323 Exam 1-practice questions

A patient is scheduled to receive "Colace 100 mg PO." The patient asks to take the medication in liquid form, and the nurse obtains an order for the change. The available syrup contains 150 mg/15 mL. Calculate how many milliliters the nurse should administer.

10 The concentration of the syrup is 10 mg/mL (150 mg÷15 mL=10 mg/mL). Therefore, a 100-mg dose necessitates 10 mL (100 mg÷10 mg/mL=10 mL).

The patient has an order for albuterol 5 mg via nebulizer. Available is a solution containing 2 mg/mL. Calculate how many milliliters the nurse should use to prepare the patient's dose._____ mL

2.5 5 mg ÷ 2 mg/mL = 2.5 mL

The nurse is teaching resident at the retirement village about prevention of UTIs. One person asks how much fluid she should drink each day. The nurse determines that she weighs 140 lb. Calculate how many ounces of fluid this person should drink each day.________________ oz

56 Divide the weight in pounds by 2; then multiply this number by 80% because 20% of a person's fluid is obtained from food. So 140/2 = 70, 70 × 0.80 = 56 oz to be drunk each day, or seven 8-oz gl

The nurse cares for a 34-yr-old woman after bariatric surgery. The nurse determines that discharge teaching related to diet is successful if the patient makes which statement? a) "A high-protein diet that is low in carbohydrates and fat will prevent diarrhea." b) "Food should be high in fiber to prevent constipation from the pain medication." c) "Three meals a day with no snacks between meals will provide optimal nutrition." d) "Fluid intake should be at least 2000 mL per day with meals to avoid dehydration."

a) "A high-protein diet that is low in carbohydrates and fat will prevent diarrhea.": The diet generally prescribed is high in protein and low in carbohydrates, fat, and roughage and consists of six small feedings daily. Fluids should not be ingested with the meal, and in some cases, fluids should be restricted to less than 1000 mL per day. Fluids and foods high in carbohydrate tend to promote diarrhea and symptoms of the dumping syndrome. Generally, calorically dense foods (foods high in fat) should be avoided to permit more nutritionally sound food to be consumed.

When evaluating the patient's understanding about the care of the ileostomy, which statement by the patient indicates the patient needs more teaching? a) "I will be able to regulate when I have stools." b) "I will be able to wear the pouch until it leaks." c) "The drainage from my stoma can damage my skin." d) "Dried fruit and popcorn must be chewed very well."

a) "I will be able to regulate when I have stools." An ileostomy is in the ileum and drains liquid stool frequently, unlike a colostomy, which has more formed stool the farther distal the ostomy is in the colon. The ileostomy pouch is usually worn for 4 to 7 days or until it leaks. It must be changed immediately if it leaks because the drainage is very irritating to the skin. To avoid obstruction, popcorn, dried fruit, coconut, mushrooms, olives, stringy vegetables, food with skin, and meats with casings must be chewed extremely well before swallowing because of the narrow diameter of the ileostomy lumen.

The nurse is caring for a patient who is 5'6" tall and weighs 186 lb. The nurse has discussed reasonable weight loss goals and a low-calorie diet with the patient. Which statement made by the patient indicates a need for further teaching? a) "I will limit intake to 500 calories a day." b) "I will try to eat very slowly during mealtimes." c) "I'll try to pick foods from all of the basic food groups." d) "It's important for me to begin a regular exercise program."

a) "I will limit intake to 500 calories a day." : Limiting intake to 500 calories per day is not indicated for this patient, and the severe calorie energy restriction would place this patient at risk for multiple nutrient deficiencies. Decreasing caloric intake at least 500 to 1000 calories a day is recommended for weight loss of 1 to 2 lb per week. The other options show understanding of the teaching.

A 21-yr-old female patient came to the clinic for instruction to prevent recurrence of urinary tract infections. Which patient statement indicates that teaching was effective? a) "I will urinate before and after having intercourse." b) "I will use vinegar as a vaginal douche every week." c) "I should drink three 8-oz glasses of water daily." d) "I can stop the antibiotics when symptoms disappear."

a) "I will urinate before and after having intercourse." The woman should empty her bladder before and after sexual intercourse. She should avoid vaginal douches and maintain adequate oral fluid intake (15 mL per pound of body weight). All of the antibiotics should be taken as prescribed even if symptoms are no longer present.

The nurse is preparing to administer famotidine to a postoperative patient with a colostomy. The patient states they do not have heartburn. What response by the nurse would be the most appropriate? a) "It will reduce the amount of acid in the stomach." b) "It will prevent air from accumulating in the stomach, causing gas pains." c) "It will prevent the heartburn that occurs as a side effect of general anesthesia." d) "The stress of surgery is likely to cause stomach bleeding if you do not receive it."

a) "It will reduce the amount of acid in the stomach." Famotidine is an H2-receptor antagonist that inhibits gastric HCl secretion and thus minimizes damage to gastric mucosa while the patient is not eating a regular diet after surgery. Famotidine does not prevent air from accumulating in the stomach or stop the stomach from bleeding. Heartburn is not a side effect of general anesthesia.

The results of a patient's recent endoscopy indicate the presence of peptic ulcer disease (PUD). Which teaching point should the nurse provide to the patient based on this new diagnosis? a) "It would be beneficial for you to eliminate drinking alcohol." b) "You'll need to drink at least two to three glasses of milk daily." c) "Many people find that a minced or pureed diet eases their symptoms of PUD." d) "Taking medication will allow you to keep your present diet while minimizing symptoms."

a) "It would be beneficial for you to eliminate drinking alcohol." Alcohol increases the amount of stomach acid produced. so it should be avoided. Although there is no specific recommended dietary modification for PUD, most patients find it necessary to make some sort of dietary modifications to minimize symptoms. Milk may exacerbate PUD.

The nurse teaches senior citizens at a community center how to prevent food poisoning at social events. Which community member statement reflects accurate understanding? a) "Pasteurized juices and milk are safe to drink." b) "Alfalfa sprouts are safe if rinsed before eating." c) "Fresh fruits do not need to be washed before eating." d) "Ground beef is safe to eat if cooked until it is brown."

a) "Pasteurized juices and milk are safe to drink." Drink only pasteurized milk, juice, or cider. Ground beef should be cooked thoroughly. Browned meat can still harbor live bacteria. Cook ground beef until a thermometer reads at least 160° F. If a thermometer is unavailable, decrease the risk of illness by cooking the ground beef until there is no pink color in the middle. Fruits and vegetables should be washed thoroughly, especially those that will not be cooked. Persons who are immunocompromised or older should avoid eating alfalfa sprouts until the safety of the sprouts can be ensured.

Although a diagnosis of cystic fibrosis (CF) is most often made before age 2 years, an 18-yr-old patient at the student health center with a history of frequent lung and sinus infections has clinical manifestations consistent with undiagnosed CF. Which information would be accurate for the nurse to include when teaching the patient about a scheduled sweat chloride test? a) "Sweat chloride greater than 60 mmol/L is consistent with a diagnosis of CF." b) "The test measures the amount of sodium chloride in your postexercise sweat." c) "If sweating occurs after an oral dose of pilocarpine, the test result for CP is positive." d) "If the sweat chloride test result is positive on two occasions, genetic testing will be necessary."

a) "Sweat chloride greater than 60 mmol/L is consistent with a diagnosis of CF." The diagnostic criteria for CF involve a combination of clinical presentation, sweat chloride testing, and genetic testing to confirm the diagnosis. The sweat chloride test is performed by placing pilocarpine on the skin and carried by a small electric current to stimulate sweat production. This takes about 5 minutes, and the patient feels a slight tingling or warmth. The sweat is collected on filter paper or gauze and then analyzed for sweat chloride concentrations (for about 1 hour). Values above 60 mmol/L for sweat chloride are consistent with the diagnosis of CF. However, a second sweat chloride test is recommended to confirm the diagnosis, unless genetic testing identifies a CF mutation. Genetic testing is used if the results from a sweat chloride test are unclear.

The nurse instructs an obese 22-yr-old man with a sedentary job about the health benefits of an exercise program. The nurse evaluates that teaching is effective when the patient makes which statement? a)"The goal is to walk at least 10,000 steps every day of the week." b)"Weekend aerobics for 2 hours is better than exercising every day." c)"Aerobic exercise will increase my appetite and result in weight gain." d)"Exercise causes weight loss by decreasing my resting metabolic rate."

a) "The goal is to walk at least 10,000 steps every day of the week.": A realistic activity goal is to walk 10,000 steps a day. Increased activity does not promote an increase in appetite or lead to weight gain. Exercise should be done daily, preferably 30 minutes to an hour a day. Exercise increases metabolic rate.

The nurse is preparing to insert a nasogastric (NG) tube into a patient with a suspected small intestinal obstruction that is vomiting. The patient asks the nurse why this procedure is necessary. What response by the nurse is most appropriate? a) "The tube will help to drain the stomach contents and prevent further vomiting." b) "The tube will push past the area that is blocked and thus help to stop the vomiting." c) "The tube is just a standard procedure before many types of surgery to the abdomen." d) "The tube will let us measure your stomach contents so we can give you the right IV fluid replacement."

a) "The tube will help to drain the stomach contents and prevent further vomiting." The NG tube is used to decompress the stomach by draining stomach contents and thereby prevent further vomiting. The NG tube will not push past the blocked area. Potential surgery is not currently indicated. The location of the obstruction will determine the type of fluid to use, not measure the amount of stomach contents.

Which nursing diagnosis is priority when caring for a patient with renal calculi? a) Acute pain b) Risk for constipation c) Deficient fluid volume d) Risk for powerlessness

a) Acute pain Urinary stones are associated with severe abdominal or flank pain. Whereas deficient fluid volume is unlikely to result from urinary stones, constipation is more likely to be an indirect consequence rather than a primary clinical manifestation of the problem. The presence of pain supersedes powerlessness as an immediate focus of nursing care.

The stable patient has a gastrostomy tube for enteral feeding. Which care could the RN delegate to the LPN (select all that apply.)? a) Administer bolus or continuous feedings. b) Evaluate the nutritional status of the patient. c) Administer medications through the gastrostomy tube. d) Monitor for complications related to the tube and enteral feeding. e) Teach the caregiver about feeding via the gastrostomy tube at home.

a) Administer bolus or continuous feedings. c) Administer medications through the gastrostomy tube. For the stable patient, the LPN can administer bolus or continuous feedings and administer medications through the gastrostomy. The RN must evaluate the nutritional status of the patient, monitor for complications related to the tube and the enteral feeding, and teach the caregiver about feeding via the gastrostomy tube at home.

The patient has an order for each of the following inhalers. Which one should the nurse offer to the patient at the onset of an asthma attack? a) Albuterol b) Ipratropium bromide c) Salmeterol (Serevent) d) Beclomethasone (Qvar)

a) Albuterol Albuterol is a short-acting bronchodilator that should be given initially when the patient experiences an asthma attack. Salmeterol (Serevent) is a long-acting β2-adrenergic agonist, which is not used for acute asthma attacks. Beclomethasone (Qvar) is a corticosteroid inhaler and not recommended for an acute asthma attack. Ipratropium bromide is an anticholinergic agent that is less effective than β2-adrenergic agonists. It may be used in an emergency with a patient unable to tolerate short-acting β2-adrenergic agonists (SABAs).

A 45-yr-old man with asthma is brought to the emergency department by automobile. He is short of breath and appears frightened. During the initial nursing assessment, which clinical manifestation might be present as an early manifestation during an exacerbation of asthma? a) Anxiety b) Cyanosis c) Bradycardia d) Hypercapnia

a) Anxiety An early manifestation during an asthma attack is anxiety because the patient is acutely aware of the inability to get sufficient air to breathe. He will be hypoxic early on with decreased PaCO2 and increased pH as he is hyperventilating. If cyanosis occurs, it is a later sign. The pulse and blood pressure will be increased.

A male patient with chronic obstructive pulmonary disease (COPD) becomes dyspneic at rest. His baseline blood gas results are PaO2 70 mm Hg, PaCO2 52 mm Hg, and pH 7.34. What updated patient assessment requires the nurse's priority intervention? a) Arterial pH 7.26 b) PaCO2 50 mm Hg c) Patient in tripod position d) Increased sputum expectoration

a) Arterial pH 7.26 The patient's pH shows acidosis that supports an exacerbation of COPD along with the worsening dyspnea. The PaCO2 has improved from baseline, the tripod position helps the patient's breathing, and the increase in sputum expectoration will improve the patient's ventilation.

The patient with Parkinson's disease has a pulse oximetry reading of 72%, but he is not displaying any other signs of decreased oxygenation. What is most likely contributing to his low SpO2 level? a) Artifact b) Anemia c) Dark skin color d) Thick acrylic nails

a) Artifact Motion is the most likely cause of the low SpO2 for this patient with Parkinson's disease. Anemia, dark skin color, and thick acrylic nails as well as low perfusion, bright fluorescent lights, and intravascular dyes may also cause an inaccurate pulse oximetry result. There is no mention of these or reason to suspect these in this question.

The nurse is obtaining a focused respiratory assessment of a 44-yr-old female patient who is in severe respiratory distress 2 days after abdominal surgery. What is most important for the nurse to assess? a) Auscultation of bilateral breath sounds b) Percussion of anterior and posterior chest wall c) Palpation of the chest bilaterally for tactile fremitus d) Inspection for anterior and posterior chest expansion

a) Auscultation of bilateral breath sounds Important assessments obtained during a focused respiratory assessment include auscultation of lung (breath) sounds. Assessment of tactile fremitus has limited value in acute respiratory distress. It is not necessary to assess for both anterior and posterior chest expansion. Percussion of the chest wall is not essential in a focused respiratory assessment.

A frail 82-yr-old female patient develops sudden shortness of breath while sitting in a chair. What location on the chest should the nurse begin auscultation of the lung fields? a) Bases of the posterior chest area b) Apices of the posterior lung fields c) Anterior chest area above the breasts d) Midaxillary on the left side of the chest

a) Bases of the posterior chest area Baseline data with the most information is best obtained by auscultation of the posterior chest, especially in female patients because of breast tissue interfering with the assessment or if the patient may tire easily (e.g., shortness of breath, dyspnea, weakness, fatigue). Usually auscultation proceeds from the lung apices to the bases unless it is possible the patient will tire easily. In this case, the nurse should start at the bases.

A community health nurse is conducting an initial assessment of a new patient. Which assessments should the nurse include when screening the patient for metabolic syndrome (select all that apply.)? a) Blood pressure b) Resting heart rate c) Physical endurance d) Waist circumference e) Fasting blood glucose

a) Blood pressure d) Waist circumference e) Fasting blood glucose The diagnostic criteria for metabolic syndrome include elevated blood pressure, fasting blood glucose, waist circumference, triglycerides, and high-density lipoprotein cholesterol. Resting heart rate and physical endurance are not part of the diagnostic criteria.

A patient with type 2 diabetes is reporting a second urinary tract infections(UTI)within the past month. Which medication should the nurse expect to be ordered for the recurrent infection? a) Ciprofloxacin b) Fosfomycin c) Nitrofurantoin d) Trimethoprim-sulfamethoxazole

a) Ciprofloxacin This UTI is a complicated UTI because the patient has type 2 diabetes, and the UTI is recurrent. Ciprofloxacin would be used for a complicated UTI. Fosfomycin, nitrofurantoin , and trimethoprim-sulfamethoxazole should be used for uncomplicated UTIs.

When assessing a patient's sleep-rest pattern related to respiratory health, what should the nurse ask the patient (select all that apply.)? a) Do you awaken abruptly during the night? b) Do you sleep more than 8 hours per night? c) Do you need to sleep with the head elevated? d) Do you often need to urinate during the night? e) Do you toss and turn when trying to fall asleep?

a) Do you awaken abruptly during the night? c) Do you need to sleep with the head elevated? e) Do you toss and turn when trying to fall asleep? A patient with obstructive sleep apnea may have insomnia, abrupt awakenings, or both. Patients with cardiovascular disease (e.g., heart failure that may affect respiratory health) may need to sleep with the head elevated on several pillows (orthopnea). Sleeping more than 8 hours per night or needing to urinate during the night is not indicative of impaired respiratory health.

The nurse is talking with a patient who was just diagnosed with a urinary tract infection. The patient asks the nurse how to prevent such infections in the future. The nurse should make which appropriate recommendations for the patient? Select all that apply. a) Drink 6 to 8 glasses of non-caffeinated fluids daily. b) Exercise daily. c) Increase fiber in the diet. d) Void when the urge is felt. e) Eat fruit twice daily.

a) Drink 6 to 8 glasses of non-caffeinated fluids daily. d) Void when the urge is felt Drinking non-caffeinated drinks and voiding when the urge happens are the most appropriate measures for avoiding a urinary tract infection. Increasing fiber, exercising, and eating fruit do not prevent a urinary tract infection.

A malnourished patient has been diagnosed with protein deficiency. Which complications should the nurse anticipate (select all that apply.)? a) Edema b) Asthma c) Anemia d) Malabsorption syndrome e) Impaired wound healing f) Gastrointestinal bleeding

a) Edema c) Anemia e) Impaired wound healing: Protein deficiency can cause complications such as edema, anemia, and impaired wound healing. Decreased albumin in the vascular space allows fluids to leak into the interstitial spaces causing edema. Without adequate protein, blood formation is impaired. Adequate protein is required for wound healing. Asthma does not develop due to protein deficiency. However, protein deficiency causes muscle weakness that could contribute to exacerbation of many conditions. A malabsorption syndrome may affect the amount of nutrients that are absorbed causing protein deficiency. Gastrointestinal bleeding is not a complication of protein deficiency.

When admitting a patient with a diagnosis of asthma exacerbation, the nurse will assess for what potential triggers (select all that apply.)? a) Exercise b) Allergies c) Emotional stress d) Decreased humidity e) Upper respiratory infections

a) Exercise b) Allergies c) Emotional stress e) Upper respiratory infections Although the exact mechanism of asthma is unknown, there are several triggers that may precipitate an attack. These include allergens, exercise, air pollutants, upper respiratory infections, drug and food additives, psychological factors, and gastroesophageal reflux disease (GERD).

A patient after a stroke who primarily uses a wheelchair for mobility has developed diarrhea with fecal incontinence. What is a priority assessment by the nurse? a) Fecal impaction b) Perineal hygiene c) Dietary fiber intake d) Antidiarrheal agent use

a) Fecal impaction Patients with limited mobility are at risk for fecal impactions caused by constipation that may lead to liquid stool leaking around the hardened impacted feces, so assessing for fecal impaction is the priority. Perineal hygiene can be assessed at the same time. Assessing the dietary fiber and fluid intake and antidiarrheal agent use will be assessed and considered next.

What should the nurse inspect when assessing a patient with shortness of breath for evidence of long-standing hypoxemia? a) Fingernails b) Chest excursion c) Spinal curvatures d) Respiratory pattern

a) Fingernails Clubbing, a sign of long-standing hypoxemia, is evidenced by an increase in the angle between the base of the nail and fingernail to 180 degrees or more, usually accompanied by an increase in the depth, bulk, and sponginess of the end of the finger.

The patient has parenteral nutrition (PN) infusing with amino acids and dextrose. During shift change, the nurse reports the tubing, bag, and dressing were changed 20 hours ago. What care should the incoming nurse plan to deliver (select all that apply.)? a) Giving the patient insulin if needed b) Ensuring that the next bag has been ordered c) Checking amount of solution left in the bag d) Assessing the insertion site and change the tubing e) Verifying the accuracy of the new solution and ingredients

a) Giving the patient insulin if needed b) Ensuring that the next bag has been ordered c) Checking amount of solution left in the bag e) Verifying the accuracy of the new solution and ingredients

Two days after a colectomy for an abdominal mass, a patient reports gas pains and abdominal distention. The nurse plans care for the patient based on the knowledge that the symptoms are occurring as a result what event? a) Impaired peristalsis b) Irritation of the bowel c) Nasogastric suctioning d) Inflammation of the incision site

a) Impaired peristalsis Until peristalsis returns to normal after anesthesia, the patient may experience slowed gastrointestinal motility, leading to gas pains and abdominal distention. Irritation of the bowel, nasogastric suctioning, and inflammation of the surgical site do not cause gas pains or abdominal distention.

When teaching the patient with bronchiectasis about manifestations to report to the health care provider, which manifestation should be included? a) Increasing dyspnea b) Temperature below 98.6°F c) Decreased sputum production d) Unable to drink 3 L of low-sodium fluids

a) Increasing dyspnea The significant clinical manifestations to report to the health care provider include increasing dyspnea, fever, chills, increased sputum production, bloody sputum, and chest pain. Although drinking at least 3 L of low-sodium fluid will help liquefy secretions to make them easier to expectorate, the health care provider does not need to be notified if the patient cannot do this one day.

A hospitalized patient has just been diagnosed with diarrhea due to Clostridium difficile. Which nursing interventions should be included in the patient's plan of care (select all that apply.)? a) Initiate contact isolation precautions. b) Place the patient on a clear liquid diet. c) Disinfect the room with 10% bleach solution. d) Teach any visitors to wear gloves and gowns. e) Use hand sanitizer before and after patient or bodily fluid contact.

a) Initiate contact isolation precautions. c) Disinfect the room with 10% bleach solution. d) Teach any visitors to wear gloves and gowns. Initiation of contact isolation precautions must be done immediately with a patient with C. difficile, which includes washing hands with soap and water before and after patient or bodily fluid contact. Alcohol-based sanitizers are ineffective. Visitors need to be taught to wear gloves and gowns and wash hands. A clear liquid diet is not necessary. The room will be disinfected with 10% bleach solution when the patient is dismissed and may be done periodically during the patient's stay, depending on the agency policy.

While teaching a patient with asthma about the appropriate use of a peak flow meter, what should the nurse instruct the patient to do? a) Keep a record of the peak flow meter numbers if symptoms of asthma are getting worse. b) Use the flow meter each morning after taking medications to evaluate their effectiveness. c) Increase the doses of the long-term control medication if the peak flow numbers decrease. d) Empty the lungs and then inhale quickly through the mouthpiece to measure how fast air can be inhaled.

a) Keep a record of the peak flow meter numbers if symptoms of asthma are getting worse. It is important to keep track of peak flow readings daily, especially when the patient's symptoms are getting worse. The patient should have specific directions as to when to call the physician based on personal peak flow numbers. Peak flow is measured by exhaling into the flow meter and should be assessed before and after medications to evaluate their effectiveness.

What is the nurse's priority when changing the appliance for a patient with an ileal conduit? a) Keep the skin free of urine. b) Inspect the peristomal area. c) Cleanse and dry the area gently. d) Affix the appliance to the faceplate.

a) Keep the skin free of urine. The nurse's priority is to keep the skin free of urine because the peristomal skin is at high risk for damage from the urine if it is alkaline. The peristomal area will be assessed; the area will be gently cleaned and dried, and the appliance will be affixed to the faceplate if one is being used, but these are not as much of a priority as keeping the skin free of urine to prevent skin damage.

Eight months after the delivery of her first child, a 31-yr-old woman sought care for occasional incontinence when sneezing or laughing. Which measure should the nurse recommend first? a) Kegel exercises b) Use of adult incontinence pads c) Intermittent self-catheterization d) Dietary changes including fluid restriction

a) Kegel exercises Patients who experience stress incontinence frequently benefit from Kegel exercises (pelvic floor muscle exercises). The use of incontinence pads does not resolve the problem, and intermittent self-catheterization would be a premature recommendation. Dietary changes are not likely to influence the patient's urinary continence.

A patient has newly diagnosed hyperparathyroidism. What should the nurse expect to find during an assessment at the beginning of the nursing shift? a) Lethargy and constipation from hypercalcemia b) Positive Trousseau's sign from hypercalcemia c) Lethargy and constipation from hypocalcemia d) Positive Trousseau's sign from hypocalcemia

a) Lethargy and constipation from hypercalcemia Parathyroid hormone (PTH) shifts calcium from the bones into the extracellular fluid (ECF). Excessive PTH causes hypercalcemia, which is manifested by lethargy and constipation. A positive Trousseau's sign is characteristic of hypocalcemia rather than hypercalcemia. Answers that indicate hypocalcemia are not correct, because PTH moves calcium into the ECF.

The nurse is conducting discharge teaching for a patient with metastatic lung cancer who was admitted with a bowel impaction. Which instructions would be most helpful to prevent further episodes of constipation? a) Maintain a high intake of fluid and fiber in the diet. b) Discontinue intake of medications causing constipation. c) Eat several small meals per day to maintain bowel motility. d) Sit upright during meals to increase bowel motility by gravity.

a) Maintain a high intake of fluid and fiber in the diet. Increased fluid intake and a high-fiber diet reduce the incidence of constipation caused by immobility, medications, and other factors. Fluid and fiber provide bulk that in turn increases peristalsis and bowel motility. Analgesics taken for lung cancer probably cannot be discontinued. Eating several small meals per day and position do not facilitate bowel motility.

A patient with recurrent shortness of breath has just had a bronchoscopy. What is a priority nursing action immediately after the procedure? a) Monitor the patient for laryngeal edema. b) Assess the patient's level of consciousness. c) Monitor and manage the patient's level of pain. d) Assess the patient's heart rate and blood pressure.

a) Monitor the patient for laryngeal edema. Priorities for assessment are the patient's airway and breathing, both of which may be compromised after bronchoscopy by laryngeal edema. These assessment parameters supersede the importance of loss of consciousness (LOC), pain, heart rate, and blood pressure, although the nurse should also be assessing these.

A 50-yr-old African American woman has a body mass index (BMI) of 35 kg/m2, type 2 diabetes mellitus, hypercholesterolemia, and irritable bowel syndrome (IBS). She is seeking assistance in losing weight because, "I have trouble stopping eating when I should, but I do not want to have bariatric surgery." Which drug therapy should the nurse question if it is prescribed for this patient? a) Orlistat (Xenical) b) Lorcaserin (Belviq) c) Phentermine (Adipex-P) d) Phentermine and topiramate (Qsymia)

a) Orlistat (Xenical): Orlistat (Xenical), which blocks fat breakdown and absorption in the intestine, produces some unpleasant gastrointestinal side effects. This drug would not be appropriate for someone with IBS. Lorcaserin (Belviq) suppresses the appetite and creates a sense of satiety that may be helpful for this patient. Phentermine (Adipex-P) needs to be used for a limited period of time (3 months or less). Qsymia is a combination of two drugs, phentermine and topiramate. Phentermine is a sympathomimetic agent that suppresses appetite and topiramate induces a sense of satiety.

The urinalysis of a patient reveals a high microorganism count. What data should the nurse use to determine which part of the urinary tract is infected (select all that apply.)? a) Pain location b) Fever and chills c) Mental confusion d) Urinary hesitancy e) Urethral discharge f) Post-void dribbling

a) Pain location e) Urethral discharge Although all the manifestations are evident with urinary tract infections (UTIs), pain location is useful in differentiating among pyelonephritis, cystitis, and urethritis because flank pain is characteristic of pyelonephritis, but dysuria is characteristic of cystitis and urethritis. Urethral discharge is indicative of urethritis, not pyelonephritis or cystitis. Fever and chills and mental confusion are nonspecific indicators of UTIs. Urinary hesitancy and postvoid dribbling may occur with a UTI but may also occur with prostate enlargement in the male patient.

The nurse is caring for a patient who complains of abdominal pain and hematemesis. Which new assessment finding(s) would indicate the patient is experiencing a decline in condition? a) Pallor and diaphoresis b) Ecchymotic peripheral IV site c) Guaiac-positive diarrhea stools d) Heart rate 90, respiratory rate 20, BP 110/60

a) Pallor and diaphoresis: A patient with hematemesis has some degree of bleeding from an unknown source. Guaiac-positive diarrhea stools would be an expected finding. When monitoring the patient for stability, the nurse observes for signs of hypovolemic shock such as tachycardia, tachypnea, hypotension, altered level of consciousness, pallor, and cool and clammy skin. An ecchymotic peripheral IV site will require assessment to determine the need for reinsertion. Access would be critical in the immediate treatment of shock, but the ecchymotic site does not represent a decline in condition.

A patient with a history of peptic ulcer disease has presented to the emergency department with severe abdominal pain and a rigid, boardlike abdomen. The health care provider suspects a perforated ulcer. Which interventions should the nurse anticipate? a) Providing IV fluids and inserting a nasogastric (NG) tube b) Administering oral bicarbonate and testing the patient's gastric pH level c) Performing a fecal occult blood test and administering IV calcium gluconate d) Starting parenteral nutrition and placing the patient in a high-Fowler's position

a) Providing IV fluids and inserting a nasogastric (NG) tube A perforated peptic ulcer requires IV replacement of fluid losses and continued gastric aspiration by NG tube. Nothing is given by mouth, and gastric pH testing is not a priority. Calcium gluconate is not a medication directly relevant to the patient's suspected diagnosis, and parenteral nutrition is not a priority in the short term.

The patient's arterial blood gas results show the PaO2 at 65 mmHg and SaO2 at 80%. What early manifestations should the nurse expect to observe in this patient? a) Restlessness, tachypnea, tachycardia, and diaphoresis b) Unexplained confusion, dyspnea at rest, hypotension, and diaphoresis c) Combativeness, retractions with breathing, cyanosis, and decreased output d) Coma, accessory muscle use, cool and clammy skin, and unexplained fatigue

a) Restlessness, tachypnea, tachycardia, and diaphoresis With inadequate oxygenation, early manifestations include restlessness, tachypnea, tachycardia, and diaphoresis, decreased urinary output, and unexplained fatigue. The unexplained confusion, dyspnea at rest, hypotension, and diaphoresis; combativeness, retractions with breathing, cyanosis, and decreased urinary output; coma, accessory muscle use, cool and clammy skin, and unexplained fatigue occur as later manifestations of inadequate oxygenation.

The wound, ostomy, and continence nurse (WOCN) selects the site where the ostomy will be placed. What should be included in site consideration? a) The patient must be able to see the site. b) The site should be outside the rectus muscle area. c) It is easier to seal the drainage bag to a protruding area. d) A waistline site will allow using a belt to hold the appliance in place.

a) The patient must be able to see the site. In selection of the ostomy site, the WOC nurse will want a site visible to the patient so the patient can take care of it, within the rectus muscle to avoid hernias, and on a flat surface to more easily create a good seal with the drainage bag. Care should be taken to avoid skin creases, scars, and belt lines, which can interfere with the adherence of the appliance.

A patient complaining of nausea receives a dose of metoclopramide. Which potential adverse effect should the nurse tell the patient to report? a) Tremors b) Constipation c) Double vision d) Numbness in fingers and toes

a) Tremors Extrapyramidal side effects, including tremors and tardive dyskinesias, may occur with metoclopramide administration. Constipation, double vision, and numbness in fingers and toes are not adverse effects of metoclopramide.

The nurse counsels a 64-yr-old man on dietary restrictions to prevent recurrent uric acid renal calculi. Which foods should the patient avoid? a) Venison, crab, and liver b) Spinach, cabbage, and tea c) Milk, yogurt, and dried fruit e) Asparagus, lentils, and chocolate

a) Venison, crab, and liver Foods high in purines (e.g., venison, crab, liver) should be avoided to prevent uric acid calculi formation. Foods high in calcium (e.g., milk, yogurt, dried fruit, lentils, chocolate) should be avoided to prevent calcium calculi formation. Foods high in oxalate (e.g., spinach, cabbage, tea, asparagus, chocolate) should be avoided to prevent oxalate calculi formation (see Table 45-12).

The nurse is caring for a patient diagnosed with peptic ulcer disease (PUD). The patient was prescribed the proton pump inhibitor Prevacid (lansoprazole). Which of the following supplements may be prescribed to prevent deficiency? a) Vitamin B12 b) Vitamin C c) Vitamin D d) Omega 3-fatty acids

a) Vitamin B12: Vitamin B12 deficiency can occur as a result of the reduced gastric acidity associated with use of proton pump inhibitors, and supplementation is often warranted. Vitamin C deficiency is not a known deficiency associated with medications. Vitamin D deficiency may occur in patients who take cholesterol medication, and this link is currently being investigated. Omega-3 fatty acids may be used as monotherapy or in conjunction with cholesterol medication for patients with hyperlipidemia.

A patient with oral cancer is not eating. A small-bore feeding tube was inserted and the patient started on enteral feedings. Which patient goal would indicate improvement? a) Weight gain of 1 kg in 1 week b) Administer tube feeding at 25 mL/hr. c) Consume 50% of clear liquid tray this shift. d) Monitor for tube for placement and gastrointestinal residual.

a) Weight gain of 1 kg in 1 week The goal for a patient with oral cancer that is not eating would be to note weight gain rather than loss. Consuming 50% of the clear liquid tray is not a realistic goal. Administering feedings, monitoring tube placement, and tolerance are interventions used to achieve the goal.

The nurse is caring for a patient with an acute exacerbation of asthma. After initial treatment, what finding indicates to the nurse that the patient's respiratory status is improving? a) Wheezing becomes louder. b) Cough remains nonproductive. c) Vesicular breath sounds decrease. d) Aerosol bronchodilators stimulate coughing.

a) Wheezing becomes louder. The primary problem during an exacerbation of asthma is narrowing of the airway and subsequent diminished air exchange. As the airways begin to dilate, wheezing gets louder because of better air exchange. Vesicular breath sounds will increase with improved respiratory status. After a severe asthma exacerbation, the cough may be productive and stringy. Coughing after aerosol bronchodilators may indicate a problem with the inhaler or its use.

The nurse identifies the nursing diagnosis of activity intolerance for a patient with asthma. In patients with asthma, the nurse assesses for which etiologic factor for this nursing diagnosis? a) Work of breathing b) Fear of suffocation c) Effects of medications d) Anxiety and restlessness

a) Work of breathing When the patient does not have sufficient gas exchange to engage in activity, the etiologic factor is often the work of breathing. When patients with asthma do not have effective respirations, they use all available energy to breathe and have little left over for purposeful activity. Fear of suffocation, effects of medications or anxiety, and restlessness are not etiologies for activity intolerance for a patient with asthma.

A nurse in a home setting is assessing a 79-year-old male patient's risk for malnutrition. The nurse suspects malnutrition when reviewing which laboratory results? a)Body mass index (BMI) of 17 b)Weight loss of 6% since last month's visit c)Prealbumin level of 16 mg/dL d)hematocrit 50% e) Hemoglobin level of 8.2 g/dL

a)Body mass index (BMI) of 17 b)Weight loss of 6% since last month's visit e) Hemoglobin level of 8.2 g/dL

The nurse teaches a 50-yr-old woman who has a body mass index (BMI) of 39 kg/m2 about weight loss. Which dietary change would be most appropriate to recommend? a)Decrease fat intake and control portion size. b)Increase vegetables and decrease fluid intake. c)Increase protein intake and avoid carbohydrates. d)Decrease complex carbohydrates and limit fiber.

a)Decrease fat intake and control portion size: The safest dietary guideline for weight loss is to decrease caloric intake by maintaining a balance of nutrients and adequate hydration while controlling portion size and decreasing fat intake.

Gary is an 82 year old man with GOLD stage 3 COPD. Which of the following statements if made by the patient indicate further teaching is necessary? a. "It doesn't matter if I stop smoking since the lung damage has already occurred and is non-reversible." b. "I will eat small frequent meals to ensure I get enough calories in and maintain my weight." c. "I will use my albuterol inhaler if I am feeling short of breath." d. "I will get the yearly influenza vaccine."

a. "It doesn't matter if I stop smoking since the lung damage has already occurred and is non-reversible."

Which of the following patients are most at risk for developing pneumonia? a. A 75 year old nursing home resident with a recent stroke b. A 45 year old male with alcoholism and poor nutrition c. A 68 year old female who smokes cigarettes d. A 50 year old male with COPD and a recent upper respiratory infection

a. A 75 year old nursing home resident with a recent stroke

A 74-old female patient with GERD takes over-the-counter meds. Which med, if taken long-term, should the nurse teach the patient about increased risk of fractures? a. A proton pump inhibitor such as omeprazole (Prilosec) b. An antiulcer such as sucralfate (Carafate) c. A promotility drug such as metoclopramide (Reglan) d. An antacid such as calcium carbonate (Tums)

a. A proton pump inhibitor such as omeprazole (Prilosec)

Identify the population(s) at risk for developing malnutrition (select all that apply): a. Adolescents b. Hospitalized patients c. Older adults d. Children

a. Adolescents b. Hospitalized patients c. Older adults d. Children

1. The nurse is providing discharge instructions to an older adult client. The client tells the nurse that she has been having problems with nocturia. Which of the following would be most appropriate for the nurse to include in their teaching? a. Avoid drinking fluids 2 hours before bedtime b. Drink warm, caffeinated beverages in the evening c. Not to worry; it is a normal finding in older adults d. How to perform Kegal exercises

a. Avoid drinking fluids 2 hours before bedtime

Parenteral nutrition can be given through the same line as Normal Saline: a. False b. True

a. False

A patient has their jaw wired shut and needs long-term nutritional support. Which route of tube feed is most appropriate? a. Gastrostomy (G-tube) b. Orogastric (OG tube) c. Nasogastric (NG tube) d. Jejunostomu (J-tube)

a. Gastrostomy (G-tube)

Clinical manifestations of undernutrition include (SELECT ALL THAT APPLY): a. Impaired wound healing b. Brittle nails c. Increased muscle mass d. Moist, pink oral mucosa

a. Impaired wound healing b. Brittle nails

Your patient with constipation states he would like to stop having hard stools each time he has a bowel movement. What education should the nurse provide for the patient? a. Increased fiber and water intake with adequate amounts of exercise help prevent constipation b. A stimulant laxative should be used everyday for people who are constipated c. Increasing mobility does not help with constipation d. Osmotic laxatives are not supposed to be used to maintain bowel regularity

a. Increased fiber and water intake with adequate amounts of exercise help prevent constipation

1) Malnutrition can result in (SELECT ALL THAT APPLY): a. Less capacity to absorb nutrients b. Mental or physical disability c. Decreased metabolic rate d. Increased insulin secretion

a. Less capacity to absorb nutrients b. Mental or physical disability c. Decreased metabolic rate

Which lab is the most accurate representation of malnutrition? a. Pre-albumin b. Albumin c. Hemoglobin A1C d. Glucose

a. Pre-albumin

Which of the following tests are required to confirm the diagnosis of COPD? a. Pulmonary function testing b. Chest X Ray c. ABGs d. Lung biopsy

a. Pulmonary function testing

20. Which subclass of laxatives should patients try to avoid for maintenance management of chronic constipation? a. Stimulant laxatives b. Osmotic laxatives c. Bulk-forming laxatives d. Stool softeners

a. Stimulant laxatives

Sandra has mild intermittent asthma and uses an albuterol inhaler as needed. Over the last month Sandra has needed to use her albuterol inhaler about 3-4 times per week due to wheezing. She has also woken up from sleep 4 times in the last month with symptoms. Her FEV1 is still >80% predicted. The nurse can anticipate which of the following changes to her treatment plan? a. The initiation of an inhaled corticosteroid like fluticasone b. The initiation of a prednisone burst c. No change is necessary, she can continue to use her rescue inhaler as needed d. The initiation of an inhaled long acting bronchodilator

a. The initiation of an inhaled corticosteroid like fluticasone

1) Which interventions are most appropriate to prevent skin breakdown in a hospitalized patient who is undernourished (SELECT ALL THAT APPLY)? a. Turning the patient every two hours b. Promoting movement and ambulation as tolerated c. Promoting a diet high in protein d. Promoting a diet high in sugar

a. Turning the patient every two hours b. Promoting movement and ambulation as tolerated c. Promoting a diet high in protein

Your patient's HR increases by 10 beats per minute and they become febrile. They have CHF and a foley for acute urinary retention. The RN is concerned for: a. Urinary tract infection b. Cerebrovascular accident c. Impaired skin integrity d. Cardiac arrest

a. Urinary tract infection

1. Which information will the nurse include when teaching a patient how to avoid chronic constipation (select all that apply)? a. Walking or cycling frequently will help bowel motility b. Bulk-forming laxatives are an excellent source of fiber c. Stimulant and saline laxatives can be used regularly d. Some over-the-counter (OTC) medications cause constipation e. A good time for a bowel movement may be after breakfast

a. Walking or cycling frequently will help bowel motility b. Bulk-forming laxatives are an excellent source of fiber d. Some over-the-counter (OTC) medications cause constipation e. A good time for a bowel movement may be after breakfast

The nurse is teaching a patient how to self-administer ipratropium via a metered-dose inhaler (MDI). Which instruction given by the nurse is most appropriate to help the patient learn the proper inhalation technique? a) "Avoid shaking the inhaler before use." b) "Breathe out slowly before positioning the inhaler." c) "Using a spacer should be avoided for this type of medication." d) "After taking a puff, hold the breath for 30 seconds before exhaling."

b) "Breathe out slowly before positioning the inhaler." It is important to breathe out slowly before positioning the inhaler. This allows the patient to take a deeper breath while inhaling the medication, thus enhancing the effectiveness of the dose. The inhaler should be shaken well. A spacer may be used. Holding the breath after the inhalation of medication helps keep the medication in the lungs, but 30 seconds will not be possible for a patient with COPD.

The nurse has completed initial instruction with a patient regarding a weight loss program. The nurse determines that the teaching has been effective when the patient makes which statement? a) "I plan to lose 4 lb a week until I have lost the 60-lb goal." b) "I will keep a diary of weekly weights to illustrate my weight loss." c) "I will restrict my carbohydrate intake to less than 30 g/day to maximize weight loss." d) "I should not exercise more than my program requires because increased activity increases the appetite."

b) "I will keep a diary of weekly weights to illustrate my weight loss."

The nurse teaches a 53-yr-old male patient with chronic obstructive pulmonary disease (COPD) how to administer fluticasone by metered-dose inhaler (MDI). Which statement by the patient to the nurse indicates correct understanding of the instructions? a) "I should not use a spacer device with this inhaler." b) "I will rinse my mouth each time after I use this inhaler." c) "I will feel my breathing improve over the next 2 to 3 days." d) "I should use this inhaler immediately if I have trouble breathing."

b) "I will rinse my mouth each time after I use this inhaler." Fluticasone may cause oral candidiasis (thrush). The patient should rinse the mouth with water or mouthwash after use or use a spacer device to prevent oral fungal infections. Fluticasone is an inhaled corticosteroid and it may take 2 weeks of regular use for effects to be evident. This medication is not recommended for an acute asthma attack.

The nurse determines that the patient understood medication instructions about the use of a spacer device when taking inhaled medications after hearing the patient state what as the primary benefit? a) "I will pay less for medication because it will last longer." b) "More of the medication will get down into my lungs to help my breathing." c) "Now I will not need to breathe in as deeply when taking the inhaler medications." d) "This device will make it so much easier and faster to take my inhaled medications."

b) "More of the medication will get down into my lungs to help my breathing." A spacer assists more medication to reach the lungs, with less being deposited in the mouth and the back of the throat. It does not affect the cost or increase the speed of using the inhaler.

The nurse is caring for a 62-yr-old woman taking tolterodine (Detrol) to treat urinary urgency and incontinence. Which instruction should be included in the discharge plan? a) "Stop smoking for 2 to 3 weeks before starting to take this medication." b) "Suck on sugarless candy or chew sugarless gum if you develop a dry mouth." c) "Have your vision checked every 6 months because this drug can cause cataracts." e)"Ask your physician to prescribe an extended-release form if you have loose stools."

b) "Suck on sugarless candy or chew sugarless gum if you develop a dry mouth." Dry mouth is a common side effect of tolterodine. Patients can suck on hard candy or ice chips or chew gum if dry mouth occurs. Tobacco use does not affect the initiation of this medication. Visual changes (but not cataracts) can occur while taking this medication. Constipation may occur as a side effect of this medication.

The physician has prescribed salmeterol (Serevent) for a patient with asthma. In reviewing the use of dry powder inhalers (DPIs) with the patient, what instructions should the nurse provide? a) "Close lips tightly around the mouthpiece and breathe in deeply and quickly." b) "To administer a DPI, you must use a spacer that holds the medicine so that you can inhale it." c) "You will know you have correctly used the DPI when you taste or sense the medicine going into your lungs." d) "Hold the inhaler several inches in front of your mouth and breathe in slowly, holding the medicine as long as possible."

b) "To administer a DPI, you must use a spacer that holds the medicine so that you can inhale it." The patient should be instructed to tightly close the lips around the mouthpiece and breathe in deeply and quickly to ensure the medicine moves down deeply into the lungs. Dry powder inhalers do not require spacer devices. The patient may not taste or sense the medicine going into the lungs.

A patient is given a bisacodyl suppository and asks the nurse how long it will take to work. What is the best response by the nurse? a) 2 to 5 minutes b) 15 to 60 minutes c) 2 to 4 hours d) 6 to 8 hours

b) 15 to 60 minutes Bisacodyl suppositories usually are effective within 15 to 60 minutes of administration, so the nurse should plan accordingly to assist the patient to use the bedpan or commode.

The nurse is caring for a patient with chronic obstructive pulmonary disorder (COPD) and pneumonia who has an order for arterial blood gases to be drawn. What is the minimum length of time the nurse should plan to hold pressure on the puncture site? a) 2 minutes b) 5 minutes c) 10 minutes d) 15 minutes

b) 5 minutes After obtaining blood for an arterial blood gas measurement, the nurse should hold pressure on the puncture site for 5 minutes by the clock to be sure that bleeding has stopped. An artery is an elastic vessel under much higher pressure than veins, and significant blood loss or hematoma formation could occur if the time is insufficient.

A patient with suspected bowel obstruction had a nasogastric tube inserted at 4:00 AM. The nurse shares in the morning report that the day shift staff should check the tube for patency at what times? a) 7:00 AM, 10:00 AM, and 1:00 PM b) 8:00 AM, 12:00 PM, and 4:00 PM c) 9:00 AM and 3:00 PM d) 9:00 AM, 12:00 PM, and 3:00 PM

b) 8:00 AM, 12:00 PM, and 4:00 PM A nasogastric tube should be checked for patency routinely at 4-hour intervals. Thus if the tube were inserted at 4:00 AM, it would be due to be checked at 8:00 AM, 12:00 PM, and 4:00 PM.

The nurse identifies that which patient is at highest risk for developing colon cancer? a) A 28-yr-old man who has a body mass index of 27 kg/m2 b) A 32-yr-old woman with a 12-year history of ulcerative colitis c) A 52-yr-old man who has followed a vegetarian diet for 24 years d) A 58-yr-old woman taking prescribed estrogen replacement therapy

b) A 32-yr-old woman with a 12-year history of ulcerative colitis Risk for colon cancer includes personal history of inflammatory bowel disease (especially ulcerative colitis for longer than 10 years); obesity (body mass index ?5= 30 kg/m2); family (first-degree relative) or personal history of colorectal cancer, adenomatous polyposis, or hereditary nonpolyposis colorectal cancer syndrome; eating red meat (?5=7 servings/week); cigarette use; and drinking alcohol (?5=4 drinks/week).

Which test result identifies that a patient with asthma is responding to treatment? a) An increase in CO2 levels b) A decreased exhaled nitric oxide c) A decrease in white blood cell count d) An increase in serum bicarbonate levels

b) A decreased exhaled nitric oxide Nitric oxide levels are increased in the breath of people with asthma. A decrease in the exhaled nitric oxide concentration suggests that the treatment may be decreasing the lung inflammation associated with asthma and adherence to treatment. An increase in CO2 levels, decreased white blood cell count, and increased serum bicarbonate levels do not indicate a positive response to treatment in a patient with asthma.

A colectomy is scheduled for a patient with ulcerative colitis. The nurse should plan to include which prescribed measure in the preoperative preparation of this patient? a) Instruction on irrigating a colostomy b) Administration of a cleansing enema c) A high-fiber diet the day before surgery d) Administration of IV antibiotics for bowel preparation

b) Administration of a cleansing enema Preoperative preparation for bowel surgery typically includes bowel cleansing with antibiotics, such as oral neomycin and cleansing enemas, including Fleet enemas. Instructions to irrigate the colostomy will be done postoperatively. Oral antibiotics are given preoperatively and an IV antibiotic may be used in the operating room. A clear liquid diet will be used the day before surgery with the bowel cleansing.

The nurse is caring for a postoperative patient who has just vomited yellow green liquid and reports nausea. Which action would be an appropriate nursing intervention? a) Offer the patient an herbal supplement such as ginseng. b) Apply a cool washcloth to the forehead and provide mouth care. c) Take the patient for a walk in the hallway to promote peristalsis. d) Discontinue any medications that may cause nausea or vomiting.

b) Apply a cool washcloth to the forehead and provide mouth care: Cleansing the face and hands with a cool washcloth and providing mouth care are appropriate comfort interventions for nausea and vomiting. Ginseng is not used to treat postoperative nausea and vomiting. Unnecessary activity should be avoided. The patient should rest in a quiet environment. Medications may be temporarily withheld until the acute phase is over, but the medications should not be discontinued without consultation with the health care provider.

The nurse is caring for a patient after bariatric surgery. What should be included in the plan of care (select all that apply.)? a) Teach the patient to increase carbohydrate intake. b) Assess for incisional pain versus anastomosis leak. c) Maintain elevation of the head of bed at 35-45 degrees. d) Monitor for vomiting that is a common complication. c) Instruct the patient to consume liquids frequently during meals. e) Assist with early independent ambulation during hospitalization.

b) Assess for incisional pain versus anastomosis leak. c) Maintain elevation of the head of bed at 35-45 degrees. d) Monitor for vomiting that is a common complication. d) Assist with early independent ambulation during hospitalization.

A patient is admitted with anorexia nervosa and a serum potassium level of 2.4 mEq/L. What complication is most important for the nurse to observe for in this patient? a)Muscle weakness b)Cardiac dysrhythmias c)Increased urine output d)Anemia and leukopenia

b) Cardiac dysrhythmias: A serum potassium level less than 2.5 mEq/L indicates severe hypokalemia, which can lead to life-threatening cardiac dysrhythmias (e.g., bradycardia, tachycardia, ventricular dysrhythmias). Other manifestations of potassium deficiency include muscle weakness and renal failure. Patients with anorexia nervosa commonly have iron-deficiency anemia and an elevated blood urea nitrogen level related to intravascular volume depletion and abnormal renal function

A patient who has sustained severe burns in a motor vehicle accident is starting parenteral nutrition (PN). Which principle should guide the nurse's administration of PN? a) Administration of PN requires clean technique. b) Central PN requires rapid dilution in a large volume of blood. c) Peripheral PN delivery is preferred over the use of a central line. d) Only water-soluble medications may be added to the PN by the nurse.

b) Central PN requires rapid dilution in a large volume of blood.: Central PN is hypertonic and requires rapid dilution in a large volume of blood. Because PN is an excellent medium for microbial growth, aseptic technique is necessary during administration. Administration through a central line is preferred over the use of peripheral PN, and the nurse may not add any medications to PN.

The nurse, who has administered a first dose of oral prednisone to a patient with asthma, writes on the care plan to begin monitoring for which patient parameters? a) Apical pulse b) Daily weight c) Bowel sounds d) Deep tendon reflexes

b) Daily weight Corticosteroids such as prednisone can lead to weight gain. For this reason, it is important to monitor the patient's daily weight. The drug should not affect the apical pulse, bowel sounds, or deep tendon reflexes

A patient has a tumor that secretes excessive antidiuretic hormone (ADH). He is confused and lethargic. His partner wants to know how a change in blood sodium can cause these symptoms. What should the nurse teach the patient's partner? a) Decreased sodium in the blood causes the blood volume to decrease so that not enough oxygen reaches the brain. b) Decreased sodium in the blood causes brain cells to swell so that they do not work as effectively. c) Increased sodium in the blood causes the blood volume to increase so that too much oxygen reaches the brain. d) Increased sodium in the blood causes brain cells to shrivel so that they do not work as effectively.

b) Decreased sodium in the blood causes brain cells to swell so that they do not work as effectively. The normal action of ADH is renal reabsorption of water, which dilutes the blood. Excessive ADH causes hyponatremia, which is manifested by a decreased level of consciousness because the osmotic shift of water into the brain cells impairs their function. Hyponatremia does not decrease the blood volume. Answers that include increased sodium in the blood are incorrect because ADH excess causes hyponatremia rather than hypernatremia.

The patient talks with the nurse about bladder health. What is one of the most important recommendations the nurse can make for this patient? a) Eat foods high in fiber. b) Drink 6 to 8 glasses of non-caffeinated fluids daily. c) Exercise in the morning and evening. d) Visit the urologist once yearly.

b) Drink 6 to 8 glasses of non-caffeinated fluids daily. This helps with bladder health because urine is not stagnating in the bladder. Exercising and eating foods high in fiber help with bowel elimination but do not have an effect on urination. Visiting the urologist is good if there is a problem, but this is not the most important recommendation from the nurse.

After administering a dose of promethazine to a patient with nausea and vomiting, what medication side effect does the nurse explain is common and expected? a) Tinnitus b) Drowsiness c) Reduced hearing d) Sensation of falling

b) Drowsiness Although being given to this patient as an antiemetic, promethazine also has sedative and amnesic properties. For this reason, the patient is likely to experience drowsiness as an adverse effect of the medication. Tinnitus, reduced hearing, and loss of balance are not side effects of promethazine.

The nurse is caring for a patient treated with IV fluid therapy for severe vomiting. As the patient recovers and begins to tolerate oral intake, which food choice would be most appropriate? a) Iced tea b) Dry toast c) Hot coffee d) Plain yogurt

b) Dry toast Dry toast or crackers may alleviate the feeling of nausea and prevent further vomiting. Water is the initial fluid of choice. Extremely hot or cold liquids and fatty foods are generally not well tolerated.

Which focused assessments would have priority in the care of a patient recently started on parenteral nutrition (PN)? a) Skin integrity and skin turgor b) Electrolyte levels and daily weights c) Auscultation of lung and bowel sounds d) Peripheral edema and level of consciousness

b) Electrolyte levels and daily weights:

A patient is seeking emergency care after choking on a piece of steak. The nursing assessment reveals a history of alcoholism, cigarette smoking, and hemoptysis. Which diagnostic study is most likely to be performed on this patient? a) Barium swallow b) Endoscopic biopsy c) Capsule endoscopy d) Endoscopic ultrasonography

b) Endoscopic biopsy Because of this patient's history of excessive alcohol intake, smoking, and hemoptysis and the current choking episode, cancer may be present. A biopsy is necessary to make a definitive diagnosis of carcinoma, so an endoscope will be used to obtain a biopsy and observe other abnormalities as well. A barium swallow may show narrowing of the esophagus, but it is more diagnostic for achalasia. An endoscopic ultrasonography may be used to stage esophageal cancer. Capsule endoscopy can show alterations in the esophagus but is more often used for small intestine problems. A barium swallow, capsule endoscopy, and endoscopic ultrasonography cannot provide a definitive diagnosis for cancer.

The home health nurse should assess a patient who has chronic diarrhea for which fluid and electrolyte imbalances? Select all that apply. a) Extracellular fluid volume (ECV) excess b) Extracellular fluid volume (ECV) deficit c) Hypokalemia d) Hyperkalemia e) Hypocalcemia f) Hypercalcemia

b) Extracellular fluid volume (ECV) deficit c) Hypokalemia e) Hypocalcemia Chronic diarrhea has a high risk of causing ECV deficit, hypokalemia, and hypocalcemia because it increases the fecal output of sodium-containing fluid, potassium, and calcium. Unless the intake of these substances increases appropriately, imbalances will occur. Excesses of ECV, potassium, and calcium are not likely, because the ECV, potassium, and calcium are being removed from the body.

A patient is being admitted with anorexia nervosa. Which clinical manifestations should the nurse anticipate? a) Sensitivity to heat, fatigue, and polycythemia b) Hair loss; dry, yellowish skin; and constipation c) Tented skin turgor, hyperactive reflexes, and diarrhea d) Dysmenorrhea, hypoactive bowel sounds, and hunger

b) Hair loss; dry, yellowish skin; and constipation: The patient with anorexia nervosa, along with abnormal weight loss, is likely to have hair loss; dry, yellow skin; constipation; sensitivity to cold, and absent or irregular menstruation. Other signs of malnutrition may also be noted during physical examination.

The patient who is admitted with a diagnosis of diverticulitis and a history of irritable bowel disease and gastroesophageal reflux disease (GERD) has received a dose of Mylanta 30 mL PO. The nurse will determine the medication was effective when which symptom has been resolved? a) Diarrhea b) Heartburn c) Constipation d) Lower abdominal pain

b) Heartburn Mylanta is an antacid that contains both aluminum and magnesium. It is indicated for the relief of gastrointestinal discomfort, such as heartburn associated with GERD. Mylanta can cause both diarrhea and constipation as a side effect. Mylanta does not affect lower abdominal pain.

A nurse is admitting a patient with advanced renal carcinoma. Which clinical manifestations represent the "classic triad" observed in patients with renal cancer? a) Fever, chills, and flank pain b) Hematuria, flank pain, and palpable mass c) Hematuria, proteinuria, and palpable mass d) Flank pain, palpable abdominal mass, and proteinuria

b) Hematuria, flank pain, and palpable mass There are no characteristic early symptoms of renal carcinoma. The classic manifestations of gross hematuria, flank pain, and a palpable mass are those of advanced disease.

The nurse is developing a plan of care for a patient with an abdominal mass and suspected bowel obstruction. Which factor in the patient's history does the nurse recognize as increasing the patient's risk for colorectal cancer? a) Osteoarthritis b) History of colorectal polyps c) History of lactose intolerance d) Use of herbs as dietary supplements

b) History of colorectal polyps A history of colorectal polyps places this patient at risk for colorectal cancer. This tissue can degenerate over time and become malignant. Osteoarthritis, lactose intolerance, and the use of herbs do not pose additional risk to the patient.

What information would have the highest priority for the nurse to include in preoperative teaching for a patient scheduled for a colectomy? a) How to care for the wound b) How to deep breathe and cough c) The location and care of drains after surgery d) Which medications will be used during surgery

b) How to deep breathe and cough Because anesthesia, an abdominal incision, and pain can impair the patient's respiratory status in the postoperative period, it is of high priority to teach the patient to cough and deep breathe. Otherwise, the patient could develop atelectasis and pneumonia, which would delay early recovery from surgery and hospital discharge. Care for the wound and location and care of the drains will be briefly discussed preoperatively but will be done again with higher priority after surgery. Knowing which drugs will be used during surgery may not be meaningful to the patient and should be reviewed with the patient by the anesthesiologist.

When planning teaching for the patient with chronic obstructive pulmonary disease (COPD), the nurse understands that what causes the manifestations of the disease? a) An overproduction of the antiprotease a1-antitrypsin b) Hyperinflation of alveoli and destruction of alveolar walls c) Hypertrophy and hyperplasia of goblet cells in the bronchi d) Collapse and hypoventilation of the terminal respiratory unit

b) Hyperinflation of alveoli and destruction of alveolar walls In COPD, structural changes include hyperinflation of alveoli, destruction of alveolar walls, destruction of alveolar capillary walls, narrowing of small airways, and loss of lung elasticity. An autosomal recessive deficiency of antitrypsin may cause COPD. Not all patients with COPD have excess mucus production by the increased number of goblet cells.

The nurse is evaluating if a patient understands how to safely determine whether a metered-dose inhaler (MDI) is empty. The nurse interprets that the patient understands this important information to prevent medication underdosing when the patient describes which method to check the inhaler? a) Place it in water to see if it floats. b) Keep track of the number of inhalations used. c) Shake the canister while holding it next to the ear. d) Check the indicator line on the side of the canister.

b) Keep track of the number of inhalations used. It is no longer appropriate to see if a canister floats in water or not because this is not an accurate way to determine the remaining inhaler doses. The best method to determine when to replace an inhaler is by knowing the maximum puffs available per MDI and then replacing it after the number of days when those inhalations have been used (100 puffs/2 puffs each day = 50 days).

The nurse should administer an as-needed dose of magnesium hydroxide after noting what information when reviewing a patient's medical record? a) Abdominal pain and bloating b) No bowel movement for 3 days c) A decrease in appetite by 50% over 24 hours d) Muscle tremors and other signs of hypomagnesemia

b) No bowel movement for 3 days Magnesium hydroxide is an osmotic laxative that produces a soft, semisolid stool usually within 15 minutes to 3 hours. This medication would benefit the patient who has not had a bowel movement for 3 days. It would not be given for abdominal pain and bloating, decreased appetite, or signs of hypomagnesemia.

A frail older adult with recent severe weight loss is instructed to eat a high-protein, high-calorie diet at home. Which foods would the nurse suggest for breakfast? a)Orange juice and dry toast b)Oatmeal with butter and cream c)Waffles with fresh strawberries d)Banana and unsweetened yogurt

b) Oatmeal with butter and cream

The nurse provides nutritional counseling for a 45-yr-old man with nephrotic syndrome. The nurse determines teaching has been successful if the patient selects which breakfast menu? a) Scrambled eggs, milk, yogurt, and sliced ham b) Oatmeal, nondairy creamer, banana, and orange juice c) Cottage cheese, peanut butter, white bread, and coffee d) Waffle, bacon strips, tomato juice, and canned peaches

b) Oatmeal, non-dairy creamer, banana, and orange juice Patients with nephrotic syndrome should follow a low-sodium (2-3 g/day), low- to moderate-protein (0.5-0.6 g/kg/day) diet. Ham, milk products, peanut butter, and bacon are high in sodium. Eggs, milk products, and peanut butter are high in protein.

The patient receiving chemotherapy rings the call bell and reports the onset of nausea. The nurse should prepare an as-needed dose of which medication? a) Zolpidem b) Ondansetron c) Dexamethasone d) Morphine sulfate

b) Ondansetron Ondansetron is a 5-HT3 receptor antagonist antiemetic that is especially effective in reducing cancer chemotherapy-induced nausea and vomiting. Morphine sulfate may cause nausea and vomiting. Zolpidem does not relieve nausea and vomiting. Dexamethasone is usually used in combination with ondansetron for acute and chemotherapy-induced emesis.

When caring for a patient with chronic obstructive pulmonary disease (COPD), the nurse identifies a nursing diagnosis of imbalanced nutrition: less than body requirements after noting a weight loss of 30 lb. Which intervention should the nurse add to the plan of care for this patient? a) Order fruits and fruit juices to be offered between meals. b) Order a high-calorie, high-protein diet with six small meals a day. c) Teach the patient to use frozen meals at home that can be microwaved. d) Provide a high-calorie, high-carbohydrate, nonirritating, frequent feeding diet.

b) Order a high-calorie, high-protein diet with six small meals a day. Because the patient with COPD needs to use greater energy to breathe, there is often decreased oral intake because of dyspnea. A full stomach also impairs the ability of the diaphragm to descend during inspiration, thus interfering with the work of breathing. For these reasons, the patient with COPD should eat six small meals per day taking in a high-calorie, high-protein diet, with nonprotein calories divided evenly between fat and carbohydrate. The other interventions will not increase the patient's caloric intake.

The nurse determines that a patient is experiencing common adverse effects from the inhaled corticosteroid beclomethasone after what occurs? a) Hypertension and pulmonary edema b) Oropharyngeal candidiasis and hoarseness c) Elevation of blood glucose and calcium levels d) Adrenocortical dysfunction and hyperglycemia

b) Oropharyngeal candidiasis and hoarseness Oropharyngeal candidiasis and hoarseness are common adverse effects from the use of inhaled corticosteroids because the medication can lead to overgrowth of organisms and local irritation if the patient does not rinse the mouth following each dose.

The nurse is caring for a 45-yr-old woman with a herniated lumbar disc. The patient realizes that weight loss is necessary to lessen back strain. The patient is 5'6" tall and weighs 186 lb (84.5 kg) with a body mass index (BMI) of 28 kg/m2. The nurse explains this measurement places her in which weight category? a) Obese b) Overweight c) Severely obese d) Normal weight

b) Overweight

After assisting at the bedside with a thoracentesis, the nurse should continue to assess the patient for signs and symptoms of what? a) Bronchospasm b) Pneumothorax c) Pulmonary edema d) Respiratory acidosis

b) Pneumothorax Because thoracentesis involves the introduction of a catheter into the pleural space, there is a risk of pneumothorax. Thoracentesis does not carry a significant potential for causing bronchospasm, pulmonary edema, or respiratory acidosis.

A 22-yr-old patient's blood pressure during a pre-employment physical examination was 110/68 mm Hg. During a health fair 2 months later, the blood pressure is 154/96 mm Hg. What renal problem could contribute to this rise in blood pressure? a) Renal trauma b) Renal artery stenosis c) Renal vein thrombosis d) Benign nephrosclerosis

b) Renal artery stenosis Renal artery stenosis contributes to an abrupt rise in blood pressure, especially in people younger than 30 or older than 50 years of age. Renal trauma usually has hematuria. Renal vein thrombosis causes flank pain, hematuria, fever, or nephrotic syndrome. Benign nephrosclerosis usually occurs in adults 30 to 50 years of age and is a result of vascular changes resulting from hypertension.

A patient injured in an earthquake today when a wall fell on his legs received 9 units of blood an hour ago because he was hemorrhaging. Which laboratory value should the nurse check first when the report returns? a) Serum sodium b) Serum potassium c) Serum total calcium d) Serum magnesium

b) Serum potassium The patient has two major risk factors for hyperkalemia: massive sudden cell death from a crushing injury (potassium shift from cells into the extracellular fluid) and massive blood transfusion (rapid potassium intake). Although massive blood transfusion may cause calcium and magnesium ions to bind to citrate in the blood, thereby decreasing the physiological availability of those ions, it does not decrease the total calcium or magnesium laboratory measurements. Clinically significant changes in serum sodium are the least likely in this patient.

The nurse is evaluating the nutritional status of a patient undergoing radiation treatment for oropharyngeal cancer. Which laboratory test would best indicate the patient has protein-calorie malnutrition (PCM)? a)Serum transferrin b)Serum prealbumin c)C-reactive protein (CRP) d)Alanine transaminase (ALT)

b) Serum prealbumin: n the absence of an inflammatory condition, the best indicator of PCM is prealbumin; prealbumin is a protein synthesized by the liver and indicates recent or current nutritional status. Decreased transferrin levels and elevated liver enzyme levels (ALT) are other indicators that protein is deficient. CRP is elevated during inflammation and is used to determine if prealbumin, albumin, and transferrin are decreased related to protein deficiency or an inflammatory process.

Which nursing intervention is most appropriate in providing care for an adult patient with newly diagnosed adult onset polycystic kidney disease (PKD)? a) Help the patient cope with the rapid progression of the disease. b) Suggest genetic counseling resources for the children of the patient. c) Expect the patient to have polyuria and poor concentration ability of the kidneys. d)Implement appropriate measures for the patient's deafness and blindness in addition to the renal problems.

b) Suggest genetic counseling resources for the children of the patient. PKD is one of the most common genetic diseases. The adult form of PKD may range from a relatively mild disease to one that progresses to chronic kidney disease. Polyuria, deafness, and blindness are not associated with PKD.

The nurse is caring for a confused patient who is wearing a vest restraint in bed. The nurse speaks with an unlicensed assistant about toileting the patient. The nurse knows the unlicensed assistant understands the toileting procedure when making which statement? a) The patient must remain in the restraints all day. b) The patient needs to be toileted to maintain a regular toileting schedule. c) The patient needs to be provided with adult briefs for incontinence. d) The patient will use the call bell when he or she feels the urge to void.

b) The patient needs to be toileted to maintain a regular toileting schedule. The correct answer is toileting the patient so he or she can maintain a normal toileting schedule. Leaving the patient in restraints all day is against the standard of care. Providing the patient with briefs when he or she is not incontinent does not meet the patient's toileting needs. If the patient is confused, he or she will not be able to use the call bell.

In assessment of the patient with acute respiratory distress, what should the nurse expect to observe (select all that apply.)? a) Cyanosis b) Tripod position c) Kussmaul respirations d) Accessory muscle use e) Increased AP diameter

b) Tripod position d) Accessory muscle use Tripod position and accessory muscle use indicate moderate to severe respiratory distress. Cyanosis may be related to anemia, decreased oxygen transfer in the lungs, or decreased cardiac output. Therefore, it is a nonspecific and unreliable indicator of only respiratory distress. Kussmaul respirations occur when the patient is in metabolic acidosis to increase CO2 excretion. Increased AP diameter occurs with lung hyperinflation from chronic obstructive pulmonary disease, cystic fibrosis, or with advanced age.

A person of Northern heritage is at an increased risk for which of the following? a) Vitamin C deficiency b) Type 1 diabetes c) Celiac disease d) Type 2 diabetes e) HTN f) Metabolic syndrome

b) Type 1 diabetes c) Celiac disease: Type 1 diabetes and Celiac disease are more common in Northern heritage. African Americans and Hispanics are at increased risk for Type 2 diabetes, hypertension, and metabolic syndrome. Vitamin C deficiency is not a common deficiency related to heritage or ethnicity.

The nurse is caring for a patient with a nephrostomy tube. The tube has stopped draining. After receiving orders, what should the nurse do? a) Keep the patient on bed rest. b) Use 5 mL of sterile saline to irrigate. c) Use 30 mL of water to gently irrigate. d) Have the patient turn from side to side.

b) Use 5 mL of sterile saline to irrigate. With a nephrostomy tube, if the tube is occluded and irrigation is ordered, the nurse should use 5 mL or less of sterile saline to gently irrigate it. The patient with a ureteral catheter may be kept on bed rest after insertion, but this is unrelated to obstruction. Only sterile solutions are used to irrigate any type of urinary catheter. With a suprapubic catheter, the patient should be instructed to turn from side to side to ensure patency.

A patient with an acute exacerbation of chronic obstructive pulmonary disease (COPD) needs to receive precise amounts of oxygen. Which equipment should the nurse prepare to use? a) Oxygen tent b) Venturi mask c) Nasal cannula d) Oxygen-conserving cannula

b) Venturi mask The Venturi mask delivers precise concentrations of oxygen and should be selected whenever this is a priority concern. The other methods are less precise in terms of amount of oxygen delivered.

A patient who cannot afford enough food for her family states she only eats after her children have eaten. At a clinic visit, she reports bleeding gums; loose teeth; and dry, itchy skin. Which vitamin deficiency would the nurse suspect? a) Folic acid b) Vitamin C c) Vitamin D d) Vitamin K

b) Vitamin C: This patient is lacking vitamin C as evidenced by the bleeding gums, loose teeth, and dry, itchy skin. Clinical manifestations of folic acid deficiency include megaloblastic anemia, anorexia, fatigue, sore tongue, diarrhea, or forgetfulness. Clinical manifestations of vitamin D deficiency include muscular weakness, excess sweating, diarrhea, bone pain, rickets, or osteomalacia. Clinical manifestations of vitamin K deficiency include defective blood coagulation.

The nurse is caring for a patient who had abdominal surgery yesterday. Today the patient's lung sounds in the lower lobes are diminished. The nurse knows this could be related to the occurrence of: a) pain. b) atelectasis. c) pneumonia. d) pleural effusion.

b) atelectasis. Postoperatively, there is an increased risk for atelectasis from anesthesia as well as restricted breathing from pain. Without deep breathing to stretch the alveoli, surfactant secretion to hold the alveoli open is not promoted. Pneumonia will occur later after surgery. Pleural effusion occurs because of blockage of lymphatic drainage or an imbalance between intravascular and oncotic fluid pressures, which is not expected in this case.

The nurse is teaching a patient with type 1 diabetes mellitus who had surgery to revise a lower leg stump with a skin graft about nutrition. What food should the nurse teach the patient to eat to best facilitate healing? a) Nonfat milk b) Chicken breast c) Fortified oatmeal d) Olive oil and nuts

b) chicken breast: High-quality protein such as chicken breast is important for tissue repair. Nonfat milk, nuts, and fortified oatmeal have some protein but not as much as chicken breast.

The nurse is assessing a group of patients to determine their risk of vitamin D deficiency. Which of the following patients has the highest risk for vitamin D deficiency? a)A Caucasian female who is 39 weeks gestation b)An African-American female who is breastfeeding c)An Asian female diagnosed with hypoglycemia d)A Hispanic female who has a BMI of 24.1

b)An African-American female who is breastfeeding: Vitamin D deficiency is more frequently found among persons of African heritage and has increased in prevalence, especially among the infants of breastfeeding African-American mothers. Caucasian females do not share these risk factors. There is no known risk of hypoglycemia and vitamin D deficiency; however, diabetes increases the risk for vitamin D deficiency. There is no known risk of vitamin D deficiency in normal-weight females of Hispanic heritage; however, obesity is a risk factor.

A patient was admitted with a fractured hip after being found on the floor of her home. She was extremely malnourished and started on parenteral nutrition (PN) 3 days ago. Which assessment finding would be of most concern to the nurse? a)Blood glucose level of 125 mg/dL b)Serum phosphate level of 1.9 mg/dL c)White blood cell count of 10,500/µL d)Serum potassium level of 4.6 mEq/L

b)Serum phosphate level of 1.9 mg/dL: Refeeding syndrome can occur if a malnourished patient is started on aggressive nutritional support. Hypophosphatemia (serum phosphate level 11,000/µL) could indicate an infection. Normal serum potassium levels are between 3.5 and 5.0 mEq/L.

A 26-year-old man with cystic fibrosis and his partner talk to you about having children. Which of the following statements made by the patient indicate that the nurse's teaching has been effective? a. "Almost all men with cystic fibrosis do not produce sperm." b. "Any children that we have will be a carrier for cystic fibrosis." c. "Any children that we have will have cystic fibrosis." d. "Men with cystic fibrosis usually have no problem with reproduction."

b. "Any children that we have will be a carrier for cystic fibrosis."

A nurse has been working with an obese man and is evaluating a weight-reduction plan designed for the client. Which statement by the client indicates the need for additional teaching? a. "It is so difficult to find food exchanges that taste good and fill me up." b. "This diet doesn't let me go out for lunch with my friends at work anymore." c. "I wish my mother could have seen me lose the 60 pounds in the last 9 months." d. "My wife was kidding me the other night about my being a whole new husband."

b. "This diet doesn't let me go out for lunch with my friends at work anymore."-eating has a social component

15. Which of the following patients should the nurse assess first? a. 55-year-old male with a history of poorly controlled diabetes who is reporting numbness and tingling to his bilateral lower extremities. b. A 78 year old female with COPD who has a RR of 36 and using accessory muscles for breathing c. A 45 year old male with a venous ulcer on his lower extremity and WBC count of 8,000 d. A 47 year old female with a potassium level of 3.0

b. A 78 year old female with COPD who has a RR of 36 and using accessory muscles for breathing

Which of the following patients is a candidate for enteral nutrition: a. A patient with malabsorption due to Crohn's disease b. An older adult with an ulcer that is not healing due to poor oral intake

b. An older adult with an ulcer that is not healing due to poor oral intake

A nurse is caring for a patient with pneumonia. The patient reports shortness of breath and his pulse oximetry is 83% on room air. The patient appears to be in respiratory distress. What action should the nurse take FIRST? a. Auscultate breath sounds b. Apply oxygen c. Notify the provider d. Check a full set of vital signs

b. Apply oxygen

Which nursing diagnosis is most appropriate for an older adult with undernutrition? a. Impaired gas exchange b. At risk for impaired skin integrity c. Constipation d. Decreased cardiac output

b. At risk for impaired skin integrity

The most common form of malabsorption syndrome is treated with: a. Administration of antibiotics b. Avoidance of milk and milk products c. Supplementation of pancreatic enzymes d. Avoidance of gluten found in wheat, barley, oats and rye

b. Avoidance of milk and milk products-The most common form of malabsorption syndrome is lactose intolerance and it is managed by restricting intake of milk and milk products.

Your 88-year-old, male patient is delirious and standing up frequently because he feels like he needs to urinate. The nurse should first: a. Insert a foley catheter b. Bladder scan the patient c. Educate the patient about Kegel exercises d. Place a condom catheter

b. Bladder scan the patient to check for residual volume

What is a key pathophysiologic component of cystic fibrosis? a. Decreased mucous clearance b. Blockage of sodium and chloride channels c. Hyperinflation of the lungs d. Chronic airway inflammation

b. Blockage of sodium and chloride channels

Which is an example of a complete protein? a. Peanuts b. Eggs c. Peas d. Corn

b. Eggs

Your patient is on parenteral nutrition for inflammatory bowel disease. Which of the following is most concerning? a. Loose stools b. Elevated heart rate c. Brittle nails d. Blanchable erythema to the buttock

b. Elevated heart rate

A patient with COPD has PFTs done. The FEV1 is 60% of predicted. The patient likely falls into which of the following GOLD categories? a. GOLD 1 b. GOLD 2 c. GOLD 3 d. GOLD 4

b. GOLD 2

1. A patient who has chronic constipation asks the nurse about the use of psyllium (Metamucil). Which information will the nurse include in the response? a. Using this type of laxative to prevent constipation does not cause adverse effects. b. Large amounts of fluid should be taken to prevent impaction or bowel obstruction. c. Dietary sources of fiber should be eliminated to prevent excessive gas formation. d. Absorption of fat-soluble vitamins may be reduced by fiber-containing laxatives.

b. Large amounts of fluid should be taken to prevent impaction or bowel obstruction.

A 19-year old male is seen in clinic with episodic wheezing. He complains of chest tightening and wheezing three or four times per week. He uses an albuterol inhaler as needed for wheezing and has been using it 3-4 times per week. Based on his presenting symptoms, what type of asthma do you think he has? a. Mild, intermittent b. Mild, persistent c. Moderate, persistent d. Severe, persistent

b. Mild, persistent

Which assessment should the nurse prioritize for a patient with fecal incontinence? a. Lung sounds b. Perineal skin integrity c. Abdominal inspection d. Facial symmetry

b. Perineal skin integrity

1. A client presents with symptoms of protein calorie undernutrition. Upon reviewing the client's labs, the nurse expects which of the following results? (select all that apply) a. Sodium is 150 mEq/L b. Potassium is 2.5 mEq/L c. Creatinine is 2.0 mg/dL d. Fasting blood glucose is 55

b. Potassium is 2.5 mEq/L d. Fasting blood glucose is 55

Which of the following are defining characteristics of COPD? a. Lung consolidation seen on chest X ray b. Progressive, persistent airflow limitation c. Variable airway inflammation d. Chronic cough with sputum production

b. Progressive, persistent airflow limitation

A patient is diagnosed with community-acquired pneumonia (CAP) and is prescribed empiric antibiotic therapy in the clinic. The provider requests a sputum sample from the patient. The nurse knows this sample will be used to: a. Confirm the diagnosis of CAP b. Send for culture to identify the causative agent c. Send to chemistry d. Determine whether it is community acquired or nosocomial

b. Send for culture to identify the causative agent

The test that is most specific for renal function is the: a. Renal biopsy b. Serum creatinine c. BUN d. Creatinine clearance

b. Serum creatinine d. Creatinine clearance- The rate at which creatinine is cleared from the blood and eliminated in the urine approximates the GFR and is the most specific test of renal function.

The FEV1 result on pulmonary function test is an indicator of which of the following? a. Exercise capacity b. Severity of airway obstruction c. Small airway disease d. Bronchoconstriction

b. Severity of airway obstruction

1. A 55-yr-old woman admitted for shoulder surgery asks the nurse for a perineal pad, stating that laughing or coughing causes leakage of urine. Which intervention is most appropriate to include in the care plan? a. Place a commode at the patient's bedside. b. Teach the patient how to perform Kegel exercises. c. Use an ultrasound scanner to check post voiding residuals. d. Assist the patient to the bathroom q3 hours.

b. Teach the patient how to perform Kegel exercises.

A hospitalized patient is experiencing involuntary passage of stool. Which doesn't contribute to fecal incontinence? a. Infection b. atrial fibrillation c. chronic constipation d. impaired mobility

b. atrial fibrillation

Part of the pathophysiology of pneumonia includes the process of alveoli filling with fluid and debris. The nurse knows that this process best represents which of the following manifestations of pneumonia? a. hypoxia b. consolidation seen on chest Xray c. Clubbing of nails d. wheezing

b. consolidation seen on chest Xray

A 67-yr-old male patient had a right total knee replacement 2 days ago. Upon auscultation of the patient's posterior chest, the nurse detects discontinuous, high-pitched breath sounds just before the end of inspiration in the lower portion of both lungs. Which statement most appropriately reflects how the nurse should document the breath sounds? a) "Bibasilar wheezes present on inspiration." b) "Diminished breath sounds in the bases of both lungs." c) "Fine crackles posterior right and left lower lung fields." d) "Expiratory wheezing scattered throughout the lung fields."

c) "Fine crackles posterior right and left lower lung fields." Fine crackles are described as a series of short-duration, discontinuous, high-pitched sounds heard just before the end of inspiration.

The nurse is interpreting a tuberculin skin test (TST) for a 58-yr-old female patient with end-stage renal disease secondary to diabetes mellitus. Which finding would indicate a positive reaction? a) Acid-fast bacilli cultured at the injection site b) 15-mm area of redness at the TST injection site c) 11-mm area of induration at the TST injection site d) Wheal formed immediately after intradermal injection

c) 11-mm area of induration at the TST injection site An area of induration 10 mm or larger would be a positive reaction in a person with end-stage renal disease. Reddened, flat areas do not indicate a positive reaction. A wheal appears when the TST is administered that indicates correct administration of the intradermal antigen. Presence of acid-fast bacilli in the sputum indicates active tuberculosis.

In developing a weight reduction program with a 45-yr-old female patient who weighs 197 lb, the nurse encourages the patient to set a weight loss goal of how many pounds in 4 weeks? a) 1 to 2 b) 3 to 5 c) 4 to 8 d) 5 to 10

c) 4 to 8 A realistic weight loss goal for patients is 1 to 2 lb/wk, which prevents the patient from becoming frustrated at not meeting weight loss goals.

Which patient would be at highest risk for developing oral candidiasis? a) A 74-yr-old patient who has vitamin B and C deficiencies b) A 22-yr-old patient who smokes 2 packs of cigarettes per day c) A 32-yr-old patient who is receiving ciprofloxacin for 3 weeks d) A 58-yr-old patient who is receiving amphotericin B for 2 days

c) A 32-yr-old patient who is receiving ciprofloxacin for 3 weeks Oral candidiasis is caused by prolonged antibiotic treatment (e.g., ciprofloxacin) or high doses of corticosteroids. Amphotericin B is used to treat candidiasis. Vitamin B and C deficiencies may lead to Vincent's infection. Use of tobacco products leads to stomatitis, not candidiasis.

Which patient is exhibiting an early clinical manifestation of hypoxemia? a) A 48-yr-old patient who is intoxicated and acutely disoriented to time and place b) A 67-yr-old patient who has dyspnea while resting in the bed or in a reclining chair c) A 72-yr-old patient who has four new premature ventricular contractions per minute d) A 94-yr-old patient who has renal insufficiency, anemia, and decreased urine output

c) A 72-yr-old patient who has four new premature ventricular contractions per minute Early clinical manifestations of hypoxemia include dysrhythmias (e.g., premature ventricular contractions), unexplained decreased level of consciousness (e.g., disorientation), dyspnea on exertion, and unexplained decreased urine output.

A patient is planned for discharge home today after ostomy surgery for colon cancer. The nurse should assign the patient to which staff member? a) A nursing assistant on the unit who also has hospice experience b) A licensed practical nurse that has worked on the unit for 10 years c) A registered nurse with 6 months of experience on the surgical unit d) A registered nurse who has floated to the surgical unit from pediatrics

c) A registered nurse with 6 months of experience on the surgical unit The patient needs ostomy care directions and reinforcement at discharge and should be assigned to a registered nurse with experience in providing discharge teaching for ostomy care. Teaching should not be delegated to a licensed practical/vocational nurse or unlicensed assistive personnel.

The patient with chronic gastritis is being put on a combination of medications to eradicate Helicobacter pylori. Which drugs does the nurse know will probably be used? a) Antibiotic(s), antacid, and corticosteroid b) Antibiotic(s), aspirin, and antiulcer/protectant c) Antibiotic(s), proton pump inhibitor, and bismuth d) Antibiotic(s) and nonsteroidal antiinflammatory drugs (NSAIDs)

c) Antibiotic(s), proton pump inhibitor, and bismuth To eradicate H. pylori, a combination of antibiotics, a proton pump inhibitor, and possibly bismuth (for quadruple therapy) will be used. Corticosteroids, aspirin, and NSAIDs are drugs that can cause gastritis and do not affect H. pylori.

The patient is hospitalized with pneumonia. Which diagnostic test should be used to measure the efficiency of gas exchange in the lung and tissue oxygenation? a) Thoracentesis b) Bronchoscopy c) Arterial blood gases d) Pulmonary function tests

c) Arterial blood gases Arterial blood gases are used to assess the efficiency of gas exchange in the lung and tissue oxygenation as is pulse oximetry. Thoracentesis is used to obtain specimens for diagnostic evaluation, remove pleural fluid, or instill medication into the pleural space. Bronchoscopy is used for diagnostic purposes, to obtain biopsy specimens, and to assess changes resulting from treatment. Pulmonary function tests measure lung volumes and airflow to diagnose pulmonary disease, monitor disease progression, evaluate disability, and evaluate response to bronchodilators. Awarded 0.0 points out of 1.0 possible points.

An older male patient visits his primary care provider because of burning on urination and production of foul-smelling urine. What contributing factor should the health care provider consider? a) High-purine diet b) Sedentary lifestyle c) Benign prostatic hyperplasia (BPH) d) Recent use of broad-spectrum antibiotics

c) Benign prostatic hyperplasia (BPH) BPH causes urinary stasis, which is a predisposing factor for UTIs. A sedentary lifestyle and recent antibiotic use are unlikely to contribute to UTIs, but a diet high in purines is associated with renal calculi.

Which clinical manifestations of inflammatory bowel disease does the nurse determine are common to both patients with ulcerative colitis (UC) and Crohn's disease (select all that apply.)? a) Restricted to rectum b) Strictures are common c) Bloody, diarrhea stools d) Cramping abdominal pain e) Lesions penetrate intestine

c) Bloody, diarrhea stools d) Cramping abdominal pain Clinical manifestations of UC and Crohn's disease include bloody diarrhea, cramping abdominal pain, and nutritional disorders. Intestinal lesions associated with UC are usually restricted to the rectum before moving into the colon. Lesions that penetrate the intestine or cause strictures are characteristic of Crohn's disease.

A patient has scleroderma and hypertension. The nurse knows this could be related to which renal diagnoses? a) Obstructive uropathy b) Goodpasture syndrome c) Chronic glomerulonephritis d) Calcium oxalate urinary calculi

c) Chronic glomerulonephritis Hypertension occurs with chronic glomerulonephritis, which may be found in patients with scleroderma. Obstructive uropathy, Goodpasture syndrome, and calcium oxalate urinary calculi are not related to scleroderma and do not cause hypertension.

The nurse, when auscultating the lower lungs of the patient, hears these breath sounds. How should the nurse document these sounds? a) Stridor b) Vesicular c) Coarse crackles d) Bronchovesicular

c) Coarse crackles Coarse crackles are a series of long-duration, discontinuous, low-pitched sounds caused by air passing through an airway intermittently occluded by mucus, an unstable bronchial wall, or a fold of mucosa. Coarse crackles are evident on inspiration and at times expiration. Stridor is a continuous crowing sound of constant pitch from partial obstruction of larynx or trachea. Vesicular sounds are relatively soft, low-pitched, gentle, rustling sounds. They are heard over all lung areas except the major bronchi. Bronchovesicular sounds are normal sounds heard anteriorly over the mainstem bronchi on either side of the sternum and posteriorly between the scapulae with a medium pitch and intensity.

Which instruction should the nurse provide when teaching a patient to exercise the pelvic floor? a) Tighten both buttocks together. b) Squeeze thighs together tightly. c) Contract muscles around rectum. d) Lie on back and lift the legs together.

c) Contract muscles around rectum. To teach pelvic floor exercises (Kegel exercise), the nurse should instruct the patient (without contracting the legs, buttocks, or abdomen) to contract the muscles around the rectum (pelvic floor muscles) as if stopping a stool, which should result in a pelvic lifting sensation.

The patient is calling the clinic with a cough. What assessment should be made first before the nurse advises the patient? a) Frequency, family history, hematemesis b) Weight loss, activity tolerance, orthopnea c) Cough sound, sputum production, pattern d) Smoking status, medications, residence location

c) Cough sound, sputum production, pattern The sound of the cough, sputum production and description, and the pattern of the cough's occurrence (including acute or chronic) and what its occurrence is related to are the first assessments to be made to determine the severity. Frequency of the cough will not provide a lot of information. Family history can help to determine a genetic cause of the cough. Hematemesis is vomiting blood and not as important as hemoptysis. Smoking is an important risk factor for chronic obstructive pulmonary disease, and lung cancer and may cause a cough. Medications may or may not contribute to a cough as does residence location. Weight loss, activity intolerance, and orthopnea may be related to respiratory or cardiac problems, but are not as important when dealing with a cough.

When teaching the patient with chronic obstructive pulmonary disease (COPD) about smoking cessation, what information should be included related to the effects of smoking on the lungs and the increased incidence of pulmonary infections? a) Smoking causes a hoarse voice. b) Cough will become nonproductive. c) Decreased alveolar macrophage function d) Sense of smell is decreased with smoking.

c) Decreased alveolar macrophage function The damage to the lungs includes alveolar macrophage dysfunction that increases the incidence of infections and thus increases patient discomfort and cost to treat the infections. Other lung damage that contributes to infections includes cilia paralysis or destruction, increased mucus secretion, and bronchospasms that lead to sputum accumulation and increased cough. The patient may already be aware of respiratory mucosa damage with hoarseness and decreased sense of smell and taste, but these do not increase the incidence of pulmonary infection

A patient who had a gastroduodenostomy (Billroth I operation) for stomach cancer reports generalized weakness, sweating, palpitations, and dizziness 15 to 30 minutes after eating. What long-term complication does the nurse suspect is occurring? a) Malnutrition b) Bile reflux gastritis c) Dumping syndrome d) Postprandial hypoglycemia

c) Dumping syndrome After a Billroth I operation, dumping syndrome may occur 15 to 30 minutes after eating because of the hypertonic fluid going to the intestine and additional fluid being drawn into the bowel. Malnutrition may occur but does not cause these symptoms. Bile reflux gastritis cannot happen when the stomach has been removed. Postprandial hypoglycemia occurs with similar symptoms, but 2 hours after eating.

The nurse evaluates that nursing interventions to promote airway clearance in a patient admitted with chronic obstructive pulmonary disease (COPD) are successful based on which finding? a) Absence of dyspnea b) Improved mental status c) Effective and productive coughing d) PaO2 within normal range for the patient

c) Effective and productive coughing Airway clearance is most directly evaluated as successful if the patient can engage in effective and productive coughing. Absence of dyspnea, improved mental status, and PaO2 within normal range for the patient show improved respiratory status but do not evaluate airway clearance.

After an exploratory laparotomy, a patient on a clear liquid diet reports severe gas pains and abdominal distention. Which action by the nurse is most appropriate? a) Return the patient to NPO status. b) Place cool compresses on the abdomen. c) Encourage the patient to ambulate as ordered. d) Administer an as-needed dose of IV morphine sulfate.

c) Encourage the patient to ambulate as ordered. Swallowed air and reduced peristalsis after surgery can result in abdominal distention and gas pains. Early ambulation helps restore peristalsis and eliminate flatus and gas pain. Medications used to reduce gas pain include metoclopramide, which stimulates peristalsis. A heating pad can help to alleviate some of the pain and help make the patient more comfortable. There is no need for the patient to return to NPO status. Drinking ginger ale may be helpful.

The nurse determines a patient has experienced the beneficial effects of therapy with famotidine when which symptom is relieved? a) Nausea b) Belching c) Epigastric pain d) Difficulty swallowing

c) Epigastric pain Famotidine is an H2-receptor antagonist that inhibits parietal cell output of HCl acid and minimizes damage to gastric mucosa related to hyperacidity, thus relieving epigastric pain. It is not indicated for nausea, belching, and dysphagia.

The nurse is assigned to care for a patient who has anxiety and an exacerbation of asthma. What is the primary reason for the nurse to carefully inspect the chest wall of this patient? a) Allow time to calm the patient. b) Observe for signs of diaphoresis. c) Evaluate the use of intercostal muscles. d) Monitor the patient for bilateral chest expansion.

c) Evaluate the use of intercostal muscles. The nurse physically inspects the chest wall to evaluate the use of intercostal (accessory) muscles, which gives an indication of the degree of respiratory distress experienced by the patient. The other options may also occur, but they are not the primary reason for inspecting the chest wall of this patient.

A patient is admitted to the emergency department after a motor vehicle crash with suspected abdominal trauma. What assessment finding by the nurse is of highest priority? a) Nausea and vomiting b) Hyperactive bowel sounds c) Firmly distended abdomen d) Abrasions on all extremities

c) Firmly distended abdomen Clinical manifestations of abdominal trauma are guarding and splinting of the abdominal wall; a hard, distended abdomen (indicating possible intra-abdominal bleeding); decreased or absent bowel sounds; contusions, abrasions, or bruising over the abdomen; abdominal pain; pain over the scapula; hematemesis or hematuria; and signs of hypovolemic shock (tachycardia and decreased blood pressure).

Nursing assessment findings of jugular venous distention and pedal edema would be indicative of what complication of chronic obstructive pulmonary disease (COPD)? a) Acute respiratory failure b) Secondary respiratory infection c) Fluid volume excess resulting from cor pulmonale d) Pulmonary edema caused by left-sided heart failure

c) Fluid volume excess resulting from cor pulmonale Cor pulmonale is a right-sided heart failure caused by resistance to right ventricular outflow resulting from lung disease. With failure of the right ventricle, the blood emptying into the right atrium and ventricle would be slowed, leading to jugular venous distention and pedal edema.

A patient who has dysphagia after a stroke is receiving enteral feedings through a percutaneous endoscopic gastrostomy (PEG). What intervention should the nurse integrate into the plan of care? a) Use 30 mL of normal saline to flush the tube every 4 hours. b) Avoid flushing the tube any time the patient is receiving continuous feedings. c) Flush the tube before and after feedings if the patient's feedings are intermittent. d) Flush the PEG with 100 mL of sterile water before and after medication administration.

c) Flush the tube before and after feedings if the patient's feedings are intermittent.: The nurse should flush feeding tubes with 30 mL of water, not normal saline, every 4 hours and before and after medication administration during continuous feeding or before and after intermittent feeding. Flushes of 100 mL are excessive and may cause fluid overload in the patient.

A patient has a sliding hiatal hernia. What nursing intervention will reduce the symptoms of heartburn and dyspepsia? a) Keeping the patient NPO b) Putting the bed in the Trendelenburg position c) Having the patient eat 4 to 6 smaller meals each day d) Giving various antacids to determine which one works for the patient

c) Having the patient eat 4 to 6 smaller meals each day Eating smaller meals during the day will decrease the gastric pressure and symptoms of hiatal hernia. Keeping the patient NPO or in a Trendelenburg position is not safe or realistic for a long period of time for any patient. Varying antacids will only be done with the health care provider's prescription, so this is not a nursing intervention.

Which position is most appropriate for the nurse to place a patient experiencing an asthma exacerbation? a) Supine b) Lithotomy c) High Fowler's d) Reverse Trendelenburg

c) High Fowler's The patient experiencing an asthma attack should be placed in high Fowler's position and may need to lean forward to allow for optimal chest expansion and enlist the aid of gravity during inspiration. The supine, lithotomy, and reverse Trendelenburg positions will not facilitation ventilation.

A 68-yr-old patient with bronchiectasis has copious thick respiratory secretions. Which intervention should the nurse add to the plan of care for this patient? a) Use the incentive spirometer for at least 10 breaths every 2 hours. b) Administer prescribed antibiotics and antitussives on a scheduled basis. c) Increase intake to at least 12 eight-ounce glasses of fluid every 24 hours. d) Provide nutritional supplements that are high in protein and carbohydrates.

c) Increase intake to at least 12 eight-ounce glasses of fluid every 24 hours. Adequate hydration helps to liquefy secretions and thus make it easier to remove them. Unless there are contraindications, the nurse should instruct the patient to drink at least 3 L of fluid daily. Although nutrition, breathing exercises, and antibiotics may be indicated, these interventions will not liquefy or thin secretions. Antitussives may reduce the urge to cough and clear sputum, increasing congestion. Expectorants may be used to liquefy and facilitate clearing secretions

The nurse evaluates that a patient is experiencing the expected beneficial effects of ipratropium after noting which assessment finding? a) Decreased respiratory rate b) Increased respiratory rate c) Increased peak flow readings d) Decreased sputum production

c) Increased peak flow readings Ipratropium is a bronchodilator that should result in increased peak expiratory flow rates.

The patient is having an esophagoenterostomy with anastomosis of a segment of the colon to replace the resected portion. What initial postoperative care should the nurse expect when this patient returns to the nursing unit? a) Turn, deep breathe, cough, and use spirometer every 4 hours. b) Maintain an upright position for at least 2 hours after eating. c) NG will have bloody drainage and it should not be repositioned. d) Keep in a supine position to prevent movement of the anastomosis.

c) NG will have bloody drainage and it should not be repositioned. The patient will have bloody drainage from the nasogastric (NG) tube for 8 to 12 hours, and it should not be repositioned or reinserted without contacting the surgeon. Turning and deep breathing will be done every 2 hours, and the spirometer will be used more often than every 4 hours. Coughing would put too much pressure in the area and should not be done. Because the patient will have the NG tube, the patient will not be eating yet. The patient should be kept in a semi-Fowler's or Fowler's position, not supine, to prevent reflux and aspiration of secretions.

During an assessment of a 45-yr-old patient with asthma, the nurse notes wheezing and dyspnea. The nurse interprets that these symptoms are related to what pathophysiologic change? a) Laryngospasm b) Pulmonary edema c) Narrowing of the airway d) Overdistention of the alveoli

c) Narrowing of the airway Narrowing of the airway by persistent but variable inflammation leads to reduced airflow, making it difficult for the patient to breathe and producing the characteristic wheezing. Laryngospasm, pulmonary edema, and overdistention of the alveoli do not produce wheezing.

A 74-yr-old female patient with osteoporosis is diagnosed with gastroesophageal reflux disease (GERD). Which over-the-counter medication to treat GERD should be used with caution? a) Sucralfate b) Cimetidine c) Omeprazole d) Metoclopramide

c) Omeprazole There is a potential link between proton pump inhibitors (PPIs) (e.g., omeprazole) use and bone metabolism. Long-term use or high doses of PPIs may increase the risk of fractures of the hip, wrist, and spine.

When teaching the patient with cystic fibrosis about the diet and medications, what is the priority information to be included in the discussion? a) Fat soluble vitamins and dietary salt should be avoided. b) Insulin may be needed with a diabetic diet if diabetes mellitus develops. c) Pancreatic enzymes and adequate fat, calories, protein, and vitamins are needed. d) Distal intestinal obstruction syndrome (DIOS) can be treated with increased water.

c) Pancreatic enzymes and adequate fat, calories, protein, and vitamins are needed. The patient must take pancreatic enzymes before each meal and snack and adequate fat, calories, protein, and vitamins should be eaten. Fat-soluble vitamins are needed because they are malabsorbed with the excess mucus in the gastrointestinal system. Insulin may be needed, but there is no longer a diabetic diet, and this is not priority information at this time. DIOS develops in the terminal ileum and is treated with balanced polyethylene glycol electrolyte solution (MiraLAX) to thin bowel contents.

The nurse recognizes that the majority of patients' caloric needs should come from which source? a) Fats b) Proteins c) Polysaccharides d) Monosaccharides

c) Polysaccharides: Carbohydrates should constitute between 45% and 65% of caloric needs compared with 20% to 35% from fats and 10% to 35% from proteins. Polysaccharides are the complex carbohydrates that are contained in breads and grains. Monosaccharides are simple sugars.

The nurse teaches pursed-lip breathing to a patient who is newly diagnosed with chronic obstructive pulmonary disease (COPD). The nurse reinforces that this technique will assist respiration by which mechanism? a) Loosening secretions so that they may be coughed up more easily b) Promoting maximal inhalation for better oxygenation of the lungs c) Preventing bronchial collapse and air trapping in the lungs during exhalation d) Increasing the respiratory rate and giving the patient control of respiratory patterns

c) Preventing bronchial collapse and air trapping in the lungs during exhalation The purpose of pursed-lip breathing is to slow down the exhalation phase of respiration, which decreases bronchial collapse and subsequent air trapping in the lungs during exhalation. It does not affect secretions, inhalation, or increase the rate of breathing.

The nurse determines that the patient is not experiencing adverse effects of albuterol (Proventil) after noting which patient vital sign? a) Temperature of 98.4°F b) Oxygen saturation 96% c) Pulse rate of 72 beats/min d) Respiratory rate of 18/ breaths/min

c) Pulse rate of 72 beats/min Albuterol is a β2-agonist that can sometimes cause adverse cardiovascular effects. These would include tachycardia and angina. A pulse rate of 72 beats/min indicates that the patient did not experience tachycardia as an adverse effect.

After administration of a dose of metoclopramide, which patient assessment finding would show the medication was effective? a) Decreased blood pressure b) Absence of muscle tremors c) Relief of nausea and vomiting d) No further episodes of diarrhea

c) Relief of nausea and vomiting Metoclopramide is classified as a prokinetic and antiemetic medication. If it is effective, the patient's nausea and vomiting should resolve. Metoclopramide does not affect blood pressure, muscle tremors, or diarrhea.

A patient with an intestinal obstruction has a nasogastric (NG) tube to suction but complains of nausea and abdominal distention. The nurse irrigates the tube as necessary as ordered, but the irrigating fluid does not return. What should be the priority action by the nurse? a) Notify the physician. b) Auscultate for bowel sounds. c) Reposition the tube and check for placement. d) Remove the tube and replace it with a new one.

c) Reposition the tube and check for placement. The tube may be resting against the stomach wall. The first action by the nurse is to reposition the tube and check it again for placement. The physician does not need to be notified unless the nurse cannot restore the tube function. The patient does not have bowel sounds, which is why the NG tube is in place. The NG tube would not be removed and replaced unless it was no longer in the stomach or the obstruction of the tube could not be relieved.

When caring for a patient with nephrotic syndrome, which food selection indicates the patient understands dietary teaching? a) Peanut butter and crackers b) One small grilled pork chop c) Salad made of fresh vegetables d) Spaghetti with canned spaghetti sauce

c) Salad made of fresh vegetables Of the options listed, only salad made with fresh vegetables would be acceptable for the diet that limits sodium and protein as well as saturated fat if hyperlipidemia is present. Peanut butter and crackers are processed, so they contain significant sodium, and peanut butter contains some protein. A pork chop is a high-protein food with saturated fat. Canned spaghetti sauce is also high in sodium.

If a patient has a colostomy in the area known as the "ascending colon," what would the nurse expect of the stool in the colostomy device? a) Stool would be dark. b) Stool would be formed. c) Stool would be loose. d) Stool would have flecks of blood.

c) Stool would be loose. The correct answer is C because stool in the ascending colon is loose or watery. Stool should not be dark or have flecks of blood. This would be an abnormal finding. Stool would not be loose, because the colon has not reabsorbed the water yet.

The nurse is assigned to care for a patient in the emergency department admitted with an exacerbation of asthma. The patient has received a â-adrenergic bronchodilator and supplemental oxygen. If the patient's condition does not improve, the nurse should anticipate what as the most likely next step in treatment? a) IV fluids b) Biofeedback therapy c) Systemic corticosteroids d) Pulmonary function testing

c) Systemic corticosteroids Systemic corticosteroids speed the resolution of asthma exacerbations and are indicated if the initial response to the β-adrenergic bronchodilator is insufficient. IV fluids may be used but not to improve ventilation. Biofeedback therapy and pulmonary function testing may be used after recovery to assist the patient and monitor the asthma.

The nurse is caring for a 48-yr-old male patient admitted for exacerbation of chronic obstructive pulmonary disease. The patient develops severe dyspnea at rest, with a change in respiratory rate from 26 breaths/min to 44 breaths/min. Which action by the nurse would be the most appropriate? a) Have the patient perform huff coughing. b) Perform chest physiotherapy for 5 minutes. c) Teach the patient to use pursed-lip breathing. d) Instruct the patient in diaphragmatic breathing.

c) Teach the patient to use pursed-lip breathing. Pursed-lip breathing (PLB) prolongs exhalation and prevents bronchiolar collapse and air trapping. PLB is simple and easy to teach and learn. It also gives the patient more control over breathing. Evidence from controlled studies does not support the use of diaphragmatic breathing in patients with COPD. Diaphragmatic breathing results in hyperinflation because of increased fatigue and dyspnea and abdominal paradoxical breathing rather than with normal chest wall motion. Chest physiotherapy (percussion and vibration) is used primarily for patients with excessive bronchial secretions who have difficulty clearing them. Huff coughing is a technique that helps patients with COPD to use a forced expiratory technique to clear secretions.

In developing an effective weight reduction plan for an overweight patient who expresses willingness to try to lose weight, which factor should the nurse assess first? a) The length of time the patient has been obese b) The patient's current level of physical activity c) The patient's social, emotional, and behavioral influences on obesity d) Anthropometric measurements, such as body mass index and skinfold thickness

c) The patient's social, emotional, and behavioral influences on obesity

During the assessment in the emergency department, the nurse is palpating the patient's chest. Which finding is a medical emergency? a) Increased tactile fremitus b) Diminished chest movement c) Tracheal deviation to the left d) Decreased anteroposterior (AP) diameter

c) Tracheal deviation to the left Tracheal deviation is a medical emergency when it is caused by a tension pneumothorax. Tactile fremitus increases with pneumonia or pulmonary edema and decreases in pleural effusion or lung hyperinflation. Diminished chest movement occurs with barrel chest, restrictive disease, and neuromuscular disease.

A patient with a history of cardiac problems talks with the nurse about bowel elimination. The nurse stresses to the patient not to strain during bowel movements. Straining can put pressure on the vagus nerve and cause bradycardia. The nurse is explaining which physiological action? a) First-degree heart block b) Eupnea c) Valsalva maneuver d) Tachypnea

c) Valsalva maneuver The Valsalva maneuver happens when the cardiac patient strains to have a bowel movement. First-degree heart block is not brought on by straining. Eupnea means normal respirations and tachypnea means fast respirations; neither has any connection to straining during a bowel movement.

The nurse is providing care for a patient who is a strict vegetarian. Which dietary choices would the nurse recommend to prevent iron deficiency? A)Brown rice and kidney beans b)Cauliflower and egg substitutes c)Soybeans and hot breakfast cereal d)Whole-grain bread and citrus fruits

c)Soybeans and hot breakfast cereal: Vegetarians are at a particular risk for iron deficiency, a problem that can be prevented by regularly consuming high-iron foods such as hot cereals and soybeans. The other foods listed are not classified as high sources of iron.

Which of the following lab results is an expected finding in a patient with advanced COPD that occurs when the body is attempting to compensate for hypoxemia? a. A white blood cell count of 16,000 b. A white blood cell count of 2,000 c. A hemoglobin level of 20.0 d. A hemoglobin level of 6.0

c. A hemoglobin level of 20.0

The nurse is taking care of Miguel who is a 67-year-old patient with COPD. Miguel begins to have an episode of severe shortness of breath and asks for his inhaler. Which type of inhaler would be most appropriate to give Miguel at this time? a. Fluticasone b. Salmeterol c. Albuterol d. Symbicort

c. Albuterol

Which of the following is NOT true about encopresis? a. Withholding behavior and constipation may cause rectal dilation b. Interventions may include bowel training and use of laxatives c. Encopresis is equally common in girls and boys d. Fecal impaction may lead to uncontrollable passage of liquid stool

c. Encopresis is equally common in girls and boys. Boys get screwed and I am so lucky I am a girl

The nurse is caring for a patient with COPD. The patient completes pulmonary function testing and her post-bronchodilator FEV1 is 40% of predicted. The nurse knows that this patient falls into which GOLD category? a. GOLD 1 b. GOLD 2 c. GOLD 3 d. GOLD 4

c. GOLD 3

Failure of the sodium-potassium pump during severe protein depletion may lead to: a. Ascites b. Anemia c. Hyperkalemia d. Hypoalbuminemia

c. Hyperkalemia-Potassium becomes extracellular, raising the serum potassium level.

The nurse inserts a nasogastric tube and 1200 mL of fluid immediately drains from the tube. Which of the following electrolyte imbalance is of greatest concern at this time? a. Hypernatremia b. Hypocalcemia c. Hypokalemia d. Hypermagnesemia

c. Hypokalemia

An indication for nutritional supplementation that is not appropriate for enteral tube feeding is: a. Head and neck cancer b. Hypermetabolic states c. Malabsorption syndrome d. Protein-calorie undernutrition

c. Malabsorption syndrome

1. A 76-yr-old patient with constipation has a fecal impaction and is incontinent of liquid stool. Which action should the nurse take first? a. Increase the patient's oral fluid intake b. Administer bulk-forming laxatives c. Manually remove the impacted stool d. Assist the patient to sit on the toilet

c. Manually remove the impacted stool

When a patient's serum sodium level is decreased (120 mEq/L), the priority nursing assessment is to monitor the status of which body system? a. Gastrointestinal b. Pulmonary c. Neurological d. Hepatic

c. Neurological

What is the primary pathophysiologic process of asthma? a. Airflow limitation b. airway hyperresponsiveness c. Persistent but variable inflammation of the airways d. Airway remodeling

c. Persistent but variable inflammation of the airways

A patient, diagnosed with hypocalcemia, develops a carpopedal spasm after the blood pressure cuff is inflated. The nurse should record this as: a. Positive Chvostek sign b. Paresthesia c. Positive Trousseau sign d. Tetany

c. Positive Trousseau sign

1. You are caring for a patient with short bowel syndrome. The nursing diagnosis that is most appropriate for this patient is a. Risk for fluid volume overload due to malnutrition b. Risk for imbalanced nutrition due to excessive caloric intake c. Risk for fluid volume deficit due to malnutrition d. Risk for impaired gas exchange due to malnutrition

c. Risk for fluid volume deficit due to malnutrition

Protein degradation occurs in which stage of starvation: a. Stage I b. Stage II c. Stage III

c. Stage III

Following a morning shift assessment, the nurse determines which client is most likely to develop problems with constipation a. The client who consumes a high-fiber diet b. The client receiving Bactrim (antibiotic) for an infection c. The client with history of chronic laxative use d. The client who has 2,200 mL/day fluid intake

c. The client with history of chronic laxative use

Sally gets continuous feeding through a NG tube. The nurse knows: a. To always keep the head of the bed at 10 degrees b. NG tubes deliver nutrition parenterally c. To always keep the head of the bed elevated when the tube feed is running d. Residual does not need to be checked for patients with NG tubes

c. To always keep the head of the bed elevated when the tube feed is running

Your patient with constipation asks you which foods are NOT high in fiber. You respond: a. Raspberries b. Broccoli c. White rice d. Bran

c. White rice

A patient has acute gastroenteritis with watery diarrhea. Which statement by this patient would indicate that the nurse's teaching has been effective? a) "I should drink a lot of tap water today." b) "I need to take more calcium tablets today." c) "I should avoid fruits with potassium in them." d) "I need to drink liquids with some sodium in them."

d) "I need to drink liquids with some sodium in them." Sodium-containing fluids are removed from the body by acute diarrhea and must be replaced to prevent an extracellular fluid volume (ECV) deficit. Drinking tap water will not prevent ECV deficit from diarrhea, because tap water does not contain enough sodium to hold the water in the extracellular compartment. Taking calcium tablets is an incorrect answer because hypocalcemia is characteristic of chronic diarrhea rather than acute diarrhea. Restricting fruits is an incorrect answer because diarrhea increases the potassium output and the potassium intake should be increased to balance it.

Which statement made by the patient with chronic obstructive pulmonary disease (COPD) indicates a need for further teaching regarding the use of an ipratropium inhaler? a) "I can rinse my mouth following the two puffs to get rid of the bad taste." b) "I should wait at least 1 to 2 minutes between each puff of the inhaler." c) "Because this medication is not fast acting, I cannot use it in an emergency if my breathing gets worse." d) "If my breathing gets worse, I should keep taking extra puffs of the inhaler until I can breathe more easily."

d) "If my breathing gets worse, I should keep taking extra puffs of the inhaler until I can breathe more easily." The patient should not just keep taking extra puffs of the inhaler to make breathing easier. Excessive treatment could trigger paradoxical bronchospasm, which would worsen the patient's respiratory status. Rinsing the mouth after the puffs will eliminate a bad taste. Waiting 1 to 2 minutes between each puff will facilitate the effectiveness of the administration. Ipratropium is not used in an emergency for COPD.

At the first visit to the clinic, the female patient with a BMI of 29 kg/m2 tells the nurse that she does not want to become obese. Which question used for assessing weight issues would be most effective? a) "What factors contributed to your current body weight?" b) "How is your overall health affected by your body weight?" c) "What is your history of gaining weight and losing weight?" d) "In what ways are you interested in managing your weight differently?"

d) "In what ways are you interested in managing your weight differently?" Asking the patient about her desire to manage her weight in a different manner helps the nurse determine the patient's readiness for learning, degree of motivation, and willingness to change lifestyle habits. The nurse can help the patient set realistic goals

The nurse is preparing to administer a dose of bisacodyl to a patient with constipation and the patient asks how it will work. What is the best response by the nurse? a) "It will increase bulk in the stool." b) "It will lubricate the intestinal tract to soften feces." c) "It will increase fluid retention in the intestinal tract." d) "It will increase peristalsis by stimulating nerves in the colon wall."

d) "It will increase peristalsis by stimulating nerves in the colon wall." Bisacodyl is a stimulant laxative that aids in producing a bowel movement by irritating the colon wall and stimulating enteric nerves. Fiber and bulk- forming drugs increase bulk in the stool. Water and stool softeners soften feces, and saline and osmotic solutions cause fluid retention in the intestinal tract.

The severely obese patient has elected to have the Roux-en-Y gastric bypass (RYGB) procedure. The nurse will know the patient understands the preoperative teaching when the patient makes which statement? a) "This surgery will preserve the function of my stomach." b) "This surgery will remove the fat cells from my abdomen." c) "This surgery can be modified whenever I need it to be changed." d) "This surgery decreases how much I can eat and how many calories I can absorb."

d) "This surgery decreases how much I can eat and how many calories I can absorb." The RYGB decreases the size of the stomach to a gastric pouch and attaches it directly to the small intestine so food bypasses 90% of the stomach, the duodenum, and a small segment of the jejunum. The vertical sleeve gastrectomy removes 85% of the stomach but preserves the function of the stomach. Lipectomy and liposuction remove fat tissue from the abdomen or other areas. Adjustable gastric banding can be modified or reversed at a later date.

The nurse is teaching a group of college students how to prevent food poisoning. Which comment shows an understanding of foodborne illness protection? a) "Eating raw cookie dough from the package is a great snack when you do not have time to bake." b) "Since we only have one cutting board, we can cut up chicken and salad vegetables at the same time." c) "To save refrigerator space, leftover food can be kept on the counter if it is in sealed containers." d) "When the cafeteria gave me a pink hamburger, I sent it back and asked for a new bun and clean plate."

d) "When the cafeteria gave me a pink hamburger, I sent it back and asked for a new bun and clean plate." The student who did not accept the pink hamburger and asked for a new bun and clean plate understood that the pink meat may not have reached 160°F and could be contaminated with bacteria. Improperly storing cooked foods, eating raw cookie dough from a refrigerated package, and only using one cutting board without washing it with hot soapy water between the chicken and salad vegetables could all lead to food poisoning from contamination.

A patient has been receiving oxygen per nasal cannula while hospitalized for chronic obstructive pulmonary disease (COPD). The patient asks the nurse whether oxygen use will be needed at home. What is the most appropriate response by the nurse? a) "Long-term home oxygen therapy should be used to prevent respiratory failure." b) "Oxygen will not be needed until or unless you are in the terminal stages of this disease." c) "Long-term home oxygen therapy should be used to prevent heart problems related to COPD." d) "You will not need oxygen until your oxygen saturation drops to 88% and you have symptoms of hypoxia."

d) "You will not need oxygen until your oxygen saturation drops to 88% and you have symptoms of hypoxia." Long-term oxygen therapy in the home will not be considered until the oxygen saturation is less than or equal to 88% and the patient has signs of tissue hypoxia, such as cor pulmonale, erythrocytosis, or impaired mental status. PaO2 less than 55 mm Hg will also allow home oxygen therapy to be considered.

Which patient is at risk for developing metabolic syndrome? a) A 62-yr-old white man who has coronary artery disease with chronic stable angina b) A 54-yr-old Hispanic woman who is sedentary and has nephrogenic diabetes insipidus c)A 27-yr-old Asian American woman who has preeclampsia and gestational diabetes mellitus d) A 38-yr-old Native American man who has diabetes mellitus and elevated hemoglobin A1C

d) A 38-yr-old Native American man who has diabetes mellitus and elevated hemoglobin A1C: African Americans, Hispanics, Native Americans, and Asians are at an increased risk for development of metabolic syndrome. Other risk factors include individuals who have diabetes that cannot maintain a normal glucose level, have hypertension, and secrete a large amount of insulin, or who have survived a heart attack and have hyperinsulinemia.

The nurse is reviewing the laboratory test results for a patient with metastatic lung cancer who was admitted with a diagnosis of malnutrition. The serum albumin level is 4.0 g/dL, and prealbumin is 10 mg/dL. How will the nurse interpret these results? a) The albumin level is normal therefore the patient does not have protein malnutrition. b) The albumin level is increased, which is common in patients with cancer who have malnutrition. c) Both the serum albumin and prealbumin levels are reduced, consistent with the diagnosis of malnutrition. d) Although the serum albumin level is normal, the prealbumin level more accurately reflects the patient's nutritional status.

d) Although the serum albumin level is normal, the prealbumin level more accurately reflects the patient's nutritional status.: Prealbumin has a half-life of 2 days and is a better indicator of recent or current nutritional status. Serum albumin has a half-life of approximately 20 to 22 days. The serum level may lag behind actual protein changes by more than 2 weeks and is therefore not the best indicator of acute changes in nutritional status.

The nurse is preparing to administer a scheduled dose of docusate sodium when the patient reports an episode of loose stool and does not want to take the medication. What is the appropriate action by the nurse? a) Write an incident report about this untoward event. b) Attempt to have the family convince the patient to take the ordered dose. c) Withhold the medication at this time and try to administer it later in the day. d) Chart the dose as not given on the medical record and explain in the nursing progress notes.

d) Chart the dose as not given on the medical record and explain in the nursing progress notes. Whenever a patient refuses medication, the dose should be charted as not given with an explanation of the reason documented in the nursing progress notes. In this instance, the refusal indicates good judgment by the patient, and the patient should not be encouraged to take it today.

After identifying that a patient has possible nutritional deficits, which action will the nurse perform next? a) Provide supplements between meals. b) Encourage eating meals with others. c) Have family bring in food from home. d) Complete a full nutritional assessment.

d) Complete a full nutritional assessment.

The nurse is providing care for a patient admitted to the hospital for treatment of nephrotic syndrome. What are the priority nursing assessments? a) Assessment of pain and level of consciousness b) Assessment of serum calcium and phosphorus levels c) Blood pressure and assessment for orthostatic hypotension d) Daily weights and measurement of the patient's abdominal girth

d) Daily weights and measurement of the patient's abdominal girth Peripheral edema is characteristic of nephrotic syndrome, and a key nursing responsibility in the care of patients with the disease is close monitoring of abdominal girth, weights, and extremity size. Pain, level of consciousness, and orthostatic blood pressure are less important in the care of patients with nephrotic syndrome. Abnormal calcium and phosphorus levels are not commonly associated with the diagnosis of nephrotic syndrome.

After swallowing, a 73-yr-old patient is coughing and has a wet voice. What changes of aging could be contributing to this abnormal finding? a) Decreased response to hypercapnia b) Decreased number of functional alveoli c) Increased calcification of costal cartilage d) Decreased respiratory defense mechanisms

d) Decreased respiratory defense mechanisms These manifestations are associated with aspiration, which more easily occur in the right lung as the right mainstem bronchus is shorter, wider, and straighter than the left mainstem bronchus. Aspiration occurs more easily in the older patient related to decreased respiratory defense mechanisms (e.g., decreases in immunity, ciliary function, cough force, sensation in pharynx). Changes of aging include a decreased response to hypercapnia, decreased number of functional alveoli, and increased calcification of costal cartilage, but these do not increase the risk of aspiration.

The nurse requests a patient scheduled for colectomy to sign the operative permit as directed in the physician's preoperative orders. The patient states that the physician has not really explained very well what is involved in the surgical procedure. What is the most appropriate action by the nurse? a) Ask family members whether they have discussed the surgical procedure with the physician. b) Have the patient sign the form and state the physician will visit to explain the procedure before surgery. c) Explain the planned surgical procedure as well as possible and have the patient sign the consent form. d) Delay the patient's signature on the consent and notify the physician about the conversation with the patient.

d) Delay the patient's signature on the consent and notify the physician about the conversation with the patient. The patient should not be asked to sign a consent form unless the procedure has been explained to the satisfaction of the patient. The nurse should notify the physician, who has the responsibility for obtaining consent.

The nurse is admitting a patient with severe dehydration and frequent watery diarrhea. A 10-day outpatient course of antibiotic therapy for bacterial pneumonia has just been completed. What is the most important for the nurse to take which action? a) Wear a mask to prevent transmission of infection. b) Wipe equipment with ammonia-based disinfectant. c) Instruct visitors to use the alcohol-based hand sanitizer. d) Don gloves and gown before entering the patient's room.

d) Don gloves and gown before entering the patient's room. Clostridium difficile is an antibiotic-associated diarrhea transmitted by contact, and the spores are extremely difficult to kill. Patients with suspected or confirmed infection with C. difficile should be placed in a private room, and gloves and gowns should be worn by visitors and health care providers. Alcohol-based hand cleaners and ammonia-based disinfectants are ineffective and do not kill all of the spores. Equipment cannot be shared with other patients, and a disposable stethoscope and individual patient thermometer are kept in the room. Objects should be disinfected with a 10% solution of household bleach.

When teaching the patient about the diet for diverticular disease, which foods should the nurse recommend? a) White bread, cheese, and green beans b) Fresh tomatoes, pears, and corn flakes c) Oranges, baked potatoes, and raw carrots d) Dried beans, All Bran (100%) cereal, and raspberries

d) Dried beans, All Bran (100%) cereal, and raspberries A high-fiber diet is recommended for diverticular disease. Dried beans, All Bran (100%) cereal, and raspberries all have higher amounts of fiber than white bread, cheese, green beans, fresh tomatoes, pears, corn flakes, oranges, baked potatoes, and raw carrots.

Which patient has the morbidity risk? a) Male 6 ft, 1 in. tall; BMI 29 kg/m2 b) Female 5 ft, 6 in. tall; weight 150 lb c) Male with waist circumference 46 in d) Female 5 ft, 10 in. tall; obesity class III

d) Female 5 ft, 10 in. tall; obesity class III: The patient in class III obesity has the risk for disease because class III denotes severe obesity or a BMI greater than 40 kg/m2. The patient with the waist circumference of 46 in has a high risk for disease, but without the BMI or obesity class, a more precise determination cannot be mad

The nurse is caring for a patient admitted with a suspected bowel obstruction. The nurse auscultating the abdomen listens for which type of bowel sounds that are consistent with the patient's clinical picture? a) Low-pitched and rumbling above the area of obstruction b) High-pitched and hypoactive below the area of obstruction c) Low-pitched and hyperactive below the area of obstruction d) High-pitched and hyperactive above the area of obstruction

d) High-pitched and hyperactive above the area of obstruction Early in intestinal obstruction, the patient's bowel sounds are hyperactive and high pitched, sometimes referred to as "tinkling," above the level of the obstruction. This occurs because peristaltic action increases to "push past" the area of obstruction. As the obstruction becomes complete, bowel sounds decrease and finally become absent.

When the patient is experiencing metabolic acidosis secondary to type 1 diabetes mellitus, what physiologic response should the nurse expect to assess in the patient? a) Vomiting b) Increased urination c) Decreased heart rate d) Increased respiratory rate

d) Increased respiratory rate When a patient with type 1 diabetes has hyperglycemia and ketonemia causing metabolic acidosis, the physiologic response is to increase the respiratory rate and tidal volume to blow off the excess CO2. Vomiting and increased urination may occur with hyperglycemia, but not as physiologic responses to metabolic acidosis. The heart rate will increase.

The nurse supervises a team including another registered nurse (RN), a licensed practical/vocational nurse (LPN/LVN), and unlicensed assistive personnel (UAP) on a medical unit. The team is caring for many patients with respiratory problems. In what situation should the nurse intervene with teaching for a team member? a) LPN/LVN obtained a pulse oximetry reading of 94% but did not report it. b) RN taught the patient about home oxygen safety in preparation for discharge. c) UAP report to the nurse that the patient is complaining of difficulty breathing. d) LPN/LVN changed the type of oxygen device based on arterial blood gas results.

d) LPN/LVN changed the type of oxygen device based on arterial blood gas results. It is not within the LPN scope to change oxygen devices based on analysis of lab results. It is within the scope of practice of the RN to assess, teach, and evaluate. The LPN provides care for stable patients and may adjust oxygen flow rates depending on desired oxygen saturation levels of stable patients. The UAP may obtain oxygen saturation levels, assist patients with comfort adjustment of oxygen devices, and report changes in patient's level of consciousness or difficulty breathing.

The nurse is administering a cathartic agent to a patient with renal insufficiency. Which order will the nurse question? a) Bisacodyl b) Lubiprostone c) Cascara sagrada d) Magnesium hydroxide

d) Magnesium hydroxide Milk of Magnesia may cause hypermagnesemia in patients with renal insufficiency. The nurse should question this order with the health care provider. Bisacodyl, lubiprostone, and cascara sagrada are safe to use in patients with renal insufficiency as long as the patient is not currently dehydrated.

A patient admitted to the emergency department after a motor vehicle accident. Which urinalysis findings would the nurse expect if kidney trauma occurred (select all that apply.)? a) Casts b) Glucose c) Bilirubin d) Myoglobinuria e) Red blood cells f) White blood cells

d) Myoglobinuria e) Red blood cells After kidney trauma, the nurse will expect urinalysis results to be positive for myoglobin and red blood cells. Casts in urine indicate blood destruction intravascularly. Glucose in urine could indicate diabetes. Bilirubin in urine is suggestive liver dysfunction. White blood cells in urine indicate infection.

The nurse is caring for a 73-yr-old male patient with a history of benign prostatic hyperplasia and symptoms of a urinary tract infection. Which diagnostic finding would support this diagnosis? a) White blood cell count is 7500 cells/µL. b) Antistreptolysin-O (ASO) titer is 106 Todd units/mL. c) Glucose, protein, and ketones are present in the urine. d) Nitrites and leukocyte esterase are present in the urine.

d) Nitrites and leukocyte esterase are present in the urine. A diagnosis of urinary tract infection is suspected if there are nitrites (indicating bacteriuria), white blood cells (WBCs), and leukocyte esterase (an enzyme present in WBCs indicating pyuria). The presence of glucose and ketones indicate uncontrolled diabetes mellitus. An elevated WBC count (>11,000 cells/µL) indicates a bacterial infection. AASO titer is a blood test to measure antibodies against streptolysin O, a substance produced by group A Streptococcus bacteria.

In the immediate postoperative period a nurse cares for a severely obese 72-yr-old man who had surgery for repair of a lower leg fracture. Which assessment is most important? a) Cardiac rhythm b) Surgical dressing c) Postoperative pain d) Oxygen saturation

d) Oxygen saturation : After surgery, an older or severely obese patient should be closely monitored for oxygen desaturation. The body stores anesthetics in adipose tissue, placing patients with excess adipose tissue (e.g., obesity, older) at risk for resedation. As adipose cells release anesthetic back into the bloodstream, the patient may become sedated after surgery. This may depress the respiratory rate and result in a drop in oxygen saturation.

A patient who is unable to swallow because of progressive amyotrophic lateral sclerosis is prescribed enteral nutrition through a newly placed gastrostomy tube. Which task is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a)Irrigate the tube between feedings. b)Provide wound care at the gastrostomy site. c)Administer prescribed liquid medications through the tube. d)Position the patient with a 45-degree head of bed elevation.

d) Position the patient with a 45-degree head of bed elevation.

A patient with a recent history of a dry cough has had a chest x-ray that revealed the presence of nodules. In an effort to determine whether the nodules are malignant or benign, what is the primary care provider likely to order? a) Thoracentesis b) Pulmonary angiogram c) CT scan of the patient's chest d) Positron emission tomography (PET)

d) Positron emission tomography (PET) PET is used to distinguish benign and malignant pulmonary nodules. Because malignant lung cells have an increased uptake of glucose, the PET scan (which uses an IV radioactive glucose preparation) can demonstrate increased uptake of glucose in malignant lung cells. This differentiation cannot be made using CT, a pulmonary angiogram, or thoracentesis.

A patient was admitted with epigastric pain because of a gastric ulcer. Which patient assessment warrants an urgent change in the nursing plan of care? a) Back pain 3 or 4 hours after eating a meal b) Chest pain relieved with eating or drinking water c) Burning epigastric pain 90 minutes after breakfast d) Rigid abdomen and vomiting following indigestion

d) Rigid abdomen and vomiting following indigestion A rigid abdomen with vomiting in a patient who has a gastric ulcer indicates a perforation of the ulcer, especially if the manifestations of perforation appear suddenly. Midepigastric pain is relieved by eating, drinking water, or antacids with duodenal ulcers, not gastric ulcers. Back pain 3 to 4 hours after a meal is more likely to occur with a duodenal ulcer. Burning epigastric pain 1 to 2 hours after a meal is an expected manifestation of a gastric ulcer related to increased gastric secretions and does not cause an urgent change in the nursing plan of care.

The nurse is assisting a patient to learn self-administration of beclomethasone, two puffs inhaled every 6 hours. What should the nurse explain as the best way to prevent oral infection while taking this medication? a) Chew a hard candy before the first puff of medication. b) Rinse the mouth with water before each puff of medication. c) Ask for a breath mint after the second puff of medication. d) Rinse the mouth with water after the second puff of medication.

d) Rinse the mouth with water after the second puff of medication. Because beclomethasone is a corticosteroid, the patient should rinse the mouth with water after the second puff of medication to reduce the risk of fungal overgrowth and oral infection.

The nurse is preparing to administer a daily dose of docusate sodium to a patient that will continue taking it after discharge. What information should the nurse provide to the patient to optimize the outcome of the medication? a) Take a dose of mineral oil at the same time. b) Add extra salt to food on at least one meal tray. c) Ensure a dietary intake of 10 g of fiber each day. d) Take each dose with a full glass of water or other liquid.

d) Take each dose with a full glass of water or other liquid. Docusate lowers the surface tension of stool, permitting water and fats to penetrate and soften the stool for easier passage. The patient should take the dose with a full glass of water and should increase overall fluid intake, if able, to enhance effectiveness of the medication. Dietary fiber intake should be a minimum of 20 g daily to prevent constipation. Mineral oil and extra salt are not recommended.

A patient received a small-bore nasogastric (NG) tube after a laryngectomy. Which action has the highest priority before initiating enteral feedings? a) Testing aspirated fluid pH b) Auscultating while instilling air c) Elevating head of bed to 40 degrees d) Verifying NG tube placement on x-ray

d) Verifying NG tube placement on x-ray: It is imperative to ensure that an NG tube is in the gastrointestinal tract rather than the patient's lungs. When an NG tube has been recently inserted, it is important to confirm this placement with an x-ray that will identify the tube's radiopaque tip.

Before discharge, the nurse discusses activity levels with a 61-yr-old patient with chronic obstructive pulmonary disease (COPD) and pneumonia. Which exercise goal is most appropriate once the patient is fully recovered from this episode of illness? a) Slightly increase activity over the current level. b) Swim for 10 min/day, gradually increasing to 30 min/day. c) Limit exercise to activities of daily living to conserve energy. d) Walk for 20 min/day, keeping the pulse rate less than 130 beats/min.

d) Walk for 20 min/day, keeping the pulse rate less than 130 beats/min. The patient will benefit from mild aerobic exercise that does not stress the cardiorespiratory system. The patient should be encouraged to walk for 20 min/day, keeping the pulse rate less than 75% to 80% of maximum heart rate (220 - patient's age).

A client is diagnosed with celiac disease following a work-up for iron-deficiency anemia and decreased bone density. The nurse identifies that additional teaching about disease management is needed with the client says: a. "I should ask my close relatives to be screened for celiac disease." b. "If I do not follow a gluten-free diet I might develop lymphoma." c. "It is going to be difficult to follow a gluten-free diet because it is found in so many foods. d. "I don't need to restrict gluten intake because I don't have diarrhea or bowel symptoms

d. "I don't need to restrict gluten intake because I don't have diarrhea or bowel symptoms

Identify the subjective data related to nutrition: a. Waist circumference b. Body mass index c. Height and weight d. 24 hour recall of diet

d. 24 hour recall of diet

Which of the following are NOT causes of urinary incontinence? a. Delirium, dehydration, and depression b. infection, inflammation, and impaction c. restricted mobility and rectal impaction d. Acute otitis media and sinusitis

d. Acute otitis media and sinusitis

The nurse is caring for a patient newly diagnosed with asthma. The nurse knows more teaching is necessary of the patient makes which of the following statements? a. I will use my albuterol inhaler when I am experiencing shortness of breath b. I will notify my healthcare provider if I am using my rescue inhaler more than twice per week c. I will rinse my mouth after using my fluticasone inhaler d. As long as I have my rescue inhaler with me I do not need to avoid asthma triggers

d. As long as I have my rescue inhaler with me I do not need to avoid asthma triggers

In instituting a bowel training program for a client with fecal incontinence, the nurse plans to: a. Teach the client to use a fecal management system b. Place the client on the bedpan 30 minutes before breakfast c. Insert a rectal suppository at the same time every morning d. Assist the client to the bathroom at the same time of the client's normal defecation

d. Assist the client to the bathroom at the same time of the client's normal defecation

1. A 68-yr-old female patient admitted to the hospital with dehydration is confused and incontinent of urine. Which nursing action should be included in the plan of care? a. Insert an indwelling catheter until symptoms have resolved. b. Apply a condom catheter to collect the urine. c. Restrict fluids between meals and after the evening meal. d. Assist the patient to the bathroom every 2 hours during the day.

d. Assist the patient to the bathroom every 2 hours during the day.

The nurse knows that aggressive treatment with antibiotics is crucial to the care of a patient with cystic fibrosis. Which of the following statements if made by the patient indicate teaching has been effective? a. Since I am immunocompromised I will need to wear a mask. b. I should only take antibiotics if I have an elevated WBC count c. Since I have a chronic lung illness I do not need to bother with sputum cultures d. Cystic fibrosis is characterized by chronic airway infection requiring intermittent use of antibiotics

d. Cystic fibrosis is characterized by chronic airway infection requiring intermittent use of antibiotics

An age-related change in the kidney that leads to nocturia in an older adult is: a. Decreased renal mass b. Decreased detrusor muscle tone c. Decreased ability to conserve sodium d. Decreased ability to concentrate urine

d. Decreased ability to concentrate urine

1. The nurse is caring for a client who has a calcium level of 12.1. Which of the following actions would the nurse include in their plan of care? a. Put the client on seizure precautions b. Keep the client on bed rest c. Monitor for tetany d. Encourage fluid intake

d. Encourage fluid intake

When establishing a bowel training program for a hospitalized patient, the nurse considers all of the following EXCEPT: a. Scheduled toileting, as bowel elimination is regular for most people b. Within 30 minutes after breakfast is a good time to attempt a BM c. The patient's normal bowel pattern d. How the patient will get home at discharge

d. How the patient will get home at discharge

1. A client presents to the Emergency Department (ED) with severe hyponatremia. What type of fluid would the nurse anticipate administering? a. Gin and tonic b. Hypotonic c. Isotonic d. Hypertonic

d. Hypertonic-we want the fluid to go into the cell

Consistent cardiovascular activity may result in: a. Increased LDL b. Increased Hemoglobin A1C c. Increased Total Cholesterol d. Increased HDL

d. Increased HDL

Potassium is considered which major component of nutrition? a. Vitamin b. Protein c. Macronutrient d. Mineral

d. Mineral

A symptom of age-related changes in the GI system the nurse would expect an older adult to report is: a. Gastric hyperacidity b. Intolerance to fatty foods c. Yellowish tinge to the skin d. Reflux of gastric contents into the esophagus

d. Reflux of gastric contents into the esophagus-There is decreased tone of the LES with aging and regurgitation of gastric contents back into the esophagus occurs.

Which one of these assessments indicates that a patient may be experiencing fluid volume deficit (FVD)? a. Low urine specific gravity (1.002) b. Bilateral crackles on auscultation c. Jugular vein distention d. Weak, thready pulses

d. Weak, thready pulses

Your patient has a new nasogastric tube. How should placement be verified before the first feeding? a. Checking for residual b. CT scan c. Elevating the head of the bed d. X-ray

d. X-ray