristalsis and GI Inflammation B) Activity Intolerance Related to Generalized Weakness C) Bowel Incontinence Related to Increased Intestinal Peristalsis D) Deficient Fluid Volume Related to Anorexia, Nausea, and Diarrhea E) Impaired Urinary Elimination Related to GI Pressure on the Bladder

Acute pain related to increased peristalsis and GI inflammation, activity intolerance related to generalized weakness, deficient fluid volume related to anorexia nausea and diarrhea Patients with diverticulitis are likely to experience pain and decreased activity levels, and are at risk of fluid volume deficit. The patient is unlikely to experience fecal incontinence and urinary function is not directly influenced.

An audit of a large, university medical center reveals that four patients in the hospital have current orders for restraints. You know that restraints are an intervention of last resort, and that it is inappropriate to apply restraints to which of the following patients. A postlaryngectomy patient who is attempting to pull out his tracheostomy tube A patient in hypovolemic shock trying to remove the dressing over his central venous catheter. A patient with urosepsis who is ringing the call bell incessantly to use the bedside commode. A patient with depression who has just tried to commit suicide and whose medicaitons are no achieveing adequate symptom control.

A patient with urosepsis who is ringing the call bell incessantly to use the bedside commode.

Staff nurses in an ICU setting have noticed that their patients required lower and fewer doses of analgesia when noise levels on the unit were consciously reduced. They informed an advanced practice RN of this and asked the APRN to quantify the effects of noise on the pain levels of hospitalized patients. How does this demonstrate a role of the APRN? A) Involving patients in their care while hospitalized B) Contributing to the scientific basis of nursing practice C) Critiquing the quality of patient care D) Explaining medical studies to patients and RNs

B) Contributing to the scientific basis of nursing practice

A nurse is caring for a patient who is receiving PN. The patient's care plan should include nursing actions relevant to what potential complications? SATA A) Dumping syndrome B) Clotted or displaced catheter C) Pneumothorax D) Hyperglycemia E) Line sepsis

Clotted/displaced catheter, pneumothorax, hyperglycemia, line sepsis Common complications of PN include a clotted or displaced catheter, pneumothorax, hyperglycemia, and infection from the venous access device (line sepsis). Dumping syndrome applies to enteral nutrition, not PN.

An adult patient has been diagnosed with diverticular disease after ongoing challenges with constipation. The patient will be treated on an outpatient basis. What components of treatment should the nurse anticipate? SATA A) Anticholinergic medications B) Increased fiber intake C) Enemas on alternating days D) Reduced fat intake E) Fluid reduction

Increased fiber intake, reduced fat intake Patients whose diverticular disease does not warrant hospital treatment often benefit from a high-fiber, low-fat diet. Neither enemas nor anticholinergics are indicated, and fluid intake is encouraged.

The nurse is performing an assessment on a patient who has been diagnosed with cancer of the larynx. Part of the nurses assessment addresses the patient's general state of nutrition. Which laboratory values would be assessed when determining the nutritional status of the patient? SATA A) White blood cell count B) Protein level C) Albumin level D) Platelet count E) Glucose level

Protein level, albumin level, and glucose level The nurse also assesses the patients general state of nutrition, including height and weight and body mass index, and reviews laboratory values that assist in determining the patients nutritional status (albumin, protein, glucose, and electrolyte levels). The white blood cell count and the platelet count would not normally assist in determining the patients nutritional status.

The nurse is caring for a patient on the med surg unit postoperative day 5. During each patient assessment, the nurse evaluates the patient for infection. Which of the following would be most indicative of infection? A) Presence of an indwelling urinary catheter B) Rectal temperature of 99.5F (37.5C) C) Red, warm, tender incision D) White blood cell (WBC) count of 8,000/mL

Red, warm, tender incision Redness, warmth, and tenderness in the incision area should lead the nurse to suspect a postoperative infection. The presence of any invasive device predisposes a patient to infection, but by itself does not indicate infection. An oral temperature of 99.5F may not signal infection in a postoperative patient because of the inflammatory process. A normal WBC count ranges from 4,000 to 10,000/mL.

In two days you are scheduled to discharge a patient home after left hip replacement. You have initiated a home health referral and you have met with a team of people who have been involved with this patients discharge planning. Knowing that the patient lives alone, who would be appropriate people to be on the discharge planning team? Select all that apply. A) Home health nurse B) Physical therapist C) Pharmacy technician D) Social worker E) Meal-on-Wheels provider

·A) Home health nurse B) Physical therapist D) Social worker

A patient receiving tube feedings is experiencing diarrhea. The nurse and the physician suspect that the patient is experiencing dumping syndrome. What intervention is most appropriate?

Dilute the concentration of the feeding solution

A patient returns to the unit after neck dissection. The surgeon placed a Jackson Pratt drain in the wound. When assessing the wound drainage over the first 24 postoperative hours the nurse would notify the physician immediately for what?

60 mL of milky or cloudy drainage

A patient presents to the ED stating she was in a boating accident about 3 hours ago. Now the patient has complaints of headache, fatigue, and the feeling that he just can't breathe enough. The nurse notes that the patient is restless and tachycardic with an elevated blood pressure. This patient may be in the early stages of what respiratory problem? A) Pneumoconiosis B) Pleural effusion C) Acute respiratory failure D) Pneumonia

Acute respiratory failure Early signs of acute respiratory failure are those associated with impaired oxygenation and may include restlessness, fatigue, headache, dyspnea, air hunger, tachycardia, and increased blood pressure. As the hypoxemia progresses, more obvious signs may be present, including confusion, lethargy, tachycardia, tachypnea, central cyanosis, diaphoresis, and, finally, respiratory arrest. Pneumonia is infectious and would not result from trauma. Pneumoconiosis results from exposure to occupational toxins. A pleural effusion does not cause this constellation of symptoms.

A patient with end stage liver disease has developed hypervolemia. What nursing interventions would be most appropriate when addressing the patients fluid volume excess? SATA A) Administering diuretics B) Administering calcium channel blockers C) Implementing fluid restrictions D) Implementing a 1500 kcal/day restriction E) Enhancing patient positioning

Administering diuretics, implementing fluid restrictions, enhancing patient position Administering diuretics, implementing fluid restrictions, and enhancing patient positioning can optimize the management of fluid volume excess. Calcium channel blockers and calorie restriction do not address this problem.

A patient's physician has ordered a liver panel in response to the patient's development of jaundice. When reviewing the results of this laboratory testing, the nurse should expect to review which blood tests? SATA A) Alanine aminotransferase (ALT) B) C-reactive protein (CRP) C) Gamma-glutamyl transferase (GGT) D) Aspartate aminotransferase (AST) E) B-type natriuretic peptide (BNP)

Alanine aminotransferase (ALT), Gamma-glutamyl transferase (GGT), Aspartate aminotransferase (AST) Liver function testing includes GGT, ALT, and AST. CRP addresses the presence of generalized inflammation and BNP is relevant to heart failure; neither is included in a liver panel.

The nurse is performing a respiratory assessment of a patient who has been experiencing episodes of hypoxia. The nurse is aware that this is ultimately attributable to impaired gas exchange. On what factor does adequate gas exchange primarily depend? A) An appropriate perfusiondiffusion ratio B) An adequate ventilationperfusion ratio C) Adequate diffusion of gas in shunted blood D) Appropriate blood nitrogen concentration

An adequate ventilation perfusion ratio Adequate gas exchange depends on an adequate ventilationperfusion ratio. There is no perfusiondiffusion ratio. Adequate gas exchange does not depend on the diffusion of gas in shunted blood or a particular concentration of nitrogen.

A patient has been diagnosed with peptic ulcer disease and the nurse is reviewing his prescribed medication regimen with him. What is currently the most commonly used drug regimen for peptic ulcer disease? A) Bismuth salts, antivirals, and histamine-2 (H2) antagonists B) H2 antagonists, antibiotics, and bicarbonate salts C) Bicarbonate salts, antibiotics, and ZES D) Antibiotics, proton pump inhibitors, and bismuth salts

Antibiotics, proton pump inhibitors, and bismuth salts Currently, the most commonly used therapy for peptic ulcers is a combination of antibiotics, proton pump inhibitors, and bismuth salts that suppress or eradicate H. pylori. H2 receptor antagonists are used to treat NSAID-induced ulcers and other ulcers not associated with H. pylori infection, but they are not the drug of choice. Bicarbonate salts are not used. ZES is the Zollinger-Ellison syndrome and not a drug.

Most individuals with mitral valve prolapse never have any symptoms, although this is not the case for every patient. What symptoms might a patient with mitral prolapse have? SATA A) Anxiety B) Fatigue C) Shoulder pain D) Tachypnea E) Palpitations

Anxiety, fatigue, palpitations Most people who have mitral valve prolapse never have symptoms. A few have symptoms of fatigue, shortness of breath, lightheadedness, dizziness, syncope, palpitations, chest pain, and anxiety. Hyperpnea and shoulder pain are not characteristic symptoms of mitral valve prolapse.

A nurse is caring for a patient who has been admitted for treatment of advanced cirrhosis. What assessment should the nurse prioritize in this patient's plan of care? A) Measurement of abdominal girth and body weight B) Assessment for variceal bleeding C) Assessment for signs and symptoms of jaundice D) Monitoring of results of liver function testing

Assessment for variceal bleeding Esophageal varices are a major cause of mortality in patients with uncompensated cirrhosis. Consequently, this should be a focus of the nurses assessments and should be prioritized over the other listed assessments, even though each should be performed

A patient's plan of care specifies postural drainage. What action should the nurse perform when providing this noninvasive therapy? A) Administer the treatment with the patient in a high Fowlers or semi-Fowlers position. B) Perform the procedure immediately following the patients meals. C) Apply percussion firmly to bare skin to facilitate drainage. D) Assist the patient into a position that will allow gravity to move secretions.

Assist the patient into a position that will allow gravity to move secretions Postural drainage is usually performed two to four times per day. The patient uses gravity to facilitate postural draining. The skin should be covered with a cloth or a towel during percussion to protect the skin. Postural drainage is not administered in an upright position or directly following a meal.

A nurse is providing care for a patient who is postoperative day 2 following gastric surgery. The nurses assessment should be planned in light of the possibility of what potential complications? SATA A) Malignant hyperthermia B) Atelectasis C) Pneumonia D) Metabolic imbalances E) Chronic gastritis

Atelectasis, pneumonia, metabolic imbalances After surgery, the nurse assesses the patient for complications secondary to the surgical intervention, such as pneumonia, atelectasis, or metabolic imbalances resulting from the GI disruption. Malignant hyperthermia is an intraoperative complication. Chronic gastritis is not a surgical complication.

A patient's NG tube has become clogged after the nurse instilled a medication that was insufficiently crushed. The nurse has attempted to aspirate with a large-bore syringe, with no success. What should the nurse do next? A) Withdraw the NG tube 3 to 5 cm and reattempt aspiration. B) Attach a syringe filled with warm water and attempt an in-and-out motion of instilling and aspirating. C) Withdraw the NG tube slightly and attempt to dislodge by flicking the tube with the fingers. D) Remove the NG tube promptly and obtain an order for reinsertion from the primary care provider.

Attach a syringe filled with warm water and attempt and in-and-out motion of instilling and aspirating When a tube is first noted to be clogged, a 30- to 60-mL syringe should be attached to the end of the tube and any contents aspirated and discarded. Then the syringe should be filled with warm water, attached to the tube again, and a back-and-forth motion initiated to help loosen the clog. Removal is not warranted at this early stage and a flicking motion is not recommended. The tube should not be withdrawn, even a few centimeters.

A home health nurse is preparing to make the initial visit to a new patient's home. When planning educational interventions, what information should the nurse provide to the patient and his or her family? Available community resources to meet their needs Information on other patients in the area with similar health care needs The nurse contact information and credentials Dates and times of all scheduled home care visits

Available community resources to meet their needs

A patient with a peptic ulcer disease has metronidazole added to his current medication regimen What health education related to this medication should the nurse provide? A) Take the medication on an empty stomach. B) Take up to one extra dose per day if stomach pain persists. C) Take at bedtime to mitigate the effects of drowsiness. D) Avoid drinking alcohol while taking the drug.

Avoid drinking alcohol while taking the drug Alcohol must be avoided when taking Flagyl and the medication should be taken with food. This drug does not cause drowsiness and the dose should not be adjusted by the patient.

The case manager is working with an 84-year-old patient newly admitted to a rehabilitation facility. When developing a care plan for this older adult, which factors should the nurse identify as positive attributes to benefit coping in this age group? Select all that apply: A) Decreased risk taking B) Effective adaptation skills C) Avoiding participation in untested roles D) Increase life expectancy E) Resilience during change

B) Effective adaptation skills D) Increase life expectancy E) Resilience during change. The nurses role in genetic counseling is to provide information, collect relevant data, offer support, andcoordinate resources. Most patients do not need to know each of the different patterns of inheritance.The other listed actions are inappropriate

A nurse is completing a focused respiratory assessment of a child with asthma. What assessment finding is most closely associated with the characteristic signs and symptoms of asthma? A) Shallow respirations B) Increased anterior-posterior (A-P) diameter C) Bilateral wheezes D) Bradypnea

Bilateral wheezes The three most common symptoms of asthma are cough, dyspnea, and wheezing. There may be generalized wheezing (the sound of airflow through narrowed airways), first on expiration and then, possibly, during inspiration as well. Respirations are not usually slow and the childs A-P diameter does not normally change.

As an intra-operative nurse, you are the advocate for each of the patients who receive care in the surgical setting. How can you best exemplify principles of patient advocacy? A) By encouraging the patient to perform deep breathing preoperatively B) By limiting the patients contact with family members preoperatively C) By maintaining each of your patients privacy D) By eliciting informed consent from patients

By maintaining each of your patients privacy Patient advocacy in the OR entails maintaining the patients physical and emotional comfort, privacy, rights, and dignity. Deep breathing is not necessary before surgery and obtaining informed consent is the purview of the physician. Family contact should not be limited.

The nurse is preparing a patient for surgery. The patient states that she is very nervous and really does not understand what the surgical procedure is for or how it will be performed. What is the most appropriate nursing action for the nurse to take A) Have the patient sign the informed consent and place it in the chart. B) Call the physician to review the procedure with the patient. C) Explain the procedure clearly to the patient and her family. D) Provide the patient with a pamphlet explaining the procedure.

Call the physician to review the procedure with the patient While the nurse may ask the patient to sign the consent form and witness the signature, it is the surgeons responsibility to provide a clear and simple explanation of what the surgery will entail prior to the patient giving consent. The surgeon must also inform the patient of the benefits, alternatives, possible risks, complications, disfigurement, disability, and removal of body parts as well as what to expect in the early and late postoperative periods. The nurse clarifies the information provided, and, if the patient requests additional information, the nurse notifies the physician. The consent formed should not be signed until the patient understands the procedure that has been explained by the surgeon. The provision of a pamphlet will benefit teaching the patient about the surgical procedure, but will not substitute for the information provided by the physician.

A patient has been discharged home on PN. Much of the nurses discharge instructions focus on coping. What must a patient learn to cope with? SATA A) Changes in lifestyle B) Loss of eating as a social behavior C) Chronic bowel incontinence from GI changes D) Sleep disturbances related to frequent urination during nighttime infusions E) Stress of choosing the correct PN formulation

Changes in lifestyle, loss of eating as a social behavior, sleep disturbances related to frequent urination during nighttime infusions Feedback: Patients must cope with the loss of eating as a social behavior and with changes in lifestyle brought on by sleep disturbances related to frequent urination during night time infusions. PN is not associated with bowel incontinence and the patient does not select or adjust the formulation of PN.

The nurse is administering TPN to a client who underwent surgery for gastric cancer. Which of the nurses assessments most directly addresses a major complication of TPN? A) Checking the patients capillary blood glucose levels regularly B) Having the patient frequently rate his or her hunger on a 10-point scale C) Measuring the patients heart rhythm at least every 6 hours D) Monitoring the patients level of consciousness each shift

Checking the patient's blood glucose levels regularly The solution, used as a base for most TPN, consists of a high dextrose concentration and may raise blood glucose levels significantly, resulting in hyperglycemia. This is a more salient threat than hunger, though this should be addressed. Dysrhythmias and decreased LOC are not among the most common complications.

nurse is working with a child who is undergoing a diagnostic workup for suspected asthma. What are the signs and symptoms that are consistent with a diagnosis of asthma? SATA A) Chest tightness B) Crackles C) Bradypnea D) Wheezing E) Cough

Chest tightness, wheezing, cough Asthma is a chronic inflammatory disease of the airways that causes airway hyperresponsiveness, mucosal edema, and mucus production. This inflammation ultimately leads to recurrent episodes of asthma symptoms: cough, chest tightness, wheezing, and dyspnea. Crackles and bradypnea are not typical symptoms of asthma.

The nurse is caring for a patient in metabolic alkalosis. The patient has an NG tube to low intermittent suction for a diagnosis of bowel obstruction. What drug would the nurse expect to find on the medication orders? A) Cimetidine B) Maalox C) Potassium chloride elixir D) Furosemide

Cimetidine H2 receptor antagonists, such as cimetidine (Tagamet), reduce the production of gastric HCl, thereby decreasing the metabolic alkalosis associated with gastric suction. Maalox is an oral simethicone used to break up gas in the GI system and would be of no benefit in treating a patient in metabolic alkalosis. KCl would only be given if the patient were hypokalemic, which is not stated in the scenario. Furosemide (Lasix) would only be given if the patient were fluid overloaded, which is not stated in the scenario.

Nursing care is provided in an increasingly diverse variety of settings. Despite the variety in settings, some characteristics of professional nursing practice are required in any and every setting. These characteristics should include what? A) Advanced education B) Certification in a chosen specialty C) Cultural competence D) Independent practice

Cultural competence Cultural competence is necessary in any and every care setting. The other answers are incorrect because an advanced education, specialty certification, and the ability to practice independently are not consistencies between every nursing care delivery setting.

The nurse is reviewing the medication administration record of a patient who takes a variety of medications for the treatment of hypertension. What potential therapeutic benefits of antihypertensives should the nurse identify? SATA A) Increased venous return B) Decreased peripheral resistance C) Decreased blood volume D) Decreased strength and rate of myocardial contractions E) Decreased blood viscosity

Decreased peripheral resistance, decreased blood volume, decreased strength and rate of myocardial contractions The medications used for treating hypertension decrease peripheral resistance, blood volume, or the strength and rate of myocardial contraction. Antihypertensive medications do not increase venous return or decrease blood viscosity.

A gerontologic nurse is teaching students about the high incidence and prevalence of dehydration in older adults. What factors contribute to this phenomena? SATA A) Decreased kidney mass B) Increased conservation of sodium C) Increased total body water D) Decreased renal blood flow E) Decreased excretion of potassium

Decreased kidney mass, decreased renal blood flow, decreased excretion of sodium Dehydration in the elderly is common as a result of decreased kidney mass, decreased glomerular filtration rate, decreased renal blood flow, decreased ability to concentrate urine, inability to conserve sodium, decreased excretion of potassium, and a decrease of total body water.

A patient has been experiencing significant psychosocial stress in recent weeks. The nurse is aware of the hormonal effects of stress, including norepinephrine release. Release of this substance would have what effect on the patients gastrointestinal function? SATA A) Decreased motility B) Increased sphincter tone C) Increased enzyme release D) Inhibition of secretions E) Increased peristalsis

Decreased motility Norepinephrine generally decreases GI motility and secretions, but increases muscle tone of sphincters. Norepinephrine does not increase the release of enzymes.

A nurse is performing an abdominal assessment of an older adult patient. When collecting and analyzing data, the nurse should be cognizant of what age related change in gastrointestinal structure and function? A) Increased gastric motility B) Decreased gastric pH C) Increased gag reflex D) Decreased mucus secretion

Decreased mucus secretion Older adults tend to secrete less mucus than younger adults. Gastric motility slows with age and gastric pH rises due to decreased secretion of gastric acids. Older adults tend to have a blunted gag reflex compared to younger adults.

A patient is receiving education about his upcoming Biliroth I procedure (gastroduodenostomy). This patient should be informed that he may experience which of the following adverse effects associated with this procedure?

Diarrhea and feelings of fullness

While the surgical patient is anesthetized, the scrub nurse hears a member of the surgical team make an inappropriate remark about the patient's weight. How should the nurse best respond? A) Ignore the comment because the patient is unconscious. B) Discourage the colleague from making such comments. C) Report the comment immediately to a supervisor. D) Realize that humor is needed in the workplace.

Discourage the colleague from making such comments Patients, whether conscious or unconscious, should not be subjected to excess noise, inappropriate conversation, or, most of all, derogatory comments. The nurse must act as an advocate on behalf of the patient and discourage any such remarks. Reporting to a supervisor, however, is not likely necessary.

The home health nurse is caring for a client who has a diagnosis of hypertension. What assessment question most directly addresses the possibility of worsening hypertension? A) Are you eating less salt in your diet? B) How is your energy level these days? C) Do you ever get chest pain when you exercise? D) Do you ever see spots in front of your eyes?

Do you ever see spots in front of your eyes? To identify complications or worsening hypertension, the patient is questioned about blurred vision, spots in front of the eyes, and diminished visual acuity. The heart, nervous system, and kidneys are also carefully assessed, but angina pain and decreased energy are not normally suggestive of worsening hypertension. Sodium limitation is a beneficial lifestyle modification, but nonadherence to this is not necessarily a sign of worsening symptoms.

The nurse is admitting a patient with complaints of dyspnea on exertion and fatigue. The patients ECG shows dysrhythmias that are sometimes associated with left ventricular hypertrophy. What diagnostic tool would be most helpful in diagnosing cardiomyopathy? A) Cardiac catheterization B) Arterial blood gases C) Echocardiogram D) Exercise stress test

ECG The echocardiogram is one of the most helpful diagnostic tools because the structure and function of the ventricles can be observed easily. The ECG is also important, and can demonstrate dysrhythmias and changes consistent with left ventricular hypertrophy. Cardiac catheterization specifically addresses coronary artery function and arterial blood gases evaluate gas exchange and acid balance. Stress testing is not normally used to differentiate cardiomyopathy from other cardiac pathologies.

The role of the certified nurse practitioner (CNP) has become a dominant role for nurses in all levels of healthcare. Which of the following activities are considered integral to the CNP role? SATA A) Educating patients and family members B) Coordinating care with other disciplines C) Using direct provision of interventions D) Educating registered nurses and practical nurses E) Coordinating payment plans for patients

Educating patients and family members, coordinating care with other disciplines, using direct provision of interventions This role is a dominant one for nurses in primary, secondary, and tertiary health care settings and in home care and community nursing. Nurses help patients meet their needs by using direct intervention, by teaching patients and family members to perform care, and by coordinating and collaborating with other disciplines to provide needed services. The other answers are incorrect because NPs do not commonly perform education of nurses and they do not focus on matters related to payment.

You are a community based care manager in a medium sized community that does not have an up to date resource directory available. AS a result, you have been given the task of beginning to compile such a directory. What would be important to include? SATA A) Links to online health sciences journals B) Lists of social service workers in the community C) Eligibility requirements for services D) Lists of the most commonly used resources E) Costs associated with services

Eligibility requirements for services, lists of the most commonly used resources, costs associated with services If a community does not have a resource booklet, an agency may develop one for its staff. It should include the commonly used community resources that patients need, as well as the costs of the services and eligibility requirements. The other answers are incorrect because a community resource booklet usually would not include links to online professional journals and it would not identify specific social service workers, only agencies.

You are assessing a new patient and his home environment following the patients referral for community-based care. Which of the following is the most important responsibility that you have at this initial visit? Encourage the patient and family to become more involved in their community Encourage the patient and his family to delegate someone to contact community resources Encourage the patient and his family to focus primarily on online supports Encourage the patient and his family to connect with appropriate community resources

Encourage the patient and his family to connect with appropriate community resources

Achieving adequate pain management for a postoperative patient will require sophisticated critical thinking skills by the nurse. What are potential benefits of critical thinking in nursing? SATA A) Enhancing the nurses clinical decision making B) Identifying the patients individual preferences C) Planning the best nursing actions to assist the patient D) Increasing the accuracy of the nurses judgments E) Helping identify the patients priority needs

Enhancing the nurses clinical decision making, planning the best nursing actions to assist the patient, increasing the accuracy of the nurses judgement, helping identify the patients priority needs Independent judgments and decisions evolve from a sound knowledge base and the ability to synthesize information within the context in which it is presented. Critical thinking enhances clinical decision making, helping to identify patient needs and the best nursing actions that will assist patients in meeting those needs. Critical thinking does not normally focus on identify patient desires; these would be identified by asking the patient.

A nurse has integrated the principles of evidence-based practice into care. EBP has the potential to help the nurse achieve what goal? Increasing career satisfaction Obtaining federal grant money Ensuring high quality patient care Enhancing the public's esteem for nursing

Ensuring high quality patient care

A nurse in the preoperative holding area is admitting a woman prior to reduction mammoplasty. What should the nurse include in the care given to this patient? SATA A) Establishing an IV line B) Verifying the surgical site with the patient C) Taking measures to ensure the patients comfort D) Applying a grounding device to the patient E) Preparing the medications to be administered in the OR

Establishing an IV line, verifying the surgical site with the patient, Taking measures to ensure the patients comfort In the holding area, the nurse reviews charts, identifies patients, verifies surgical site and marks site per institutional policy, establishes IV lines, administers medications, if prescribed, and takes measures to ensure each patients comfort. A nurse in the preoperative holding area does not prepare medications to be administered by anyone else. A grounding device is applied in the OR.

the critical care nurse is caring for a patient who is cardiogenic shock. What assessments must the nurse perform on this patient? SATA A) Platelet level B) Fluid status C) Cardiac rhythm D) Action of medications E) Sputum volume

Fluid status, cardiac rhythm, action of medications The critical care nurse must carefully assess the patient in cardiogenic shock, observe the cardiac rhythm, monitor hemodynamic parameters, monitor fluid status, and adjust medications and therapies based on the assessment data. Platelet levels and sputum production are not major assessment parameters in a patient who is experiencing cardiogenic shock.

A patient with pancreatic cancer has been scheduled for a pancreaticoduodenectomy (Whipple procedure). During health education, the patient should be informed that this procedure will involve the removal of which of the following? SATA A) Gallbladder B) Part of the stomach C) Duodenum D) Part of the common bile duct E) Part of the rectum

Gallbladder, part of the stomach, duodenum, part of the common bile duct A pancreaticoduodenectomy (Whipple procedure or resection) is used for potentially resectable cancer of the head of the pancreas (Fig. 50-7). This procedure involves removal of the gallbladder, a portion of the stomach, duodenum, proximal jejunum, head of the pancreas, and distal common bile duct. The rectum is not affected.

Genetics-related health care is a component of holistic nursing practice. What action should a nurse who practices in the area of genetics prioritize? A) Teaching families about the different patterns of inheritance B) Gathering relevant family and medical history information C) Providing advice on termination of pregnancy D) Discouraging females from conceiving after the age of 40 years

Gathering relevant family and medical history information. The nurses role in genetic counseling is to provide information, collect relevant data, offer support, and coordinate resources. Most patients do not need to know each of the different patterns of inheritance. The other listed actions are inappropriate.

A patient is brought to the emergency department by the paramedics. The patient is a type 2 diabetic and is experiencing HHS. The nurse should identify what components of HHS? SATA A) Leukocytosis B) Glycosuria C) Dehydration D) Hypernatremia E) Hyperglycemia

Glycosuria, dehydration, hypernatremia, hyperglycemia In HHS, persistent hyperglycemia causes osmotic diuresis, which results in losses of water and electrolytes. To maintain osmotic equilibrium, water shifts from the intracellular fluid space to the extracellular fluid space. With glycosuria and dehydration, hypernatremia and increased osmolarity occur. Leukocytosis does not take place.

A nurse on a post-surgical unit is providing care based on a clinical pathway. When performing assessments and interventions with the aid of a pathway, the nurse should prioritize which goal? A) Helping the patient to achieve specific outcomes B) Balancing risks and benefits of interventions C) Documenting the patients response to therapy D) Staying accountable to the interdisciplinary team

Helping the patient to achieve specific outcomes Pathways are an EBP tool that is used primarily to move patients toward predetermined outcomes. Documentation, accountability, and balancing risks and benefits are appropriate, but helping the patient achieve outcomes is paramount.

A patient's assessment and diagnostic testing are suggestive of acute pancreatitis. When the nurse is performing the health interview, what assessment questions address likely etiologic factors? SATA A) How many alcoholic drinks do you typically consume in a week? B) Have you ever been tested for diabetes? C) Have you ever been diagnosed with gallstones? D) Would you say that you eat a particularly high-fat diet? E) Does anyone in your family have cystic fibrosis?

How many alcoholic drinks do you typically consume a day? Have you ever been diagnosed with gallstones? Eighty percent of patients with acute pancreatitis have biliary tract disease such as gallstones or a history of long-term alcohol abuse. Diabetes, high-fat consumption, and cystic fibrosis are not noted etiologic factors.

The nurse is caring for a patient in the ICU admitted with ARDS after exposure to toxic fumes from a hazardous spill at work. The patient has become hypotensive. What is the cause of this complication to the ARDS treatment? A) Pulmonary hypotension due to decreased cardiac output B) Severe and progressive pulmonary hypertension C) Hypovolemia secondary to leakage of fluid into the interstitial spaces D) Increased cardiac output from high levels of PEEP therapy

Hypovolemia secondary to leakage of fluid into the interstitial spaces Systemic hypotension may occur in ARDS as a result of hypovolemia secondary to leakage of fluid into the interstitial spaces and depressed cardiac output from high levels of PEEP therapy. Pulmonary hypertension, not pulmonary hypotension, sometimes is a complication of ARDS, but it is not the cause of the patient becoming hypotensive.

The management of the patients gastrostomy is an assessment priority for the home care nurse. What statement would indicate that the patient is managing the tube correctly?

I flush my tube with water before and after each of my medications

A nurse is participating in emergency care of a patient who just developed variceal bleeding. What intervention should the nurse anticipate?

IV administration of octreotide (Sandostatin)

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? A) Ineffective Tissue Perfusion B) Impaired Skin Integrity C) Aspiration D) Imbalanced Nutrition: Less Than Body Requirements

Imbalanced Nutrition: Less than body requirements Because digestion normally begins in the mouth, adequate nutrition is related to good dental health and the general condition of the mouth. Any discomfort or adverse condition in the oral cavity can affect a persons nutritional status. Dental caries do not typically affect the patients tissue perfusion or skin integrity. Aspiration is not a likely consequence of dental caries.

A nurse educator is teaching a group of recent nursing graduates about their occupational risks for contracting hepatitis B. What preventative measures should the educator promote? SATA A) Immunization B) Use of standard precautions C) Consumption of a vitamin-rich diet D) Annual vitamin K injections E) Annual vitamin B12 injections

Immunization, use of standard precautions People who are at high risk, including nurses and other health care personnel exposed to blood or blood products, should receive active immunization. The consistent use of standard precautions is also highly beneficial. Vitamin supplementation is unrelated to an individuals risk of HBV.

The nurse is planning the care of a patient with HF. The nurse should identify what overall goals of this patients care? SATA A) Improve functional status B) Prevent endocarditis. C) Extend survival. D) Limit physical activity. E) Relieve patient symptoms.

Improve functional status, extend survival, relieve patient symptoms The overall goals of management of HF are to relieve the patients symptoms, to improve functional status and quality of life, and to extend survival. Activity limitations should be accommodated, but reducing activity is not a goal. Endocarditis is not a common complication of HF and preventing it is not a major goal of care.

A nurse is caring for a patient who is acutely ill and has included vigilant oral care in the patients plan of care. Why are patients who are ill at increased risk for developing dental caries?

Inadequate nutrition and decreased saliva production can cause cavities

A nurse is caring for a patient with COPD. The patient's medication regimen has been recently changed and the nurse is assessing the therapeutic effect of a new bronchodilator. What assessment parameters suggest a consequent improvement in respiratory status? SATA A) Negative sputum culture B) Increased viscosity of lung secretions C) Increased respiratory rate D) Increased expiratory flow rate E) Relief of dyspnea

Increased expiratory flow rate, relief of dyspnea The relief of bronchospasm is confirmed by measuring improvement in expiratory flow rates and volumes (the force of expiration, how long it takes to exhale, and the amount of air exhaled) as well as by assessing the dyspnea and making sure that it has lessened. Increased respiratory rate and viscosity of secretions would suggest a worsening of the patients respiratory status. Bronchodilators would not have a direct result on the patients infectious process.

A 25 year old male patient presents at the emergency department with symptoms of a small bowel obstruction. In collaboration with the PCP, what intervention should the nurse prioritize? A) Insertion of a nasogastric tube B) Insertion of a central venous catheter C) Administration of a mineral oil enema D) Administration of a glycerin suppository and an oral laxative

Insertion of a nasogastric tube Decompression of the bowel through a nasogastric tube is necessary for all patients with small bowel obstruction. Peripheral IV access is normally sufficient. Enemas, suppositories, and laxatives are not indicated if an obstruction is present.

A patient seeking care because of recurrent heartburn and regurgitation is subsequently diagnosed with a hiatal hernia. Which of the following should the nurse include in health education?

Instead of eating 3 meals a day, try eating smaller amounts more often

A nurse is providing patient education for a patient with PUD secondary to chronic NSAID use. The patient has recently been prescribed misoprostol (Cytotec). What would the nurse be most accurate in informing the patient about the drug?

It protects the stomach lining

The care team has deemed the occasional use of restraints necessary in the care of a patient with Alzheimer's disease. What ethical violation is most often posed when using restraints in long-term care settings? A) It limits the patients personal safety. B) It exacerbates the patients disease process. C) It threatens the patients autonomy. D) It is not normally legal.

It threatens the patients autonomy Because safety risks are involved when using restraints on elderly confused patients, this is a common ethical problem, especially in long-term care settings. By definition, restraints limit the individuals autonomy. Restraints are not without risks, but they should not normally limit a patients safety. Restraints will not affect the course of the patients underlying disease process, though they may exacerbate confusion. The use of restraints is closely legislated, but they are not illegal.

A patient with a cholelithiasis has been scheduled for a laparoscopic cholecystectomy. Why is a laparoscopic cholecystectomy preferred by surgeons over an open procedure? A) Laparoscopic cholecystectomy poses fewer surgical risks than an open procedure. B) Laparoscopic cholecystectomy can be performed in a clinic setting, while an open procedure requires an OR. C) A laparoscopic approach allows for the removal of the entire gallbladder. D) A laparoscopic approach can be performed under conscious sedation.

Laparoscopic poses fewer surgical risks than an open procedure Open surgery has largely been replaced by laparoscopic cholecystectomy (removal of the gallbladder through a small incision through the umbilicus). As a result, surgical risks have decreased, along with the length of hospital stay and the long recovery period required after standard surgical cholecystectomy. Both approaches allow for removal of the entire gallbladder and must be performed under general anesthetic in an operating theater.

A patient is brought to the ED by ambulance after a motor vehicle accident in which the patient received blunt trauma to the chest. The patient is in acute respiratory failure, is intubated, and is transferred to the ICU. What parameters of care should the nurse monitor most closely? Select all that apply. A) Coping B) Level of consciousness C) Oral intake D) Arterial blood gases E) Vital signs

Level of consciousness, arterial blood gases, and vital signs Patients are usually treated in the ICU. The nurse assesses the patients respiratory status by monitoring the level of responsiveness, ABGs, pulse oximetry, and vital signs. Oral intake and coping are not immediate priorities during the acute stage of treatment, but would become more important later during recovery.

The community health nurse is performing a home visit to an 84 year old woman recovering from hip surgery. The nurse notes that the woman seems uncharacteristically confused and has dry mucous membranes. When asked about her fluid intake, the patient states, I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom. What would be the nurse's best response? A) I will need to have your medications adjusted so you will need to be readmitted to the hospital for a complete workup. B) Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of your fluids. C) It is normal to be a little confused following surgery, and it is safe not to urinate at night. D) If you build up too much urine in your bladder, it can cause you to get confused, especially when your body is under stress.

Limiting your fluids can create imbalances in your body that can cause confusion. Maybe we need to adjust the timing of your fluids In elderly patients, the clinical manifestations of fluid and electrolyte disturbances may be subtle or atypical. For example, fluid deficit may cause confusion or cognitive impairment in the elderly person. There is no mention of medications in the stem of the question or any specific evidence given for the need for readmission to the hospital. Confusion is never normal, common, or expected in the elderly. Urinary retention does normally cause confusion.

A staff educator is reviewing the causes of GERD with new staff nurses. What area of the GI tract should the educator identify as the cause of reduced pressure associated with GERD? A) Pyloric sphincter B) Lower esophageal sphincter C) Hypopharyngeal sphincter D) Upper esophageal sphincter

Lower esophageal sphincter The lower esophageal sphincter, also called the gastroesophageal sphincter or cardiac sphincter, is located at the junction of the esophagus and the stomach. An incompetent lower esophageal sphincter allows reflux (backward flow) of gastric contents. The upper esophageal sphincter and the hypopharyngeal sphincter are synonymous and are not responsible for the manifestations of GERD. The pyloric sphincter exists between the stomach and the duodenum.

A patient has been diagnosed with small bowel obstruction and has been admitted to the medical unit. The nurses care should prioritize which of the following outcomes? A) Preventing infection B) Maintaining skin and tissue integrity C) Preventing nausea and vomiting D) Maintaining fluid and electrolyte balance

Maintaining fluid and electrolyte balance All of the listed focuses of care are important for the patient with a small bowel obstruction. However, the patients risk of fluid and electrolyte imbalances is an immediate threat to safety, and is a priority in nursing assessment and interventions.

Falls, which are a major health problem in the elderly population, occur from multifactorial causes. When implementing a comprehensive plan to reduce the incidence of falls on a geriatric unit, what risk factors should the nurse identify? SATA A) Medication effects B) Overdependence on assistive devices C) Poor lighting D) Sensory impairment E) Ineffective use of coping strategies

Medication effects, poor lighting, sensory impairment Causes of falls are multifactorial. Both extrinsic factors, such as changes in the environment or poor lighting, and intrinsic factors, such as physical illness, neurologic changes, or sensory impairment, play a role. Mobility difficulties, medication effects, foot problems or unsafe footwear, postural hypotension, visual problems, and tripping hazards are common, treatable causes. Overdependence on assistive devices and ineffective use of coping strategies have not been shown to be factors in the rate of falls in the elderly population.

You are an emergency room nurse caring for a trauma patient. Your patient has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11. How would you interpret these results? A) Respiratory acidosis with no compensation B) Metabolic alkalosis with a compensatory alkalosis C) Metabolic acidosis with no compensation D) Metabolic acidosis with a compensatory respiratory alkalosis

Metabolic acidosis with a compensatory respiratory alkalosis A low pH indicates acidosis (normal pH is 7.35 to 7.45). The PaCO3 is also low, which causes alkalosis. The bicarbonate is low, which causes acidosis. The pH bicarbonate more closely corresponds with a decrease in pH, making the metabolic component the primary problem.

You are doing discharge teaching with a patient who has hypophosphatemia during his time in hospital. The patient has a diet ordered that is high in phosphate. What foods would you teach this patient to include in his diet? SATA A) Milk B) Beef C) Poultry D) Green vegetables E) Liver

Milk, poultry, liver If the patient experiences mild hypophosphatemia, foods such as milk and milk products, organ meats, nuts, fish, poultry, and whole grains should be encouraged.

The client has just returned to the floor after balloon valvuloplasty of the aortic valve and the nurse is planning appropriate assessments. The nurse should assess for indications of what potential complications? SATA A) Emboli B) Mitral valve damage C) Ventricular dysrhythmia D) Atrial-septal defect E) Plaque formation

Mitral valve damage, emboli, ventricular dysrhythmia Possible complications include aortic regurgitation, emboli, ventricular perforation, rupture of the aortic valve annulus, ventricular dysrhythmia, mitral valve damage, and bleeding from the catheter insertion sites. Atrial-septal defect and plaque formation are not complications of a balloon valvuloplasty.

The student nurse is preparing a teaching plan for a patient being discharged post-MI. What should the nurse include in the teaching plan? SATA A) Need for careful monitoring for cardiac symptoms B) Need for carefully regulated exercise C) Need for dietary modifications D) Need for early resumption of prediagnosis activity E) Need for increased fluid intake

Need for careful monitoring of cardiac symptoms, need for carefully regulated exercise, need for dietary modifications Dietary modifications, exercise, weight loss, and careful monitoring are important strategies for managing three major cardiovascular risk factors: hyperlipidemia, hypertension, and diabetes. There is no need to increase fluid intake and activity should be slowly and deliberately increased.

A nurse who has an advanced degree in primary care for a pediatric population is employed in a health clinic. In what role is this nurse functioning? A) Nurse practitioner B) Case coordinator C) Clinical nurse specialist D) Clinic supervisor

Nurse Practitioner Nurse practitioners, educated in primary care, often practice in ambulatory care settings that focus on gerontology, pediatrics, family or adult health, or womens health. Case coordinators and clinical supervisors do not necessarily require an advanced degree, and a clinical nurse specialist is not educated in primary care. Primary care is the specific focus of CNPs.

The nurse is caring for a patient who is withdrawing from heavy alcohol use and who is consequently combative and confused, despite the administration of benzodiazepines. The patient has a fractured hip that he suffered in a traumatic accident and is trying to get out of bed. What is the most appropriate action for the nurse to take? A) Leave the patient and get help. B) Obtain a physicians order to restrain the patient. C) Read the facilitys policy on restraints. D) Order soft restraints from the storeroom.

Obtain a physician's order to restrain the patient It is mandatory in most settings to have a physicians order before restraining a patient. Before restraints are used, other strategies, such as asking family members to sit with the patient, or utilizing a specially trained sitter, should be tried. A patient should never be left alone while the nurse summons assistance.

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 tooth decay? A) Organic fruit juice B) Roasted nuts C) Red meat that is high in fat D) Cheddar cheese

Organic fruit juice Dental caries may be prevented by decreasing the amount of sugar and starch in the diet. Patients who snack should be encouraged to choose less cariogenic alternatives, such as fruits, vegetables, nuts, cheeses, or plain yogurt. Fruit juice is high in sugar, regardless of whether it is organic.

A nurse is caring for a patient in the late stages of esophageal cancer. The nurse should plan to prevent or address what characteristics of this stage of the disease? SATA A) Perforation into the mediastinum B) Development of an esophageal lesion C) Erosion into the great vessels D) Painful swallowing E) Obstruction of the esophagus

Perforation into the mediastinum, erosion into the great vessels, obstruction of the esophagus In the later stages of esophageal cancer, obstruction of the esophagus is noted, with possible perforation into the mediastinum and erosion into the great vessels. Painful swallowing and the emergence of a lesion are early signs of esophageal cancer.

The OR nurse acts in the circulating role during a patients scheduled cesarean section. For what task is this nurse solely responsible? A) Performing documentation B) Estimating the patients blood loss C) Setting up the sterile tables D) Keeping track of drains and sponges

Performing documentation Main responsibilities of the circulating nurse include verifying consent; coordinating the team; and ensuring cleanliness, proper temperature and humidity, lighting, safe function of equipment, and the availability of supplies and materials. The circulating nurse monitors aseptic practices to avoid breaks in technique while coordinating the movement of related personnel as well as implementing fire safety precautions. The circulating nurse also monitors the patient and documents specific activities throughout the operation to ensure the patients safety and well-being. Estimating the patients blood loss is the surgeons responsibility; setting up the sterile tables is the responsibility of the first scrub; and keeping track of the drains and sponges is the joint responsibility of the circulating nurse and the scrub nurse.

The nurse is caring for a patient who is postoperative day 2 following colon resection. While turning him, wound dehiscence with evisceration occurs. What should be the nurses first response?

Place saline-soaked sterile dressing on the wound

The nurse is assessing an adult patient following a motor vehicle accident. The nurse observes that the patient has an increased use of accessory muscles and is complaining of chest pain and shortness of breath. The nurse should recognize the possibility of what condition? A) Pneumothorax B) Anxiety C) Acute bronchitis D) Aspiration

Pneumothorax If the pneumothorax is large and the lung collapses totally, acute respiratory distress occurs. The patient is anxious, has dyspnea and air hunger, has increased use of the accessory muscles, and may develop central cyanosis from severe hypoxemia. These symptoms are not definitive of pneumothorax, but because of the patients recent trauma they are inconsistent with anxiety, bronchitis, or aspiration.

A nurse is participating in a vaccination clinic at the local public health clinic. The nurse is describing the public health benefits of vaccinations to participants. Vaccine programs addressing which of the following diseases have been deemed successful? SATA A) Polio B) Diphtheria C) Hepatitis D) Tuberculosis E) Pertussis

Polio, Diphtheria, Pertussis The most successful vaccine programs have been ones for the prevention of smallpox, measles, mumps, rubella, polio, diphtheria, pertussis, and tetanus. There is no vaccine for tuberculosis. Hepatitis is not counted as one of the most successful vaccination programs, because vaccination rates for hepatitis leave room for improvement.

A nurse educator is reviewing the indications for chest drainage systems with a group of medical nurses. What indications should the nurses identify? Select all that apply. A) Post thoracotomy B) Spontaneous pneumothorax C) Need for postural drainage D) Chest trauma resulting in pneumothorax E) Pleurisy

Post thoracotomy, Spontaneous pneumothorax, and chest trauma resulting in pneumothorax Chest drainage systems are used in treatment of spontaneous pneumothorax and trauma resulting in pneumothorax. Postural drainage and pleurisy are not criteria for use of a chest drainage system.

A nurse is preparing to d/c a patient home on PN. What should an effective home care teaching program address? SATA A) Preparing the patient to troubleshoot for problems B) Teaching the patient and family strict aseptic technique C) Teaching the patient and family how to set up the infusion D) Teaching the patient to flush the line with sterile water E) Teaching the patient when it is safe to leave the access site open to air

Preparing the patient for troubleshoot problems, teaching the patient and family strict aseptic technique, teaching the patient and family how to set up an infusion An effective home care teaching program prepares the patient to store solutions, set up the infusion, flush the line with heparin, change the dressings, and troubleshoot for problems. The most common complication is sepsis. Strict aseptic technique is taught for hand hygiene, handling equipment, changing the dressing, and preparing the solution. Sterile water is never used for flushes and the access site must never be left open to air.

CNPs are educated as specialists in areas such as family care, pediatrics, or geriatrics. In most states, what right do CNPs have that RNs do not possess? Perform health interventions independently Make referrals to members of other health disciplines Prescribe medications Perform surgery independently

Prescribe medications

A patient who has suffered a stroke had an NG tube inserted to facilitate feeding shortly after admission. The patient has since become comatose and the patient's family asks why the physician is recommending the removal of the NGT and insertion of a GT. What is the nurse's best response? A) It eliminates the risk for infection. B) Feeds can be infused at a faster rate. C) Regurgitation and aspiration are less likely. D) It allows caregivers to provide personal hygiene more easily.

Regurgitation and aspiration are less likely Gastrostomy is preferred over NG feedings in the patient who is comatose because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely than with NG feedings. Both tubes carry a risk for infection; this change in care is not motivated by the possibility of faster infusion or easier personal care.

A recent nursing graduate has been surprised at the sharp contrast between some patients lifestyles in their homes and the nurses own practices and beliefs. To work therapeutically with the patient, what must the nurse do? Request another assignment if there is dissonance with the patients lifestyle Ask the patient to come to the agency to receive treatment, if possible Resolve to convey respect for the patients beliefs and choices Try to adapt the patient home to the norms of a hospital environment

Resolve to convey respect for the patients beliefs and choices

A patient who is being treated for pneumonia starts complaining of sudden shortness of breath. An ABG is drawn. The ABG has the following values: pH 7.21, PaCO2 64, HCO3 24. What does this ABG reflect? A) Respiratory acidosis B) Metabolic alkalosis C) Respiratory alkalosis D) Metabolic acidosis

Respiratory acidosis The pH is below 7.40, PaCO2 is greater than 40, and the HCO3 is normal; therefore, it is a respiratory acidosis, and compensation by the kidneys has not begun, which indicates this was probably an acute event. The HCO3 of 24 is within the normal range so it is not metabolic alkalosis. The pH of 7.21 indicates an acidosis, not alkalosis. The pH of 7.21 indicates it is an acidosis but the HCO3 of 24 is within the normal range, ruling out metabolic acidosis.

the nurse providing care for a patient post PTCA (percutaneous transluminal coronary angioplasty) knows to monitor the client closely. For what complications should the nurse monitor the client? SATA A) Abrupt closure of the coronary artery B) Venous insufficiency C) Bleeding at the insertion site. D) Retroperitoneal bleeding E) Arterial occlusion

Retroperitoneal bleeding, arterial occlusion, bleeding at the insertion site, abrupt closure of the coronary artery Nursing management includes accurate measurement of urine output. An output of less than 1 mL/kg/h may indicate hypovolemia or renal insufficiency. Prompt referral is necessary. IV fluid replacement may be indicated, but is beyond the independent scope of the dietitian or nurse.

You are auditing the electronic health record of a 33 year old patient who was treated for postpartum hemorrhage. When reviewing the patient's record, you can see various demonstrations of negative feedback loops. Which of the following constitute negative feedback loops? SATA A) Serum glucose levels B) Acid-base balance C) Temperature D) Blood clotting E) Labor onset

Serum glucose levels, acid-base balance, temperature These mechanisms work by sensing deviations from a predetermined set point or range of adaptability and triggering a response aimed at offsetting the deviation. Blood pressure, acidbase balance, blood glucose level, body temperature, and fluid and electrolyte balance are examples of functions regulated through such compensatory mechanisms. Coagulation and labor onset are results of positive feedback loops.

The nurse is admitting a 51 year old patient to the medical surgical unit after a diagnosis of cellulitis of the calf. What factors does the nurse know impact the process of inflammation, repair, and replacement? SATA A) Severity of the injury B) Social relationships C) Condition of the host D) Familial support E) Nature of the injury

Severity of the injury, condition of the host, nature of the injury The condition of the host, the environment, and the nature and severity of the injury affect the processesof inflammation, repair, and replacement. The patients social relationships and familial support do not directly affect the processes of inflammation, repair, and replacement.

A nursing student has taught a colleague that nursing practice is not limited to hospital settings, explaining that nurses are now working in ambulatory health clinics, hospice settings, and homeless shelters and clinics. What factor has most influenced increased diversity in practice settings for nurses? A) Population shift to more rural areas B) Shift of health care delivery into the community C) Advent of primary care clinics D) Increased use of rehabilitation hospitals

Shift of health care delivery into the community As health care delivery shifts into the community, more nurses are working in a variety of communitybased settings. These settings include public health departments, ambulatory health clinics, long-term care facilities, hospice settings, industrial settings (as occupational nurses), homeless shelters and clinics, nursing centers, home health agencies, urgent care centers, same-day surgical centers, short-stay facilities, and patients homes. The other answers are incorrect because our population has not shifted to a more rural base, and the use of primary care clinics has not influenced an increase in practice settings or the use of rehabilitation hospitals.

A patient has had a nasogastric tube in place for 6 days due to the development of paralytic ileus after surgery. In light of the prolonged pressure of the nasogastric tube, the nurse should prioritize assessments related to which complication? A) Sinus infections B) Esophageal strictures C) Pharyngitis D) Laryngitis

Sinus infection Patients with nasotracheal and nasogastric tubes in place are at risk for development of sinus infections. Thus, accurate assessment of patients with these tubes is critical. Use of a nasogastric tube is not associated with the development of the other listed pathologies.

The nurse educator is reviewing the blood supply of the GI tract with a group of medical nurses. The nurse is explaining the fact that veins return blood from the digestive organs and the spleen form the portal venous system. What large veins will the nurse list when describing this system? SATA A) Splenic vein B) Inferior mesenteric vein C) Gastric vein D) Inferior vena cava E) Saphenous vein

Splenic vein, inferior mesenteric vein, gastric vein This portal venous system is composed of five large veins: the superior mesenteric, inferior mesenteric, gastric, splenic, and cystic veins, which eventually form the vena portae that enters the liver. The inferior vena cava is not part of the portal system. The saphenous vein is located in the leg.

A nurse is caring for an 83 year old patient who is being assessed for recurrent and intractable nausea. What age related change to the GI system may be a contributor to the patients health complaint? A) Stomach emptying takes place more slowly. B) The villi and epithelium of the small intestine become thinner. C) The esophageal sphincter becomes incompetent. D) Saliva production decreases.

Stomach emptying taking place more slowly Delayed gastric emptying occurs in older adults and may contribute to nausea. Changes to the small intestine and decreased saliva production would be less likely to contribute to nausea. Loss of esophageal sphincter function is pathologic and is not considered an age-related change.

An inpatient has returned to the medical unit after a barium enema. When assessing the patient's subsequent bowel patterns and stools, what finding should the nurse report to the physician? A) Large, wide stools B) Milky white stools C) Three stools during an 8-hour period of time D) Streaks of blood present in the stool

Streaks of blood present in the stool Barium has a high osmolarity and may draw fluid into the bowel, thus increasing the intraluminal contents and resulting in greater output (large stools). The barium will give the stools a milky white appearance, and it is not uncommon for the patient to experience an increase in the number of bowel movements. Blood in fecal matter is not an expected finding and the nurse should notify the physician.

The nurse is analyzing a rhythm strip. What component of the ECG corresponds to the resting state of the patient's heart? A) P wave B) T wave C) U wave D) QRS complex

T wave The T wave specifically represents ventricular muscle depolarization, also referred to as the resting state. Ventricular muscle depolarization does not result in the P wave, U wave, or QRS complex.

An obese client describes symptoms of palpitations, chronic fatigue, and dyspnea on exertion to the cardiologist. Upon completing the examination, the cardiologist schedules a procedure to confirm the suspected diagnosis. What diagnostic procedure should the nurse expect to be ordered?

TEE

The nurse is teaching a patient about some of the health consequences of uncontrolled HTN. What health problems should the nurse describe? SATA A) Transient ischemic attacks B) Cerebrovascular accident C) Retinal hemorrhage D) Venous insufficiency E) Right ventricular hypertrophy

TIAs, CVA, retinal hemorrhage Potential complications of hypertension include the following: left ventricular hypertrophy; MI; heart failure; transient ischemic attacks (TIAs); cerebrovascular accident; renal insufficiency and failure; and retinal hemorrhage. Venous insufficiency and right ventricular hypertrophy are not potential complications of uncontrolled hypertension.

A nurse is participating in a patient's care conference and the team is deciding between PN and TNA. What advantages are associated with providing TNA rather than PN? A) TNA can be mixed by a certified registered nurse. B) TNA can be administered over 8 hours, while PN requires 24-hour administration. C) TNA is less costly than PN. D) TNA does not require the use of a micron filter.

TNA is less costly than PN TNA is mixed in one container and administered to the patient over a 24-hour period. A 1.5-micron filter is used with the TNA solution. Advantages of the TNA over PN include cost savings. Pharmacy staff must prepare both solutions.

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

Nursing is, by necessity, a flexible profession. It has adapted to meet both the expectations and the changing health needs of our aging population. What is one factor that has impacted the need for CNPs? The increased need for primary care providers The need to improve patient diagnostic services The push to drive institutional excellence The need to decrease the number of medical errors

The increased need for primary care providers

A patient's sigmoidoscopy has been successfully completed and the patient is preparing to return home. Which of the following teaching points should the nurse include in the patients discharge education? A) The patient should drink at least 2 liters of fluid in the next 12 hours. B) The patient can resume a normal routine immediately. C) The patient should expect fecal urgency for several hours. D) The patient can expect some scant rectal bleeding.

The patient can resume a normal routine immediately Following sigmoidoscopy, patients can resume their regular activities and diet. There is no need to push fluids and neither fecal urgency nor rectal bleeding is expected.

An older adult patient has been diagnosed with COPD. What characteristic of the patients current health status would precede the safe and effective use of a metered-dose inhaler (MDI)?

The patient has severe arthritis in her hand

You are taking a health history on an adult patient who is new to the clinic. While performing your assessment, the patient informs you that her mother has type 1 diabetes. What is the primary significance of this information to the health history? A) The patient may be at risk for developing diabetes. B) The patient may need teaching on the effects of diabetes. C) The patient may need to attend a support group for individuals with diabetes. D) The patient may benefit from a dietary regimen that tracks glucose intake.

The patient may be at risk for developing diabetes Nurses incorporate a genetics focus into the health assessments of family history to assess for geneticsrelated risk factors. The information aids the nurse in determining if the patient may be predisposed todiseases that are genetic in origin. The results of diabetes testing would determine whether dietary changes, support groups or health education would be needed.

A patient with GERD has a diagnosis of Barrett's esophagus with minor cell changes. Which of the following principles should be integrated into the patient's subsequent care? A) The patient will require an upper endoscopy every 6 months to detect malignant changes. B) Liver enzymes must be checked regularly, as H2 receptor antagonists may cause hepatic damage. C) Small amounts of blood are likely to be present in the stools and are not cause for concern. D) Antacids may be discontinued when symptoms of heartburn subside.

The patient will require an upper endoscopy every 6 months to detect malignant changes In the patient with Barretts esophagus, the cells lining the lower esophagus have undergone change and are no longer squamous cells. The altered cells are considered precancerous and are a precursor to esophageal cancer. In order to facilitate early detection of malignant cells, an upper endoscopy is recommended every 6 months. H2 receptor antagonists are commonly prescribed for patients with GERD; however, monitoring of liver enzymes is not routine. Stools that contain evidence of frank bleeding or that are tarry are not expected and should be reported immediately. When antacids are prescribed for patients with GERD, they should be taken as ordered whether or not the patient is symptomatic.

The nurse is caring for a patient who has been in a motor vehicle accident and the care team suspects that the patient has developed pleurisy. Which of the nurse's assessment findings would best corroborate this diagnosis? A) The patient is experiencing painless hemoptysis. B) The patients arterial blood gases (ABGs) are normal, but he demonstrates increased work of breathing. C) The patients oxygen saturation level is below 88%, but he denies shortness of breath. D) The patients pain intensifies when he coughs or takes a deep breath.

The patients pain intensifies when he coughs or takes a deep breath The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. The patients ABGs would most likely be abnormal and shortness of breath would be expected.

A patient with a complex cardiac history is scheduled for a TEE. What should the nurse teach the patient in anticipation of this diagnostic procedure? The test is noninvasive, and nothing will be inserted into the patients body. B) The patients pain will be managed aggressively during the procedure. C) The test will provide a detailed profile of the hearts electrical activity. D) The patient will remain on bed rest for 1 to 2 hours after the test.

The test is non-invasive and nothing will be inserted into the patient's body Before transthoracic echocardiography, the nurse informs the patient about the test, explaining that it is painless. The test does not evaluate electrophysiology and bed rest is unnecessary after the procedure.

A group of nurses are participating in orientation to a telemetry unit. What should the staff educator tell this class about ST segments? A) They are the part of an ECG that reflects systole. B) They are the part of an ECG used to calculate ventricular rate and rhythm. C) They are the part of an ECG that reflects the time from ventricular depolarization through repolarization. D) They are the part of an ECG that represents early ventricular repolarization.

They are the part of an ECG that represents early ventricular repolarization ST segment is the part of an ECG that reflects the end of the QRS complex to the beginning of the T wave. The part of an ECG that reflects repolarization of the ventricles is the T wave. The part of an ECG used to calculate ventricular rate and rhythm is the RR interval. The part of an ECG that reflects the time from ventricular depolarization through repolarization is the QT interval.

A patient with the diagnosis of PUD has just been prescribed omeprazole (Prilosec). How should the nurse best describe this medications therapeutic action?

This medication will reduce the amount of acid secreted in your stomach

In your role as the nurse at a genetics clinic, you are reviewing the health & genetic history of a woman whose mother died of breast cancer. Which of the following is the most important factor documented in the patient's history? A) Three generations of information about the family B) Current medications taken C) Health problems present in the womans children D) Immunizations received for the past three generations

Three generations of information about the family A well-documented family history is a tool used by the health care team to make a diagnosis, identify teaching strategies, and establish a pattern of inheritance. The family history should include at least three generations, as well as information about the current and past health status of all family members, including the age of onset of any illnesses and cause of death and age at death. Information on current medications and immunizations are important factors to be gathered in the health history, but are not part of the genetic history. It is not sufficient to just identify illnesses in the patients children.

The occupational health nurse is assessing new employees at a company. What would be important to assess in employees with a potential occupational respiratory exposure to a toxin? SATA A) Time frame of exposure B) Type of respiratory protection used C) Immunization status D) Breath sounds E) Intensity of exposure

Time frame of exposure, type of respiratory protection used, breath sounds, intensity of exposure Key aspects of any assessment of patients with a potential occupational respiratory history include job and job activities, exposure levels, general hygiene, time frame of exposure, effectiveness of respiratory protection used, and direct versus indirect exposures. The patients current respiratory status would also be a priority. Occupational lung hazards are not normally influenced by immunizations.

A diabetic patient calls the clinic complaining of having a flu bug. The nurse tells him to take his regular dose of insulin. What else should the nurse tell the patient? A) Make sure to stick to your normal diet. B) Try to eat small amounts of carbs, if possible. C) Ensure that you check your blood glucose every hour. D) For now, check your urine for ketones every 8 hours.

Try to eat small amounts of carbs, if possible For prevention of DKA related to illness, the patient should attempt to consume frequent small portions of carbohydrates (including foods usually avoided, such as juices, regular sodas, and gelatin). Drinking fluids every hour is important to prevent dehydration. Blood glucose and urine ketones must be assessed every 3 to 4 hours.

the nurse is assessing a client with ACS. The nurse includes a careful history in the assessment, especially in regards to signs and symptoms. What signs and symptoms are most suggestive of ACS? SATA A) Dyspnea B) Unusual fatigue C) Hypotension D) Syncope E) Peripheral cyanosis

Unusual fatigue, dyspnea, syncope Systematic assessment includes a careful history, particularly as it relates to symptoms: chest pain or discomfort, difficulty breathing (dyspnea), palpitations, unusual fatigue, faintness (syncope), or sweating (diaphoresis). Each symptom must be evaluated with regard to time, duration, and the factors that precipitate the symptom and relieve it, and in comparison with previous symptoms. Hypotension and peripheral cyanosis are not typically associated with ACS.

The nurse educator is discussing emerging diseases with a group of nurses. The educator should cite what causes of emerging diseases? SATA A) Progressive weakening of human immune systems B) Use of extended-spectrum antibiotics C) Population movements D) Increased global travel E) Globalization of food supplies

Use of extended-spectrum antibiotics, population movements, increased global travel, globalization of food supplies Many factors contribute to newly emerging or re-emerging infectious diseases. These include travel, globalization of food supply and central processing of food, population growth, increased urban crowding, population movements (e.g., those that result from war, famine, or man-made or natural disasters), ecologic changes, human behavior (e.g., risky sexual behavior, IV/injection drug use), antimicrobial resistance, and breakdown in public health measures. Not noted is an overall decline in human immunity.

The nurse is performing nasotracheal suctioning on a medical patient and obtains copious amounts of secretions from the patient's airway, even after inserting and withdrawing the catheter several times. How should the nurse proceed? A) Continue suctioning the patient until no more secretions are obtained. B) Perform chest physiotherapy rather than nasotracheal suctioning. C) Wait several minutes and then repeat suctioning. D) Perform postural drainage and then repeat suctioning.

Wait several minutes and then repeat suctioning If additional suctioning is needed, the nurse should withdraw the catheter to the back of the pharynx, reassure the patient, and oxygenate for several minutes before resuming suctioning. Chest physiotherapy and postural drainage are not necessarily indicated.

The prevention of VTE is an important part of the nursing care of high risk patients. When providing patient teaching for these high risk patients, the nurse should advise lifestyle changes, including which of the following? SATA A) High-protein diet B) Weight loss C) Regular exercise D) Smoking cessation E) Calcium and vitamin D supplementation

Weight loss, regular exercise, smoking cessation Patients at risk for VTE should be advised to make lifestyle changes, as appropriate, which may include weight loss, smoking cessation, and regular exercise. Increased protein intake and supplementation with vitamin D and calcium do not address the main risk factors for VTE.