Acute 222 midterm all chapters
A nurse is caring for a patient who is orally intubated and receiving mechanical ventilation. To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care?
Elevate head of bed to 30 to 45 degrees.
A nurse is caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP). Which assessment finding by the nurse indicates that the PEEP may need to be reduced?
The patient has subcutaneous emphysema on the upper thorax
After providing a patient with discharge instructions on the management of a new permanent pacemaker, the nurse knows that teaching has been effective when the patient states a. "I will avoid cooking with a microwave oven or being near one in use." b. "It will be 1 month before I can take a bath or return to my usual activities." c. "I will notify the airlines when I make a reservation that I have a pacemaker." d. "I won't lift the arm on the pacemaker side up very high until I see the doctor."
"I won't lift the arm on the pacemaker side up very high until I see the doctor."
Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the family members of a patient with ARDS is accurate?
"PEEP prevents the lung air sacs from collapsing during exhalation."
A chemotherapy patient has gained 5 pounds in 2 days. Which assessment question by the nurse is most appropriate?
"how many times a day do you urinate?"
) are a first-line therapy for this type of angina. Lipid-lowering drugs help reduce atherosclerosis (i.e., plaque formation), and β-adrenergic blockers decrease sympathetic stimulation of the heart (i.e., palpitations). Medications or activities that increase myocardial contractility will increase the incidence of angina by increasing oxygen demand.
...
Which fluid order should the nurse question for a patient with a traumatic brain injury?
0.45% sodium chloride
A patient presents to the emergency department with the complaint of vomiting and diarrhea for the past 48 hours. The nurse anticipates which fluid therapy initially?
0.9% sodium chloride
A nurse begins infusing a 250-mL bag of IV fluid at 1845 on Monday and programs the pump to infuse at 20 mL/hr. At what time should the infusion be completed?
0715 Tuesday
A nurse is prioritizing care. Match the level of priority to the patients. a. Patient that needs to be turned to prevent pneumonia b. Patient with acute asthma attack c. Patient who will be discharged in 2 days who needs teaching 1. High priority 2. Intermediate priority 3. Low priority
1. B 2. A 3. C
Regarding grief in older adults, which understanding helps guide your relationship with an elderly pt? 1. Older adults have usually sustained many losses in life, which influence the current loss 2. Older adults with a poor memory experience grief less intensely 3. Older adults generally handle loss better because they have more experience with it 4. Social support is less important because an older adult's circle of friends has become smaller
1. Older adults have usually sustained many losses in life, which influence the current loss
Regarding the request for organ and tissue donation at the time of death, the nurse needs to be aware that: 1. Specially educated personnel make requests 2. Requests are usually made by the nurse caring for the pt. at the time of death 3. Only pts. who have given prior instruction regarding donation become donors 4. Professionals need to be very selective in whom they ask for organ and tissue donation
1. Specially educated personnel make requests
A patient is to receive 1500 mL of 0.9% sodium chloride intravenously at a rate of 125 mL/hr. The nurse is using microdrip gravity drip tubing. What is the minute flow rate (drops per minute)?
125 gtt/min
The health care provider's order is 1000 mL 0.9% NaCl IV over 6 hours. Which rate do you program into the infusion pump?
167 mL/hr
The nurse suggests that a pt. receive a palliative care consultation for symptom management related to anxiety and increasing pain. A family member asks the nurse if this means the the pt. is dying and is now "in hospice." What does the nurse tell the family member about palliative care? (SATA) 1. Hospice and palliative care are the same thing 2. Palliative care is for any patient, any time, any disease, in any setting 3. Palliative care strategies are primarily designed to treat the pt's illness 4. Palliative care interventions relieve the symptoms of illness and treatment
2, 4
A pt. who has a serious, life-limiting chronic illness wants to continue to engage in self-care and live as normally as possible. Which of the following nursing responses reflect a helpful understanding of pt. self-care at the end of life? 1. " Learning to accept that you can't perform some activities anymore will bring you new acceptance and peace." 2. " Which activities are most important to you, and how can you continue to do them?" 3. " People in your life want to help you with things; allow them to do what they want for you." 4. " Spending more of your time resting or reading will conserve your energy."
2. " Which activities are most important to you, and how can you continue to do them?"
A family member of a recently deceased pt. talks casually with the nurse at the time of the pt's death and expresses relief that she will not have to visit at the hospital anymore. What theoretical description of grief best applies to this family member? 1. Denial 2. Anticipatory grief 3. Dysfunctional grief 4. Yearning and searching
2. Anticipatory grief
Which of the following nursing actions best reflects sensitivity to cultural differences related to end-of-life care? 1. Practice honesty with everyone, telling pts. about their illness, even if the new is not good 2. Ask family members if they prefer to help with the care of the body after death 3. Provide postmortem care at the time of death to relieve family members of this difficult job 4. Value pt. self-determination, understanding that each person makes his or her own decisions
2. Ask family members if they prefer to help with the care of the body after death
The nurse notes that a woman who recently began cancer treatment appears quiet and withdrawn, states that she does not believe the treatments will make any difference, does not ask about her progress, and missed 2 chemotherapy sessions. Based on the above assessment data, the nurse gathers more information to consider making which of the following nursing diagnoses? 1. Anxiety 2. Hopelessness 3. Spiritual distress 4. Complicated grieving
2. Hopelessness
A nurse is providing postmortem care. Which action is the priority? 1. Locating the pt's clothing 2. Providing culturally and religiously sensitive care in body preparation 3. Transporting the body to the morgue as soon as possible to prevent body decomposition 4. Providing all postmortem care to protect the family of the deceased from having to see the body
2. Providing culturally and religiously sensitive care in body preparation
You assess four patients. Which patient is at greatest risk for the development of hypocalcemia?
28 year old who has acute pacreatitis
You have identified three nursing diagnoses for a pt. who is having anxiety and hopelessness as a result of a loss. Which general approach do you take to prioritize the nursing diagnoses? (SATA) 1. Use family members and physician orders as primary resources for prioritizing your actions 2. Address the nursing diagnosis that most affects the medical diagnosis 3. Ask the pt. to identify the most distressing symptom and first address that diagnosis 4. Use nursing knowledge to address the problem that is the underlying cause of other diagnoses
3, 4
Which approach to helping grieving people is most consistent with postmodern grief theories? 1. Help the pt. identify the tasks to be accomplished during his or her grief 2. Encourage people to recognize stages of grieving in anticipation of what is to come 3. Listen carefully to a person's story of how his or her grief experience is unfolding 4. Offer general grief timelines to help the person know when a phase will pass
3. Listen carefully to a person's story of how his or her grief experience is unfolding
A self-care goal you set when caring for dying and grieving pts. includes: 1. Learning not to take loses so seriously 2. Limiting involvement with pts who are grieving 3. Maintaining life balance and reflecting on the meaning of your work 4. Admitting that you are not well suited to care for people who are grieving and asking the charge nurse not to assign you to care for these pts.
3. Maintaining life balance and reflecting on the meaning of your work
A nurse has just received a bag of packed red blood cells. The nurse knows that the blood must not remain at room temperature for longer than?
4 hours
A family member asks a home care nurse what he should do if the pt's serious chronic illness worsens even with increased medical interventions. How does the nurse best begin a conversation about the goals of care at the end of life? 1. Encourage the family member to think more positively about the pt's new therapy 2. Avoid the discussion because it has to do with medical, not nursing, diagnoses 3. Initiate a discussion about advance directives with the pt, family, and health care team 4. Begin the discussion by asking the pt. to identify his or her beliefs about the goals of care while the family member is present
4. Begin the discussion by asking the pt. to identify his or her beliefs about the goals of care while the family member is present
A woman experiences the loss of a very early-term pregnancy. Her friends do not mention the loss, and someone suggests to her that she can "always try again." The woman feels confusion over her sadness and stops talking about it with others. What type of grief response is she most likely experiencing? 1. Delayed 2. Anticipated 3. Exaggerated 4. Disenfranchised
4. Disenfranchised
A young man is diagnosed with a serious, life-changing illness. His conversations during his first 2 days of hospitalization are abrupt, superficial, and unrelated to his illness. What understanding about communication enhances your therapeutic communication with this pt? 1. Younger pts. are usually less talkative about their diagnosis 2. All pts. benefit by talking about their feelings with another person 3. Avoid discussing illness-related topics with quiet pts. 4. Remain alert for signals that the pt. wants to discuss his illness
4. Remain alert for signals that the pt. wants to discuss his illness
A patient has a junctional escape rhythm on the monitor. The nurse will expect the patient to have a heart rate of _____ beats/minute. a. 15 to 20 b. 20 to 40 c. 40 to 60 d. 60 to 100
40 to 60
When analyzing an electrocardiographic (ECG) rhythm strip of a patient with a regular heart rhythm, the nurse counts 30 small blocks from one R wave to the next. The nurse calculates the patient's heart rate as ____.
50
A nurse has the responsibility of managing a deceased pt's post-mortem care. Arrange the steps for post-mortem care in the proper order: 1. Bathe the body of the deceased 2. Collect any needed specimens 3. Remove all tubes and indwelling lines 4. Position the body for family visit/viewing 5. Speak to the family members about their possible participation 6. Confirm that request for organ/tissue donation and/or autopsy has been made 7. Notify a support person for the family 8. Accurately tag the body, indicating the identity of the deceased and safety issues regarding infection control 9. Elevate the head of the bed
6, 9, 2, 5, 7, 3, 1, 4, 8
A patient in the intensive care unit with acute decompensated heart failure (ADHF) complains of severe dyspnea and is anxious, tachypneic, and tachycardic. All of the following medications have been ordered for the patient. The nurse's priority action will be to a. give IV morphine sulfate 4 mg. b. give IV diazepam (Valium) 2.5 mg. c. increase nitroglycerin (Tridil) infusion by 5 mcg/min. d. increase dopamine (Intropin) infusion by 2 mcg/kg/min.
A
After receiving change-of-shift report on a heart failure unit, which patient should the nurse assess first? a. A patient who is cool and clammy, with new-onset confusion and restlessness b. A patient who has crackles bilaterally in the lung bases and is receiving oxygen. c. A patient who had dizziness after receiving the first dose of captopril (Capoten) d. A patient who is receiving IV nesiritide (Natrecor) and has a blood pressure of 100/62
A
During a visit to a 78-year-old with chronic heart failure, the home care nurse finds that the patient has ankle edema, a 2-kg weight gain over the past 2 days, and complains of "feeling too tired to get out of bed." Based on these data, the best nursing diagnosis for the patient is a. activity intolerance related to fatigue. b. disturbed body image related to weight gain. c. impaired skin integrity related to ankle edema. d. impaired gas exchange related to dyspnea on exertion.
A
Which patient is most at risk for sensible water loss?
an 80 year old patent with pneumonia
Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires the most immediate action by the nurse? a. Oxygen saturation of 88% b. Weight gain of 1 kg (2.2 lb) c. Heart rate of 106 beats/minute d. Urine output of 50 mL over 2 hours
A
When preparing to defibrillate a patient. In which order will the nurse perform the following steps? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Turn the defibrillator on. b. Deliver the electrical charge. c. Select the appropriate energy level. d. Place the paddles on the patient's chest. e. Check the location of other staff and call out "all clear."
A C D E B
In order to assist an older diabetic patient to engage in moderate daily exercise, which action is most important for the nurse to take? A. Determine what type of activities the patient enjoys. B. Remind the patient that exercise will improve self-esteem. C. Teach the patient about the effects of exercise on glucose level. D. Give the patient a list of activities that are moderate in intensity.
A - Because consistency with exercise is important, assessment for the types of exercise that the patient finds enjoyable is the most important action by the nurse in ensuring adherence to an exercise program. The other actions will also be implemented but are not the most important in improving compliance.
Which patient action indicates a good understanding of the nurse's teaching about the use of an insulin pump? A. The patient programs the pump for an insulin bolus after eating. B. The patient changes the location of the insertion site every week. C. The patient takes the pump off at bedtime and starts it again each morning. D. The patient plans for a diet that is less flexible when using the insulin pump.
A - In addition to the basal rate of insulin infusion, the patient will adjust the pump to administer a bolus after each meal, with the dosage depending on the oral intake. The insertion site should be changed every 2 or 3 days. There is more flexibility in diet and exercise when an insulin pump is used. The pump will deliver a basal insulin rate 24 hours a day.
A 32-year-old patient with diabetes is starting on intensive insulin therapy. Which type of insulin will the nurse discuss using for mealtime coverage? A. Lispro (Humalog) B. Glargine (Lantus) C. Detemir (Levemir) D. NPH (Humulin N)
A - Rapid- or short-acting insulin is used for mealtime coverage for patients receiving intensive insulin therapy. NPH, glargine, or detemir will be used as the basal insulin.
Which statement by the patient indicates a need for additional instruction in administering insulin? A. "I need to rotate injection sites among my arms, legs, and abdomen each day." B. "I can buy the 0.5 mL syringes because the line markings will be easier to see." C. "I should draw up the regular insulin first after injecting air into the NPH bottle." D. "I do not need to aspirate the plunger to check for blood before injecting insulin."
A - Rotating sites is no longer recommended because there is more consistent insulin absorption when the same site is used consistently. The other patient statements are accurate and indicate that no additional instruction is needed.
A 38-year-old patient who has type 1 diabetes plans to swim laps daily at 1:00 PM. The clinic nurse will plan to teach the patient to A. Check glucose level before, during, and after swimming. B. Delay eating the noon meal until after the swimming class. C. Increase the morning dose of neutral protamine Hagedorn (NPH) insulin. D. Time the morning insulin injection so that the peak occurs while swimming.
A - The change in exercise will affect blood glucose, and the patient will need to monitor glucose carefully to determine the need for changes in diet and insulin administration. Because exercise tends to decrease blood glucose, patients are advised to eat before exercising. Increasing the morning NPH or timing the insulin to peak during exercise may lead to hypoglycemia, especially with the increased exercise.
A 55-year-old female patient with type 2 diabetes has a nursing diagnosis of imbalanced nutrition: more than body requirements. Which goal is most important for this patient? A. The patient will reach a glycosylated hemoglobin level of less than 7%. B. The patient will follow a diet and exercise plan that results in weight loss. C. The patient will choose a diet that distributes calories throughout the day. D. The patient will state the reasons for eliminating simple sugars in the diet.
A - The complications of diabetes are related to elevated blood glucose, and the most important patient outcome is the reduction of glucose to near-normal levels. The other outcomes also are appropriate but are not as high in priority.
A patient receives aspart (NovoLog) insulin at 8:00 AM. Which time will it be most important for the nurse to monitor for symptoms of hypoglycemia? A. 10:00 AM B. 12:00 AM C. 2:00 PM D. 4:00 PM
A - The rapid-acting insulins peak in 1 to 3 hours. The patient is not at a high risk for hypoglycemia at the other listed times, although hypoglycemia may occur.
In which patient would the nurse expect to see a positive Chvostek sign?
A 24 year old adult admitted for chronic alcohol abuse
Which of these patients do you expect will need teaching regarding dietary sodium restriction?
A 65-year-old recently diagnosed with heart failure
The nurse is caring for a patient with sepsis. The plan of care for the patient is to administer antibiotics 3 times a day for 4 weeks. What device will be used to administer these antibiotics?
A PICC line
The nurse has received change-of-shift report about the following patients on the progressive care unit. Which patient should the nurse see first? a. A patient who is in a sinus rhythm, rate 98, after having electrical cardioversion 2 hours ago b. A patient with new onset atrial fibrillation, rate 88, who has a first dose of warfarin (Coumadin) due c. A patient with second-degree atrioventricular (AV) block, type 1, rate 60, who is dizzy when ambulating d. A patient whose implantable cardioverter-defibrillator (ICD) fired two times today who has a dose of amiodarone (Cordarone) due
A patient whose implantable cardioverter-defibrillator (ICD) fired two times today who has a dose of amiodarone (Cordarone) due
After receiving change-of-shift report on a medical unit, which patient should the nurse assess first?
A patient with septicemia who has intercostal and suprasternal retractions
Based on the Joint Commission Core Measures for patients with heart failure, which topics should the nurse include in the discharge teaching plan for a patient who has been hospitalized with chronic heart failure (select all that apply)? a. How to take and record daily weight b. Importance of limiting aerobic exercise c. Date and time of follow-up appointment d. Symptoms indicating worsening heart failure e. Actions and side effects of prescribed medications
A, C, D, E
When the patient with a persisting cough is diagnosed with pertussis (instead of acute bronchitis), the nurse knows that treatment will include which type of medication? A. Antibiotic B. Corticosteroid C. Bronchodilator D. Cough suppressant
A. Antibiotic Pertussis, unlike acute bronchitis, is caused by a gram-negative bacillus, Bordella pertussis, which must be treated with antibiotics. Corticosteroids and bronchodilators are not helpful in reducing symptoms. Cough suppressants and antihistamines are ineffective and may induce coughing episodes with pertussis.
24. A common, serious complication of rheumatic fever is: a. Seizures. c. Pulmonary hypertension. b. Cardiac arrhythmias. d. Cardiac valve damage.
ANS: D Cardiac valve damage is the most significant complication of rheumatic fever. Seizures, cardiac arrhythmias, and pulmonary hypertension are not common complications of rheumatic fever. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1345 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
Which physical assessment finding in a patient with a lower respiratory problem best supports the nursing diagnosis of ineffective airway clearance? A. Basilar crackles B. Respiratory rate of 28 C. Oxygen saturation of 85% D. Presence of greenish sputum
A. Basilar crackles The presence of adventitious breath sounds indicates that there is accumulation of secretions in the lower airways. This would be consistent with a nursing diagnosis of ineffective airway clearance because the patient is retaining secretions. The rapid respiratory rate, low oxygen saturation, and presence of greenish sputum may occur with a lower respiratory problem, but do not definitely support the nursing diagnosis of ineffective airway clearance.
Measurements related to fluid balance of clients that a nurse can initiate without a physician's order include: A. Daily weights, vital signs, and fluid intake and output B. Daily weights, diuretics, and waist measurement C. Monitoring temperature, fluid intake and output, and calorie count D. Auscultating lung sounds, monitoring color of urine, and placing a Foley catheter into the client
A. Daily weights, vital signs, and fluid intake and output
Assessment findings consistent with intravenous (IV) fluid infiltration include: (Select all that apply.)
A. Edema and pain D. Pallor and coolness
The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, the nurse notes a temperature of 101.4° F, a productive cough with yellow sputum, and a respiratory rate of 20. Which nursing diagnosis is most appropriate based upon this assessment? A. Hyperthermia related to infectious illness B. Ineffective thermoregulation related to chilling C. Ineffective breathing pattern related to pneumonia D. Ineffective airway clearance related to thick secretions
A. Hyperthermia related to infectious illness Because the patient has spiked a temperature and has a diagnosis of pneumonia, the logical nursing diagnosis is hyperthermia related to infectious illness. There is no evidence of a chill, and her breathing pattern is within normal limits at 20 breaths/minute. There is no evidence of ineffective airway clearance from the information given because the patient is expectorating sputum.
To promote airway clearance in a patient with pneumonia, what should the nurse instruct the patient to do (select all that apply)? A. Maintain adequate fluid intake. B. Splint the chest when coughing. C. Maintain a 30-degree elevation. D. Maintain a semi-Fowler's position. E. Instruct patient to cough at end of exhalation.
A. Maintain adequate fluid intake. B. Splint the chest when coughing. E. Instruct patient to cough at end of exhalation. Maintaining adequate fluid intake liquefies secretions, allowing easier expectoration. The nurse should instruct the patient to splint the chest while coughing. This will reduce discomfort and allow for a more effective cough. Coughing at the end of exhalation promotes a more effective cough. The patient should be positioned in an upright sitting position (high Fowler's) with head slightly flexed.
A patient who is comatose is admitted to the hospital with an unknown history. Respirations are deep and rapid. Arterial blood gas levels on admission are pH, 7.20; PaCO2, 21 mm Hg; PaO2, 92 mm Hg; and HCO3-, 8. You interpret these laboratory values to indicate:
A. Metabolic acidosis
During discharge teaching for a 65-year-old patient with chronic obstructive pulmonary disease (COPD) and pneumonia, which vaccine should the nurse recommend that this patient receive? A. Pneumococcal B. Staphylococcus aureus C. Haemophilus influenzae D. Bacille-Calmette-Guerin (BCG)
A. Pneumococcal The pneumococcal vaccine is important for patients with a history of heart or lung disease, recovering from a severe illness, age 65 or over, or living in a long-term care facility. A Staphylococcus aureus vaccine has been researched but not yet been effective. The Haemophilus influenzae vaccine would not be recommended as adults do not need it unless they are immunocompromised. The BCG vaccine is for infants in parts of the world where tuberculosis (TB) is prevalent.
Edema that forms in clients with kidney disease is due to:
A. Reduced plasma oncotic pressure, so that fluid is not drawn into the capillaries from interstitial tissues
A client suffering from a narcotic overdose is seen in the Emergency Department. The client is confused, with warm, flushed skin, headache, and weakness. Vital signs of noted are T 102.6, HR 128, R 24, and BP 130/86. A blood gas analysis sample was drawn on room air, and the results are as follows: pH 7.33, PaCO2 53, PaO2 72, HCO3 24. This client is at risk for:
A. Respiratory acidosis
The nurse notes new onset confusion in an 89-year-old patient in a long-term care facility. The patient is normally alert and oriented. In which order should the nurse take the following actions? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. Obtain the oxygen saturation. b. Check the patient's pulse rate. c. Document the change in status. d. Notify the health care provider.
ANS: A, B, D, C Assessment for physiologic causes of new onset confusion such as pneumonia, infection, or perfusion problems should be the first action by the nurse. Airway and oxygenation should be assessed first, then circulation. After assessing the patient, the nurse should notify the health care provider. Finally, documentation of the assessments and care should be done. DIF: Cognitive Level: Analysis REF: 549 | 551 OBJ: Special Questions: Alternate Item Format, Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiolog
The following four patients arrive in the emergency department (ED) after a motor vehicle collision. In which order should the nurse assess them? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. A 74-year-old with palpitations and chest pain b. A 43-year-old complaining of 7/10 abdominal pain c. A 21-year-old with multiple fractures of the face and jaw d. A 37-year-old with a misaligned left leg with intact pulses
ANS: C, A, B, D The highest priority is to assess the 21-year-old patient for airway obstruction, which is the most life-threatening injury. The 74-year-old patient may have chest pain from cardiac ischemia and should be assessed and have diagnostic testing for this pain. The 43-year-old patient may have abdominal trauma or bleeding and should be seen next to assess circulatory status. The 37-year-old appears to have a possible fracture of the left leg and should be seen soon, but this patient has the least life-threatening injury. DIF: Cognitive Level: Analyze (analysis) REF: 1676 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
42. When assessing the patient on return to the surgical unit following a total laryngectomy and radical neck dissection, what would the nurse expect to find? a. A closed-wound drainage system b. A nasal endotracheal tube in place c. A nasogastric tube with orders for tube feeding d. A tracheostomy tube and mechanical ventilation
ANS: A Following a radical neck dissection, drainage tubes are often used to prevent fluid accumulation in the wound as well as possible pressure on the trachea. The patient has placement of a nasogastric tube to suction immediately after surgery, which will later be used to administer tube feeding until swallowing can be accomplished. A tracheostomy tube is in place but mechanical ventilation is usually not indicated.
38. A patients tracheostomy tube becomes dislodged with vigorous coughing. What should be the nurses first action? a. Attempt to replace the tube b. Notify the health care provider c. Place the patient in high Fowler position d. Ventilate the patient with a manual resuscitation bag until the health care provider arrives
ANS: A If a tracheostomy tube is dislodged, the nurse should immediately attempt to replace the tube by grasping the retention sutures (if available) and spreading the opening. The obturator is inserted in the replacement tube, water-soluble lubricant is applied to the tip, and the tube is inserted in the stoma as a 45-degree angle tot eh neck. The obturator is immediately removed to provide an airway. If the tube cannot be reinserted, the health care provider should be notified and the patient should be assessed for the level of respiratory distress, positioned in semi-Fowler position, and ventilated with a manual resuscitation bag (MRB) only if necessary until assistance arrives.
40. The patient has been diagnosed with an early vocal cord malignancy. The nurse explains that usual treatment includes? a. Radiation therapy that preserves the quality of the voice b. a hemilaryngectomy that prevents the need for a tracheostomy c. a radical neck dissection that removes possible sites of metastasis d. a total laryngectomy yo prevent development of second primary cancers
ANS: A If laryngeal tumors are small, radiation is the treatment of chronic because it can be curative and can preserve voice quality. Surgical procedures are used if radiation treatment is not successful or if larger or advanced lesions are present.
15. A patient with an indwelling urinary catheter has been given a bed bath by a new nursing assistive personnel. The nurse evaluating the cleanliness of the patient notices crusting at the urinary meatus. Which action should the nurse take next? a. Ask the nursing assistive personnel to observe while the nurse performs catheter care. b. Leave the room and ask the nursing assistive personnel to go back and perform proper catheter care. c. Tell the nursing assistive personnel that catheter care is sloppy. d. Remove the catheter.
ANS: A If the staff member's performance is not satisfactory, give constructive and appropriate feedback. You may discover the need to review a procedure with staff and offer demonstration. Because the nursing assistant is new, it is best for the nurse to perform catheter care while the assistant observes. This action will ensure that the assistant has been shown the proper way to perform the task and fosters collaboration rather than leaving the room just to tell the assistant to come back. Telling that catheter care is sloppy does not correct the problem. The catheter does not need to be removed. DIF:Analyze (analysis)REF:287 OBJ: Discuss principles to follow in the appropriate delegation of patient care activities.
6. The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy tube. Which action by the nurse would best determine if the cuff has been properly inflated? a.Use a manometer to ensure cuff pressure is at an appropriate level. b.Check the amount of cuff pressure ordered by the health care provider. c.Suction the patient first with a fenestrated inner cannula to clear secretions. d.Insert the decannulation plug before the nonfenestrated inner cannula is removed.
ANS: A Measurement of cuff pressure using a manometer to ensure that cuff pressure is 20 mm Hg or lower will avoid compression of the tracheal wall and capillaries. Never insert the decannulation plug in a tracheostomy tube until the cuff is deflated and the nonfenestrated inner cannula is removed. Otherwise, the patient's airway is occluded. A health care provider's order is not required to determine safe cuff pressure. A nonfenestrated inner cannula must be used to suction a patient to prevent tracheal damage occurring from the suction catheter passing through the fenestrated openings.
21. The most common causative agent of bacterial endocarditis is: a. Staphylococcus albus. c. Staphylococcus albicans. b. Streptococcus hemolyticus. d. Streptococcus viridans.
ANS: D Staphylococcus viridans is the most common causative agent in bacterial (infective) endocarditis. Staphylococcus albus, Streptococcus hemolyticus, and Staphylococcus albicans are not common causative agents. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1344 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
8. A nurse obtains a health history from a patient who has a 35 pack-year smoking history. The patient complains of hoarseness and tightness in the throat and difficulty swallowing. Which question is most important for the nurse to ask? a."How much alcohol do you drink in an average week?" b."Do you have a family history of head or neck cancer?" c."Have you had frequent streptococcal throat infections?" d."Do you use antihistamines for upper airway congestion?"
ANS: A Prolonged alcohol use and smoking are associated with the development of laryngeal cancer, which the patient's symptoms and history suggest. Family history is not a risk factor for head or neck cancer. Frequent antihistamine use would be asked about if the nurse suspected allergic rhinitis, but the patient's symptoms are not suggestive of this diagnosis. Streptococcal throat infections also may cause these clinical manifestations, but patients with this type of infection will also have pain and a fever.
18. A nurse is assigned to care for the following patients who all need vital signs taken right now. Which patient is most appropriate for the nurse to delegate vital sign measurement to the nursing assistive personnel (NAP)? a. Patient scheduled for a procedure in the nuclear medicine department b. Patient transferring from the intensive care unit (ICU) c. Patient returning from a cardiac catheterization d. Patient returning from hip replacement surgery
ANS: A The nurse does not assign vital sign measurement or other tasks to NAP when patients are experiencing a change in level of care. The patient awaiting the procedure in nuclear medicine is the only patient who has not experienced a change in level of care. According to the rights of delegation, tasks that are repetitive, require little supervision, are relatively noninvasive, have results that are predictable, and have minimal risk can be delegated to assistive personnel. The patient in this question with the most predictable condition is the patient awaiting the nuclear medicine procedure. Once the nurse determines that the other patients are stable, the nurse could delegate their future vital sign measurement to the NAP. However, it is important for the nurse to assess patients coming from the ICU, the cardiac cath lab, and surgery when they first arrive on the unit. DIF:Apply (application)REF:287-288 OBJ: Discuss principles to follow in the appropriate delegation of patient care activities.
8. A nurse manager sent one of the staff nurses on the unit to a conference about new, evidence-based wound care techniques. The nurse manager asks the staff nurse to prepare a poster to present at the next unit meeting, which will be mandatory for all nursing staff on the unit. Which type of opportunity is the nurse manager providing for the staff? a. Staff education b. Interprofessional collaboration c. Providing a professional shared governance council d. Establishing a nursing practice committee
ANS: A The nurse manager is planning a staff education opportunity. Staff education is one way the nurse manager supports staff involvement in a shared decision-making model. Interprofessional collaboration between nurses and health care providers (e.g., MD, PT, TR, etc.) is critical to the delivery of quality, safe patient care and the creation of a positive work culture for practitioners. The question does not state that the nurse is establishing a practice committee or a professional shared governance council. Chaired by senior clinical staff nurses, these groups establish and maintain care standards for nursing practice on their work unit. DIF:Apply (application)REF:284 OBJ: Discuss the ways in which a nurse manager supports staff involvement in a decentralized decision-making model. TOP: Planning MSC: Management of Care
9. A nurse is making a home visit and discovers that a patient's wound infection has gotten worse. The nurse cleans and redresses the wound. What should the nurse do next? a. Notify the health care provider of the findings before leaving the home. b. Ask the home health facility nurse manager to contact the health care provider. c. Document the findings and confirm with the patient the date of the next home visit. d. Tell the patient that the health care provider will be notified before the next home visit.
ANS: A The nurse should notify the health care provider before leaving the home. Regardless of the setting, an enriching professional environment is one in which staff members respect one another's ideas, share information, and keep one another informed. The manager should avoid taking care of problems for staff. The staff nurse needs to learn how to professionally communicate with other members of the health care team and demonstrate interprofessional collaboration. DIF:Apply (application)REF:286 OBJ:Discuss the ways in which a nurse manager supports staff involvement in a decentralized decision-making model.TOP:Implementation
11. The nurse completes discharge instructions for a patient with a total laryngectomy. Which statement by the patient indicates that additional instruction is needed? a."I must keep the stoma covered with an occlusive dressing at all times." b."I can participate in most of my prior fitness activities except swimming." c."I should wear a Medic-Alert bracelet that identifies me as a neck breather." d."I need to be sure that I have smoke and carbon monoxide detectors installed."
ANS: A The stoma may be covered with clothing or a loose dressing, but this is not essential. An occlusive dressing will completely block the patient's airway. The other patient comments are all accurate and indicate that the teaching has been effective.
41. During preoperative teaching for the patient scheduled for a total laryngectomy, what should the nurse include? a. The postoperative use of of nonverbal communicate techniques b. Techniques that will be used to alleviate a dry mouth and prevent stomatitis c. The need for frequent, vigorous coughing in the first 24 hours postoperativity d. Self-help groups and community resources for parties with cancer of the larynx
ANS: A With removal of the larynx, the patient will not be able to communicate verbally and it is important to arrange with the patient a method of communication before surgery so that postoperative communication can take place. Dry mouth and stomatitis result from radiation therapy. Vigerious coughing is not encouraged immediately postoperatively and information related to community resources is usually introduced during the postoperative period.
7. Which statement by the patient indicates that the teaching has been effective for a patient scheduled for radiation therapy of the larynx? a."I will need to buy a water bottle to carry with me." b."I should not use any lotions on my neck and throat." c."Until the radiation is complete, I may have diarrhea." d."Alcohol-based mouthwashes will help clean oral ulcers."
ANS: A Xerostomia can be partially alleviated by drinking fluids at frequent intervals. Radiation will damage tissues at the site being radiated but should not affect the abdominal organs, so loose stools are not a usual complication of head and neck radiation therapy. Frequent oral rinsing with non-alcohol-based rinses is recommended. Prescribed lotions and sunscreen may be used on radiated skin, although they should not be used just before the radiation therapy.
29. When caring for a patient who has just arrived on the medical-surgical unit after having cardiac catheterization, which nursing intervention should the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Give the scheduled aspirin and lipid-lowering medication. b. Perform the initial assessment of the catheter insertion site. c. Teach the patient about the usual postprocedure plan of care. d. Titrate the heparin infusion according to the agency protocol.
ANS: A Administration of oral medications is within the scope of practice for LPNs/LVNs. The initial assessment of the patient, patient teaching, and titration of IV anticoagulant medications should be done by the registered nurse (RN).
40. What is the nurse's first action when planning to teach the parents of an infant with a congenital heart defect (CHD)? a. Assess the parents' anxiety level and readiness to learn. b. Gather literature for the parents. c. Secure a quiet place for teaching. d. Discuss the plan with the nursing team.
ANS: A Any effort to organize the right environment, plan, or literature is of no use if the parents are not ready to learn or have high anxiety. Decreasing their level of anxiety is often needed before new information can be processed. A baseline assessment of prior knowledge should be taken into consideration before developing any teaching plan. Locating a quiet place for meeting with parents is appropriate; however, an assessment should be done before any teaching is done. Discussing a teaching plan with the nursing team is appropriate after an assessment of the parents' knowledge and readiness. PTS: 1 DIF: Cognitive Level: Application REF: 1339 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance
1. The nurse is assessing a child post-cardiac catheterization. Which complication might the nurse anticipate? a. Cardiac arrhythmia c. Congestive heart failure b. Hypostatic pneumonia d. Rapidly increasing blood pressure
ANS: A Because a catheter is introduced into the heart, a risk exists of catheter-induced arrhythmias occurring during the procedure. These are usually transient. Hypostatic pneumonia, congestive heart failure, and rapidly increasing blood pressure are not risks usually associated with cardiac catheterization. PTS: 1 DIF: Cognitive Level: Application REF: 1320 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
14. A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan. Which information obtained by the nurse is a priority to communicate to the health care provider before the CT? a. Allergy to shellfish b. Apical pulse of 104 c. Respiratory rate of 30 d. Oxygen saturation of 90
ANS: A Because iodine-based contrast media is used during a spiral CT, the patient may need to have the CT scan without contrast or be premedicated before injection of the contrast media. The increased pulse, low oxygen saturation, and tachypnea all indicate a need for further assessment or intervention but do not indicate a need to modify the CT procedure. DIF: Cognitive Level: Apply (application) REF: 492 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
23. The urgent care center protocol for tick bites includes the following actions. Which action will the nurse take first when caring for a patient with a tick bite? a. Use tweezers to remove any remaining ticks. b. Check the vital signs, including temperature. c. Give doxycycline (Vibramycin) 100 mg orally. d. Obtain information about recent outdoor activities.
ANS: A Because neurotoxic venom is released as long as the tick is attached to the patient, the initial action should be to remove any ticks using tweezers or forceps. The other actions are also appropriate, but the priority is to minimize venom release. DIF: Cognitive Level: Apply (application) REF: 1697 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
9. Which drug is an angiotensin-converting enzyme (ACE) inhibitor? a. Captopril (Capoten) c. Spironolactone (Aldactone) b. Furosemide (Lasix) d. Chlorothiazide (Diuril)
ANS: A Capoten is an ACE inhibitor. Lasix is a loop diuretic. Aldactone blocks the action of aldosterone. Diuril works on the distal tubules. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1332 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
The nurse is caring for a 78-year-old patient with aortic stenosis. Which assessment data obtained by the nurse would be most important to report to the health care provider? a. The patient complains of chest pressure when ambulating. b. A loud systolic murmur is heard along the right sternal border. c. A thrill is palpated at the second intercostal space, right sternal border. d. The point of maximum impulse (PMI) is at the left midclavicular line.
ANS: A Chest pressure (or pain) occurring with aortic stenosis is caused by cardiac ischemia, and reporting this information would be a priority. A systolic murmur and thrill are expected in a patient with aortic stenosis. A PMI at the left midclavicular line is normal
34. Which information about a patient who has been receiving thrombolytic therapy for an acute myocardial infarction (AMI) is most important for the nurse to communicate to the health care provider? a. No change in the patient's chest pain b. An increase in troponin levels from baseline c. A large bruise at the patient's IV insertion site d. A decrease in ST-segment elevation on the electrocardiogram
ANS: A Continued chest pain suggests that the thrombolytic therapy is not effective and that other interventions such as percutaneous coronary intervention (PCI) may be needed. Bruising is a possible side effect of thrombolytic therapy, but it is not an indication that therapy should be discontinued. The decrease of the ST-segment elevation indicates that thrombolysis is occurring and perfusion is returning to the injured myocardium. An increase in troponin levels is expected with reperfusion and is related to the washout of cardiac markers into the circulation as the blocked vessel is opened.
A patient with bacterial pneumonia has rhonchi and thick sputum. Which action will the nurse use to promote airway clearance? a. Assist the patient to splint the chest when coughing. b. Educate the patient about the need for fluid restrictions. c. Encourage the patient to wear the nasal oxygen cannula. d. Instruct the patient on the pursed lip breathing technique.
ANS: A Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal oxygen will improve gas exchange, but will not improve airway clearance. Pursed lip breathing is used to improve gas exchange in patients with COPD, but will not improve airway clearance. DIF: Cognitive Level: Application REF: 552-553 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
4. On auscultation of a patients lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding? a. Inspiratory crackles at the bases b. Expiratory wheezes in both lungs c. Abnormal lung sounds in the apices of both lungs d. Pleural friction rub in the right and left lower lobes
ANS: A Crackles are low-pitched, bubbling sounds usually heard on inspiration. Wheezes are high-pitched sounds. They can be heard during the expiratory or inspiratory phase of the respiratory cycle. The lower third of both lungs are the bases, not apices. Pleural friction rubs are grating sounds that are usually heard during both inspiration and expiration. DIF: Cognitive Level: Understand (comprehension) REF: 487 | 489 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
The nurse is caring for a 64-year-old patient admitted with mitral valve regurgitation. Which information obtained by the nurse when assessing the patient should be communicated to the health care provider immediately? a. The patient has bilateral crackles. b. The patient has bilateral, 4+ peripheral edema. c. The patient has a loud systolic murmur across the precordium. d. The patient has a palpable thrill felt over the left anterior chest.
ANS: A Crackles that are audible throughout the lungs indicate that the patient is experiencing severe left ventricular failure with pulmonary congestion and needs immediate interventions such as diuretics. A systolic murmur and palpable thrill would be expected in a patient with mitral regurgitation. Although 4+ peripheral edema indicates a need for a change in therapy, it does not need to be addressed urgently
8. A beneficial effect of administering digoxin (Lanoxin) is that it: a. Decreases edema. c. Increases heart size. b. Decreases cardiac output. d. Increases venous pressure.
ANS: A Digoxin has a rapid onset and is useful in increasing cardiac output, decreasing venous pressure, and as a result decreasing edema. Heart size is decreased by digoxin. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1332 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
The nurse is using Bowlby's phases of mourning as a framework for assessing the client's response to the traumatic loss of her leg. During the "yearning and searching" phase, how does the nurse anticipate the client may respond? a. Crying off and on b. Becoming angry at the nurse c. Acting stunned by the loss d. Discussing the change in role that will occur
ANS: A During the "yearning and searching" phase of Bowlby's phases of mourning, the nurse anticipates that the client may have outbursts of tearful sobbing and acute distress. During Bowlby's "disorganization and despair" phase of mourning, the nurse anticipates that the client may express anger at anyone who might be responsible, including the nurse. During the "numbing" phase of Bowlby's phases of mourning, the nurse anticipates that the client may act stunned by the loss. During the "reorganization" phase of Bowlby's phases of mourning, the nurse anticipates that the client may discuss the change in role that will occur.
25. The nurse is caring for a patient who was admitted to the coronary care unit following an acute myocardial infarction (AMI) and percutaneous coronary intervention the previous day. Teaching for this patient would include a. when cardiac rehabilitation will begin. b. the typical emotional responses to AMI. c. information regarding discharge medications. d. the pathophysiology of coronary artery disease.
ANS: A Early after an AMI, the patient will want to know when resumption of usual activities can be expected. At this time, the patient's anxiety level or denial will interfere with good understanding of complex information such as the pathophysiology of coronary artery disease (CAD). Teaching about discharge medications should be done closer to discharge. The nurse should support the patient by decreasing anxiety rather than discussing the typical emotional responses to myocardial infarction (MI).
A patient is admitted to the hospital with possible acute pericarditis. The nurse should plan to teach the patient about the purpose of a. echocardiography. b. daily blood cultures. c. cardiac catheterization. d. 24-hour Holter monitor.
ANS: A Echocardiograms are useful in detecting the presence of the pericardial effusions associated with pericarditis. Blood cultures are not indicated unless the patient has evidence of sepsis. Cardiac catheterization and 24-hour Holter monitor is not a diagnostic procedure for pericarditis
The staff is having a hard time getting an older adult patient to communicate. Which technique should the nurse suggest the staff use? a. Allow the patient to reminisce. b. Try changing topics often. c. Involve only the patient in conversations. d. Ask the patient for explanations.
ANS: A Encouraging older adults to share life stories and reminisce about the past has a therapeutic effect and increases their sense of well-being. Avoid sudden shifts from subject to subject. It is helpful to include the patient's family and friends and to become familiar with the patient's favorite topics for conversation. Asking for explanations is a nontherapeutic technique.
35. Which intervention should be included in the plan of care for an infant with the nursing diagnosis of Excess Fluid Volume related to congestive heart failure? a. Weigh the infant every day on the same scale at the same time. b. Notify the physician when weight gain exceeds more than 20 g/day. c. Put the infant in a car seat to minimize movement. d. Administer digoxin (Lanoxin) as ordered by the physician.
ANS: A Excess fluid volume may not be overtly visible. Weight changes may indicate fluid retention. Weighing the infant on the same scale at the same time each day ensures consistency. An excessive weight gain for an infant is an increase of more than 50 g/day. With fluid volume excess, skin will be edematous. The infant's position should be changed frequently to prevent undesirable pooling of fluid in certain areas. Lanoxin is used in the treatment of congestive heart failure to improve cardiac function. Diuretics will help the body get rid of excess fluid. PTS: 1 DIF: Cognitive Level: Application REF: 1334 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
The mother of a recently murdered child keeps the child's room intact. Family members are encouraging her to redecorate and move forward in life. The visiting nurse recognizes this behavior as _____ grief. a. Normal b. End-of-life c. Abnormal d. Complicated
ANS: A Family members will grieve differently. One sign of normal grief is keeping the deceased individual's room intact as a way to keep that person alive in the minds of survivors. This is happening after the family member is deceased, so it is not end-of-life grief. It is not abnormal or complicated grief; the child died recently.
Which of the following assessments do you perform routinely when an older adult patient is receiving intravenous 0.9% NaCl? Auscultate dependent portions of lungs
Auscultate dependent positions of lungs
A nurse is using SOLER to facilitate active listening. Which technique should the nurse use for R? a. Relax b. Respect c. Reminisce d. Reassure
ANS: A In SOLER, the R stands for relax. It is important to communicate a sense of being relaxed and comfortable with the patient. Active listening enhances trust because the nurse communicates acceptance and respect for the patient, but it is not the R in SOLAR. Reminisce is a therapeutic communication technique, especially when used with the elderly. Reassuring can be therapeutic if the nurse reassures patients that there are many kinds of hope, and that meaning and personal growth can come from illness experiences. However, false reassurance can block communication.
The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect? a. Increased tactile fremitus b. Dry, nonproductive cough c. Hyperresonance to percussion d. A grating sound on auscultation
ANS: A Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal pneumonia typically presents with a loose, productive cough. Adventitious breath sounds such as crackles and wheezes are typical. A grating sound is more representative of a pleural friction rub rather than pneumonia.
A correctional facility nurse is called to the scene of a deceased inmate. The correction officer wants to quickly move the body to the funeral home because he is not comfortable with death. The inmate's body will need to be transported where? a. Coroner's office for an autopsy b. Police department for an investigation c. Directly to the inmate's family d. Warden for inspection
ANS: A Law often requires that an autopsy be performed if death occurred during incarceration; as the result of foul play, homicide, or suicide; or as an accidental death, as occurs in car accidents. The nurse must understand the policies that are applied in cases of foul play death and must ensure that the decedent's body is properly cared for after death, despite the emotional feelings of individuals in close contact with the decedent.
26. A patient who has recently started taking pravastatin (Pravachol) and niacin (Nicobid) reports the following symptoms to the nurse. Which is most important to communicate to the health care provider? a. Generalized muscle aches and pains b. Dizziness when changing positions quickly c. Nausea when taking the drugs before eating d. Flushing and pruritus after taking the medications
ANS: A Muscle aches and pains may indicate myopathy and rhabdomyolysis, which have caused acute kidney injury and death in some patients who have taken the statin medications. These symptoms indicate that the pravastatin may need to be discontinued. The other symptoms are common side effects when taking niacin, and although the nurse should follow-up with the health care provider, they do not indicate that a change in medication is needed.
12. A 20-year-old patient arrives in the emergency department (ED) several hours after taking "25 to 30" acetaminophen (Tylenol) tablets. Which action will the nurse plan to take? a. Give N-acetylcysteine (Mucomyst). b. Discuss the use of chelation therapy. c. Start oxygen using a non-rebreather mask. d. Have the patient drink large amounts of water.
ANS: A N-acetylcysteine is the recommended treatment to prevent liver damage after acetaminophen overdose. The other actions might be used for other types of poisoning, but they will not be appropriate for a patient with acetaminophen poisoning. DIF: Cognitive Level: Understand (comprehension) REF: 1689 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
When teaching the patient who is receiving standard multidrug therapy for tuberculosis (TB) about possible toxic effects of the antitubercular medications, the nurse will give instructions to notify the health care provider if the patient develops a. yellow-tinged skin. b. changes in hearing. c. orange-colored sputum. d. thickening of the fingernails.
ANS: A Noninfectious hepatitis is a toxic effect of isoniazid (INH), rifampin, and pyrazinamide, and patients who develop hepatotoxicity will need to use other medications. Changes in hearing and nail thickening are not expected with the four medications used for initial TB drug therapy. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider. DIF: Cognitive Level: Application REF: 555 | 556 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse should notify the health care provider if the patient exhibits which finding? a. Yellow-tinged skin b. Orange-colored sputum c. Thickening of the fingernails d. Difficulty hearing high-pitched voices
ANS: A Noninfectious hepatitis is a toxic effect of isoniazid (INH), rifampin, and pyrazinamide, and patients who develop hepatotoxicity will need to use other medications. Changes in hearing and nail thickening are not expected with the four medications used for initial TB drug therapy. Presbycusis is an expected finding in the older adult patient. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider.
After the anticipated demise of a chronically ill patient, the unit nurse is found crying in the staff lounge. The best response to her crying colleague would be a. "It is normal to feel this way. Give yourself some time to mourn." b. "Your other patients still need you, so hurry back to them." c. "You're being a bad role model to the unit's nursing students." d. "Why don't you take a sedative to cope?"
ANS: A Nurses often witness suffering on a daily basis. Nurses, as humans, also experience grief and loss when they have been intensely involved in the patient's suffering and death. Offer comfort and understanding to colleagues, and maintain a stable patient care environment. It is inappropriate to create guilt by telling a grieving nurse to hurry back to her patients or by indicating that she is a bad role model. Suggesting that a colleague take sedative during a shift is dangerous for the safety of patients in her care.
Which information will the nurse include in the patient teaching plan for a patient who is receiving rifampin (Rifadin) for treatment of tuberculosis? a. "Your urine, sweat, and tears will be orange colored." b. "Read a newspaper daily to check for changes in vision." c. "Take vitamin B6 daily to prevent peripheral nerve damage." d. "Call the health care provider if you notice any hearing loss."
ANS: A Orange-colored body secretions are a side effect of rifampin. The other adverse effects are associated with other antituberculosis medications. DIF: Cognitive Level: Application REF: 555 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
22. Which painful, tender, pea-sized nodules may appear on the pads of the fingers or toes in bacterial endocarditis? a. Osler's nodes c. Subcutaneous nodules b. Janeway lesions d. Aschoff's nodules
ANS: A Osler's nodes are red, painful, intradermal nodes found on pads of the phalanges in bacterial endocarditis. Janeway lesions are painless hemorrhagic areas on palms and soles in bacterial endocarditis. Subcutaneous nodules are nontender swellings located over bony prominences, commonly found in rheumatic fever. Aschoff's nodules are small nodules composed of cells and leukocytes found in the interstitial tissues of the heart in rheumatic myocarditis. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1344 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
A 19-year-old woman with immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion. Which information indicates that the nurse should consult with the health care provider before obtaining and administering platelets? a. The platelet count is 42,000/μL. b. Petechiae are present on the chest. c. Blood pressure (BP) is 94/56 mm Hg. d. Blood is oozing from the venipuncture site.
ANS: A Platelet transfusions are not usually indicated until the platelet count is below 10,000 to 20,000/μL unless the patient is actively bleeding. Therefore the nurse should clarify the order with the health care provider before giving the transfusion. The other data all indicate that bleeding caused by ITP may be occurring and that the platelet transfusion is appropriate.
25. A major clinical manifestation of rheumatic fever is: a. Polyarthritis. b. Osler's nodes. c. Janeway spots. d. Splinter hemorrhages of distal third of nails.
ANS: A Polyarthritis is swollen, hot, red, and painful joints. The affected joints will change every 1 to 2 days. Primarily the large joints are affected. Osler's nodes, Janeway spots, and splinter hemorrhages are characteristic of infective endocarditis. PTS: 1 DIF: Cognitive Level: Analysis REF: 1345 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
38. A child with pulmonary atresia exhibits cyanosis with feeding. On reviewing this child's laboratory values, the nurse is not surprised to notice which abnormality? a. Polycythemia c. Dehydration b. Infection d. Anemia
ANS: A Polycythemia is a compensatory response to chronic hypoxia. The body attempts to improve tissue oxygenation by producing additional red blood cells and thereby increases the oxygen-carrying capacity of the blood. Infection is not a clinical consequence of cyanosis. Although dehydration can occur in cyanotic heart disease, it is not a compensatory mechanism for chronic hypoxia. It is not a clinical consequence of cyanosis. Anemia may develop as a result of increased blood viscosity. Anemia is not a clinical consequence of cyanosis. PTS: 1 DIF: Cognitive Level: Analysis REF: 1337 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
The nurse observes nursing assistive personnel (NAP) doing all the following activities when caring for a patient with right lower lobe pneumonia. The nurse will need to intervene when NAP a. lower the head of the patient's bed to 10 degrees. b. splint the patient's chest during coughing. c. help the patient to ambulate to the bathroom. d. assist the patient to a bedside chair for meals.
ANS: A Positioning the patient with the head of the bed lowered will decrease ventilation. The other actions are appropriate for a patient with pneumonia. DIF: Cognitive Level: Application REF: 552-553 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
The nurse suspects cardiac tamponade in a patient who has acute pericarditis. To assess for the presence of pulsus paradoxus, the nurse should a. note when Korotkoff sounds are auscultated during both inspiration and expiration. b. subtract the diastolic blood pressure (DBP) from the systolic blood pressure (SBP). c. check the electrocardiogram (ECG) for variations in rate during the respiratory cycle. d. listen for a pericardial friction rub that persists when the patient is instructed to stop breathing.
ANS: A Pulsus paradoxus exists when there is a gap of greater than 10 mm Hg between when Korotkoff sounds can be heard during only expiration and when they can be heard throughout the respiratory cycle. The other methods described would not be useful in determining the presence of pulsus paradoxus
While caring for a patient with aortic stenosis, the nurse identifies a nursing diagnosis of acute pain related to decreased coronary blood flow. A priority nursing intervention for this patient would be to a. promote rest to decrease myocardial oxygen demand. b. teach the patient about the need for anticoagulant therapy. c. teach the patient to use sublingual nitroglycerin for chest pain. d. raise the head of the bed 60 degrees to decrease venous return.
ANS: A Rest is recommended to balance myocardial oxygen supply and demand and to decrease chest pain. The patient with aortic stenosis requires higher preload to maintain cardiac output, so nitroglycerin and measures to decrease venous return are contraindicated. Anticoagulation is not recommended unless the patient has atrial fibrillation
9. When planning the response to the potential use of smallpox as an agent of terrorism, the emergency department (ED) nurse manager will plan to obtain adequate quantities of a. vaccine. b. atropine. c. antibiotics. d. whole blood.
ANS: A Smallpox infection can be prevented or ameliorated by the administration of vaccine given rapidly after exposure. The other interventions would be helpful for other agents of terrorism but not for smallpox. DIF: Cognitive Level: Understand (comprehension) REF: 1690 TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
12. A patient is admitted to the emergency department complaining of sudden onset shortness of breath and is diagnosed with a possible pulmonary embolus. How should the nurse prepare the patient for diagnostic testing to confirm the diagnosis? a. Start an IV so contrast media may be given. b. Ensure that the patient has been NPO for at least 6 hours. c. Inform radiology that radioactive glucose preparation is needed. d. Instruct the patient to undress to the waist and remove any metal objects.
ANS: A Spiral computed tomography (CT) scans are the most commonly used test to diagnose pulmonary emboli, and contrast media may be given IV. A chest x-ray may be ordered but will not be diagnostic for a pulmonary embolus. Preparation for a chest x-ray includes undressing and removing any metal. Bronchoscopy is used to detect changes in the bronchial tree, not to assess for vascular changes, and the patient should be NPO 6 to 12 hours before the procedure. Positron emission tomography (PET) scans are most useful in determining the presence of malignancy, and a radioactive glucose preparation is used. DIF: Cognitive Level: Apply (application) REF: 492 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
5. Which structural defects constitute tetralogy of Fallot? a. Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy b. Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy c. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy d. Pulmonic stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy
ANS: A Tetralogy of Fallot has these four characteristics: pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy. There is pulmonic stenosis but not aortic stenosis in tetralogy of Fallot. Right ventricular hypertrophy, not left ventricular hypertrophy, is present in tetralogy of Fallot. There is a ventricular septal defect, not an atrial septal defect, and overriding aorta, not aortic hypertrophy, is present. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1327 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
15. Parents of a 3-year-old child with congenital heart disease are afraid to let their child play with other children because of possible overexertion. The nurse's reply should be based on knowing that: a. The child needs opportunities to play with peers. b. The child needs to understand that peers' activities are too strenuous. c. Parents can meet all the child's needs. d. Constant parental supervision is needed to avoid overexertion.
ANS: A The child needs opportunities for social development. Children usually limit their activities if allowed to set their own pace and regulate their activities. The child will limit activities as necessary. Parents must be encouraged to seek appropriate social activities for the child, especially before kindergarten. The child needs to have activities that foster independence. PTS: 1 DIF: Cognitive Level: Analysis REF: 1339 OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia (select all that apply)? a. Age b. Blood pressure c. Respiratory rate d. Oxygen saturation e. Presence of confusion f. Blood urea nitrogen (BUN) level
ANS: A, B, C, E, F Data collected for the CURB-65 are mental status (confusion), BUN (elevated), blood pressure (decreased), respiratory rate (increased), and age (65 and older). The other information is also essential to assess, but are not used for CURB-65 scoring.
After 2 months of tuberculosis (TB) treatment with a standard four-drug regimen, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next? a. Ask the patient whether medications have been taken as directed. b. Discuss the need to use some different medications to treat the TB. c. Schedule the patient for directly observed therapy three times weekly. d. Educate about using a 2-drug regimen for the last 4 months of treatment.
ANS: A The first action should be to determine whether the patient has been compliant with drug therapy because negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. Depending on whether the patient has been compliant or not, different medications or directly observed therapy may be indicated. A two-drug regimen will be used only if the sputum smears are negative for AFB. DIF: Cognitive Level: Application REF: 556-557 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
49. The nurse is admitting a child with rheumatic fever. Which therapeutic management should the nurse expect to implement? a. Administering penicillin b. Avoiding salicylates (aspirin) c. Imposing strict bed rest for 4 to 6 weeks d. Administering corticosteroids if chorea develops
ANS: A The goal of medical management is the eradication of the hemolytic streptococci. Penicillin is the drug of choice. Salicylates can be used to control the inflammatory process, especially in the joints, and reduce the fever and discomfort. Bed rest is recommended for the acute febrile stage, but it does not need to be strict. The chorea is transient and will resolve without treatment. PTS: 1 DIF: Cognitive Level: Application REF: 1345 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
34. In which situation is there the greatest risk that a newborn infant will have a congenital heart defect (CHD)? a. Trisomy 21 detected on amniocentesis b. Family history of myocardial infarction c. Father has type 1 diabetes mellitus d. Older sibling born with Turner's syndrome
ANS: A The incidence of congenital heart disease is approximately 50% in children with trisomy 21 (Down syndrome). A family history of congenital heart disease, not acquired heart disease, increases the risk of giving birth to a child with CHD. Infants born to mothers who are insulin dependent have an increased risk of CHD. Infants identified as having certain genetic defects, such as Turner's syndrome, have a higher incidence of CHD. PTS: 1 DIF: Cognitive Level: Application REF: 1321 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
20. The nurse assesses a patient with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea over the last 3 days. Which finding is most important for the nurse to report to the health care provider? a. Respirations are 36 breaths/minute. b. Anterior-posterior chest ratio is 1:1. c. Lung expansion is decreased bilaterally. d. Hyperresonance to percussion is present.
ANS: A The increase in respiratory rate indicates respiratory distress and a need for rapid interventions such as administration of oxygen or medications. The other findings are common chronic changes occurring in patients with COPD. DIF: Cognitive Level: Apply (application) REF: 482 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
52. The nurse is caring for an infant with congestive heart disease (CHD). The nurse should plan which intervention to decrease cardiac demands? a. Organize nursing activities to allow for uninterrupted sleep. b. Allow the infant to sleep through feedings during the night. c. Wait for the infant to cry to show definite signs of hunger. d. Discourage parents from rocking the infant
ANS: A The infant requires rest and conservation of energy for feeding. Every effort is made to organize nursing activities to allow for uninterrupted periods of sleep. Whenever possible, parents are encouraged to stay with their infant to provide the holding, rocking, and cuddling that help children sleep more soundly. To minimize disturbing the infant, changing bed linens and complete bathing are done only when necessary. Feeding is planned to accommodate the infant's sleep and wake patterns. The child is fed at the first sign of hunger, such as when sucking on fists, rather than waiting until he or she cries for a bottle because the stress of crying exhausts the limited energy supply. Because infants with CHD tire easily and may sleep through feedings, smaller feedings every 3 hours may be helpful. PTS: 1 DIF: Cognitive Level: Application REF: 1335 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
48. The nurse is talking to a parent of an infant with heart failure about feeding the infant. Which statement about feeding the child is correct? a. "You may need to increase the caloric density of your infant's formula." b. "You should feed your baby every 2 hours." c. "You may need to increase the amount of formula your infant eats with each feeding." d. "You should place a nasal oxygen cannula on your infant during and after each feeding."
ANS: A The metabolic rate of infants with heart failure is greater because of poor cardiac function and increased heart and respiratory rates. Their caloric needs are greater than those of the average infants, yet their ability to take in the calories is diminished by their fatigue. Infants with heart failure should be fed every 3 hours; a 2-hour schedule does not allow for enough rest, and a 4-hour schedule is too long. Fluids must be carefully monitored because of the heart failure. Infants do not require supplemental oxygen with feedings. PTS: 1 DIF: Cognitive Level: Application REF: 1334 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
"I know it seems strange, but I feel guilty being pregnant after the death of my son last year," said a woman during her routine obstetrical examination. The nurse spends extra time with this woman, helping her to better bond with her unborn child. This demonstrates which nursing technique? a. Facilitating mourning b. Providing curative therapy c. Promoting spirituality d. Eradicating grief
ANS: A The nurse facilitates mourning in family members who are still surviving. By acknowledging the pregnant woman's emotions, the nurse helps the mother bond with her fetus and recognize the emotions that still exist for the deceased child. The nurse is not attempting to help the patient eradicate grief, which would be unrealistic. Curative therapy and spiritual promotion are not addressed by the nurse's statement.
A staff nurse has a tuberculosis (TB) skin test of 16-mm induration. A chest radiograph is negative, and the nurse has no symptoms of TB. The occupational health nurse will plan on teaching the staff nurse about the a. use and side effects of isoniazid (INH). b. standard four-drug therapy for TB. c. need for annual repeat TB skin testing. d. bacille Calmette-Guérin (BCG) vaccine.
ANS: A The nurse is considered to have a latent TB infection and should be treated with INH daily for 6 to 9 months. The four-drug therapy would be appropriate if the nurse had active TB. TB skin testing is not done for individuals who have already had a positive skin test. BCG vaccine is not used in the United States and would not be helpful for this individual, who already has a TB infection. DIF: Cognitive Level: Application REF: 556-557 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance
27. A patient who is being admitted to the emergency department with intermittent chest pain gives the following list of medications to the nurse. Which medication has the most immediate implications for the patient's care? a. Sildenafil (Viagra) b. Furosemide (Lasix) c. Captopril (Capoten) d. Warfarin (Coumadin)
ANS: A The nurse will need to avoid giving nitrates to the patient because nitrate administration is contraindicated in patients who are using sildenafil because of the risk of severe hypotension caused by vasodilation. The other home medications also should be documented and reported to the health care provider but do not have as immediate an impact on decisions about the patient's treatment.
11. When assessing an older patient admitted to the emergency department (ED) with a broken arm and facial bruises, the nurse observes several additional bruises in various stages of healing. Which statement or question by the nurse is most appropriate? a. "Do you feel safe in your home?" b. "You should not return to your home." c. "Would you like to see a social worker?" d. "I need to report my concerns to the police."
ANS: A The nurse's initial response should be to further assess the patient's situation. Telling the patient not to return home may be an option once further assessment is done. A social worker may be appropriate once further assessment is completed. DIF: Cognitive Level: Apply (application) REF: 1682 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
Hospice nursing care has a different focus for the dying client. Which of the following should the nurse know about client care provided through a hospice? a. It is designed to meet the client's individual wishes, as much as possible. b. It is usually aimed at offering curative treatment for the client. c. It is involved in teaching families to provide postmortem care. d. It does not include an interdisciplinary care team.
ANS: A The nurse's role in hospice nursing care is to meet the primary wishes of the dying client and to be open to the individual desires of each client. The nurse supports a client's choice in maintaining comfort and dignity. Hospice care is for the terminally ill. It is not aimed at offering curative treatment, but rather the emphasis is on palliative care. Hospice care may provide bereavement follow-up for the family after a client's death, but hospice nurses typically do not teach the family postmortem care. Hospice care programs include provision of an interdisciplinary care team of physicians, nurses, spiritual advisers, social workers, and counsellors.
19. Three days after experiencing a myocardial infarction (MI), a patient who is scheduled for discharge asks for assistance with hygiene activities, saying, "I am too nervous to take care of myself." Based on this information, which nursing diagnosis is appropriate? a. Ineffective coping related to anxiety b. Activity intolerance related to weakness c. Denial related to lack of acceptance of the MI d. Disturbed personal identity related to understanding of illness
ANS: A The patient data indicate that ineffective coping after the MI caused by anxiety about the impact of the MI is a concern. The other nursing diagnoses may be appropriate for some patients after an MI, but the data for this patient do not support denial, activity intolerance, or disturbed personal identity.
Two days after an acute myocardial infarction (MI), a patient complains of stabbing chest pain that increases with a deep breath. Which action will the nurse take first? a. Auscultate the heart sounds. b. Check the patient's temperature. c. Notify the patient's health care provider. d. Give the PRN acetaminophen (Tylenol).
ANS: A The patient's clinical manifestations and history are consistent with pericarditis, and the first action by the nurse should be to listen for a pericardial friction rub. Checking the temperature and notifying the health care provider are also appropriate actions but would not be done before listening for a rub. It is not stated for what symptom (e.g., headache) or finding (e.g., increased temperature) the PRN acetaminophen (Tylenol) is ordered.
13. A triage nurse in a busy emergency department (ED) assesses a patient who complains of 7/10 abdominal pain and states, "I had a temperature of 103.9° F (39.9° C) at home." The nurse's first action should be to a. assess the patient's current vital signs. b. give acetaminophen (Tylenol) per agency protocol. c. ask the patient to provide a clean-catch urine for urinalysis. d. tell the patient that it will 1 to 2 hours before being seen by the doctor.
ANS: A The patient's pain and statement about an elevated temperature indicate that the nurse should obtain vital signs before deciding how rapidly the patient should be seen by the health care provider. A urinalysis may be appropriate, but this would be done after the vital signs are taken. The nurse will not give acetaminophen before confirming a current temperature elevation. DIF: Cognitive Level: Apply (application) REF: 1675-1676 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
15. The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first? a. Remove the patient's rings. b. Apply ice packs to both hands. c. Apply calamine lotion to any itching areas. d. Give diphenhydramine (Benadryl) 50 mg PO.
ANS: A The patient's rings should be removed first because it might not be possible to remove them if swelling develops. The other orders should also be implemented as rapidly as possible after the nurse has removed the jewelry. DIF: Cognitive Level: Apply (application) REF: 1687 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
A patient who was admitted the previous day with pneumonia complains of a sharp pain "whenever I take a deep breath." Which action will the nurse take next? a. Listen to the patient's lungs. b. Administer the PRN morphine. c. Have the patient cough forcefully. d. Notify the patient's health care provider.
ANS: A The patient's statement indicates that pleurisy or a pleural effusion may have developed and the nurse will need to listen for a pleural friction rub and/or decreased breath sounds. Assessment should occur before administration of pain medications. The patient is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provider. DIF: Cognitive Level: Application REF: 576 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
18. An unresponsive 79-year-old is admitted to the emergency department (ED) during a summer heat wave. The patient's core temperature is 105.4° F (40.8° C), blood pressure (BP) 88/50, and pulse 112. The nurse initially will plan to a. apply wet sheets and a fan to the patient. b. provide O2 at 6 L/min with a nasal cannula. c. start lactated Ringer's solution at 1000 mL/hr. d. give acetaminophen (Tylenol) rectal suppository.
ANS: A The priority intervention is to cool the patient. Antipyretics are not effective in decreasing temperature in heat stroke, and 100% oxygen should be given, which requires a high flow rate through a non-rebreather mask. An older patient would be at risk for developing complications such as pulmonary edema if given fluids at 1000 mL/hr. DIF: Cognitive Level: Apply (application) REF: 1683 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
20. Following an earthquake, patients are triaged by emergency medical personnel and are transported to the emergency department (ED). Which patient will the nurse need to assess first? a. A patient with a red tag b. A patient with a blue tag c. A patient with a black tag d. A patient with a yellow tag
ANS: A The red tag indicates a patient with a life-threatening injury requiring rapid treatment. The other tags indicate patients with less urgent injuries or those who are likely to die. DIF: Cognitive Level: Remember (knowledge) REF: 1692 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
Before meeting the patient, a nurse talks to other caregivers about the patient. The nurse is in which phase of the helping relationship? a. Pre-interaction b. Orientation c. Working d. Termination
ANS: A The time before the nurse meets the patient is called the pre-interaction phase. This phase can involve such things as reviewing available data, including the medical and nursing history, talking to other caregivers who have information about the patient, or anticipating health concerns or issues that can arise. The orientation phase occurs when the nurse and the patient meet and get to know one another. This phase can involve such things as setting the tone for the relationship by adopting a warm, empathetic, caring manner; recognizing that the initial relationship is often superficial, uncertain, and tentative; or expecting the patient to test the nurse's competence and commitment. The working phase occurs when the nurse and the patient work together to solve problems and accomplish goals. This phase can involve such things as encouraging and helping the patient express feelings about his or her health, encouraging and helping the patient with self-exploration, or providing information needed to understand and change behavior. The termination phase occurs during the ending of the relationship. This phase can involve such things as reminding the patient that termination is near, evaluating goal achievement with the patient, or reminiscing about the relationship with the patient.
Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which information best supports this diagnosis? a. Weak, nonproductive cough effort b. Large amounts of greenish sputum c. Respiratory rate of 28 breaths/minute d. Resting pulse oximetry (SpO2) of 85%
ANS: A The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern. DIF: Cognitive Level: Application REF: 551-552 TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity
How should the nurse promote comfort for the terminally ill client, specific to nausea and vomiting? a. Provide frequent mouth care. b. Suction oral secretions. c. Increase the fluid intake. d. Offer a high-residue diet.
ANS: A To promote comfort for the terminally ill client, specific to nausea and vomiting, the nurse should administer anti-emetics, provide oral care at least every two to four hours, offer a clear liquid diet and ice chips, and avoid liquids that increase stomach acidity such as coffee, milk, and citrus acid juices. Suctioning would remove respiratory secretions. Increasing the fluid intake may help prevent constipation. A low-residue diet may help prevent diarrhea.
A patient is aphasic, and the nurse notices that the patient's hands shake intermittently. Which nursing action is most appropriate to facilitate communication? a. Use a picture board. b. Use pen and paper. c. Use an interpreter. d. Use a hearing aid.
ANS: A Using a pen and paper can be frustrating for a nonverbal (aphasic) patient whose handwriting is shaky; the nurse can revise the care plan to include use of a picture board instead. An interpreter is used for a patient who speaks a foreign language. A hearing aid is used for the hard of hearing, not for an aphasic patient.
21. A few days after experiencing a myocardial infarction (MI) and successful percutaneous coronary intervention, the patient states, "I just had a little chest pain. As soon as I get out of here, I'm going for my vacation as planned." Which reply would be most appropriate for the nurse to make? a. "What do you think caused your chest pain?" b. "Where are you planning to go for your vacation?" c. "Sometimes plans need to change after a heart attack." d. "Recovery from a heart attack takes at least a few weeks."
ANS: A When the patient is experiencing denial, the nurse should assist the patient in testing reality until the patient has progressed beyond this step of the emotional adjustment to MI. Asking the patient about vacation plans reinforces the patient's plan, which is not appropriate in the immediate post-MI period. Reminding the patient in denial about the MI is likely to make the patient angry and lead to distrust of the nursing staff.
3. After the return of spontaneous circulation following the resuscitation of a patient who had a cardiac arrest, therapeutic hypothermia is ordered. Which action will the nurse include in the plan of care? a. Apply external cooling device. b. Check mental status every 15 minutes. c. Avoid the use of sedative medications. d. Rewarm if temperature is <91° F (32.8° C).
ANS: A When therapeutic hypothermia is used postresuscitation, external cooling devices or cold normal saline infusions are used to rapidly lower body temperature to 89.6° F to 93.2° F (32° C to 34° C). Because hypothermia will decrease brain activity, assessing mental status every 15 minutes is not needed at this stage. Sedative medications are administered during therapeutic hypothermia. DIF: Cognitive Level: Apply (application) REF: 1681 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
When preparing to cool a patient who is to begin therapeutic hypothermia, which intervention will the nurse plan to do (select all that apply)? a. Assist with endotracheal intubation. b. Insert an indwelling urinary catheter. c. Begin continuous cardiac monitoring. d. Obtain an order to restrain the patient. e. Prepare to give sympathomimetic drugs.
ANS: A, B, C Cooling can produce dysrhythmias, so the patient's heart rhythm should be continuously monitored and dysrhythmias treated if necessary. Bladder catheterization and endotracheal intubation are needed during cooling. Sympathomimetic drugs tend to stimulate the heart and increase the risk for fatal dysrhythmias such as ventricular fibrillation. Patients receiving therapeutic hypothermia are comatose or do not follow commands so restraints are not indicated. DIF: Cognitive Level: Apply (application) REF: 1681 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
1. A nurse uses the five rights of delegation when providing care. Which "rights" did the nurse use? (Select all that apply.) a. Right task b. Right person c. Right direction d. Right supervision e. Right circumstances f. Right cost-effectiveness
ANS: A, B, C, D, E The five rights of delegation are right task, circumstances, person, direction, and supervision. Cost-effectiveness is not a right. DIF:Understand (comprehension)REF:287 OBJ: Discuss principles to follow in the appropriate delegation of patient care activities. TOP:ImplementationMSC:Management of Care
55. A child has a total cholesterol level of 180 mg/dL. What dietary recommendations should the nurse make to the child and the child's parents (Select all that apply)? a. Replace whole milk with 2% or 1% milk b. Increase servings of red meat c. Increase servings of fish d. Avoid excessive intake of fruit juices e. Limit servings of whole grain
ANS: A, C, D A low-fat diet includes using nonfat or low-fat dairy products, limiting red meat intake, and increasing intake of fish, vegetables, whole grains, and legumes. Children should avoid excessive intake of fruit juices and other sweetened drinks, sugars, and saturated fats. PTS: 1 DIF: Cognitive Level: Application REF: 1346 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
31. While the nurse is feeding a patient, the patient appears to choke on the food. Which symptoms indicate to the nurse that the patient has a partial airway obstruction (select all that apply)? a. stridor b. Cyanosis c. Wheezing d. Bradycardia e. Rapid respiratory rate
ANS: A,B,C With partial airway obstruction, choking, stridor, use of accessory muscles, suprasternal and intercostals retraction, flaring nostrils, wheezing, restlessness, tachycardia, cyanosis, and change in level of consciousness may occur. Partial airway obstruction may progress to complete obstruction without prompt assessment and treatment.
34. During care of a patient with a cuffed tracheostomy, the nurse notes that the tracheostomy tube has an inner cannula. To Care for the tracheostomy appropriately, what should the nurse do? a. Deflate the cuff, then remove and suction the inner cannula b. Remove the inner cannula and replace it per institutional guidelines c. Remove the inner cannula if the patient shows signs of airway obstruction d. Keep the inner cannula in place at all times to prevent dislodging the tracheostomy tube
ANS: B An inner cannula is a second tubing that fits inside the outer tracheostomy tube. Disposable inner cannulas are frequently used but non disposable ones can be removed and cleaned of mucus that has accumulated on the inside of the tube. Many tracheostomy tubes do not have inner cannulas because when humidification is adequate, accumulation of mucus should not occur.
6. A staff member verbalizes satisfaction in working on a particular nursing unit because of the freedom of choice and responsibility for the choices. This nurse highly values which element of shared decision making? a. Authority b. Autonomy c. Responsibility d. Accountability
ANS: B Autonomy is freedom of choice and responsibility for the choices. Authority refers to legitimate power to give commands and make final decisions specific to a given position. Responsibility refers to the duties and activities that an individual is employed to perform. Accountability refers to individuals being answerable for their actions. DIF:Understand (comprehension)REF:282 OBJ: Describe the elements of shared decision making. TOP: Assessment
37. What is included in the nursing care of the patient with a cuffed tracheostomy tube? a. Change the tube 3 days b. Monitor cuff pressure every 8 hours c. Perform mouth care every 12 hours d. assess arterial blood gases every 8 hours
ANS: B Cuff pressure should be monitored every 8 hours to ensure an air leak around the cuff does not occur and that the pressure is not to high to allow adequate tracheal capillary perfusion. Respiratory therapists in some institutions will record the cuff pressure and identify if there is a problem maintaining cuff pressure. Tracheostomy tubes are not usually changed sooner than 7 days after a tracheostomy. Mouth care should be performed a minimum of every 8 hours and more often as needed to remove dried secretions. ABGs are not routinely assessed with tracheostomy tube placement unless symptoms of respiratory distress continue.
44. What should the nurse include in discharge teaching for the patient with a total laryngectomy? a. How to use esophageal speech to communicate b. How to use a mirror to suction the techeaostomy c. The necessity of never covering the laaryngectomy stoma d. The need to use baths instead of showers for personal hygiene
ANS: B Suctioning of the tracheostomy with the use of a mirror is a self-care activity taught to the patient before discharge. Voice rehabilitation is usually managed by a speech therapist or speech pathologist but the nurse should discuss the various types of voice rehabilitation and the advantages and disadvantages of each options. The laryngectomy stoma should be covered with a shield during showering and covered with light scarves or fabric when aspiration of foreign materials is likely.
14. Following a laryngectomy a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first? a.Cover stoma with sterile gauze and ventilate through stoma. b.Attempt to reinsert the tracheostomy tube with the obturator in place. c.Assess the patient's oxygen saturation and notify the health care provider. d.Ventilate the patient with a manual bag and face mask until the health care provider arrives.
ANS: B The first action should be to attempt to reinsert the tracheostomy tube to maintain the patient's airway. Assessing the patient's oxygenation is an important action, but it is not the most appropriate first action in this situation. Covering the stoma with a dressing and manually ventilating the patient may be an appropriate action if the nurse is unable to reinsert the tracheostomy tube. Ventilating with a facemask is not appropriate for a patient with a total laryngectomy because there is a complete separation between the upper airway and the trachea.
17. A nursing assistive personnel (NAP) reports seeing a reddened area on the patient's hip while bathing the patient. Which action should the nurse take? a. Request a wound nurse consult. b. Go to the patient's room to assess the patient's skin. c. Document the finding per the NAP's report. d. Ask the NAP to apply a dressing over the reddened area.
ANS: B The nurse needs to assess the patient's skin. Assessment should not be delegated; it is the responsibility of the licensed registered nurse. The nurse needs to document the assessment findings objectively, not subjectively, per the nursing assistive personnel. Before requesting a consult or determining treatment, the nurse needs to assess the skin. DIF:Apply (application)REF:287 OBJ: Discuss principles to follow in the appropriate delegation of patient care activities.
39. When Obtaining a health history from a patient with possible cancer of the mouth, what would the nurse expect the patient to report? a. Long-term denture use b. Heavy tobacco and/or alcohol use c. Persistent swelling of the neck and face d. Chronic herpes simplex infections of the mouth and lips
ANS: B The primary risk factor associated with head and neck cancers are heavy tobacco and alcohol use and family history. Chronic infections are not known to be risk factors, although cancers in patients younger than age 50 have been associated with human papillomavirus (HPV) infection. oral cancer may cause a change in the fit of dentures but denture use is not a risk factor for oral cancer.
3. A nurse is working in an intensive care unit (critical care). Which type of nursing care delivery model will this nurse most likely use? a. Team nursing b. Total patient care c. Primary nursing d. Case-management
ANS: B Total patient care is found primarily in critical care areas. Total patient care involves an RN being responsible for all aspects of care for one or more patients. In the team nursing care model, the RN assumes the role of group or team leader and leads a team made up of other RNs, practical nurses, and nursing assistive personnel. The primary nursing model of care delivery was developed to place RNs at the bedside and improve the accountability of nursing for patient outcomes and the professional relationships among staff members. Case-management is a care approach that coordinates and links health care services to patients and families while streamlining costs. DIF:Understand (comprehension)REF:281 OBJ:Differentiate among the types of nursing care delivery models.
45. What is the most normal functioning method of speech restoration in the patient with a total laryngectomy? a. Esophageal speech b. A transesophageal puncture c. An electrolarynx held to the neck d. An electrolarynx palced in the mouth
ANS: B Transesophageal puncture provides the most normal voice reproduction but requires a surgical fistula made between the esophagus and the trachea and possibly a valve prosthesis. Esophageal speech involves trapping air in the esophagus and releasing it to form sound but only 10% of patients can develop fluent speech with this method. The electrolarynx, whether placed in the mouth or held to the neck, allows speech that has a metallic or robotic sound.
A dying patient with liver and renal failure requires pain medication. The nurse anticipates that the medication dose will be a. Given at appropriate milligrams per kilogram medication levels. b. A decreased dose from milligrams per kilogram levels. c. An increased dose from milligrams per kilogram levels. d. Given at midrange for dosing at recommended levels.
ANS: B A dying individual will likely have a decline in renal and liver functioning. Because of reduced organ functioning, a decreased dose would be in order, so the individual does not develop toxic levels of the medications.
When caring for a patient who is hospitalized with active tuberculosis (TB), the nurse observes a student nurse who is assigned to take care of a patient. Which action, if performed by the student nurse, would require an intervention by the nurse? a. The patient is offered a tissue from the box at the bedside. b. A surgical face mask is applied before visiting the patient. c. A snack is brought to the patient from the unit refrigerator. d. Hand washing is performed before entering the patient's room.
ANS: B A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the patient's room because the HEPA mask can filter out 100% of small airborne particles. Hand washing before entering the patient's room is appropriate. Because anorexia and weight loss are frequent problems in patients with TB, bringing food to the patient is appropriate. The student nurse should perform hand washing after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue.
A patient has trouble speaking words, and the patient's speech is garbled. Which nursing diagnosis is most appropriate for this patient? a. Hopelessness b. Impaired verbal communication c. Hearing loss d. Self-care deficit
ANS: B A patient with impaired verbal communication has defining characteristics such as an inability to articulate words, inappropriate verbalization, difficulty forming words, and difficulty comprehending. Hopelessness implies that the patient has no hope for the future. Hearing loss is not a nursing diagnosis. Just because a patient has garbled speech does not mean that a hearing loss has occurred; a physical problem such as a stroke could cause the garbled speech. Self-care deficit does not apply in this situation because this usually relates to bathing, grooming, etc.
A client has been diagnosed with terminal cancer of the liver and is receiving chemotherapy on a medical unit. In an in-depth conversation with the nurse, the client states, "It can't be happening to me." According to Kübler-Ross, with which of the following is this stage of dying associated? a. Anxiety b. Denial c. Confrontation d. Depression
ANS: B According to Kübler-Ross, the client is in the denial stage of dying. The client may act as though nothing has happened, may refuse to believe or understand that a loss has occurred and may seem stunned, as though it is "unreal" or difficult to believe. No stage of anxiety is found in Kübler-Ross's five stages of dying. No stage of confrontation is found in Kübler-Ross's five stages of dying. During depression, the individual may feel overwhelmingly lonely and withdraw from interpersonal interaction. Depression is one of Kübler-Ross's five stages of dying, but is not represented by this example.
The nurse reviews the medication administration record (MAR) for a patient having an acute asthma attack. Which medication should the nurse administer first? a. Methylprednisolone (Solu-Medrol) 60 mg IV b. Albuterol (Ventolin HFA) 2.5 mg per nebulizer c. Salmeterol (Serevent) 50 mcg per dry-powder inhaler (DPI) d. Ipratropium (Atrovent) 2 puffs per metered-dose inhaler (MDI)
ANS: B Albuterol is a rapidly acting bronchodilator and is the first-line medication to reverse airway narrowing in acute asthma attacks.
Which intervention will be included in the nursing care plan for a patient with immune thrombocytopenic purpura (ITP)? a. Assign the patient to a private room. b. Avoid intramuscular (IM) injections. c. Use rinses rather than a soft toothbrush for oral care. d. Restrict activity to passive and active range of motion.
ANS: B IM or subcutaneous injections should be avoided because of the risk for bleeding. A soft toothbrush can be used for oral care. There is no need to restrict activity or place the patient in a private room.
A confused older adult patient is wearing thick glasses and a hearing aid. Which intervention is priority to facilitate communication? a. Focus on tasks to be completed. b. Allow time for the patient to respond. c. Limit conversations with the patient. d. Use gestures and other nonverbal cues.
ANS: B Allowing time for the patient to respond will facilitate communication, especially for an older confused patient. Focusing on tasks to be completed and limiting conversations do not facilitate communication; in fact, they block communication. Using gestures and other nonverbal cues is not effective for visually impaired or cognitively impaired patients.
A smiling patient angrily states, "I will not cough and deep breathe." How will the nurse interpret this finding? a. The patient's personal space was violated. b. The patient's affect is inappropriate. c. The patient's vocabulary is poor. d. The patient's denotative meaning is wrong.
ANS: B An inappropriate affect is a facial expression that does not match the content of a verbal message (e.g., smiling when describing a sad situation). The patient is smiling but is angry, which indicates an inappropriate affect. The patient's personal space was not violated. The patient's vocabulary is not poor. Individuals who use a common language share denotative meaning: baseball has the same meaning for everyone who speaks English, but code denotes cardiac arrest primarily to health care providers. The patient's denotative meaning is correct for cough and deep breathe.
A nurse encounters a family that experienced the death of their adult child last year. The parents are talking about the upcoming anniversary of their child's death. The nurse spends time with them discussing their child's life and death. The nurse's action best demonstrates which nursing principle? a. Pain management technique b. Facilitating normal mourning c. Grief evaluation d. Palliative care
ANS: B Anniversary reactions can reopen grief processes. A nurse should openly acknowledge the loss and talk about the common renewal of grief feeling around the anniversary of the individual's death. This facilitates normal mourning. The nurse is not attempting to alleviate a physical pain. The actions are of open communication, not evaluation. Palliative care refers to comfort measures for symptom relief.
A patient says, "You are the worst nurse I have ever had." Which response by the nurse is the most assertive? a. "If I were you, I'd feel grateful for a nurse like me." b. "I feel uncomfortable hearing that statement." c. "How can you say that when I have been checking on you regularly?" d. "You shouldn't say things like that, it is not right."
ANS: B Assertive responses contain "I" messages such as "I want," "I need," "I think," or "I feel." Giving personal opinions ("If I were you") is nontherapeutic and not assertive. Arguing ("How can you say that?") is not assertive or therapeutic. Showing disapproval (using words like should, good, bad, right) is not assertive or therapeutic.
33. When admitting a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI) to the intensive care unit, which action should the nurse perform first? a. Obtain the blood pressure. b. Attach the cardiac monitor. c. Assess the peripheral pulses. d. Auscultate the breath sounds.
ANS: B Because dysrhythmias are the most common complication of myocardial infarction (MI), the first action should be to place the patient on a cardiac monitor. The other actions also are important and should be accomplished as quickly as possible.
39. To improve the physical activity level for a mildly obese 71-year-old patient, which action should the nurse plan to take? a. Stress that weight loss is a major benefit of increased exercise. b. Determine what kind of physical activities the patient usually enjoys. c. Tell the patient that older adults should exercise for no more than 20 minutes at a time. d. Teach the patient to include a short warm-up period at the beginning of physical activity.
ANS: B Because patients are more likely to continue physical activities that they already enjoy, the nurse will plan to ask the patient about preferred activities. The goal for older adults is 30 minutes of moderate activity on most days. Older adults should plan for a longer warm-up period. Benefits of exercises, such as improved activity tolerance, should be emphasized rather than aiming for significant weight loss in older mildly obese adults.
18. After the nurse has received change-of-shift report, which patient should the nurse assess first? a. A patient with pneumonia who has crackles in the right lung base b. A patient with possible lung cancer who has just returned after bronchoscopy c. A patient with hemoptysis and a 16-mm induration with tuberculin skin testing d. A patient with chronic obstructive pulmonary disease (COPD) and pulmonary function testing (PFT) that indicates low forced vital capacity
ANS: B Because the cough and gag are decreased after bronchoscopy, this patient should be assessed for airway patency. The other patients do not have clinical manifestations or procedures that require immediate assessment by the nurse. DIF: Cognitive Level: Apply (application) REF: 492 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
Which collaborative problem will the nurse include in a care plan for a patient admitted to the hospital with idiopathic aplastic anemia? a. Potential complication: seizures b. Potential complication: infection c. Potential complication: neurogenic shock d. Potential complication: pulmonary edema
ANS: B Because the patient with aplastic anemia has pancytopenia, the patient is at risk for infection and bleeding. There is no increased risk for seizures, neurogenic shock, or pulmonary edema.
10. The nurse is evaluating a child who is taking digoxin for her cardiac condition. The nurse is cognizant that a common sign of digoxin toxicity is: a. Seizures. c. Bradypnea. b. Vomiting. d. Tachycardia.
ANS: B Vomiting is a common sign of digoxin toxicity. Seizures are not associated with digoxin toxicity. The child will have a slower heart rate, not respiratory rate. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1335 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
29. One of the most frequent causes of hypovolemic shock in children is: a. Myocardial infarction. c. Anaphylaxis. b. Blood loss. d. Congenital heart disease.
ANS: B Blood loss and extracellular fluid loss are two of the most frequent causes of hypovolemic shock in children. Myocardial infarction is rare in a child; if it occurred, the resulting shock would be cardiogenic, not hypovolemic. Anaphylaxis results in distributive shock from extreme allergy or hypersensitivity to a foreign substance. Congenital heart disease tends to contribute to hypervolemia, not hypovolemia. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1355 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
3. Which assessment data collected by the nurse who is admitting a patient with chest pain suggest that the pain is caused by an acute myocardial infarction (AMI)? a. The pain increases with deep breathing. b. The pain has lasted longer than 30 minutes. c. The pain is relieved after the patient takes nitroglycerin. d. The pain is reproducible when the patient raises the arms.
ANS: B Chest pain that lasts for 20 minutes or more is characteristic of AMI. Changes in pain that occur with raising the arms or with deep breathing are more typical of musculoskeletal pain or pericarditis. Stable angina is usually relieved when the patient takes nitroglycerin.
A woman is called into her supervisor's office regarding her deteriorating work performance since the loss of her husband 2 years ago. The woman begins sobbing and saying that she is "falling apart" at home as well. The woman is escorted to the nurse's office, where the nurse recognizes the woman's symptoms as which of the following? a. Normal grief b. Complicated grief c. Disenfranchised grief d. Perceived grief
ANS: B Complicated or dysfunctional grief occurs when an individual has a complicated grieving process that interferes with common routines of life for excessively long periods of time. Normal grief is the most common reaction to death; it involves a complex range of normal coping strategies. Disenfranchised grief involves a relationship that is not socially sanctioned. Perceived grief is not a type of grief; perceived loss is a loss that is not obvious to other people.
The nurse identifies the nursing diagnosis of decreased cardiac output related to valvular insufficiency for the patient with infective endocarditis (IE) based on which assessment finding(s)? a. Fever, chills, and diaphoresis b. Urine output less than 30 mL/hr c. Petechiae on the inside of the mouth and conjunctiva d. Increase in heart rate of 15 beats/minute with walking
ANS: B Decreased renal perfusion caused by inadequate cardiac output will lead to decreased urine output. Petechiae, fever, chills, and diaphoresis are symptoms of IE, but are not caused by decreased cardiac output. An increase in pulse rate of 15 beats/minute is normal with exercise
20. When caring for a patient who is recovering from a sudden cardiac death (SCD) event and has no evidence of an acute myocardial infarction (AMI), the nurse will anticipate teaching the patient that a. sudden cardiac death events rarely reoccur. b. additional diagnostic testing will be required. c. long-term anticoagulation therapy will be needed. d. limited physical activity after discharge will be needed to prevent future events.
ANS: B Diagnostic testing (e.g., stress test, Holter monitor, electrophysiologic studies, cardiac catheterization) is used to determine the possible cause of the SCD and treatment options. SCD is likely to recur. Anticoagulation therapy will not have any effect on the incidence of SCD, and SCD can occur even when the patient is resting.
Which information obtained by the nurse caring for a patient with thrombocytopenia should be immediately communicated to the health care provider? a. The platelet count is 52,000/µL. b. The patient is difficult to arouse. c. There are purpura on the oral mucosa. d. There are large bruises on the patient's back.
ANS: B Difficulty in arousing the patient may indicate a cerebral hemorrhage, which is life threatening and requires immediate action. The other information should be documented and reported but would not be unusual in a patient with thrombocytopenia.
12. As part of the treatment for congestive heart failure, the child takes the diuretic furosemide. As part of teaching home care, the nurse encourages the family to give the child foods such as bananas, oranges, and leafy vegetables. These foods are recommended because they are high in: a. Chlorides. c. Sodium. b. Potassium. d. Vitamins.
ANS: B Diuretics that work on the proximal and distal renal tubules contribute to increased losses of potassium. The child's diet should be supplemented with potassium. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1333 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity
1. During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient is breathing and has an unobstructed airway. Which action should the nurse take next? a. Palpate extremities for bilateral pulses. b. Observe the patient's respiratory effort. c. Check the patient's level of consciousness. d. Examine the patient for any external bleeding.
ANS: B Even with a patent airway, patients can have other problems that compromise ventilation, so the next action is to assess the patient's breathing. The other actions are also part of the initial survey but assessment of breathing should be done immediately after assessing for airway patency. DIF: Cognitive Level: Apply (application) REF: 1676 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
6. A patient who has experienced blunt abdominal trauma during a motor vehicle collision is complaining of increasing abdominal pain. The nurse will plan to teach the patient about the purpose of a. peritoneal lavage. b. abdominal ultrasonography. c. nasogastric (NG) tube placement. d. magnetic resonance imaging (MRI).
ANS: B For patients who are at risk for intraabdominal bleeding, focused abdominal ultrasonography is the preferred method to assess for intraperitoneal bleeding. An MRI would not be used. Peritoneal lavage is an alternative, but it is more invasive. An NG tube would not be helpful in diagnosis of intraabdominal bleeding. DIF: Cognitive Level: Apply (application) REF: 1678 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
After receiving report on the following patients, which patient should the nurse assess first? a. Patient with rheumatic fever who has sharp chest pain with a deep breath b. Patient with acute aortic regurgitation whose blood pressure is 86/54 mm Hg c. Patient with infective endocarditis who has a murmur and splinter hemorrhages d. Patient with dilated cardiomyopathy who has bilateral crackles at the lung bases
ANS: B Hypotension in patients with acute aortic regurgitation may indicate cardiogenic shock. The nurse should immediately assess this patient for other findings such as dyspnea or chest pain. The findings in the other patients are typical of their diagnoses and do not indicate a need for urgent assessment and intervention
44. An adolescent being seen by the nurse practitioner for a sports physical is identified as having hypertension. On further testing, it is discovered the child has a cardiac abnormality. The initial treatment of secondary hypertension initially involves: a. Weight control and diet. b. Treating the underlying disease. c. Administration of digoxin. d. Administration of -adrenergic receptor blockers.
ANS: B Identification of the underlying disease should be the first step in treating secondary hypertension. Weight control and diet are nonpharmacologic treatments for primary hypertension. Digoxin is indicated in the treatment of congestive heart failure. -Adrenergic receptor blockers are indicated in the treatment of primary hypertension. PTS: 1 DIF: Cognitive Level: Application REF: 1350 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
16. Gastric lavage and administration of activated charcoal are ordered for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which action should the nurse plan to do first? a. Insert a large-bore orogastric tube. b. Assist with intubation of the patient. c. Prepare a 60-mL syringe with saline. d. Give first dose of activated charcoal.
ANS: B In an unresponsive patient, intubation is done before gastric lavage and activated charcoal administration to prevent aspiration. The other actions will be implemented after intubation. DIF: Cognitive Level: Apply (application) REF: 1689 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
14. The nurse is caring for a child with persistent hypoxia secondary to a cardiac defect. The nurse recognizes that a risk of cerebrovascular accidents (strokes) exists. An important objective to decrease this risk is to: a. Minimize seizures. c. Promote cardiac output. b. Prevent dehydration. d. Reduce energy expenditure.
ANS: B In children with persistent hypoxia, polycythemia develops. Dehydration must be prevented in hypoxemic children because it potentiates the risk of strokes. Minimizing seizures, promoting cardiac output, and reducing energy expenditure will not reduce the risk of cerebrovascular accidents. PTS: 1 DIF: Cognitive Level: Analysis REF: 1337 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
31. Which clinical changes occur as a result of septic shock? a. Hypothermia c. Vasoconstriction b. Increased cardiac output d. Angioneurotic edema
ANS: B Increased cardiac output, which results in warm, flushed skin, is one of the manifestations of septic shock. Fever and chills are characteristic of septic shock. Vasodilation is more common in septic shock. Angioneurotic edema occurs as a manifestation in anaphylactic shock. PTS: 1 DIF: Cognitive Level: Analysis REF: 1356 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
During assessment of the chest in a patient with pneumococcal pneumonia, the nurse would expect to find a. vesicular breath sounds. b. increased tactile fremitus. c. dry, nonproductive cough. d. hyperresonance to percussion.
ANS: B Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal pneumonia typically presents with a loose, productive cough. Adventitious breath sounds such as crackles and wheezes are typical. DIF: Cognitive Level: Application REF: 549 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first? a. Chest x-ray via stretcher b. Blood cultures from two sites c. Ciprofloxacin (Cipro) 400 mg IV d. Acetaminophen (Tylenol) rectal suppository
ANS: B Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic administration. The chest x-ray and acetaminophen administration can be done last.
An Orthodox Jewish Rabbi has been pronounced dead. The nursing assistant respectfully asks family members to leave the room and go home as postmortem care is provided. Which of the following statements from the supervising nurse reflects correct knowledge of Jewish culture? a. "I wish they would go home because we have work to do here." b. "Family members stay with the body until burial the next day." c. "I should have called a male colleague to handle the body." d. "I thought they would quietly leave after praying and touching the Rabbi's head."
ANS: B Jewish culture calls for family members or religious officials to stay with the decedent's body until the time of burial. A male provider is unnecessary. Requesting or expecting the family to go home is not providing culturally sensitive care.
3. A diabetic patients arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg; HCO3 18 mEq/L. The nurse would expect which finding? a. Intercostal retractions b. Kussmaul respirations c. Low oxygen saturation (SpO2) d. Decreased venous O2 pressure
ANS: B Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis. The low pH and low bicarbonate result indicate metabolic acidosis. Intercostal retractions, a low oxygen saturation rate, and a decrease in venous O2 pressure would not be caused by acidosis. DIF: Cognitive Level: Apply (application) REF: 479 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
22. Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a. Listen to a patients lung sounds for wheezes or rhonchi. b. Label specimens obtained during percutaneous lung biopsy. c. Instruct a patient about how to use home spirometry testing. d. Measure induration at the site of a patients intradermal skin test.
ANS: B Labeling of specimens is within the scope of practice of UAP. The other actions require nursing judgment and should be done by licensed nursing personnel. DIF: Cognitive Level: Apply (application) REF: 15 OBJ: Special Questions: Delegation TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
During the initial home visit, a home health nurse lets the patient know that the visits are expected to end in about a month. The nurse is in which phase of the helping relationship? a. Pre-interaction b. Orientation c. Working d. Termination
ANS: B Letting the patient know when to expect the relationship to be terminated occurs in the orientation phase. Pre-interaction occurs before the nurse meets the patient. Working occurs when the nurse and the patient work together to solve problems and accomplish goals. Termination occurs during the ending of the relationship.
A man is hospitalized after surgery that amputated both lower extremities owing to injuries sustained during military service. The nurse should recognize his need to grieve for what type of loss? a. Maturational loss b. Situational loss c. Perceived loss d. Uncomplicated loss
ANS: B Loss of a body part from injury is a situational loss. Maturational losses occur as part of normal life transitions. Perceived loss is not obvious to other people. Uncomplicated is not a type of loss; it is a description of normal grief.
Which of the following statements is true regarding cultural beliefs and death? a. The ethical decisions surrounding a client's death should be based on hospital policy and not culture. b. Maintaining rituals and practices allows a sense of acceptance of the dying process. c. The nurse must decide which cultural practices will be incorporated in care of the dying. d. Regardless of culture, following hospital practices will help focus client and family on the dying process.
ANS: B Maintaining the integrity of rituals and mourning practices gives families a sense of acceptance of the client's death and an inner peace. The nurse should be familiar with policies and procedures, but ethical decisions should be made with an understanding and appreciation of the client's culture. The nurse must assess the terminally ill client's and family's wishes for end-of-life care and develop a plan of care by integrating client culture and spiritual beliefs. On the contrary, the nurse must assess the terminally ill client's and family's wishes for end-of-life care and develop a plan of care by integrating client culture and spiritual beliefs.
The nurse is assessing a patient with myocarditis before administering the scheduled dose of digoxin (Lanoxin). Which finding is most important for the nurse to communicate to the health care provider? a. Leukocytosis b. Irregular pulse c. Generalized myalgia d. Complaint of fatigue
ANS: B Myocarditis predisposes the heart to digoxin-associated dysrhythmias and toxicity. The other findings are common symptoms of myocarditis and there is no urgent need to report these.
During the assessment of a 25-year-old patient with infective endocarditis (IE), the nurse would expect to find a. substernal chest pressure. b. a new regurgitant murmur. c. a pruritic rash on the chest. d. involuntary muscle movement.
ANS: B New regurgitant murmurs occur in IE because vegetations on the valves prevent valve closure. Substernal chest discomfort, rashes, and involuntary muscle movement are clinical manifestations of other cardiac disorders such as angina and rheumatic fever
The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first? a. A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled b. A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath c. A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes d. A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 100.2° F (37.8° C)
ANS: B Patients on bed rest who are immobile are at high risk for deep vein thrombosis (DVT). Sudden onset of shortness of breath in a patient with a DVT suggests a pulmonary embolism and requires immediate assessment and action such as oxygen administration. The other patients should also be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration.
The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement, if made by the patient, indicates a good understanding of the instructions? a. "I will call the doctor if I still feel tired after a week." b. "I will continue to do the deep breathing and coughing exercises at home." c. "I will schedule two appointments for the pneumonia and influenza vaccines." d. "I'll cancel my chest x-ray appointment if I'm feeling better in a couple weeks."
ANS: B Patients should continue to cough and deep breathe after discharge. Fatigue is expected for several weeks. The Pneumovax and influenza vaccines can be given at the same time in different arms. Explain that a follow-up chest x-ray needs to be done in 6 to 8 weeks to evaluate resolution of pneumonia
10. The nurse will suspect that the patient with stable angina is experiencing a side effect of the prescribed metoprolol (Lopressor) if the a. patient is restless and agitated. b. blood pressure is 90/54 mm Hg. c. patient complains about feeling anxious. d. cardiac monitor shows a heart rate of 61 beats/minute.
ANS: B Patients taking β-adrenergic blockers should be monitored for hypotension and bradycardia. Because this class of medication inhibits the sympathetic nervous system, restlessness, agitation, hypertension, and anxiety will not be side effects.
An elderly patient is wearing a hearing aid. Which technique should the nurse use to facilitate communication? a. Speak clearly and loudly. b. Turn off the television. c. Chew gum. d. Use at least 14-point print.
ANS: B Patients who are hearing impaired benefit when the following techniques are used: Check for hearing aids and glasses, reduce environmental noise, get the patient's attention before speaking, do not chew gum, and speak at normal volume—do not shout. Using at least 14-point print is for sight/visually impaired, not hearing impaired.
7. After the nurse teaches the patient about the use of carvedilol (Coreg) in preventing anginal episodes, which statement by a patient indicates that the teaching has been effective? a. "Carvedilol will help my heart muscle work harder." b. "It is important not to suddenly stop taking the carvedilol." c. "I can expect to feel short of breath when taking carvedilol." d. "Carvedilol will increase the blood flow to my heart muscle."
ANS: B Patients who have been taking β-adrenergic blockers can develop intense and frequent angina if the medication is suddenly discontinued. Carvedilol (Coreg) decreases myocardial contractility. Shortness of breath that occurs when taking β-adrenergic blockers for angina may be due to bronchospasm and should be reported to the health care provider. Carvedilol works by decreasing myocardial oxygen demand, not by increasing blood flow to the coronary arteries.
The nurse is performing tuberculosis (TB) screening in a clinic that has many patients who have immigrated to the United States. Before doing a TB skin test on a patient, which question is most important for the nurse to ask? a. "Is there any family history of TB?" b. "Have you received the bacille Calmette-Guérin (BCG) vaccine for TB?" c. "How long have you lived in the United States?" d. "Do you take any over-the-counter (OTC) medications?"
ANS: B Patients who have received the BCG vaccine will have a positive Mantoux test. Another method for screening (such as a chest x-ray) will need to be used in determining whether the patient has a TB infection. The other information also may be valuable but is not as pertinent to the decision about doing TB skin testing. DIF: Cognitive Level: Application REF: 557 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
To assess the patient with pericarditis for evidence of a pericardial friction rub, the nurse should a. listen for a rumbling, low-pitched, systolic murmur over the left anterior chest. b. auscultate by placing the diaphragm of the stethoscope on the lower left sternal border. c. ask the patient to cough during auscultation to distinguish the sound from a pleural friction rub. d. feel the precordial area with the palm of the hand to detect vibrations with cardiac contraction.
ANS: B Pericardial friction rubs are heard best with the diaphragm at the lower left sternal border. The nurse should ask the patient to hold his or her breath during auscultation to distinguish the sounds from a pleural friction rub. Friction rubs are not typically low pitched or rumbling and are not confined to systole. Rubs are not assessed by palpation
A nurse is sitting at the patient's bedside taking a nursing history. Which zone of personal space is the nurse using? a. Intimate b. Personal c. Social d. Public
ANS: B Personal space is 18 inches to 4 feet and involves such things as sitting at a patient's bedside, taking a patient's nursing history, or teaching an individual patient. Intimate space is 0 to 18 inches and involves such things as performing a physical assessment, bathing, grooming, dressing, feeding, and toileting a patient. Social zone is 4 to 12 feet and involves such things as making rounds with a physician, sitting at the head of a conference table, or teaching a class for patients with diabetes. Public zone is 12 feet and greater and involves such things as speaking at a community forum, testifying at a legislative hearing, or lecturing.
Which of the following is a nurse-initiated or independent activity for promotion of respiratory function in a terminally ill client? a. Limiting fluids b. Positioning the client upright c. Reducing narcotic analgesic use d. Administering bronchodilators
ANS: B Positioning the client upright is an independent nursing intervention for the promotion of respiratory function in a terminally ill client. Limiting fluids may not promote respiratory function, and the nurse should not do so unless a client is on a fluid-restricted diet. Reducing narcotic analgesic use is not a nurse-initiated activity to promote respiratory function. A respiratory rate should be assessed before administering narcotics to prevent further respiratory depression. Management of dyspnea (air hunger) involves judicious administration of morphine and anxiolytics for relief of respiratory distress. The administration of bronchodilators would require a physician's order. It is not an independent nursing activity.
9. Diltiazem (Cardizem) is ordered for a patient with newly diagnosed Prinzmetal's (variant) angina. When teaching the patient, the nurse will include the information that diltiazem will a. reduce heart palpitations. b. decrease spasm of the coronary arteries. c. increase the force of the heart contractions. d. help prevent plaque from forming in the coronary arteries.
ANS: B Prinzmetal's angina is caused by coronary artery spasm. Calcium channel blockers (e.g., diltiazem, amlodipine [Norvasc
A nurse wants to present information about flu immunizations to the elderly in the community. Which type of communication should the nurse use? a. Interpersonal b. Public c. Transpersonal d. Small group
ANS: B Public communication is interaction with an audience. Nurses have opportunities to speak with groups of consumers about health-related topics, present scholarly work to colleagues at conferences, or lead classroom discussions with peers or students. Intrapersonal communication is a powerful form of communication that occurs within an individual. Transpersonal communication is interaction that occurs within a person's spiritual domain. When nurses work on committees, lead patient support groups, form research teams, or participate in patient care conferences, they use a small group communication process.
The nurse is admitting a patient with possible rheumatic fever. Which question on the admission health history will be most pertinent to ask? a. "Do you use any illegal IV drugs?" b. "Have you had a recent sore throat?" c. "Have you injured your chest in the last few weeks?" d. "Do you have a family history of congenital heart disease?"
ANS: B Rheumatic fever occurs as a result of an abnormal immune response to a streptococcal infection. Although illicit IV drug use should be discussed with the patient before discharge, it is not a risk factor for rheumatic fever, and would not be as pertinent when admitting the patient. Family history is not a risk factor for rheumatic fever. Chest injury would cause musculoskeletal chest pain rather than rheumatic fever.
6. A patient with a chronic cough has a bronchoscopy. After the procedure, which intervention by the nurse is most appropriate? a. Elevate the head of the bed to 80 to 90 degrees. b. Keep the patient NPO until the gag reflex returns. c. Place on bed rest for at least 4 hours after bronchoscopy. d. Notify the health care provider about blood-tinged mucus.
ANS: B Risk for aspiration and maintaining an open airway is the priority. Because a local anesthetic is used to suppress the gag/cough reflexes during bronchoscopy, the nurse should monitor for the return of these reflexes before allowing the patient to take oral fluids or food. Blood-tinged mucus is not uncommon after bronchoscopy. The patient does not need to be on bed rest, and the head of the bed does not need to be in the high-Fowlers position. DIF: Cognitive Level: Apply (application) REF: 492 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
The nurse has had three patients die during the past 2 days. Which approach is most appropriate to manage the nurse's sadness? a. Telling the next patients why the nurse is sad b. Talking with a colleague or writing in a journal c. Exercising vigorously rather than sleeping d. Avoiding friends until the nurse feels better
ANS: B Self-care strategies for nurses include talking with a close colleague and reflecting on feelings by writing in a journal. It is inappropriate for a nurse to talk with patients to resolve the nurse's grief. Although exercise is important for self-care, sleep is also important. Shutting oneself away from friends is not self-care; the nurse should spend time with people who are nurturing.
23. A patient who is recovering from an acute myocardial infarction (AMI) asks the nurse about when sexual intercourse can be resumed. Which response by the nurse is best? a. "Most patients are able to enjoy intercourse without any complications." b. "Sexual activity uses about as much energy as climbing two flights of stairs." c. "The doctor will provide sexual guidelines when your heart is strong enough." d. "Holding and cuddling are good ways to maintain intimacy after a heart attack."
ANS: B Sexual activity places about as much physical stress on the cardiovascular system as most moderate-energy activities such as climbing two flights of stairs. The other responses do not directly address the patient's question or may not be accurate for this patient.
Which assessment finding in a patient who is admitted with infective endocarditis (IE) is most important to communicate to the health care provider? a. Generalized muscle aching b. Sudden onset right flank pain c. Janeway's lesions on the palms d. Temperature 100.7° F (38.1° C)
ANS: B Sudden onset of flank pain indicates possible embolization to the kidney and may require diagnostic testing such as a renal arteriogram and interventions to improve renal perfusion. The other findings are typically found in IE, but do not require any new interventions
A patient with a history of a transfusion-related acute lung injury (TRALI) is to receive a transfusion of packed red blood cells (PRBCs). Which action by the nurse will decrease the risk for TRALI for this patient? a. Infuse the PRBCs slowly over 4 hours. b. Transfuse only leukocyte-reduced PRBCs. c. Administer the scheduled diuretic before the transfusion. d. Give the PRN dose of antihistamine before the transfusion.
ANS: B TRALI is caused by a reaction between the donor and the patient leukocytes that causes pulmonary inflammation and capillary leaking. The other actions may help prevent respiratory problems caused by circulatory overload or by allergic reactions, but they will not prevent TRALI.
The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective? a. "I will avoid being outdoors whenever possible." b. "My husband will be sleeping in the guest bedroom." c. "I will take the bus instead of driving to visit my friends." d. "I will keep the windows closed at home to contain the germs."
ANS: B Teach the patient how to minimize exposure to close contacts and household members. Homes should be well ventilated, especially the areas where the infected person spends a lot of time. While still infectious, the patient should sleep alone, spend as much time as possible outdoors, and minimize time in congregate settings or on public transportation.
47. A nurse is teaching nursing students the physiology of congenital heart defects. Which defect results in decreased pulmonary blood flow? a. Atrial septal defect c. Ventricular septal defect b. Tetralogy of Fallot d. Patent ductus arteriosus
ANS: B Tetralogy of Fallot results in decreased blood flow to the lungs. The pulmonic stenosis increases the pressure in the right ventricle, causing the blood to go from right to left across the interventricular septal defect. Atrial and ventricular septal defects and patent ductus arteriosus result in increased pulmonary blood flow. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1327 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
4. A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. During the primary survey of the patient, the nurse should a. obtain a complete set of vital signs. b. obtain a Glasgow Coma Scale score. c. ask about chronic medical conditions. d. attach a cardiac electrocardiogram monitor.
ANS: B The Glasgow Coma Scale is included when assessing for disability during the primary survey. The other information is part of the secondary survey. DIF: Cognitive Level: Apply (application) REF: 1676 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
A patient cancels a scheduled appointment because she will be attending a Shiva for a family member. Recognizing the importance of this cultural ritual, the nurse's best comment would be which of the following? a. "Congratulations, what's the baby's name?" b. "I'm so sorry for your loss." c. "Missionary church outreach is so important." d. "Can I buy a ticket to this fundraiser?"
ANS: B The Jewish mourning ritual of Shiva incorporates the community's helping behaviors toward those experiencing death, sets expectations for behaviors of the survivor, and provides the community with sustaining traditions and rituals. An understanding of the religious and cultural significance of Shiva allows the nurse to know how to appropriately respond.
28. Which assessment finding by the nurse caring for a patient who has had coronary artery bypass grafting using a right radial artery graft is most important to communicate to the health care provider? a. Complaints of incisional chest pain b. Pallor and weakness of the right hand c. Fine crackles heard at both lung bases d. Redness on both sides of the sternal incision
ANS: B The changes in the right hand indicate compromised blood flow, which requires immediate evaluation and actions such as prescribed calcium channel blockers or surgery. The other changes are expected and/or require nursing interventions.
16. When preparing a school-age child and the family for heart surgery, the nurse should consider: a. Not showing unfamiliar equipment. b. Letting child hear the sounds of an electrocardiograph monitor. c. Avoiding mentioning postoperative discomfort and interventions. d. Explaining that an endotracheal tube will not be needed if the surgery goes well.
ANS: B The child and family should be exposed to the sights and sounds of the intensive care unit. All positive, nonfrightening aspects of the environment are emphasized. The child should be shown unfamiliar equipment, and its use should be demonstrated on a doll. Carefully prepare the child for the postoperative experience, including intravenous lines, incision, and endotracheal tube. PTS: 1 DIF: Cognitive Level: Analysis REF: 1341 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
45. The nurse is preparing an adolescent for discharge after a cardiac catheterization. Which statement by the adolescent would indicate a need for further teaching? a. "I should avoid tub baths but may shower." b. "I have to stay on strict bed rest for 3 days." c. "I should remove the pressure dressing the day after the procedure." d. "I may attend school but should avoid exercise for several days."
ANS: B The child does not need to be on strict bed rest for 3 days. Showers are recommended; children should avoid a tub bath. The pressure dressing is removed the day after the catheterization and replaced by an adhesive bandage to keep the area clean. Strenuous activity must be avoided for several days, but the child can return to school. PTS: 1 DIF: Cognitive Level: Analysis REF: 1320 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
36. The nurse assessing a premature newborn infant auscultates a continuous machinery-like murmur. This finding is associated with which congenital heart defect? a. Pulmonary stenosis c. Ventricular septal defect b. Patent ductus arteriosus d. Coarctation of the aorta
ANS: B The classic murmur associated with patent ductus arteriosus is a machinery-like one that can be heard throughout both systole and diastole. A systolic ejection murmur that may be accompanied by a palpable thrill is a manifestation of pulmonary stenosis. The characteristic murmur associated with ventricular septal defect is a loud, harsh, holosystolic murmur. A systolic murmur that is accompanied by an ejection click may be heard on auscultation when coarctation of the aorta is present. PTS: 1 DIF: Cognitive Level: Application REF: 1323 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
A severely depressed patient cannot state any positive attributes to his or her life. The nurse patiently sits with this patient and assists the patient to identify several activities the patient is actually looking forward to in life. The nurse is helping the patient to demonstrate which spiritual concept? a. Time management b. Hope c. Charity d. Faith
ANS: B The concept of hope is vital to nursing; it enables a person to anticipate positive experiences. Being patient and friendly and creating positive relationships are key concepts in all areas of nursing, but especially with depressed patients. The nurse's actions do not address time management, charity, or faith.
13. An 8-month-old infant has a hypercyanotic spell while blood is being drawn. The nurse's first action should be to: a. Assess for neurologic defects. b. Place the child in the knee-chest position. c. Begin cardiopulmonary resuscitation. d. Prepare the family for imminent death.
ANS: B The first action is to place the infant in the knee-chest position. Blow-by oxygen may be indicated. Neurologic defects are unlikely. The child should be assessed for airway, breathing, and circulation. Often calming the child and administering oxygen and morphine can alleviate the hypercyanotic spell; cardiopulmonary resuscitation is not necessary, and death is unlikely. PTS: 1 DIF: Cognitive Level: Application REF: 1337 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
After 2 months of tuberculosis (TB) treatment with isoniazid (INH), rifampin (Rifadin), pyrazinamide (PZA), and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next? a. Teach about treatment for drug-resistant TB treatment. b. Ask the patient whether medications have been taken as directed. c. Schedule the patient for directly observed therapy three times weekly. d. Discuss with the health care provider the need for the patient to use an injectable antibiotic.
ANS: B The first action should be to determine whether the patient has been compliant with drug therapy because negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. Assessment is the first step in the nursing process. Depending on whether the patient has been compliant or not, different medications or directly observed therapy may be indicated. The other options are interventions based on assumptions until an assessment has been completed.
13. When titrating IV nitroglycerin (Tridil) for a patient with a myocardial infarction (MI), which action will the nurse take to evaluate the effectiveness of the medication? a. Monitor heart rate. b. Ask about chest pain. c. Check blood pressure. d. Observe for dysrhythmias.
ANS: B The goal of IV nitroglycerin administration in MI is relief of chest pain by improving the balance between myocardial oxygen supply and demand. The nurse also will monitor heart rate and blood pressure (BP) and observe for dysrhythmias, but these parameters will not indicate whether the medication is effective.
A patient has recently started on digoxin (Lanoxin) in addition to furosemide (Lasix) and captopril (Capoten) for the management of heart failure. Which assessment finding by the home health nurse is a priority to communicate to the health care provider? a. Presence of 1 to 2+ edema in the feet and ankles b. Palpable liver edge 2 cm below the ribs on the right side c. Serum potassium level 3.0 mEq/L after 1 week of therapy d. Weight increase from 120 pounds to 122 pounds over 3 days
C
40. Which patient at the cardiovascular clinic requires the most immediate action by the nurse? a. Patient with type 2 diabetes whose current blood glucose level is 145 mg/dL b. Patient with stable angina whose chest pain has recently increased in frequency c. Patient with familial hypercholesterolemia and a total cholesterol of 465 mg/dL d. Patient with chronic hypertension whose blood pressure today is 172/98 mm Hg
ANS: B The history of more frequent chest pain suggests that the patient may have unstable angina, which is part of the acute coronary syndrome spectrum. This will require rapid implementation of actions such as cardiac catheterization and possible percutaneous coronary intervention. The data about the other patients suggest that their conditions are stable.
When developing a community health program to decrease the incidence of rheumatic fever, which action would be most important for the community health nurse to include? a. Vaccinate high-risk groups in the community with streptococcal vaccine. b. Teach community members to seek treatment for streptococcal pharyngitis. c. Teach about the importance of monitoring temperature when sore throats occur. d. Teach about prophylactic antibiotics to those with a family history of rheumatic fever.
ANS: B The incidence of rheumatic fever is decreased by treatment of streptococcal infections with antibiotics. Family history is not a risk factor for rheumatic fever. There is no immunization that is effective in decreasing the incidence of rheumatic fever. Teaching about monitoring temperature will not decrease the incidence of rheumatic fever.
The father has recently begun to attend his children's school functions since the death of his wife. This would best be described as which task in the Worden Grief Tasks Model? a. Task I b. Task II c. Task III d. Task IV
ANS: C The Worden Grief Tasks Model consists of four tasks. Task III is seen when the surviving family member begins to adjust to life without the deceased. Task I is accepting the reality of the loss, Task II is working through the pain of grief, and Task IV is emotionally relocating the deceased and moving on with life.
23. The primary nursing intervention necessary to prevent bacterial endocarditis is to: a. Institute measures to prevent dental procedures. b. Counsel parents of high risk children about prophylactic antibiotics. c. Observe children for complications such as embolism and heart failure. d. Encourage restricted mobility in susceptible children.
ANS: B The objective of nursing care is to counsel the parents of high risk children about both the need for prophylactic antibiotics for dental procedures and the necessity of maintaining excellent oral health. The child's dentist should be aware of the child's cardiac condition. Dental procedures should be done to maintain a high level of oral health. Prophylactic antibiotics are necessary. Observing for complications and encouraging restricted mobility in susceptible children should be done, but maintaining good oral health and using prophylactic antibiotics are most important.
The nurse asks a patient where the pain is, and the patient responds by pointing to the area of pain. Which form of communication did the patient use? a. Verbal b. Nonverbal c. Intonation d. Vocabulary
ANS: B The patient gestured (pointed), which is a type of nonverbal communication. Gestures emphasize, punctuate, and clarify the spoken word. Pointing to an area of pain is sometimes more accurate than describing its location. Verbal is the spoken word or message. Intonation or tone of voice dramatically affects the meaning of a message. Vocabulary consists of words used for verbal communication.
After receiving the following information about four patients during change-of-shift report, which patient should the nurse assess first? a. Patient with acute pericarditis who has a pericardial friction rub b. Patient who has just returned to the unit after balloon valvuloplasty c. Patient who has hypertrophic cardiomyopathy and a heart rate of 116 d. Patient with a mitral valve replacement who has an anticoagulant scheduled
ANS: B The patient who has just arrived after balloon valvuloplasty will need assessment for complications such as bleeding and hypotension. The information about the other patients is consistent with their diagnoses and does not indicate any complications or need for urgent assessment or intervention. DIF
A patient with rheumatic fever has subcutaneous nodules, erythema marginatum, and polyarthritis. Based on these findings, which nursing diagnosis would be most appropriate? a. Pain related to permanent joint fixation b. Activity intolerance related to arthralgia c. Risk for infection related to open skin lesions d. Risk for impaired skin integrity related to pruritus
ANS: B The patient's joint pain will lead to difficulty with activity. The skin lesions seen in rheumatic fever are not open or pruritic. Although acute joint pain will be a problem for this patient, joint inflammation is a temporary clinical manifestation of rheumatic fever and is not associated with permanent joint changes
27. The leading cause of death after heart transplantation is: a. Infection. c. Cardiomyopathy. b. Rejection. d. Congestive heart failure.
ANS: B The posttransplantation course is complex. The leading cause of death after cardiac transplantation is rejection. Infection is a continued risk secondary to the immunosuppression necessary to prevent rejection. Cardiomyopathy is one of the indications for cardiac transplant. Congestive heart failure is not a leading cause of death. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1351 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
19. A patient is admitted to the emergency department (ED) after falling through the ice while ice skating. Which assessment will the nurse obtain first? a. Heart rate b. Breath sounds c. Body temperature d. Level of consciousness
ANS: B The priority assessment relates to ABCs (airway, breathing, circulation) and how well the patient is oxygenating, so breath sounds should be assessed first. The other data will also be collected rapidly but are not as essential as the breath sounds. DIF: Cognitive Level: Apply (application) REF: 1685 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
The nurse develops a plan of care to prevent aspiration in a high-risk patient. Which nursing action will be most effective? a. Turn and reposition immobile patients at least every 2 hours. b. Place patients with altered consciousness in side-lying positions. c. Monitor for respiratory symptoms in patients who are immunosuppressed. d. Insert nasogastric tube for feedings for patients with swallowing problems.
ANS: B The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and oxygen saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Conditions that increase the risk of aspiration include decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, and nasogastric intubation with or without tube feeding. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Other high-risk groups are those who are seriously ill, have poor dentition, or are receiving acid-reducing medications.
A patient who has chronic heart failure tells the nurse, "I was fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!" The nurse will document this assessment finding as a. orthopnea. b. pulsus alternans. c. paroxysmal nocturnal dyspnea. d. acute bilateral pleural effusion.
C
Which nursing action will be most effective in preventing aspiration pneumonia in patients who are at risk? a. Turn and reposition immobile patients at least every 2 hours. b. Place patients with altered consciousness in side-lying positions. c. Monitor for respiratory symptoms in patients who are immunosuppressed. d. Provide for continuous subglottic aspiration in patients receiving enteral feedings.
ANS: B The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and oxygen saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Continuous subglottic suction is recommended for intubated patients but not for all patients receiving enteral feedings. DIF: Cognitive Level: Application REF: 551 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
42. What is the appropriate priority nursing action for the infant with a CHD who has an increased respiratory rate, is sweating, and is not feeding well? a. Recheck the infant's blood pressure. c. Withhold oral feeding. b. Alert the physician. d. Increase the oxygen rate.
ANS: B These are signs of early congestive heart failure, and the physician should be notified. Although rechecking blood pressure may be indicated, it is not the priority action. Withholding the infant's feeding is an incomplete response to the problem. Increasing oxygen may alleviate symptoms; however, medications such as digoxin and furosemide are necessary to improve heart function and fluid retention. Notifying the physician is the priority nursing action. PTS: 1 DIF: Cognitive Level: Analysis REF: 1331 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
When planning care for a patient hospitalized with a streptococcal infective endocarditis (IE), which intervention is a priority for the nurse to include? a. Monitor labs for streptococcal antibodies. b. Arrange for placement of a long-term IV catheter. c. Teach the importance of completing all oral antibiotics. d. Encourage the patient to begin regular aerobic exercise.
ANS: B Treatment for IE involves 4 to 6 weeks of IV antibiotic therapy in order to eradicate the bacteria, which will require a long-term IV catheter such as a peripherally inserted central catheter (PICC) line. Rest periods and limiting physical activity to a moderate level are recommended during the treatment for IE. Oral antibiotics are not effective in eradicating the infective bacteria that cause IE. Blood cultures, rather than antibody levels, are used to monitor the effectiveness of antibiotic therapy
Which admission order written by the health care provider for a patient admitted with infective endocarditis (IE) and a fever would be a priority for the nurse to implement? a. Administer ceftriaxone (Rocephin) 1 g IV. b. Order blood cultures drawn from two sites. c. Give acetaminophen (Tylenol) PRN for fever. d. Arrange for a transesophageal echocardiogram.
ANS: B Treatment of the IE with antibiotics should be started as quickly as possible, but it is essential to obtain blood cultures before initiating antibiotic therapy to obtain accurate sensitivity results. The echocardiogram and acetaminophen administration also should be implemented rapidly, but the blood cultures (and then administration of the antibiotic) have the highest priority
The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to unlicensed assistive personnel (UAP)? a. Verify the patient identification (ID) according to hospital policy. b. Obtain the temperature, blood pressure, and pulse before the transfusion. c. Double-check the product numbers on the PRBCs with the patient ID band. d. Monitor the patient for shortness of breath or chest pain during the transfusion.
ANS: B UAP education includes measurement of vital signs. UAP would report the vital signs to the registered nurse (RN). The other actions require more education and a larger scope of practice and should be done by licensed nursing staff members.
22. When evaluating the effectiveness of preoperative teaching with a patient scheduled for coronary artery bypass graft (CABG) surgery using the internal mammary artery, the nurse determines that additional teaching is needed when the patient says which of the following? a. "They will circulate my blood with a machine during the surgery." b. "I will have small incisions in my leg where they will remove the vein." c. "They will use an artery near my heart to go around the area that is blocked." d. "I will need to take an aspirin every day after the surgery to keep the graft open."
ANS: B When the internal mammary artery is used there is no need to have a saphenous vein removed from the leg. The other statements by the patient are accurate and indicate that the teaching has been effective.
1. A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient? a. Ask the patient to lie down to complete a full physical assessment. b. Briefly ask specific questions about this episode of respiratory distress. c. Complete the admission database to check for allergies before treatment. d. Delay the physical assessment to first complete pulmonary function tests.
ANS: B When a patient has severe respiratory distress, only information pertinent to the current episode is obtained, and a more thorough assessment is deferred until later. Obtaining a comprehensive health history or full physical examination is unnecessary until the acute distress has resolved. Brief questioning and a focused physical assessment should be done rapidly to help determine the cause of the distress and suggest treatment. Checking for allergies is important, but it is not appropriate to complete the entire admission database at this time. The initial respiratory assessment must be completed before any diagnostic tests or interventions can be ordered. DIF: Cognitive Level: Apply (application) REF: 482 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity;
Which types of patients can cause challenging communication situations? (Select all that apply.) a. A male patient who is cooperative with treatments b. A female patient who is outgoing and flirty c. An older adult patient who is demanding d. An elderly patient who can clearly see small print e. A teenager frightened by the prospect of impending surgery f. A child who is developmentally delayed
ANS: B, C, E, F Challenging communication situations include patients who are flirtatious, demanding, frightened, or developmentally delayed. A child who has received little environmental stimulation possibly is behind in language development, thus making communication more challenging. Patients who are cooperative and have good eyesight (see small print) do not cause challenging communication situations.
When selecting a site to insert an intravenous catheter on an adult, the nurse should (Select all that apply.)
ANS: B, D, F Choose a vein with minimal curvature Check for contraindications to the extremity avoid areas of flexion
5. A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action should the nurse include in the plan of care in collaboration with the speech therapist? a.Leave the tracheostomy inner cannula inserted at all times. b.Place the decannulation cap in the tube before cuff deflation. c.Assess the ability to swallow before using the fenestrated tube. d.Inflate the tracheostomy cuff during use of the fenestrated tube.
ANS: C Because the cuff is deflated when using a fenestrated tube, the patient's risk for aspiration should be assessed before changing to a fenestrated tracheostomy tube. The decannulation cap is never inserted before cuff deflation because to do so would obstruct the patient's airway. The cuff is deflated and the inner cannula removed to allow air to flow across the patient's vocal cords when using a fenestrated tube.
10. A patient who had a total laryngectomy has a nursing diagnosis of hopelessness related to loss of control of personal care. Which information obtained by the nurse is the best indicator that this identified problem is resolving? a.The patient lets the spouse provide tracheostomy care. b.The patient allows the nurse to suction the tracheostomy. c.The patient asks how to clean the tracheostomy stoma and tube. d.The patient uses a communication board to request "No Visitors."
ANS: C Independently caring for the laryngectomy tube indicates that the patient has regained control of personal care and hopelessness is at least partially resolved. Letting the nurse and spouse provide care and requesting no visitors may indicate that the patient is still experiencing hopelessness.
43. Following a supraglottic laryngectomy, the patient is taught how to use the supraglottic swallow to minimize the risk of aspiration. In teaching the patient about this technique, what should the nurse instruct the patient to do? a. Perform Valsalva maneuver immediately after swallowing b. Breath between each Valsalva maneuver and cough sequence c. Cough after swallowing to remove food from the top of the vocal cords. d. Practice swallowing thin, watery fluids before attempting to swallow solid foods
ANS: C Supraglottic laryngectomy involves removal of the epiglottis and false vocal cords and the removal of the epiglottis allows food to enter to trachea. Supraglottic swallowing protects the trachea from aspiration by taking a deep breath, putting the food or fluid in the mouth, swallowing while holding the breath, coughing immediately after swallowing to remove the food from the top of the vocal cord, swallowing again, then breathing. Super-supraglottis swallowing requires performance of the Valsalva maneuver before placing food in the mouth and swallowing.
19. Which staff member does the nurse assign to provide morning care for an older-adult patient who requires assistance with activities of daily living? a. Licensed practical nurse b. Cardiac monitor technician c. Nursing assistive personnel (NAP) d. Another registered nurse on the floor
ANS: C The NAP is capable of caring for this patient and is the most cost-effective choice. The cardiac monitor technician's role is to watch the cardiac monitors for patients on the floor. The nurse and the licensed practical nurse are not the most cost-effective options in this case, even though each could assist with activities of daily living. These nurses would be better used to administer medications, perform assessments, etc. DIF:Apply (application)REF:287 | 288 OBJ: Discuss principles to follow in the appropriate delegation of patient care activities. TOP:PlanningMSC:Management of Care
A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the health care provider? a. The Mantoux test had an induration of 7 mm. b. The chest-x-ray showed infiltrates in the lower lobes. c. The patient is being treated with antiretrovirals for HIV infection. d. The patient has a cough that is productive of blood-tinged mucus.
ANS: C Drug interactions can occur between the antiretrovirals used to treat HIV infection and the medications used to treat TB. The other data are expected in a patient with HIV and TB.
12. Which approach will be most appropriate for a nurse to take when faced with the challenge of performing many tasks in one shift? a. Do as much as possible by oneself before seeking assistance from others. b. Evaluate the effectiveness of all tasks when all tasks are completed. c. Complete one task before starting another task. d. Delegate tasks the nurse does not like doing.
ANS: C The appropriate clinical care coordination skill in these options is to complete one task before starting another task. Good time management involves setting goals to help the nurse complete one task before starting another task. Evaluation is ongoing and should not be completed just at the end of task completion. The nurse should not delegate tasks simply because the nurse does not like doing them. The nurse should use delegation skills and time-management skills instead of trying to do as much as possible with no help. DIF:Understand (comprehension)REF:285 OBJ: Discuss ways to apply clinical care coordination skills in nursing practice.
11. A new nurse expresses frustration at not being to complete all interventions for a group of patients in a timely manner. The nurse leaves the rounds report sheets at the nurse's station when caring for patients and reports having to go back and forth between rooms for equipment and supplies. Which type of skill does the nurse need? a. Interpersonal communication b. Clinical decision making c. Organizational d. Evaluation
ANS: C The clinical care coordination skill this nurse needs to improve on is organization. This nurse needs to keep the patient report sheets in hand to anticipate what equipment and supplies a patient is going to need. Then the nurse may not have to leave the room so often; this will save time. The nurse is not having a problem communicating with others (interpersonal communication). The nurse is not having a problem using the nursing process for clinical decisions. The nurse is not having a problem comparing actual patient outcomes with expected outcomes (evaluation). DIF:Apply (application)REF:284-285 OBJ: Discuss ways to apply clinical care coordination skills in nursing practice.
5. A nurse is working in a facility that has fewer directors with managers and staff able to make shared decisions. In which type of organizational structure is the nurse employed? a. Delegation b. Research-based c. Decentralization d. Philosophy of care
ANS: C The decentralized management structure often has fewer directors, and managers and staff are able to make shared decisions. The American Nurses Association defines delegation as transferring responsibility for the performance of an activity or task while retaining accountability for the outcome. Research-based means care is based upon evidence. A philosophy of care includes the professional nursing staff's values and concerns for the way they view and care for patients. For example, a philosophy addresses the purpose of the nursing unit, how staff works with patients and families, and the standards of care for the work unit. DIF:Apply (application)REF:281-282 OBJ: Describe the elements of shared decision making. TOP: Implementation
4. A nurse who is caring for patient with a tracheostomy tube in place has just auscultated rhonchi bilaterally. If the patient is unsuccessful in coughing up secretions, what action should the nurse take? a.Encourage increased incentive spirometer use. b.Encourage the patient to increase oral fluid intake. c.Put on sterile gloves and use a sterile catheter to suction. d. Preoxygenate the patient for 3 minutes before suctioning.
ANS: C This patient needs suctioning now to secure a patent airway. Sterile gloves and a sterile catheter are used when suctioning a tracheostomy. Preoxygenation for 3 minutes is not necessary. Incentive spirometer (IS) use opens alveoli and can induce coughing, which can mobilize secretions. However, the patient with a tracheostomy may not be able to use an incentive spirometer. Increasing oral fluid intake would not moisten and help mobilize secretions in a timely manner.
32. What is an advantage of a tracheostomy over an endotracheal (ET) tube for long-term management of an upper airway obstruction? a. A tracheostomy is safer to perform in an emergency. b. An ET tube has a higher risk of tracheal pressure necrosis c. A tracheostomy tube allows for more comfort and mobility d. An ET tube is more likely to lead to lower respiratory tract infection
ANS: C With a tracheostomy, patient comfort is increased because there is n tube in the mouth. Because the tube is more secure, mobility is improved. The ET tube is more easily inserted in an emergency situation, It is perforable to perform a tracheostomy in an operating room because it requires careful dissection but it can be performed with local anesthetic in the intensive care unit or in and emergency. With a cuff, tracheal pressure necrosis is as much a risk with a tracheostomy tube as with an ET tube and infection is also as likely to occur because the defenses of the upper airway are bypassed.
15. Following an acute myocardial infarction (AMI), a patient ambulates in the hospital hallway. When the nurse is evaluating the patient's response to the activity, which assessment data would indicate that the exercise level should be decreased? a. Blood pressure (BP) changes from 118/60 to 126/68 mm Hg. b. Oxygen saturation drops from 99% to 95%. c. Heart rate increases from 66 to 92 beats/minute. d. Respiratory rate goes from 14 to 20 breaths/minute.
ANS: C A change in heart rate of more than 20 beats over the resting heart rate indicates that the patient should stop and rest. The increases in BP and respiratory rate, and the slight decrease in oxygen saturation, are normal responses to exercise.
An identified outcome for the family of the client with a terminal illness is that they will be able to provide psychological support to the dying client. To assist the family to meet this outcome, which of the following should the nurse plan to include in the teaching plan? a. Demonstration of bathing techniques b. Application of oxygen devices c. Recognition of client needs and fears d. Information on when to contact the hospice nurse
ANS: C A dying client's family is better prepared to provide psychological support if the nurse discusses with them ways to support the dying person and listen to needs and fears. Demonstration of bathing techniques may help the family meet the dying client's physical needs, but not provide psychological support. Application of oxygen devices may help the family meet physical needs for the client, but not provide psychological support for the client. Information on when to contact the hospice nurse is important knowledge for the family to have and may help them feel they are being supported in caring for the dying client. However, contact information does not help the family provide psychological support to the dying client.
When caring for a patient who is hospitalized with active tuberculosis (TB), the nurse observes a family member who is visiting the patient. The nurse will need to intervene if the family member a. washes the hands before entering the patient's room. b. hands the patient a tissue from the box at the bedside. c. puts on a surgical face mask before visiting the patient. d. brings food from a "fast-food" restaurant to the patient.
ANS: C A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the patient's room because the HEPA mask can filter out 100% of small airborne particles. Hand washing before visiting the patient is not necessary, but there is no reason for the nurse to stop the family member from doing this. Because anorexia and weight loss are frequent problems in patients with TB, bringing food from outside the hospital is appropriate. The family member should wash the hands after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue. DIF: Cognitive Level: Application REF: 557 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
32. A child is brought to the emergency department experiencing an anaphylactic reaction to a bee sting. While an airway is being established, what medication should the nurse prepare for immediate administration? a. Diphenhydramine (Benadryl) c. Epinephrine b. Dopamine d. Calcium chloride
ANS: C After the first priority of establishing an airway, epinephrine is the drug of choice. Benadryl is not a strong enough antihistamine for this severe a reaction. Dopamine and calcium chloride are not appropriate drugs for this type of reaction. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1358 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
32. A patient admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI) is restless and anxious. The blood pressure is 86/40 and heart rate is 123. Based on this information, which nursing diagnosis is a priority for the patient? a. Acute pain related to myocardial infarction b. Anxiety related to perceived threat of death c. Stress overload related to acute change in health d. Decreased cardiac output related to cardiogenic shock
ANS: C All the nursing diagnoses may be appropriate for this patient, but the hypotension and tachycardia indicate decreased cardiac output and shock from the damaged myocardium. This will result in decreased perfusion to all vital organs (e.g., brain, kidney, heart) and is a priority.
51. A preschool child is scheduled for an echocardiogram. Parents ask the nurse whether they can hold the child during the procedure. The nurse should answer with which response? a. "You will be able to hold your child during the procedure." b. "Your child can be active during the procedure, but can't sit in your lap." c. "Your child must lie quietly; sometimes a mild sedative is administered before the procedure." d. "The procedure is invasive so your child will be restrained during the echocardiogram."
ANS: C Although an echocardiogram is noninvasive, painless, and associated with no known side effects, it can be stressful for children. The child must lie quietly in the standard echocardiographic positions; crying, nursing, being held, or sitting up often leads to diagnostic errors or omissions. Therefore, infants and young children may need a mild sedative; older children benefit from psychologic preparation for the test. The distraction of a video or movie is often helpful. PTS: 1 DIF: Cognitive Level: Application REF: 1352 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
21. Family members are in the patient's room when the patient has a cardiac arrest and the staff start resuscitation measures. Which action should the nurse take next? a. Keep the family in the room and assign a staff member to explain the care given and answer questions. b. Ask the family to wait outside the patient's room with a designated staff member to provide emotional support. c. Ask the family members about whether they would prefer to remain in the patient's room or wait outside the room. d. Tell the family members that patients are comforted by having family members present during resuscitation efforts.
ANS: C Although many family members and patients report benefits from family presence during resuscitation efforts, the nurse's initial action should be to determine the preference of these family members. The other actions may be appropriate, but this will depend on what is learned when assessing family preferences. DIF: Cognitive Level: Apply (application) REF: 1679 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
IV sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to titrate the nitroprusside rate if the patient develops a. ventricular ectopy. b. a dry, hacking cough. c. a systolic BP <90 mm Hg. d. a heart rate <50 beats/minute.
C
17. A patient in metabolic alkalosis is admitted to the emergency department, and pulse oximetry (SpO2) indicates that the O2 saturation is 94. Which action should the nurse take next? a. Administer bicarbonate. b. Complete a head-to-toe assessment. c. Place the patient on high-flow oxygen. d. Obtain repeat arterial blood gases (ABGs).
ANS: C Although the O2 saturation is adequate, the left shift in the oxyhemoglobin dissociation curve will decrease the amount of oxygen delivered to tissues, so high oxygen concentrations should be given. Bicarbonate would worsen the patients condition. A head-to-toe assessment and repeat ABGs may be implemented. However, the priority intervention is to give high-flow oxygen. DIF: Cognitive Level: Apply (application) REF: eTable 26-1 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
During discharge teaching with a 68-year-old patient who had a mitral valve replacement with a mechanical valve, the nurse instructs the patient on the a. use of daily aspirin for anticoagulation. b. correct method for taking the radial pulse. c. need for frequent laboratory blood testing. d. need to avoid any physical activity for 1 month.
ANS: C Anticoagulation with warfarin (Coumadin) is needed for a patient with mechanical valves to prevent clotting on the valve. This will require frequent international normalized ratio (INR) testing. Daily aspirin use will not be effective in reducing the risk for clots on the valve. Monitoring of the radial pulse is not necessary after valve replacement. Patients should resume activities of daily living as tolerated
4. Which defect results in increased pulmonary blood flow? a. Pulmonic stenosis c. Atrial septal defect b. Tricuspid atresia d. Transposition of the great arteries
ANS: C Atrial septal defect results in increased pulmonary blood flow. Blood flows from the left atrium (higher pressure) into the right atrium (lower pressure) and then to the lungs via the pulmonary artery. Pulmonic stenosis is an obstruction to blood flowing from the ventricles. Tricuspid atresia results in decreased pulmonary blood flow. Transposition of the great arteries results in mixed blood flow. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1322 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
22. A 28-year-old patient who has deep human bite wounds on the left hand is being treated in the urgent care center. Which action will the nurse plan to take? a. Prepare to administer rabies immune globulin (BayRab). b. Assist the health care provider with suturing of the bite wounds. c. Teach the patient the reason for the use of prophylactic antibiotics. d. Keep the wounds dry until the health care provider can assess them.
ANS: C Because human bites of the hand frequently become infected, prophylactic antibiotics are usually prescribed to prevent infection. To minimize infection, deep bite wounds on the extremities are left open. Rabies immune globulin might be used after an animal bite. Initial treatment of bite wounds includes copious irrigation to help clean out contaminants and microorganisms. DIF: Cognitive Level: Apply (application) REF: 1688 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
8. A 22-year-old patient who experienced a near drowning accident in a local pool, but now is awake and breathing spontaneously, is admitted for observation. Which assessment will be most important for the nurse to take during the observation period? a. Auscultate heart sounds. b. Palpate peripheral pulses. c. Auscultate breath sounds. d.
ANS: C Because pulmonary edema is a common complication after near drowning, the nurse should assess the breath sounds frequently. The other information also will be obtained by the nurse, but it is not as pertinent to the patient's admission diagnosis. DIF: Cognitive Level: Apply (application) REF: 1686 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
Which action by the nurse will determine if the therapies ordered for a patient with chronic constrictive pericarditis are effective? a. Assess for the presence of a paradoxical pulse. b. Monitor for changes in the patient's sedimentation rate. c. Assess for the presence of jugular venous distention (JVD). d. Check the electrocardiogram (ECG) for ST segment changes.
ANS: C Because the most common finding on physical examination for a patient with chronic constrictive pericarditis is jugular venous distention, a decrease in JVD indicates improvement. Paradoxical pulse, ST-segment ECG changes, and changes in sedimentation rates occur with acute pericarditis but are not expected in chronic constrictive pericarditis
The nurse recognizes that the goals of teaching regarding the transmission of pulmonary tuberculosis (TB) have been met when the patient with TB a. demonstrates correct use of a nebulizer. b. washes dishes and personal items after use. c. covers the mouth and nose when coughing. d. reports daily to the public health department.
ANS: C Covering the mouth and nose will help decrease airborne transmission of TB. The other actions will not be effective in decreasing the spread of TB. DIF: Cognitive Level: Application REF: 557 TOP: Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance
The nurse will plan discharge teaching about the need for prophylactic antibiotics when having dental procedures for which patient? a. Patient admitted with a large acute myocardial infarction. b. Patient being discharged after an exacerbation of heart failure. c. Patient who had a mitral valve replacement with a mechanical valve. d. Patient being treated for rheumatic fever after a streptococcal infection.
ANS: C Current American Heart Association guidelines recommend the use of prophylactic antibiotics before dental procedures for patients with prosthetic valves to prevent infective endocarditis (IE). The other patients are not at risk for IE
A patient who has just been admitted with pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of severe pleuritic chest pain. Which of these prescribed medications should the nurse give first? a. guaifenesin (Robitussin) b. acetaminophen (Tylenol) c. azithromycin (Zithromax) d. codeine phosphate (Codeine)
ANS: C Early initiation of antibiotic therapy has been demonstrated to reduce mortality. The other medications also are appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy. DIF: Cognitive Level: Application REF: 549 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
A nurse believes that the nurse-patient relationship is a partnership, and that both are equal participants. Which term should the nurse use to describe this belief? a. Critical thinking b. Authentic c. Mutuality d. Attend
ANS: C Effective interpersonal communication requires a sense of mutuality, a belief that the nurse-patient relationship is a partnership, and that both are equal participants. Critical thinking in nursing, based on established standards of nursing care and ethical standards, promotes effective communication and uses such standards as humility, self-confidence, independent attitude, and fairness. To be authentic (one's self) and to respond appropriately to the other person are important for interpersonal relationships but do not mean mutuality. Attending is giving all of your attention to the patient.
7. A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED). The nurse determines that discharge teaching has been effective when the patient makes which statement? a. "I will take salt tablets when I work outdoors in the summer." b. "I should take acetaminophen (Tylenol) if I start to feel too warm." c. "I should drink sports drinks when working outside in hot weather." d. "I will move to a cool environment if I notice that I am feeling confused."
ANS: C Electrolyte solutions such as sports drinks help replace fluid and electrolytes lost when exercising in hot weather. Salt tablets are not recommended because of the risks of gastric irritation and hypernatremia. Antipyretic medications are not effective in lowering body temperature elevations caused by excessive exposure to heat. A patient who is confused is likely to have more severe hyperthermia and will be unable to remember to take appropriate action. DIF: Cognitive Level: Apply (application) REF: 1682 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
When caring for a patient with infective endocarditis of the tricuspid valve, the nurse should monitor the patient for the development of a. flank pain. b. splenomegaly. c. shortness of breath. d. mental status changes.
ANS: C Embolization from the tricuspid valve would cause symptoms of pulmonary embolus. Flank pain, changes in mental status, and splenomegaly would be associated with embolization from the left-sided valves
A couple is informed that their fetus' condition is incompatible with life after birth. Nurses can best help the couple with their end-of-life decision making by offering them which of the following? a. An advance directive to complete b. Brief discussion and funeral guidance c. Time and careful explanations d. Instructions on how to proceed
ANS: C Families can have limited knowledge when asked to make important ethical decisions. Nurses have the time, patience, and knowledge base to assist the family to understand their ethical situation and to help them make their own educated decision. Advance directives are completed by the person who is dying. Funeral guidance is best provided by a chaplain or a caretaker.
7. The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. When auscultating the patients lungs, which finding would the nurse most likely hear? a. Continuous rumbling, snoring, or rattling sounds mainly on expiration b. Continuous high-pitched musical sounds on inspiration and expiration c. Discontinuous, high-pitched sounds of short duration heard on inspiration d. A series of long-duration, discontinuous, low-pitched sounds during inspiration
ANS: C Fine crackles are likely to be heard in the early phase of heart failure. Fine crackles are discontinuous, highpitched sounds of short duration heard on inspiration. Rhonchi are continuous rumbling, snoring, or rattling sounds mainly on expiration. Course crackles are a series of long-duration, discontinuous, low-pitched sounds during inspiration. Wheezes are continuous high-pitched musical sounds on inspiration and expiration. DIF: Cognitive Level: Apply (application) REF: 489 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
9. The nurse teaches a patient about pulmonary function testing (PFT). Which statement, if made by the patient, indicates teaching was effective? a. I will use my inhaler right before the test. b. I wont eat or drink anything 8 hours before the test. c. I should inhale deeply and blow out as hard as I can during the test. d. My blood pressure and pulse will be checked every 15 minutes after the test.
ANS: C For PFT, the patient should inhale deeply and exhale as long, hard, and fast as possible. The other actions are not needed with PFT. The administration of inhaled bronchodilators should be avoided 6 hours before the procedure. DIF: Cognitive Level: Apply (application) REF: 493-495 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
12. Heparin is ordered for a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI). What is the purpose of the heparin? a. Heparin enhances platelet aggregation. b. Heparin decreases coronary artery plaque size. c. Heparin prevents the development of new clots in the coronary arteries. d. Heparin dissolves clots that are blocking blood flow in the coronary arteries.
ANS: C Heparin helps prevent the conversion of fibrinogen to fibrin and decreases coronary artery thrombosis. It does not change coronary artery plaque, dissolve already formed clots, or enhance platelet aggregation.
19. The nurse is caring for a child after heart surgery. What should she or he do if evidence is found of cardiac tamponade? a. Increase analgesia. b. Apply warming blankets. c. Immediately report this to the physician. d. Encourage the child to cough, turn, and breathe deeply.
ANS: C If evidence is noted of cardiac tamponade (blood or fluid in the pericardial space constricting the heart), the physician is notified immediately of this life-threatening complication. Increasing analgesia may be done before the physician drains the fluid, but the physician must be notified. Warming blankets are not indicated at this time. Encouraging the child to cough, turn, and breathe deeply should be deferred until after the evaluation by the physician. PTS: 1 DIF: Cognitive Level: Analysis REF: 1342 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
18. An important nursing consideration when suctioning a young child who has had heart surgery is to: a. Perform suctioning at least every hour. b. Suction for no longer than 30 seconds at a time. c. Administer supplemental oxygen before and after suctioning. d. Expect symptoms of respiratory distress when suctioning.
ANS: C If suctioning is indicated, supplemental oxygen is administered with a manual resuscitation bag before and after the procedure to prevent hypoxia. Suctioning should be done only as indicated, not on a routine basis. The child should be suctioned for no more than 5 seconds at one time. Symptoms of respiratory distress are to be avoided by using the appropriate technique. PTS: 1 DIF: Cognitive Level: Application REF: 1342 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
Which person is the best referral for a patient who speaks a foreign language? a. A family member b. A speech therapist c. An interpreter d. A mental health nurse specialist
ANS: C Interpreters are often necessary for patients who speak a foreign language. A family member can lead to legal issues, speech therapists help patients with aphasia, and mental health nurse specialists help angry or highly anxious patients to communicate more effectively.
20. An important nursing consideration when chest tubes will be removed from a child is to: a. Explain that it is not painful. b. Explain that only a Band-Aid will be needed. c. Administer analgesics before the procedure. d. Expect bright red drainage for several hours after removal.
ANS: C It is appropriate to prepare the child for the removal of chest tubes with analgesics. Short-acting medications can be used that are administered through an existing intravenous line. It is not a pain-free procedure. A sharp, momentary pain is felt, and this should not be misrepresented to the child. A petroleum gauze/airtight dressing is needed. Little or no drainage should be found on removal. PTS: 1 DIF: Cognitive Level: Analysis REF: 1342 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity
During a follow-up visit, a woman is describing new onset of marital discord with her terminally ill spouse. Using the Kübler-Ross behavioral theory, the nurse recognizes that the spouse is in which stage of dying? a. Denial b. Bargaining c. Anger d. Depression
ANS: C Kübler-Ross' traditional theory involves five stages of dying. The anger stage of adjustment to an impending death can involve resistance, anger at God, anger at people, and anger at the situation. Denial would involve failure to accept a death. Bargaining is an action to delay acceptance of death by bartering. Depression would present as withdrawal from others.
2. Which nursing intervention will be most effective when assisting the patient with coronary artery disease (CAD) to make appropriate dietary changes? a. Give the patient a list of low-sodium, low-cholesterol foods that should be included in the diet. b. Emphasize the increased risk for heart problems unless the patient makes the dietary changes. c. Help the patient modify favorite high-fat recipes by using monosaturated oils when possible. d. Inform the patient that a diet containing no saturated fat and minimal salt will be necessary.
ANS: C Lifestyle changes are more likely to be successful when consideration is given to the patient's values and preferences. The highest percentage of calories from fat should come from monosaturated fats. Although low-sodium and low-cholesterol foods are appropriate, providing the patient with a list alone is not likely to be successful in making dietary changes. Completely removing saturated fat from the diet is not a realistic expectation. Up to 7% of calories in the therapeutic lifestyle changes (TLC) diet can come from saturated fat. Telling the patient about the increased risk without assisting further with strategies for dietary change is unlikely to be successful.
10. The nurse observes a student who is listening to a patients lungs who is having no problems with breathing. Which action by the student indicates a need to review respiratory assessment skills? a. The student starts at the apices of the lungs and moves to the bases. b. The student compares breath sounds from side to side avoiding bony areas. c. The student places the stethoscope over the posterior chest and listens during inspiration. d. The student instructs the patient to breathe slowly and a little more deeply than normal through the mouth.
ANS: C Listening only during inspiration indicates the student needs a review of respiratory assessment skills. At each placement of the stethoscope, listen to at least one cycle of inspiration and expiration. During chest auscultation, instruct the patient to breathe slowly and a little deeper than normal through the mouth. Auscultation should proceed from the lung apices to the bases, comparing opposite areas of the chest, unless the patient is in respiratory distress or will tire easily. If so, start at the bases (see Fig. 26-7). Place the stethoscope over lung tissue, not over bony prominences. DIF: Cognitive Level: Apply (application) REF: 486 TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
Validation of a dying person's life would be demonstrated by which nursing action? a. Taking pictures of visitors b. Calling the organ donation coordinator c. Listening to family stories about the person d. Providing quiet visiting time
ANS: C Listening to family members' stories validates the importance of the dying individual's life and reinforces the dignity of the person's life. Taking pictures of visitors does not address the value of a person's life. Calling organ donation and providing private visiting time are components of the dying process, but they do not validate a dying person's life.
A 21-year-old woman is scheduled for percutaneous transluminal balloon valvuloplasty to treat mitral stenosis. Which information should the nurse include when explaining the advantages of valvuloplasty over valve replacement to the patient? a. Biologic valves will require immunosuppressive drugs after surgery. b. Mechanical mitral valves need to be replaced sooner than biologic valves. c. Lifelong anticoagulant therapy will be needed after mechanical valve replacement. d. Ongoing cardiac care by a health care provider is not necessary after valvuloplasty.
ANS: C Long-term anticoagulation therapy is needed after mechanical valve replacement, and this would restrict decisions about career and childbearing in this patient. Mechanical valves are durable and last longer than biologic valves. All valve repair procedures are palliative, not curative, and require lifelong health care. Biologic valves do not activate the immune system, and immunosuppressive therapy is not needed
The nurse is assigned to a client who was recently diagnosed with a terminal illness. During morning care, the client asks about organ donation. How should the nurse respond? a. Have the client first discuss the subject with the family. b. Suggest the client delay making a decision at this time. c. Assist the client to obtain the necessary information to make this decision. d. Contact the physician so consent can be obtained from the family.
ANS: C No topic that a dying client wishes to discuss should be avoided. The nurse should respond to questions openly and honestly. As client advocate, the nurse should assist the client to obtain the necessary information to make this decision. The nurse should provide the client with information with which to make such a decision. Although the nurse may suggest that the client discuss the subject with the family after having obtained information, it is up to the client to discuss the subject with his family. The nurse should respect the client and provide the necessary information for him or her to make a decision, rather than dismissing the client's question. It is not necessary to contact the physician or the family for consent for organ donation if the client is capable of making this decision.
50. Which action by the school nurse is important in the prevention of rheumatic fever? a. Encourage routine cholesterol screenings. b. Conduct routine blood pressure screenings. c. Refer children with sore throats for throat cultures. d. Recommend salicylates instead of acetaminophen for minor discomforts.
ANS: C Nurses have a role in prevention—primarily in screening school-age children for sore throats caused by group A -hemolytic streptococci. They can achieve this by actively participating in throat culture screening or by referring children with possible streptococcal sore throats for testing. Cholesterol and blood pressure screenings do not facilitate the recognition and treatment of group A -hemolytic streptococci. Salicylates should be avoided routinely because of the risk of Reye's syndrome after viral illnesses. PTS: 1 DIF: Cognitive Level: Application REF: 1346 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential
The nurse using critical thinking to enhance communication with patients is one who a. Shows sympathy appropriately. b. Uses automatic responses fluently. c. Self-examines personal communication skills. d. Demonstrates passive remarks accurately.
ANS: C Nurses who use critical thinking skills interpret messages received from others, analyze their content, make inferences about their meaning, evaluate their effects, explain rationales for communication techniques used, and self-examine personal communication skills. Sympathy is concern, sorrow, or pity felt for the patient and is nontherapeutic. Clichés and stereotyped remarks are automatic phrases that communicate that the nurse is not taking concerns seriously or responding thoughtfully. Passive responses serve to avoid conflict or to sidestep issues.
A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which is the best response by the nurse? a. Ask if the patient is experiencing shortness of breath, hives, or itching. b. Ask the patient about any visual abnormalities such as red-green color discrimination. c. Explain that orange discolored urine and tears are normal while taking this medication. d. Advise the patient to stop the drug and report the symptoms to the health care provider.
ANS: C Orange-colored body secretions are a side effect of rifampin. The patient does not have to stop taking the medication. The findings are not indicative of an allergic reaction. Alterations in red-green color discrimination commonly occurs when taking ethambutol (Myambutol), which is a different TB medication.
Which statement by a patient who has been hospitalized for pneumonia indicates a good understanding of the discharge instructions given by the nurse? a. "I will call the doctor if I still feel tired after a week." b. "I will need to use home oxygen therapy for 3 months." c. "I will continue to do the deep breathing and coughing exercises at home." d. "I will schedule two appointments for the pneumonia and influenza vaccines."
ANS: C Patients should continue to cough and deep breathe after discharge. Fatigue for several weeks is expected. Home oxygen therapy is not needed with successful treatment of pneumonia. The pneumovax and influenza vaccines can be given at the same time. DIF: Cognitive Level: Application REF: 552 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
Which statement by a patient with restrictive cardiomyopathy indicates that the nurse's discharge teaching about self-management has been most effective? a. "I will avoid taking aspirin or other antiinflammatory drugs." b. "I will need to limit my intake of salt and fluids even in hot weather." c. "I will take antibiotics when my teeth are cleaned at the dental office." d. "I should begin an exercise program that includes things like biking or swimming."
ANS: C Patients with restrictive cardiomyopathy are at risk for infective endocarditis and should use prophylactic antibiotics for any procedure that may cause bacteremia. The other statements indicate a need for more teaching by the nurse. Dehydration and vigorous exercise impair ventricular filling in patients with restrictive cardiomyopathy. There is no need to avoid salt (unless ordered), aspirin, or NSAIDs
7. A clinical manifestation of the systemic venous congestion that can occur with congestive heart failure is: a. Tachypnea. c. Peripheral edema. b. Tachycardia. d. Pale, cool extremities.
ANS: C Peripheral edema, especially periorbital edema, is a clinical manifestation of systemic venous congestion. Tachypnea is a manifestation of pulmonary congestion. Tachycardia and pale, cool extremities are clinical manifestations of impaired myocardial function. PTS: 1 DIF: Cognitive Level: Analysis REF: 1332 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
43. A nurse is teaching an adolescent about primary hypertension. The nurse knows that which of the following is correct? a. Primary hypertension should be treated with diuretics as soon as it is detected. b. Congenital heart defects are the most common cause of primary hypertension. c. Primary hypertension may be treated with weight reduction. d. Primary hypertension is not affected by exercise.
ANS: C Primary hypertension in children may be treated with weight reduction and exercise programs. If ineffective, pharmacologic intervention may be needed. Primary hypertension is considered an inherited disorder. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1350 OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance
After the nurse has received change-of-shift report about the following four patients, which patient should be assessed first? a. A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes b. A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled c. A 46-year-old patient who has a deep vein thrombosis and is complaining of sudden onset shortness of breath. d. A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 100.2° F (37.8° C)
ANS: C Sudden onset shortness of breath in a patient with a deep vein thrombosis suggests a pulmonary embolism and requires immediate assessment and actions such as oxygen administration. The other patients also should be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration. DIF: Cognitive Level: Application REF: 577-578 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
The nurse is working with a client on an inpatient hospice unit. Which of the following actions should the nurse take in order to maintain the client's sense of self-worth during the end of life? a. Leaving the client alone to deal with final affairs b. Calling on the client's spiritual advisor to take over care c. Spending time with the client and allowing him or her to share life experiences d. Having a grief counsellor visit .
ANS: C Taking time to let the client share his or her life experiences, particularly what has been meaningful, enables the nurse to know the client better. Knowing the client then facilitates choice of therapies that promote client decision making and autonomy. Planning regular visits also helps the client maintain a sense of self-worth, because it demonstrates that he or she is worthy of the nurse's time and attention. The client should not be left alone to feel abandoned or isolated. The nurses can help the client meet spiritual needs by facilitating connections to a spiritual practice or community and supporting the expression of culturally held beliefs. The client's spiritual advisor also may be called on, but is not the only source of spiritual support. The nurse who turns care over to the spiritual advisor is not promoting the client's sense of self-worth, as it may imply the client is not worthy of the nurse's time or attention. A grief counsellor may be requested to visit if the client is experiencing complicated grief. Having a grief counsellor visit may be less helpful than spending time with the client, to help maintain a client's sense of self-worth
Which assessment finding obtained by the nurse when assessing a patient with acute pericarditis should be reported immediately to the health care provider? a. Pulsus paradoxus 8 mm Hg b. Blood pressure (BP) of 168/94 c. Jugular venous distention (JVD) to jaw level d. Level 6 (0 to 10 scale) chest pain with a deep breath
ANS: C The JVD indicates that the patient may have developed cardiac tamponade and may need rapid intervention to maintain adequate cardiac output. Hypertension would not be associated with complications of pericarditis, and the BP is not high enough to indicate that there is any immediate need to call the health care provider. A pulsus paradoxus of 8 mm Hg is normal. Level 6/10 chest pain should be treated but is not unusual with pericarditis
16. During the administration of the thrombolytic agent to a patient with an acute myocardial infarction (AMI), the nurse should stop the drug infusion if the patient experiences a. bleeding from the gums. b. increase in blood pressure. c. a decrease in level of consciousness. d. a nonsustained episode of ventricular tachycardia.
ANS: C The change in level of consciousness indicates that the patient may be experiencing intracranial bleeding, a possible complication of thrombolytic therapy. Some bleeding of the gums is an expected side effect of the therapy but not an indication to stop infusion of the thrombolytic medication. A decrease in blood pressure could indicate internal bleeding. A nonsustained episode of ventricular tachycardia is a common reperfusion dysrhythmia and may indicate that the therapy is effective.
35. The nurse obtains the following data when assessing a patient who experienced an ST-segment-elevation myocardial infarction (STEMI) 2 days previously. Which information is most important to report to the health care provider? a. The troponin level is elevated. b. The patient denies ever having a heart attack. c. Bilateral crackles are auscultated in the mid-lower lobes. d. The patient has occasional premature atrial contractions (PACs).
ANS: C The crackles indicate that the patient may be developing heart failure, a possible complication of myocardial infarction (MI). The health care provider may need to order medications such as diuretics or angiotensin-converting enzyme (ACE) inhibitors for the patient. Elevation in troponin level at this time is expected. PACs are not life-threatening dysrhythmias. Denial is a common response in the immediate period after the MI.
A cancer patient asks the nurse what the criteria are for hospice care. What should the nurse answer? a. Having a terminal illness, such as cancer b. Needing assistance with pain management c. Expected to live less than 6 to 12 more months d. Completion of an advance directive
ANS: C The criterion for hospice care is being expected to live less than 6 to 12 more months. Patients with a terminal illness are not eligible until that point. Palliative care provides assistance with pain management when a patient is not eligible for hospice care. An advance directive can be completed by any person, even those who are healthy.
6. What is best described as the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures? a. Pulmonary congestion c. Congestive heart failure b. Congenital heart defect d. Systemic venous congestion
ANS: C The definition of congestive heart failure is the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures to meet the metabolic demands of the body. Pulmonary congestion is an excessive accumulation of fluid in the lungs. Congenital heart defect is a malformation of the heart present at birth. Systemic venous congestion is an excessive accumulation of fluid in the systemic vasculature. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1331 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
8. While caring for a patient with respiratory disease, the nurse observes that the patients SpO2 drops from 93 to 88 while the patient is ambulating in the hallway. What is the priority action of the nurse? a. Notify the health care provider. b. Document the response to exercise. c. Administer the PRN supplemental O2. d. Encourage the patient to pace activity.
ANS: C The drop in SpO2 to 85 indicates that the patient is hypoxemic and needs supplemental oxygen when exercising. The other actions are also important, but the first action should be to correct the hypoxemia. DIF: Cognitive Level: Apply (application) REF: 480 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
5. After the nurse has finished teaching a patient about the use of sublingual nitroglycerin (Nitrostat), which patient statement indicates that the teaching has been effective? a. "I can expect some nausea as a side effect of nitroglycerin." b. "I should only take the nitroglycerin if I start to have chest pain." c. "I will call an ambulance if I still have pain after taking 3 nitroglycerin 5 minutes apart." d. "Nitroglycerin helps prevent a clot from forming and blocking blood flow to my heart."
ANS: C The emergency medical services (EMS) system should be activated when chest pain or other symptoms are not completely relieved after 3 sublingual nitroglycerin tablets taken 5 minutes apart. Nitroglycerin can be taken to prevent chest pain or other symptoms from developing (e.g., before intercourse). Gastric upset (e.g., nausea) is not an expected side effect of nitroglycerin. Nitroglycerin does not impact the underlying pathophysiology of coronary artery atherosclerosis.
Which action by the nurse will be most effective in decreasing the spread of pertussis in a community setting? a. Providing supportive care to patients diagnosed with pertussis b. Teaching family members about the need for careful hand washing c. Teaching patients about the need for adult pertussis immunizations d. Encouraging patients to complete the prescribed course of antibiotics
ANS: C The increased rate of pertussis in adults is thought to be due to decreasing immunity after childhood immunization. Immunization is the most effective method of protecting communities from infectious diseases. Hand washing should be taught, but pertussis is spread by droplets and contact with secretions. Supportive care does not shorten the course of the disease or the risk for transmission. Taking antibiotics as prescribed does assist with decreased transmission, but patients are likely to have already transmitted the disease by the time the diagnosis is made.
A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment has been effective? a. Bronchial breath sounds are heard at the right base. b. The patient coughs up small amounts of green mucus. c. The patient's white blood cell (WBC) count is 9000/µL. d. Increased tactile fremitus is palpable over the right chest.
ANS: C The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed.
After a patient with right lower-lobe pneumonia has been treated with intravenous (IV) antibiotics for 2 days, which assessment data obtained by the nurse indicates that the treatment has been effective? a. Bronchial breath sounds are heard at the right base. b. The patient coughs up small amounts of green mucus. c. The patient's white blood cell (WBC) count is 9000/µl. d. Increased tactile fremitus is palpable over the right chest.
ANS: C The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed. DIF: Cognitive Level: Application REF: 549 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature 102° F (38.9° C), and severe back pain. Which physician order will the nurse implement first? a. Administer morphine sulfate 4 mg IV. b. Give acetaminophen (Tylenol) 650 mg. c. Infuse normal saline 500 mL over 30 minutes. d. Schedule complete blood count and coagulation studies.
ANS: C The patient's blood pressure indicates hypovolemia caused by blood loss and should be addressed immediately to improve perfusion to vital organs. The other actions also are appropriate and should be rapidly implemented, but improving perfusion is the priority for this patient.
Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has no symptoms of TB. Which information should the occupational health nurse plan to teach the staff nurse? a. Standard four-drug therapy for TB b. Need for annual repeat TB skin testing c. Use and side effects of isoniazid (INH) d. Bacille Calmette-Guérin (BCG) vaccine
ANS: C The nurse is considered to have a latent TB infection and should be treated with INH daily for 6 to 9 months. The four-drug therapy would be appropriate if the nurse had active TB. TB skin testing is not done for individuals who have already had a positive skin test. BCG vaccine is not used in the United States for TB and would not be helpful for this individual, who already has a TB infection.
A patient recovering from heart surgery develops pericarditis and complains of level 6 (0 to 10 scale) chest pain with deep breathing. Which ordered PRN medication will be the most appropriate for the nurse to give? a. Fentanyl 1 mg IV b. IV morphine sulfate 4 mg c. Oral ibuprofen (Motrin) 600 mg d. Oral acetaminophen (Tylenol) 650 mg
ANS: C The pain associated with pericarditis is caused by inflammation, so nonsteroidal antiinflammatory drugs (NSAIDs) (e.g., ibuprofen) are most effective. Opioid analgesics are usually not used for the pain associated with pericarditis
42. After reviewing information shown in the accompanying figure from the medical records of a 43-year-old, which risk factor modification for coronary artery disease should the nurse include in patient teaching? a. Importance of daily physical activity b. Effect of weight loss on blood pressure c. Dietary changes to improve lipid levels d. Ongoing cardiac risk associated with history of tobacco use
ANS: C The patient has an elevated low-density lipoprotein (LDL) cholesterol and low high-density lipoprotein (HDL) cholesterol, which will increase the risk of coronary artery disease. Although the blood pressure is in the prehypertensive range, the patient's waist circumference and body mass index (BMI) indicate an appropriate body weight. The risk for coronary artery disease a year after quitting smoking is the same as a nonsmoker. The patient's occupation indicates that daily activity is at the levels suggested by national guidelines.
30. Which electrocardiographic (ECG) change is most important for the nurse to report to the health care provider when caring for a patient with chest pain? a. Inverted P wave b. Sinus tachycardia c. ST-segment elevation d. First-degree atrioventricular block
ANS: C The patient is likely to be experiencing an ST-segment-elevation myocardial infarction (STEMI). Immediate therapy with percutaneous coronary intervention (PCI) or thrombolytic medication is indicated to minimize myocardial damage. The other ECG changes may also suggest a need for therapy, but not as rapidly.
18. In preparation for discharge, the nurse teaches a patient with chronic stable angina how to use the prescribed short-acting and long-acting nitrates. Which patient statement indicates that the teaching has been effective? a. "I will check my pulse rate before I take any nitroglycerin tablets." b. "I will put the nitroglycerin patch on as soon as I get any chest pain." c. "I will stop what I am doing and sit down before I put the nitroglycerin under my tongue." d. "I will be sure to remove the nitroglycerin patch before taking any sublingual nitroglycerin."
ANS: C The patient should sit down before taking the nitroglycerin to decrease cardiac workload and prevent orthostatic hypotension. Transdermal nitrates are used prophylactically rather than to treat acute pain and can be used concurrently with sublingual nitroglycerin. Although the nurse should check blood pressure before giving nitroglycerin, patients do not need to check the pulse rate before taking nitrates.
A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take? a. Draw blood for a new crossmatch. b. Send a urine specimen to the laboratory. c. Administer PRN acetaminophen (Tylenol). d. Give the PRN diphenhydramine (Benadryl).
ANS: C The patient's clinical manifestations are consistent with a febrile, nonhemolytic transfusion reaction. The transfusion should be stopped and antipyretics administered for the fever as ordered. A urine specimen is needed if an acute hemolytic reaction is suspected. Diphenhydramine (Benadryl) is used for allergic reactions. This type of reaction does not indicate incorrect crossmatching.
17. A patient is recovering from a myocardial infarction (MI) and develops chest pain on day 3 that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take next? a. Assess the feet for pedal edema. b. Palpate the radial pulses bilaterally. c. Auscultate for a pericardial friction rub. d. Check the heart monitor for dysrhythmias.
ANS: C The patient's symptoms are consistent with the development of pericarditis, a possible complication of MI. The other assessments listed are not consistent with the description of the patient's symptoms.
When caring for a patient with mitral valve stenosis, it is most important that the nurse assess for a. diastolic murmur. b. peripheral edema. c. shortness of breath on exertion. d. right upper quadrant tenderness.
ANS: C The pressure gradient changes in mitral stenosis lead to fluid backup into the lungs, resulting in hypoxemia and dyspnea. The other findings also may be associated with mitral valve disease but are not indicators of possible hypoxemia
37. A patient who has chest pain is admitted to the emergency department (ED) and all of the following are ordered. Which one should the nurse arrange to be completed first? a. Chest x-ray b. Troponin level c. Electrocardiogram (ECG) d. Insertion of a peripheral IV
ANS: C The priority for the patient is to determine whether an acute myocardial infarction (AMI) is occurring so that reperfusion therapy can begin as quickly as possible. ECG changes occur very rapidly after coronary artery occlusion, and an ECG should be obtained as soon as possible. Troponin levels will increase after about 3 hours. Data from the chest x-ray may impact the patient's care but are not helpful in determining whether the patient is experiencing a myocardial infarction (MI). Peripheral access will be needed but not before the ECG.
41. A patient with diabetes mellitus and chronic stable angina has a new order for captopril (Capoten). The nurse should teach the patient that the primary purpose of captopril is to a. lower heart rate. b. control blood glucose levels. c. prevent changes in heart muscle. d. reduce the frequency of chest pain.
ANS: C The purpose for angiotensin-converting enzyme (ACE) inhibitors in patients with chronic stable angina who are at high risk for a cardiac event is to decrease ventricular remodeling. ACE inhibitors do not directly impact angina frequency, blood glucose, or heart rate.
A nurse and patient take action to meet health-related goals. The nurse is in which phase of the helping relationship? a. Pre-interaction b. Orientation c. Working d. Termination
ANS: C The working phase occurs when the nurse and the patient work together to solve problems and accomplish goals. Pre-interaction occurs before the nurse meets the patient. Orientation occurs when the nurse and the patient meet and get to know each other. Termination occurs during the ending of the relationship.
The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action will the nurse take? a. Repeat the tuberculin skin testing. b. Teach about the reason for the blood tests. c. Obtain consecutive sputum specimens from the patient for 3 days. d. Instruct the patient to expectorate three specimens as soon as possible.
ANS: C Three consecutive sputum specimens are obtained on different days for bacteriologic testing for M. tuberculosis. The patient should not provide all the specimens at once. Blood cultures are not used for tuberculosis testing. Once skin testing is positive, it is not repeated. DIF: Cognitive Level: Application REF: 555 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
14. A patient with ST-segment elevation in three contiguous electrocardiographic (ECG) leads is admitted to the emergency department (ED) and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which question should the nurse ask to determine whether the patient is a candidate for thrombolytic therapy? a. "Do you have any allergies?" b. "Do you take aspirin on a daily basis?" c. "What time did your chest pain begin?" d. "Can you rate your chest pain using a 0 to 10 scale?"
ANS: C Thrombolytic therapy should be started within 6 hours of the onset of the myocardial infarction (MI), so the time at which the chest pain started is a major determinant of the appropriateness of this treatment. The other information will also be needed, but it will not be a factor in the decision about thrombolytic therapy.
39. When assessing a child for possible congenital heart defects (CHDs), where should the nurse measure blood pressure? a. The right arm c. All four extremities b. The left arm d. Both arms while the child is crying
ANS: C When a CHD is suspected, the blood pressure should be measured in all four extremities while the child is quiet. Discrepancies between upper and lower extremities may indicate cardiac disease. Blood pressure measurements for upper and lower extremities are compared during an assessment for CHDs. Blood pressure measurements when the child is crying are likely to be elevated; thus the readings will be inaccurate. PTS: 1 DIF: Cognitive Level: Application REF: 1334 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
The nurse takes an admission history on a patient with possible asthma who has new-onset wheezing and shortness of breath. Which information may indicate a need for a change in therapy? a. The patient has chronic inflammatory bowel disease. b. The patient has a history of pneumonia 6 months ago. c. The patient takes propranolol (Inderal) for hypertension. d. The patient uses acetaminophen (Tylenol) for headaches.
ANS: C Beta-Blockers such as propranolol can cause bronchospasm in some patients with asthma. The other information will be documented in the health history but does not indicate a need for a change in therapy.
Which information obtained by the nurse about a patient who has been diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease is most important to communicate to the health care provider? a. The Mantoux test had an induration of only 8 mm. b. The chest-x-ray showed infiltrates in the upper lobes. c. The patient is being treated with antiretrovirals for HIV infection. d. The patient has a cough that is productive of blood-tinged mucus.
ANS: C Drug interactions can occur between the antiretrovirals used to treat HIV infection and the medications used to treat tuberculosis. The other data are expected in a patient with HIV and TB disease. DIF: Cognitive Level: Application REF: 556 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
Which critical thinking standards should the nurse use to ensure sound effective communication with patients? (Select all that apply.) a. Faith b. Supportiveness c. Self-confidence d. Humility e. Independent attitude f. Spiritual expression
ANS: C, D, E A self-confident attitude is important because the nurse who conveys confidence and comfort while communicating more readily establishes an interpersonal helping-trusting relationship. In addition, an independent attitude encourages the nurse to communicate with colleagues and share ideas about nursing interventions. An attitude of humility is necessary to recognize and communicate the need for more information before making a decision. Faith, supportiveness, and spiritual expression are attributes of caring, not critical thinking standards.
2. The emergency department (ED) nurse is initiating therapeutic hypothermia in a patient who has been resuscitated after a cardiac arrest. Which actions in the hypothermia protocol can be delegated to an experienced licensed practical/vocational nurse (LPN/LVN) (select all that apply)? a. Continuously monitor heart rhythm. b. Check neurologic status every 2 hours. c. Place cooling blankets above and below patient. d. Give acetaminophen (Tylenol) 650 mg per nasogastric tube. e. Insert rectal temperature probe and attach to cooling blanket control panel.
ANS: C, D, E Experienced LPN/LVNs have the education and scope of practice to implement hypothermia measures (e.g., cooling blanket, temperature probe) and administer medications under the supervision of a registered nurse (RN). Assessment of neurologic status and monitoring the heart rhythm require RN-level education and scope of practice and should be done by the RN. DIF: Cognitive Level: Apply (application) REF: 15-16 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
56. A nurse is conducting discharge teaching to parents about the care of their infant after cardiac surgery. The nurse instructs the parents to notify the physician if what conditions occur (Select all that apply)? a. Respiratory rate of 36 at rest b. Appetite slowly increasing c. Temperature above 37.7° C (100° F) d. New, frequent coughing e. Turning blue or bluer than normal
ANS: C, D, E The parents should be instructed to notify the physician after their infant's cardiac surgery for a temperature above 37.7° C (100° F); new, frequent coughing; and any episodes of the infant turning blue or bluer than normal. A respiratory rate of 36 at rest for an infant is within normal expectations, and it is expected that the appetite will increase slowly. PTS: 1 DIF: Cognitive Level: Application REF: 1342 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
57. The nurse is conducting discharge teaching about signs and symptoms of heart failure to parents of an infant with a repaired tetralogy of Fallot. Which signs and symptoms should the nurse include (Select all that apply)? a. Warm flushed extremities b. Weight loss c. Decreased urinary output d. Sweating (inappropriate) e. Fatigue
ANS: C, D, E The signs and symptoms of heart failure include decreased urinary output, sweating, and fatigue. Other signs include pale, cool extremities, not warm and flushed, and weight gain, not weight loss.
54. Which clinical manifestations would the nurse expect to see as shock progresses in a child and becomes decompensated shock (Select all that apply)? a. Thirst and diminished urinary output b. Irritability and apprehension c. Cool extremities and decreased skin turgor d. Confusion and somnolence e. Normal blood pressure and narrowing pulse pressure f. Tachypnea and poor capillary refill time
ANS: C, D, F Cool extremities, decreased skin turgor, confusion, somnolence, tachypnea, and poor capillary refill time are beginning signs of decompensated shock. PTS: 1 DIF: Cognitive Level: Analysis REF: 1356 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
53. Nursing interventions for the child after a cardiac catheterization include which of the following (Select all that apply)? a. Allow ambulation as tolerated. b. Monitor vital signs every 2 hours. c. Assess the affected extremity for temperature and color. d. Check pulses above the catheterization site for equality and symmetry. e. Remove pressure dressing after 4 hours. f. Maintain a patent peripheral intravenous catheter until discharge.
ANS: C, F The extremity that was used for access for the cardiac catheterization must be checked for temperature and color. Coolness and blanching may indicate arterial occlusion. The child should have a patent peripheral intravenous line to ensure adequate hydration. Allowing ambulation, monitoring vital signs every 2 hours, checking pulses, and removing the pressure dressing after 4 hours are interventions that do not apply to a child after a cardiac catheterization. PTS: 1 DIF: Cognitive Level: Application REF: 1320 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
7. A staff nurse delegates a task to a nursing assistive personnel (NAP), knowing that the NAP has never performed the task before. As a result, the patient is injured, and the nurse defensively states that the NAP should have known how to perform such a simple task. Which element of the decision-making process is the nurse lacking? a. Authority b. Autonomy c. Responsibility d. Accountability
ANS: D Accountability refers to individuals being answerable for their actions. The nurse in this situation is not taking ownership of the inappropriate delegation of a task. Autonomy is freedom of choice and responsibility for the choices. Responsibility refers to the duties and activities that an individual is employed to perform. Authority refers to legitimate power to give commands and make final decisions specific to a given position. DIF:Analyze (analysis)REF:282 OBJ: Describe the elements of shared decision making. TOP: Evaluation
16. A nurse is prioritizing care for four patients. Which patient should the nurse see first? a. A patient needing teaching about medications b. A patient with a healed abdominal incision c. A patient with a slight temperature d. A patient with difficulty breathing
ANS: D An immediate threat to a patient's survival or safety must be addressed first, like difficulty breathing. Teaching, healed incision, and slight temperature are not immediate needs. DIF:Apply (application)REF:284-285 OBJ: Discuss ways to apply clinical care coordination skills in nursing practice.
4. A nurse manager discovers that the readmission rate of hospitalized patients is very high on the hospital unit. The nurse manager desires improved coordination of care and accountability for cost-effective quality care. Which nursing care delivery model is best suited for these needs? a. Team nursing b. Total patient care c. Primary nursing d. Case management
ANS: D Case management is a care approach that coordinates and links health care services to patients and families while streamlining costs. In team nursing, the RN assumes the role of group or team leader and leads a team made up of other RNs, practical nurses, and nursing assistive personnel. Total patient care involves an RN being responsible for all aspects of care for one or more patients. The primary nursing model of care delivery was developed to place RNs at the bedside and improve the accountability of nursing for patient outcomes and the professional relationships among staff members. DIF:Apply (application)REF:281 OBJ:Differentiate among the types of nursing care delivery models.
2. A nurse is overseeing the care of patients with severe diabetes and patients with heart failure to improve cost-effectiveness and quality of care. Which nursing care delivery model is the nurse using? a. Team nursing b. Total patient care c. Primary nursing d. Case management
ANS: D Case management is unique because clinicians, either as individuals or as part of a collaborative group, oversee the management of patients with specific, complex health problems or are held accountable for some standard of cost management and quality. Case management is a care approach that coordinates and links health care services to patients and families while streamlining costs. In the team nursing care model, the RN assumes the role of group or team leader and leads a team made up of other RNs, practical nurses, and nursing assistive personnel. Total patient care involves an RN being responsible for all aspects of care for one or more patients. The primary nursing model of care delivery was developed to place RNs at the bedside and improve the accountability of nursing for patient outcomes and the professional relationships among staff members. DIF:Apply (application)REF:281 OBJ:Differentiate among the types of nursing care delivery models. TOP:ImplementationMSC:Management of Care
1. A registered nurse (RN) is the group leader of practical nurses and nursing assistive personnel. Which nursing care model is the RN using? a. Case management b. Total patient care c. Primary nursing d. Team nursing
ANS: D In team nursing, the RN assumes the role of group or team leader and leads a team made up of other RNs, practical nurses, and nursing assistive personnel. Case management is a care approach that coordinates and links health care services to patients and families while streamlining costs. Total patient care involves an RN being responsible for all aspects of care for one or more patients. The primary nursing model of care delivery was developed to place RNs at the bedside and improve the accountability of nursing for patient outcomes and the professional relationships among staff members. DIF:Understand (comprehension)REF:281 OBJ:Differentiate among the types of nursing care delivery models.
13. Which assessment of a patient who is 1 day postsurgery to repair a hip fracture requires immediate nursing intervention? a. Patient ate 40% of clear liquid breakfast. b. Patient's oral temperature is 98.9° F. c. Patient states, "I did not realize I would be so tired after this surgery." d. Patient reports severe pain 30 minutes after receiving pain medication.
ANS: D It is important to prioritize in all caregiving situations because it allows you to see relationships among patient problems and avoid delays in taking action that possibly leads to serious complications for a patient. The nurse needs to report severe pain that is unrelieved by pain medication to the health care provider. The nurse needs to recognize and differentiate normal from abnormal findings and set priorities. Eating 40% of breakfast, having a slightly elevated temperature, and being tired the day after surgery are expected findings following surgery and do not require immediate intervention. DIF:Analyze (analysis)REF:284-285 OBJ: Discuss ways to apply clinical care coordination skills in nursing practice.
14. A nurse has a transactional leader as a manager. Which finding will the nurse anticipate from working with this leader? a. Increased turnover rate b. Increased patient mortality rate c. Increased rate of medication errors d. Increased level of patient satisfaction
ANS: D Research has found that on nursing units where the nurse manager uses transactional leadership there is an increased level of patient satisfaction, a lower patient mortality rate, and a lower rate of medication errors. Turnover rate is decreased since staff retention is increased with transformational leadership. DIF:Understand (comprehension)REF:279-280 OBJ:Describe the characteristics and traits of a transactional leader.
10. A nurse manager conducts rounds on the unit and discovers that expired stock medicine is still in the cabinet despite the e-mail that was sent stating that it had to be discarded. The staff nurse dress code is not being adhered to as requested in the same e-mail. Several staff nurses deny having received the e-mail. Which action should the nurse manager take? a. Close the staff lounge. b. Enforce a stricter dress code. c. Include the findings on each staff member's annual evaluation. d. Place a hard copy of announcements and unit policies in each staff member's mailbox.
ANS: D The identified problem is lack of staff communication. Sending an e-mail was not effective; therefore, giving each staff member a hard copy along with e-mailing is another approach the manager can take. An effective manager uses a variety of approaches to communicate quickly and accurately to all staff. For example, many managers distribute biweekly or monthly newsletters of ongoing unit or facility activities. Including the findings on evaluations, closing the lounge, and enforcing stricter dress codes do not address the problem. DIF:Apply (application)REF:283-284 OBJ:Discuss the ways in which a nurse manager supports staff involvement in a decentralized decision-making model.TOP:Implementation
13. A nurse is caring for a patient who has had a total laryngectomy and radical neck dissection. During the first 24 hours after surgery what is the priority nursing action? a.Monitor for bleeding. b.Maintain adequate IV fluid intake. c.Suction tracheostomy every eight hours. d.Keep the patient in semi-Fowler's position.
ANS: D The most important goals after a laryngectomy and radical neck dissection are to maintain the airway and ensure adequate oxygenation. Keeping the patient in a semi-Fowler's position will decrease edema and limit tension on the suture lines to help ensure an open airway. Maintenance of IV fluids and monitoring for bleeding are important, but maintaining an open airway is the priority. Tracheostomy care and suctioning should be provided as needed. During the immediate postoperative period, the patient with a laryngectomy requires frequent suctioning of the tracheostomy tube.
9. A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, "Will I be able to talk normally after surgery?" What is the best response by the nurse? a."You will breathe through a permanent opening in your neck, but you will not be able to communicate orally." b."You won't be able to talk right after surgery, but you will be able to speak again after the tracheostomy tube is removed." c."You won't be able to speak as you used to, but there are artificial voice devices that will give you the ability to speak normally." d."You will have a permanent opening into your neck, and you will need to have rehabilitation for some type of voice restoration."
ANS: D Voice rehabilitation is planned after a total laryngectomy, and a variety of assistive devices are available to restore communication. Although the ability to communicate orally is changed, it would not be appropriate to tell a patient that this ability would be lost. Artificial voice devices do not permit normal-sounding speech. In a total laryngectomy, the vocal cords are removed, so normal speech is impossible.
A nurse is standing beside the patient's bed. Nurse: How are you doing? Patient: I don't feel good. In this situation, which element is the feedback? a. Nurse b. Patient c. How are you doing? d. I don't feel good.
ANS: D "I don't feel good" is the feedback because the feedback is the message the receiver returns. The sender is the person who encodes and delivers the message, and the receiver is the person who receives and decodes the message. The nurse is the sender. The patient is the receiver. "How are you doing?" is the message.
When making rounds, the nurse finds a patient who is not able to sleep because of surgery in the morning. Which therapeutic response is most appropriate? a. "It will be okay. Your surgeon will talk to you in the morning." b. "Why can't you sleep? You have the best surgeon in the hospital." c. "Don't worry. The surgeon ordered a sleeping pill to help you sleep." d. "It must be difficult not to know what the surgeon will find. What can I do to help?"
ANS: D "It must be difficult not to know what the surgeon will find. What can I do to help?" is using therapeutic communication techniques of empathy and offering of self. False reassurances ("It will be okay" and "Don't worry") tend to block communication. Patients frequently interpret "why" questions as accusations or think the nurse knows the reason and is simply testing them.
Enuresis is reported in a previously toilet trained toddler. While gathering a health history from the grandparent, the nurse asks about which factor as the most likely cause? a. Lack of outside playtime b. Having too many toys c. Dietary changes d. Recent parental death
ANS: D A child's stage of development and chronological age will influence how he or she grieves. Toddlers can show grief through changes in their eating patterns, changes in their sleeping patterns, fussiness or irritability, and changes in their bowel and bladder habits. It is common for younger children to regress when under increased stress. Lack of outside playtime, dietary changes, and having too many toys are unlikely to cause enuresis.
10. When rewarming a patient who arrived in the emergency department (ED) with a temperature of 87° F (30.6° C), which assessment indicates that the nurse should discontinue active rewarming? a. The patient begins to shiver. b. The BP decreases to 86/42 mm Hg. c. The patient develops atrial fibrillation. d. The core temperature is 94° F (34.4° C).
ANS: D A core temperature of 89.6° F to 93.2° F (32° C to 34° C) indicates that sufficient rewarming has occurred. Dysrhythmias, hypotension, and shivering may occur during rewarming and should be treated but are not an indication to stop rewarming the patient. DIF: Cognitive Level: Apply (application) REF: 1686 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
The nurse is discussing future treatments with a client who has a terminal illness. The nurse notes that the client has not been eating and responds to the nurse's information by stating, "What does it matter?" Which of the following is the most appropriate nursing diagnosis for this client? a. Social isolation b. Spiritual distress c. Denial d. Hopelessness
ANS: D A defining characteristic for the nursing diagnosis of hopelessness may include the client stating, "What does it matter?" when offered choices or information concerning him or her. The client's behaviour of not eating also is an indicator of hopelessness. The client's behaviour and verbalization is not an example of social isolation. The client is not avoiding others or being restricted from seeing others. Spiritual distress is not the most appropriate nursing diagnosis for this client. The focus should be on the client's lack of hope. The client's behaviour and verbalization does not indicate denial.
Which of the following would be a nursing intervention to assist the client with a nursing diagnosis of Sleep pattern disturbance related to the loss of spouse and fear of nightmares? a. Administer sleeping medication per order. b. Refer the client to a psychologist or psychotherapist. c. Have the client complete a detailed sleep-pattern assessment. d. Sit with the client and encourage verbalization of feelings.
ANS: D A nursing intervention to facilitate grief work is to offer the client encouragement to explore and verbalize feelings of grief. This encouragement refocuses the client on current needs and minimizes dysfunctional adaptation behaviours (e.g., not sleeping) by facilitating resolution of grief through problem-solving skills. Administering sleeping medication may help the client get to sleep, but does not resolve the issue of grief. Without addressing the grief, the client may develop another dysfunctional adaptation behaviour. It is not necessary to refer the client to a psychologist or psychotherapist at this time. The client needs to be encouraged to verbalize his or her feelings. Having the client complete a detailed sleep-pattern assessment may help the nurse identify the number of hours of sleep the client is obtaining, but it does not address the issue causing the sleep disturbance, which is grief from the loss of the spouse.
The nurse is obtaining a health history from a 24-year-old patient with hypertrophic cardiomyopathy (HC). Which information obtained by the nurse is most important? a. The patient has a history of a recent upper respiratory infection. b. The patient has a family history of coronary artery disease (CAD). c. The patient reports using cocaine a "couple of times" as a teenager. d. The patient's 29-year-old brother died from a sudden cardiac arrest.
ANS: D About half of all cases of HC have a genetic basis, and it is the most common cause of sudden cardiac death in otherwise healthy young people. The information about the patient's brother will be helpful in planning care (such as an automatic implantable cardioverter-defibrillator [AICD]) for the patient and in counseling other family members. The patient should be counseled against the use of stimulant drugs, but the limited past history indicates that the patient is not at current risk for cocaine use. Viral infections and CAD are risk factors for dilated cardiomyopathy, but not for HC
A patient who has been receiving a heparin infusion and warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when her platelet level drops to 110,000/µL. Which action will the nurse include in the plan of care? a. Use low-molecular-weight heparin (LMWH) only. b. Administer the warfarin (Coumadin) at the scheduled time. c. Teach the patient about the purpose of platelet transfusions. d. Discontinue heparin and flush intermittent IV lines using normal saline.
ANS: D All heparin is discontinued when the HIT is diagnosed. The patient should be instructed to never receive heparin or LMWH. Warfarin is usually not given until the platelet count has returned to 150,000/µL. The platelet count does not drop low enough in HIT for a platelet transfusion, and platelet transfusions increase the risk for thrombosis.
15. The nurse analyzes the results of a patients arterial blood gases (ABGs). Which finding would require immediate action? a. The bicarbonate level (HCO3) is 31 mEq/L. b. The arterial oxygen saturation (SaO2) is 92 c. The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg. d. The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.
ANS: D All the values are abnormal, but the low PaO2 indicates that the patient is at the point on the oxyhemoglobin dissociation curve where a small change in the PaO2 will cause a large drop in the O2 saturation and a decrease in tissue oxygenation. The nurse should intervene immediately to improve the patients oxygenation. DIF: Cognitive Level: Apply (application) REF: eTable 26-1 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
A patient with pneumonia has a fever of 101.2° F (38.5° C), a nonproductive cough, and an oxygen saturation of 89%. The patient is very weak and needs assistance to get out of bed. The priority nursing diagnosis for the patient is a. hyperthermia related to infectious illness. b. impaired transfer ability related to weakness. c. ineffective airway clearance related to thick secretions. d. impaired gas exchange related to respiratory congestion.
ANS: D All these nursing diagnoses are appropriate for the patient, but the patient's oxygen saturation indicates that all body tissues are at risk for hypoxia unless the gas exchange is improved. DIF: Cognitive Level: Application REF: 552-553 OBJ: Special Questions: Prioritization TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity
6. Which statement made by a patient with coronary artery disease after the nurse has completed teaching about therapeutic lifestyle changes (TLC) diet indicates that further teaching is needed? a. "I will switch from whole milk to 1% milk." b. "I like salmon and I will plan to eat it more often." c. "I can have a glass of wine with dinner if I want one." d. "I will miss being able to eat peanut butter sandwiches."
ANS: D Although only 30% of the daily calories should come from fats, most of the fat in the TLC diet should come from monosaturated fats such as are found in nuts, olive oil, and canola oil. The patient can include peanut butter sandwiches as part of the TLC diet. The other patient comments indicate a good understanding of the TLC diet.
30. What type of shock is characterized by a hypersensitivity reaction causing massive vasodilation and capillary leaks, which may occur with drug or latex allergy? a. Neurogenic shock c. Hypovolemic shock b. Cardiogenic shock d. Anaphylactic shock
ANS: D Anaphylactic shock results from extreme allergy or hypersensitivity to a foreign substance. Neurogenic shock results from loss of neuronal control, such as the interruption of neuronal transmission that occurs from a spinal cord injury. Cardiogenic shock is decreased cardiac output. Hypovolemic shock is a reduction in the size of the vascular compartment, decreasing blood pressure, and low central venous pressure. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1356 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
1. When developing a teaching plan for a 61-year-old man with the following risk factors for coronary artery disease (CAD), the nurse should focus on the a. family history of coronary artery disease. b. increased risk associated with the patient's gender. c. increased risk of cardiovascular disease as people age. d. elevation of the patient's low-density lipoprotein (LDL) level.
ANS: D Because family history, gender, and age are nonmodifiable risk factors, the nurse should focus on the patient's LDL level. Decreases in LDL will help reduce the patient's risk for developing CAD.
11. Nadolol (Corgard) is prescribed for a patient with chronic stable angina and left ventricular dysfunction. To determine whether the drug is effective, the nurse will monitor for a. decreased blood pressure and heart rate. b. fewer complaints of having cold hands and feet. c. improvement in the strength of the distal pulses. d. the ability to do daily activities without chest pain.
ANS: D Because the medication is ordered to improve the patient's angina, effectiveness is indicated if the patient is able to accomplish daily activities without chest pain. Blood pressure and heart rate may decrease, but these data do not indicate that the goal of decreased angina has been met. The noncardioselective β-adrenergic blockers can cause peripheral vasoconstriction, so the nurse would not expect an improvement in distal pulse quality or skin temperature.
4. Which information given by a patient admitted with chronic stable angina will help the nurse confirm this diagnosis? a. The patient states that the pain "wakes me up at night." b. The patient rates the pain at a level 3 to 5 (0 to 10 scale). c. The patient states that the pain has increased in frequency over the last week. d. The patient states that the pain "goes away" with one sublingual nitroglycerin tablet.
ANS: D Chronic stable angina is typically relieved by rest or nitroglycerin administration. The level of pain is not a consistent indicator of the type of angina. Pain occurring at rest or with increased frequency is typical of unstable angina.
16. When assessing the respiratory system of an older patient, which finding indicates that the nurse should take immediate action? a. Weak cough effort b. Barrel-shaped chest c. Dry mucous membranes d. Bilateral crackles at lung bases
ANS: D Crackles in the lower half of the lungs indicate that the patient may have an acute problem such as heart failure. The nurse should immediately accomplish further assessments, such as oxygen saturation, and notify the health care provider. A barrel-shaped chest, hyperresonance to percussion, and a weak cough effort are associated with aging. Further evaluation may be needed, but immediate action is not indicated. An older patient has a less forceful cough and fewer and less functional cilia. Mucous membranes tend to be drier. DIF: Cognitive Level: Apply (application) REF: 489 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
The nurse obtains a health history from a 65-year-old patient with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse is most appropriate? a. "Do you have a history of a heart attack?" b. "Is there a family history of endocarditis?" c. "Have you had any recent immunizations?" d. "Have you had dental work done recently?"
ANS: D Dental procedures place the patient with a prosthetic mitral valve at risk for infective endocarditis (IE). Myocardial infarction (MI), immunizations, and a family history of endocarditis are not risk factors for IE.
11. The parents of a young child with congestive heart failure tell the nurse that they are "nervous" about giving digoxin. The nurse's response should be based on knowing that: a. It is a safe, frequently used drug. b. It is difficult to either overmedicate or undermedicate with digoxin. c. Parents lack the expertise necessary to administer digoxin. d. Parents must learn specific, important guidelines for administration of digoxin.
ANS: D Digoxin has a narrow therapeutic range. The margin of safety between therapeutic, toxic, and lethal doses is very small. Specific guidelines are available for parents to learn how to administer the drug safely and monitor for side effects. Digoxin is a frequently used drug, but it has a narrow therapeutic range. Very small amounts of the liquid are given to infants, which makes it easy to overmedicate or undermedicate. Parents may lack the necessary expertise to administer the drug at first, but with discharge preparation they should be prepared to administer the drug safely. PTS: 1 DIF: Cognitive Level: Analysis REF: 1351 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen? a. Arrange for a friend to administer the medication on schedule. b. Give the patient written instructions about how to take the medications. c. Teach the patient about the high risk for infecting others unless treatment is followed. d. Arrange for a daily noon meal at a community center where the drug will be administered.
ANS: D Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen, and arranging a daily meal will help ensure that the patient is available to receive the medication. The other nursing interventions may be appropriate for some patients but are not likely to be as helpful for this patient.
A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of severe pleuritic chest pain. Which prescribed medication should the nurse give first? a. Codeine b. Guaifenesin (Robitussin) c. Acetaminophen (Tylenol) d. Piperacillin/tazobactam (Zosyn)
ANS: D Early initiation of antibiotic therapy has been demonstrated to reduce mortality. The other medications are also appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy.
The patient that will cause the greatest communication concerns for a nurse is the patient who is a. Alert, has strong self-esteem, and is hungry. b. Oriented, pain free, and blind. c. Cooperative, depressed, and hard of hearing. d. Dyspneic, has a tracheostomy, and is anxious.
ANS: D Facial trauma, laryngeal cancer, or endotracheal intubation often prevents movement of air past vocal cords or mobility of the tongue, resulting in inability to articulate words. An extremely breathless person needs to use oxygen to breathe rather than speak. Persons with high anxiety are sometimes unable to perceive environmental stimuli or hear explanations. People who are alert, have strong self-esteem, and are cooperative and pain free do not cause communication concerns. Although hunger, blindness, and difficulty hearing can cause communication concerns, dyspnea, a tracheostomy, and anxiety all contribute to communication concerns.
Which of the following defining characteristics is consistent with fluid volume deficit?
Dry mucous membranes, thready pulse, tachycardia
5. A 19-year-old is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of the left hand. When asked about tetanus immunization, the patient denies having any previous vaccinations. The nurse will anticipate giving a. tetanus immunoglobulin (TIG) only. b. TIG and tetanus-diphtheria toxoid (Td). c. tetanus-diphtheria toxoid and pertussis vaccine (Tdap) only. d. TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap).
ANS: D For an adult with no previous tetanus immunizations, TIG and Tdap are recommended. The other immunizations are not sufficient for this patient. DIF: Cognitive Level: Apply (application) REF: 1681 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance
26. When discussing hyperlipidemia with a group of adolescents, the nurse should explain that high levels of what substance are thought to protect against cardiovascular disease? a. Cholesterol c. Low-density lipoproteins (LDLs) b. Triglycerides d. High-density lipoproteins (HDLs).
ANS: D HDLs contain very low concentrations of triglycerides, relatively little cholesterol, and high levels of proteins. It is thought that HDLs protect against cardiovascular disease. Cholesterol, triglycerides, and LDLs do not protect against cardiovascular disease. PTS: 1 DIF: Cognitive Level: Application REF: 1346 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
28. When caring for the child with Kawasaki disease, the nurse should understand that: a. The child's fever is usually responsive to antibiotics within 48 hours. b. The principal area of involvement is the joints. c. Aspirin is contraindicated. d. Therapeutic management includes administration of gamma globulin and aspirin.
ANS: D High-dose intravenous gamma globulin and aspirin therapy are indicated to reduce the incidence of coronary artery abnormalities when given within the first 10 days of the illness. The fever of Kawasaki disease is unresponsive to antibiotics and antipyretics. Involvement of mucous membranes and conjunctiva, changes in the extremities, and cardiac involvement are seen. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1354 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
11. A patient who has a history of chronic obstructive pulmonary disease (COPD) was hospitalized for increasing shortness of breath and chronic hypoxemia (SaO2 levels of 89 percent to 90 percent). In planning for discharge, which action by the nurse will be most effective in improving compliance with discharge teaching? a. Start giving the patient discharge teaching on the day of admission. b. Have the patient repeat the instructions immediately after teaching. c. Accomplish the patient teaching just before the scheduled discharge. d. Arrange for the patients caregiver to be present during the teaching.
ANS: D Hypoxemia interferes with the patients ability to learn and retain information, so having the patients caregiver present will increase the likelihood that discharge instructions will be followed. Having the patient repeat the instructions will indicate that the information is understood at the time, but it does not guarantee retention of the information. Because the patient is likely to be distracted just before discharge, giving discharge instructions just before discharge is not ideal. The patient is likely to be anxious and even more hypoxemic than usual on the day of admission, so teaching about discharge should be postponed. DIF: Cognitive Level: Apply (application) REF: 484 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
3. The nurse is caring for a school-age girl who has had a cardiac catheterization. The child tells the nurse that her bandage is "too wet." The nurse finds the bandage and bed soaked with blood. The most appropriate initial nursing action is to: a. Notify the physician. b. Apply a new bandage with more pressure. c. Place the child in the Trendelenburg position. d. Apply direct pressure above the catheterization site.
ANS: D If bleeding occurs, direct continuous pressure is applied 2.5 cm (1 inch) above the percutaneous skin site to localize pressure over the vessel puncture. Notifying the physician and applying a new bandage with more pressure can be done after pressure is applied. The nurse can have someone else notify the physician while the pressure is being maintained. The Trendelenburg position would not be helpful; it would increase the drainage from the lower extremities. PTS: 1 DIF: Cognitive Level: Analysis REF: 1320 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
17. Seventy-two hours after cardiac surgery, a young child has a temperature of 37.7 C (101 F). The nurse should: a. Keep the child warm with blankets. b. Apply a hypothermia blanket. c. Record the temperature on nurses' notes. d. Report findings to physician.
ANS: D In the first 24 to 48 hours after surgery, the body temperature may increase to 37.7 C (100 F) as part of the inflammatory response to tissue trauma. If the temperature is higher or an elevated temperature continues after this period, it is most likely a sign of an infection and immediate investigation is indicated. Blankets should be removed from the child to keep the temperature from increasing. A hypothermia blanket is not indicated for this level of temperature. The temperature should be recorded, but the physician must be notified for evaluation. PTS: 1 DIF: Cognitive Level: Analysis REF: 1341 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
Which of these orders will the nurse act on first for a patient who has just been admitted with probable bacterial pneumonia and sepsis? a. Administer aspirin suppository. b. Send to radiology for chest x-ray. c. Give ciprofloxacin (Cipro) 400 mg IV. d. Obtain blood cultures from two sites.
ANS: D Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic administration. The chest radiograph and aspirin administration can be done last. DIF: Cognitive Level: Application REF: 549 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
In preparation for the eventual death of a female hospice patient of the Muslim faith, the nurse organizes a meeting of all hospice caregivers. A plan of care to be followed when this patient dies is prepared. This plan of care would include a. Male health care workers care for the body after death has occurred. b. Body preparation for autopsy. c. Body preparation for cremation. d. Female health care workers care for the body after death has occurred.
ANS: D Islamic culture calls for modesty and same-sex caregivers whenever possible. Muslim faith discourages cremation and autopsy to preserve the sanctity of the soul of the deceased.
A family is grieving after learning of a family member's accidental death. The transplant coordinator requests to talk with the family about possible organ and tissue donation. The nurse recognizes that a. All religions allow for organ donation. b. Life support must be removed before organ and tissue retrieval occurs. c. The best time for organ and tissue donation is immediately after the autopsy. d. The transplant coordinator is working in accordance with federal law.
ANS: D It is a federal law to require facilities to develop policies about organ donation. The transplant coordinator has additional education on providing answers about organ donation. Not all religions allow for organ donation. A patient may be on life support during organ removal to preserve organ tissues. Autopsy compromises organ integrity; removal should occur prior.
36. A patient had a non-ST-segment-elevation myocardial infarction (NSTEMI) 3 days ago. Which nursing intervention included in the plan of care is most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Evaluation of the patient's response to walking in the hallway b. Completion of the referral form for a home health nurse follow-up c. Education of the patient about the pathophysiology of heart disease d. Reinforcement of teaching about the purpose of prescribed medications
ANS: D LPN/LVN education and scope of practice include reinforcing education that has previously been done by the RN. Evaluating the patient response to exercise after a NSTEMI requires more education and should be done by the RN. Teaching and discharge planning/ documentation are higher level skills that require RN education and scope of practice.
14. The emergency department (ED) triage nurse is assessing four victims involved in a motor vehicle collision. Which patient has the highest priority for treatment? a. A patient with no pedal pulses. b. A patient with an open femur fracture. c. A patient with bleeding facial lacerations. d. A patient with paradoxic chest movements.
ANS: D Most immediate deaths from trauma occur because of problems with ventilation, so the patient with paradoxic chest movements should be treated first. Face and head fractures can obstruct the airway, but the patient with facial injuries only has lacerations. The other two patients also need rapid intervention but do not have airway or breathing problems. DIF: Cognitive Level: Apply (application) REF: 1676 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
Which information about a patient who has a recent history of tuberculosis (TB) indicates that the nurse can discontinue airborne isolation precautions? a. Chest x-ray shows no upper lobe infiltrates. b. TB medications have been taken for 6 months. c. Mantoux testing shows an induration of 10 mm. d. Three sputum smears for acid-fast bacilli are negative.
ANS: D Negative sputum smears indicate that M. tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route. Chest x-rays are not used to determine whether treatment has been successful. Taking medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Repeat Mantoux testing would not be done since it will not change even with effective treatment. DIF: Cognitive Level: Application REF: 557 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
A patient is admitted with active tuberculosis (TB). The nurse should question a health care provider's order to discontinue airborne precautions unless which assessment finding is documented? a. Chest x-ray shows no upper lobe infiltrates. b. TB medications have been taken for 6 months. c. Mantoux testing shows an induration of 10 mm. d. Three sputum smears for acid-fast bacilli are negative.
ANS: D Negative sputum smears indicate that Mycobacterium tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route. Chest x-rays are not used to determine whether treatment has been successful. Taking medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Repeat Mantoux testing would not be done because the result will not change even with effective treatment.
A terminally ill patient is experiencing constipation secondary to pain medication. What is the best way for the nurse to improve the patient's constipation problem? a. Massage the patient's abdomen. b. Contact the provider to discontinue pain medication. c. Administer enemas twice daily for 7 days. d. Use a stimulant laxative and increase fluid intake.
ANS: D Opioid medication is known to slow gastrointestinal transit time, which places the patient at high risk for constipation. Stimulant laxatives are indicated for opioid-induced constipation. Added water to the diet will allow water to be pulled into the GI tract, softening up stool. Massaging the patient's abdomen may cause further discomfort. Discontinuing pain medication is inappropriate for a terminally ill patient. Enema administration is not the first step in the treatment of opioid-induced constipation.
The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is most important for the nurse to ask before the skin test? a. "Is there any family history of TB?" b. "How long have you lived in the United States?" c. "Do you take any over-the-counter (OTC) medications?" d. "Have you received the bacille Calmette-Guérin (BCG) vaccine for TB?"
ANS: D Patients who have received the BCG vaccine will have a positive Mantoux test. Another method for screening (such as a chest x-ray) will need to be used in determining whether the patient has a TB infection. The other information also may be valuable but is not as pertinent to the decision about doing TB skin testing.
The nurse establishes the nursing diagnosis of ineffective health maintenance related to lack of knowledge regarding long-term management of rheumatic fever when a 30-year-old recovering from rheumatic fever without carditis says which of the following? a. "I will need prophylactic antibiotic therapy for 5 years." b. "I will need to take aspirin or ibuprofen (Motrin) to relieve my joint pain." c. "I will call the doctor if I develop excessive fatigue or difficulty breathing." d. "I will be immune to further episodes of rheumatic fever after this infection."
ANS: D Patients with a history of rheumatic fever are more susceptible to a second episode. Patients with rheumatic fever without carditis require prophylaxis until age 20 and for a minimum of 5 years. The other patient statements are correct and would not support the nursing diagnosis of ineffective health maintenance
Which laboratory result will the nurse expect to show a decreased value if a patient develops heparin-induced thrombocytopenia (HIT)? a. Prothrombin time b. Erythrocyte count c. Fibrinogen degradation products d. Activated partial thromboplastin time
ANS: D Platelet aggregation in HIT causes neutralization of heparin, so that the activated partial thromboplastin time will be shorter and more heparin will be needed to maintain therapeutic levels. The other data will not be affected by HIT.
The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed? a. UAP splint the patient's chest during coughing. b. UAP assist the patient to ambulate to the bathroom. c. UAP help the patient to a bedside chair for meals. d. UAP lower the head of the patient's bed to 15 degrees.
ANS: D Positioning the patient with the head of the bed lowered will decrease ventilation. The other actions are appropriate for a patient with pneumonia.
2. José is a 4-year-old child scheduled for a cardiac catheterization. Preoperative teaching should be: a. Directed at his parents because he is too young to understand. b. Detailed in regard to the actual procedures so he will know what to expect. c. Done several days before the procedure so that he will be prepared. d. Adapted to his level of development so that he can understand.
ANS: D Preoperative teaching should always be directed at the child's stage of development. The caregivers also benefit from the same explanations. The parents may ask additional questions, which should be answered, but the child needs to receive the information based on developmental level. This age group does not understand in-depth descriptions. Preschoolers should be prepared close to the time of the cardiac catheterization. PTS: 1 DIF: Cognitive Level: Application REF: 1320 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
41. For what reason might a newborn infant with a cardiac defect, such as coarctation of the aorta, that results in a right-to-left shunt receive prostaglandin E1? a. To decrease inflammation c. To decrease respirations b. To control pain d. To improve oxygenation
ANS: D Prostaglandin E1 is given to infants with a right-to-left shunt to keep the ductus arteriosus patent. This will improve oxygenation and increase pulmonary blood flow. PTS: 1 DIF: Cognitive Level: Analysis REF: 1324 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
43. After reviewing a patient's history, vital signs, physical assessment, and laboratory data, which information shown in the accompanying figure is most important for the nurse to communicate to the health care provider? a. Q waves on ECG b. Elevated troponin levels c. Fever and hyperglycemia d. Tachypnea and crackles in lungs
ANS: D Pulmonary congestion and tachypnea suggest that the patient may be developing heart failure, a complication of myocardial infarction (MI). Mild fever and hyperglycemia are common after MI because of the inflammatory process that occurs with tissue necrosis. Troponin levels will be elevated for several days after MI. Q waves often develop with ST-segment-elevation MI.
The nurse has identified a nursing diagnosis of acute pain related to inflammatory process for a patient with acute pericarditis. The priority intervention by the nurse for this problem is to a. teach the patient to take deep, slow breaths to control the pain. b. force fluids to 3000 mL/day to decrease fever and inflammation. c. remind the patient to request opioid pain medication every 4 hours. d. place the patient in Fowler's position, leaning forward on the overbed table.
ANS: D Sitting upright and leaning forward frequently will decrease the pain associated with pericarditis. Forcing fluids will not decrease the inflammation or pain. Taking deep breaths will tend to increase pericardial pain. Opioids are not very effective at controlling pain caused by acute inflammatory conditions and are usually ordered PRN. The patient would receive scheduled doses of a nonsteroidal antiinflammatory drug (NSAID).
Mrs. Harrison's father died a week ago. Mr. Harrison is experiencing headaches and fatigue, and keeps shouting at his wife to turn down the television, although he has not done so in the past. Mrs. Harrison is having trouble sleeping, has no appetite, and says she feels like she is choking all the time. How should the nurse interpret these assessment findings as the basis for a follow-up assessment? a. Mrs. Harrison is grieving and Mr. Harrison is angry. b. Mrs. Harrison is ill and Mr. Harrison is grieving. c. Both Mr. and Mrs. Harrison likely are in denial. d. Both Mr. and Mr. Harrison likely are grieving.
ANS: D Symptoms of normal grief include headache, fatigue, oversensitivity to noise, insomnia, appetite disturbance, and choking sensation. Different people manifest different symptoms. Denial is assessed when the person indicates that he is not accepting that the loss happened.
2. During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal pulse is absent and the leg is swollen. Which action will the nurse take next? a. Send blood to the lab for a complete blood count. b. Assess further for a cause of the decreased circulation. c. Finish the airway, breathing, circulation, disability survey. d. Start normal saline fluid infusion with a large-bore IV line.
ANS: D The assessment data indicate that the patient may have arterial trauma and hemorrhage. When a possibly life-threatening injury is found during the primary survey, the nurse should immediately start interventions before proceeding with the survey. Although a complete blood count is indicated, administration of IV fluids should be started first. Completion of the primary survey and further assessment should be completed after the IV fluids are initiated. DIF: Cognitive Level: Apply (application) REF: 1676 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
The nurse recognizes that anticipatory grieving can be most beneficial to a client or family for which of the following reasons? a. It can be done in private. b. It can be discussed with others. c. It can promote separation of the ill client from the family. d. It allows time for the dying client and his or her loved ones to say goodbye and complete life affairs before the actual death or loss occurs.
ANS: D The benefit of anticipatory grief is that it allows time for "letting go"; the dying client and his or her loved ones are able to say goodbye and complete life affairs before the actual death or loss occurs. It is not most beneficial for grieving to take place only in private. It is important for grief to be acknowledged by others, and for those grieving to be able to receive the support of others in the grieving process. Anticipatory grieving can be discussed with others in most circumstances. However, anticipatory grief may be disenfranchised grief as well, meaning it cannot always be openly acknowledged, socially sanctioned, or publicly shared, such as grief over the death of a partner with acquired immune deficiency syndrome (AIDS). The discussion of grief with others can also take place with normal grief, after the loss has occurred. Anticipatory grieving is unique from normal grieving in that it allows time for "letting go" before the death occurs. Anticipatory grief is the process of disengaging or "letting go" that occurs before an actual loss or death has occurred. The benefit is not the separation of the ill client from the family as much as it is the process of being able to say good-bye, to put life affairs in order, and as a result, this type of grieving can help a client or family to progress to a higher emotional state.
24. A patient with hyperlipidemia has a new order for colesevelam (Welchol). Which nursing action is most appropriate when giving the medication? a. Have the patient take this medication with an aspirin. b. Administer the medication at the patient's usual bedtime. c. Have the patient take the colesevelam with a sip of water. d. Give the patient's other medications 2 hours after the colesevelam.
ANS: D The bile acid sequestrants interfere with the absorption of many other drugs, and giving other medications at the same time should be avoided. Taking an aspirin concurrently with the colesevelam may increase the incidence of gastrointestinal side effects such as heartburn. An increased fluid intake is encouraged for patients taking the bile acid sequestrants to reduce the risk for constipation. For maximum effect, colesevelam should be administered with meals.
33. Which postoperative intervention should be questioned for a child after a cardiac catheterization? a. Continue intravenous (IV) fluids until the infant is tolerating oral fluids. b. Check the dressing for bleeding. c. Assess peripheral circulation on the affected extremity. d. Keep the affected leg flexed and elevated.
ANS: D The child should be positioned with the affected leg straight for 4 to 6 hours after the procedure. IV fluid administration continues until the child is taking and retaining adequate amounts of oral fluids. The insertion site dressing should be observed frequently for bleeding. The nurse should also look under the child to check for pooled blood. Peripheral perfusion is monitored after catheterization. Distal pulses should be palpable, although they may be weaker than in the contralateral extremity. PTS: 1 DIF: Cognitive Level: Analysis REF: 1320 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
37. What is an expected assessment finding in a child with coarctation of the aorta? a. Orthostatic hypotension b. Systolic hypertension in the lower extremities c. Blood pressure higher on the left side of the body d. Disparity in blood pressure between the upper and lower extremities
ANS: D The classic finding in children with coarctation of the aorta is a disparity in pulses and blood pressures between the upper and lower extremities. Orthostatic hypotension is not present with coarctation of the aorta. Systolic hypertension may be detected in the upper extremities. The left arm may not accurately reflect systolic hypertension because the left subclavian artery can be involved in the coarctation. PTS: 1 DIF: Cognitive Level: Application REF: 1324 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
46. Surgical closure of the ductus arteriosus would: a. Stop the loss of unoxygenated blood to the systemic circulation. b. Decrease the edema in legs and feet. c. Increase the oxygenation of blood. d. Prevent the return of oxygenated blood to the lungs.
ANS: D The ductus arteriosus allows blood to flow from the higher-pressure aorta to the lower-pressure pulmonary artery, causing a right-to-left shunt. If this is surgically closed, no additional oxygenated blood (from the aorta) will return to the lungs through the pulmonary artery. The aorta carries oxygenated blood to the systemic circulation. Because of the higher pressure in the aorta, blood is shunted into the pulmonary artery and the pulmonary circulation. Edema in the legs and feet is usually a sign of heart failure. This repair would not directly affect the edema. Increasing the oxygenation of blood would not interfere with the return of oxygenated blood to the lungs. PTS: 1 DIF: Cognitive Level: Analysis REF: 1323 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
Which of the following is the primary concern of the nurse in providing care to a dying client? a. Promoting optimism in the client and being a source of encouragement b. Intervening in the client's activities of daily living to allow the client to focus on his or her emotional state c. Allowing the client to be alone and expecting isolation on the part of the dying person d. Selecting interventions designed to maintain the client's dignity and self-esteem
ANS: D The focus in planning nursing care is to promote self-esteem and dignity by taking a therapeutic stance that conveys respect for the client as a whole person, with feelings, accomplishments, and passions independent of the illness experience. Optimism should not be the primary focus when caring for the dying client. The nurse should promote the client's self-esteem and allow the client to die in comfort and with dignity. The client should be allowed to make choices and perform as many activities of daily living independently as possible. This allows the client to maintain self-esteem and dignity. The client does not need to be left alone. The presence of the nurse or the family may indicate to the client that he or she is being cared for and is worthy of attention.
13. The nurse admits a patient who has a diagnosis of an acute asthma attack. Which statement indicates that the patient may need teaching regarding medication use? a. I have not had any acute asthma attacks during the last year. b. I became short of breath an hour before coming to the hospital. c. Ive been taking Tylenol 650 mg every 6 hours for chest-wall pain. d. Ive been using my albuterol inhaler more frequently over the last 4 days.
ANS: D The increased need for a rapid-acting bronchodilator should alert the patient that an acute attack may be imminent and that a change in therapy may be needed. The patient should be taught to contact a health care provider if this occurs. The other data do not indicate any need for additional teaching. DIF: Cognitive Level: Apply (application) REF: 482 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
17. A 54-year-old patient arrives in the emergency department (ED) after exposure to powdered lime at work. Which action should the nurse take first? a. Obtain the patient's vital signs. b. Obtain a baseline complete blood count. c. Decontaminate the patient by showering with water. d. Brush off any visible powder on the skin and clothing.
ANS: D The initial action should be to protect staff members and decrease the patient's exposure to the toxin by decontamination. Patients exposed to powdered lime should not be showered; instead any/all visible powder should be brushed off. The other actions can be done after the decontamination is completed. DIF: Cognitive Level: Apply (application) REF: 1690 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
A patient admitted with acute dyspnea is newly diagnosed with dilated cardiomyopathy. Which information will the nurse plan to teach the patient about managing this disorder? a. A heart transplant should be scheduled as soon as possible. b. Elevating the legs above the heart will help relieve dyspnea. c. Careful compliance with diet and medications will prevent heart failure. d. Notify the doctor about any symptoms of heart failure such as shortness of breath.
ANS: D The patient should be instructed to notify the health care provider about any worsening of heart failure symptoms. Because dilated cardiomyopathy does not respond well to therapy, even patients with good compliance with therapy may have recurrent episodes of heart failure. Elevation of the legs above the heart will worsen symptoms (although this approach is appropriate for a patient with hypertrophic cardiomyopathy). The patient with terminal or end-stage cardiomyopathy may consider heart transplantation
31. When caring for a patient with acute coronary syndrome who has returned to the coronary care unit after having angioplasty with stent placement, the nurse obtains the following assessment data. Which data indicate the need for immediate action by the nurse? a. Heart rate 102 beats/min b. Pedal pulses 1+ bilaterally c. Blood pressure 103/54 mm Hg d. Chest pain level 7 on a 0 to 10 point scale
ANS: D The patient's chest pain indicates that restenosis of the coronary artery may be occurring and requires immediate actions, such as administration of oxygen and nitroglycerin, by the nurse. The other information indicates a need for ongoing assessments by the nurse.
After change-of-shift report, which patient should the nurse assess first? a. 72-year-old with cor pulmonale who has 4+ bilateral edema in his legs and feet b. 28-year-old with a history of a lung transplant and a temperature of 101° F (38.3° C) c. 40-year-old with a pleural effusion who is complaining of severe stabbing chest pain d. 64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion
ANS: D The patient's history and symptoms suggest possible tension pneumothorax, a medical emergency. The other patients also require assessment as soon as possible, but tension pneumothorax will require immediate treatment to avoid death from inadequate cardiac output or hypoxemia.
A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurse's first action should be to a. administer oxygen therapy at a high flow rate. b. obtain a urine specimen to send to the laboratory. c. notify the health care provider about the symptoms. d. disconnect the transfusion and infuse normal saline.
ANS: D The patient's symptoms indicate a possible acute hemolytic reaction caused by the transfusion. The first action should be to disconnect the transfusion and infuse normal saline. The other actions also are needed but are not the highest priority.
The palliative team's primary obligation to a patient in severe pain includes which of the following? a. Supporting the patient's nurse in her grief b. Providing postmortem care for the patient c. Teaching the patient the stages of grief d. Enhancing the patient's quality of life
ANS: D The primary goal of palliative care is to help patients and families achieve the best quality of life. Providing support for the patient's nurse is not the primary obligation when the patient is experiencing severe pain. Not all collaborative team members would be able to provide postmortem care, as is the case for nutritionists, social workers, and pharmacists. Teaching about stages of grief should not be the focus when severe pain is present.
21. Using the illustrated technique, the nurse is assessing for which finding in a patient with chronic obstructive pulmonary disease (COPD)? a. Hyperresonance b. Tripod positioning c. Accessory muscle use d. Reduced chest expansion
ANS: D The technique for palpation for chest expansion is shown in the illustrated technique. Reduced chest movement would be noted on palpation of a patients chest with COPD. Hyperresonance would be assessed through percussion. Accessory muscle use and tripod positioning would be assessed by inspection. DIF: Cognitive Level: Understand (comprehension) REF: 486 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
2. The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient? a. Supine with the head of the bed elevated 30 degrees b. In a high-Fowlers position with the left arm extended c. On the right side with the left arm extended above the head d. Sitting upright with the arms supported on an over bed table
ANS: D The upright position with the arms supported increases lung expansion, allows fluid to collect at the lung bases, and expands the intercostal space so that access to the pleural space is easier. The other positions would increase the work of breathing for the patient and make it more difficult for the health care provider performing the thoracentesis. DIF: Cognitive Level: Apply (application) REF: 492 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
19. The laboratory has just called with the arterial blood gas (ABG) results on four patients. Which result is most important for the nurse to report immediately to the health care provider? a. pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97 b. pH 7.35, PaO2 85 mm Hg, PaCO2 45 mm Hg, and O2 sat 95 c. pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98 d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96
ANS: D These ABGs indicate uncompensated respiratory acidosis and should be reported to the health care provider. The other values are normal or close to normal. DIF: Cognitive Level: Apply (application) REF: 479 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
38. After receiving change-of-shift report about the following four patients, which patient should the nurse assess first? a. 39-year-old with pericarditis who is complaining of sharp, stabbing chest pain b. 56-year-old with variant angina who is to receive a dose of nifedipine (Procardia) c. 65-year-old who had a myocardial infarction (MI) 4 days ago and is anxious about the planned discharge d. 59-year-old with unstable angina who has just returned to the unit after having a percutaneous coronary intervention (PCI)
ANS: D This patient is at risk for bleeding from the arterial access site for the PCI, so the nurse should assess the patient's blood pressure, pulse, and the access site immediately. The other patients should also be assessed as quickly as possible, but assessment of this patient has the highest priority.
5. The nurse palpates the posterior chest while the patient says 99 and notes absent fremitus. Which action should the nurse take next? a. Palpate the anterior chest and observe for barrel chest. b. Encourage the patient to turn, cough, and deep breathe. c. Review the chest x-ray report for evidence of pneumonia. d. Auscultate anterior and posterior breath sounds bilaterally.
ANS: D To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration when the patient repeats a word or phrase such as 99. After noting absent fremitus, the nurse should then auscultate the lungs to assess for the presence or absence of breath sounds. Absent fremitus may be noted with pneumothorax or atelectasis. The vibration is increased in conditions such as pneumonia, lung tumors, thick bronchial secretions, and pleural effusion. Turning, coughing, and deep breathing is an appropriate intervention for atelectasis, but the nurse needs to first assess breath sounds. Fremitus is decreased if the hand is farther from the lung or the lung is hyperinflated (barrel chest).The anterior of the chest is more difficult to palpate for fremitus because of the presence of large muscles and breast tissue. DIF: Cognitive Level: Apply (application) REF: 486 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
The nurse is preparing to assist the client in the end stage of her life. How should the nurse provide comfort for the client who is showing fatigue? a. Spend more time with the client. b. Limit the use of analgesics. c. Provide larger meals with more seasoning. d. Determine valued activities and schedule rest periods.
ANS: D To promote comfort in the terminally ill client, the nurse should help the client to identify values or desired tasks and then help the client to conserve energy for those tasks. Spending more time with the client conveys caring, and allows verbalization, but is not the best way to promote comfort for a fatigued client. The use of analgesics should not be limited. Controlling the terminally ill client's level of pain is a primary concern in promoting comfort. Nausea, vomiting, and anorexia may increase the terminally ill client's likelihood of inadequate nutrition. The nurse should serve smaller portions and bland foods, which may be more palatable.
A 53-year-old patient with Stage D heart failure and type 2 diabetes asks the nurse whether heart transplant is a possible therapy. Which response by the nurse is most appropriate? a. "Because you have diabetes, you would not be a candidate for a heart transplant." b. "The choice of a patient for a heart transplant depends on many different factors." c. "Your heart failure has not reached the stage in which heart transplants are needed." d. "People who have heart transplants are at risk for multiple complications after surgery."
B
Which technique will be most successful in ensuring effective communication? The nurse uses a. Interpersonal communication to change negative self-talk to positive self-talk. b. Small group communication to present information to an audience. c. Intrapersonal communication to build strong teams. d. Transpersonal communication to enhance meditation.
ANS: D Transpersonal communication is interaction that occurs within a person's spiritual domain. Many people use prayer, meditation, guided reflection, religious rituals, or other means to communicate with their "higher power." Interpersonal communication is one-on-one interaction between the nurse and another person that often occurs face to face. Meaningful interpersonal communication results in exchange of ideas, problem solving, expression of feelings, decision making, goal accomplishment, team building, and personal growth. Small group communication is interaction that occurs when a small number of persons meet. This type of communication is usually goal directed and requires an understanding of group dynamics. When nurses work on committees, lead patient support groups, form research teams, or participate in patient care conferences, they use a small group communication process. Intrapersonal communication is a powerful form of communication that occurs within an individual. For example, you improve your health and self-esteem through positive self-talk by replacing negative thoughts with positive assertions
8. A patient who has had chest pain for several hours is admitted with a diagnosis of rule out acute myocardial infarction (AMI). Which laboratory test should the nurse monitor to help determine whether the patient has had an AMI? a. Myoglobin b. Homocysteine c. C-reactive protein d. Cardiac-specific troponin
ANS: D Troponin levels increase about 4 to 6 hours after the onset of myocardial infarction (MI) and are highly specific indicators for MI. Myoglobin is released within 2 hours of MI, but it lacks specificity and its use is limited. The other laboratory data are useful in determining the patient's risk for developing coronary artery disease (CAD) but are not helpful in determining whether an acute MI is in progress.
Which action could the nurse delegate to unlicensed assistive personnel (UAP) trained as electrocardiogram (ECG) technicians working on the cardiac unit? a. Select the best lead for monitoring a patient with an admission diagnosis of Dressler syndrome. b. Obtain a list of herbal medications used at home while admitting a new patient with pericarditis. c. Teach about the need to monitor the weight daily for a patient who has hypertrophic cardiomyopathy. d. Check the heart monitor for changes in rhythm while a patient who had a valve replacement ambulates.
ANS: D Under the supervision of registered nurses (RNs), UAP check the patient's cardiac monitor and obtain information about changes in heart rate and rhythm with exercise. Teaching and obtaining information about home medications (prescribed or complementary) and selecting the best leads for monitoring patients require more critical thinking and should be done by the RN
While caring for a 23-year-old patient with mitral valve prolapse (MVP) without valvular regurgitation, the nurse determines that discharge teaching has been effective when the patient states that it will be necessary to a. take antibiotics before any dental appointments. b. limit physical activity to avoid stressing the heart. c. take an aspirin a day to prevent clots from forming on the valve. d. avoid use of over-the-counter (OTC) medications that contain stimulant drugs.
ANS: D Use of stimulant medications should be avoided by patients with MVP because these may exacerbate symptoms. Daily aspirin and restricted physical activity are not needed by patients with mild MVP. Antibiotic prophylaxis is needed for patients with MVP with regurgitation but will not be necessary for this patient
The newly graduated nurse is assigned to his or her first dying client. How can the nurse best prepare to care for this client? a. Complete a course dealing with death and dying. b. Control his or her own emotions about death. c. Draw on the experience of the death of a loved one. d. Develop an understanding of his or her own feelings about death.
ANS: D When caring for clients experiencing grief, it is important for the nurse to assess his or her own emotional well-being and to understand his or her own feelings about death. The nurse who is aware of his or her own feelings will be less likely to place personal situations and values before those of the client. Although coursework on death and dying may add to the nurse's knowledge base, it does not best prepare the nurse for caring for a dying client. The nurse needs to have an awareness of his or her own feelings about death first, as death can raise many emotions. Being able to control one's own emotions is important; however, it is unlikely that the nurse would be able to do so if he or she has not first developed a personal understanding of his or her own feelings about death. Experiencing the death of a loved one is not a prerequisite to caring for a dying client. Experiencing death may help an individual mature in dealing with loss, or it may bring up many negative emotions if complicated grief is present. The nurse is best prepared by first developing an understanding of his or her own feelings about death.
Family members gather in the emergency department after learning that a family member was involved in a motor vehicle accident. After learning of the family member's unexpected death, the surviving family members begin to cry and scream in despair. The nurse recognizes this as the Bowlby Attachment Theory stage of a. Numbing. b. Disorganization and despair. c. Bargaining. d. Yearning and searching.
ANS: D Yearning and searching characterize the second bereavement phase in the Bowlby Attachment Theory. Emotional outbursts are common in this phase. During the numbing phase, the family may feel a sense of unreality. During disorganization and despair, the reason why the loss occurred is constantly questioned. Bargaining is part of the Kübler-Ross stages, not of the Bowlby Attachment Theory.
35. Which actions prevent the dislodgment of a tracheostomy (select all that apply)? a. Provide tracheostomy care every 24 hours b. Keep the patient in the semi-Fowler position at all times c. Keep a same size or larger replacement tube at the bedside d. Tracheostomy ties are not changed for 24 hours after tracheostomy produce e. Suction the tracheostomy tube when there is a moist cough or a decreased SpO2 f. A physician performs the first tube change, no sooner than 7 days after the tracheostomy
ANS: D, E, F Changing the tracheostomy tapes or the tube to soon will be irritating to the trachea and could contribute to dislodgment of the tracheostomy tube. Suctioning should be done when increased secretions are evident in the tube to prevent the patient from severe coughing, which could cause tube dislodgment. Tracheostomy care is done every 8 hours. Keeping the patient in a semi-Fowler position will not prevent dislodgment. Keeping and extra tube at the bedside will speed reinsertion if the tracheotomy tube is dislodged but it will not prevent dislodgment.
33. What are the characteristics of a fenestrated tracheostomy tube(select all that apply)? a. The cuff passively fills with air b. Cuff pressure monitoring is not required c. It has two tubings with one opening just above the cuff d. Patient can squeak with an attached air source with the cuff inflated e. Airway obstruction is likely if the exact steps are not followed to produce speech f. Airflow around the tube and through the window allows speech when the cuff is deflated and the plug is inserted
ANS: E,F The fenestrated tracheostomy tube has openings on the outer cannula to allow air to pass over the vocal cords to allow speaking. If the steps of using the fenestrated tracheostomy tube are not completed in the correct order, severe respiratory distress may result. The cuff of the tracheostomy tube with a foam-filled cuff passively fills with air and does require pressure monitoring, although cuff integrity must be assessed daily. The speaking tracheostomy tube has two tubes attached. One tube allows air to pass over the vocal cords to enable the person to speak with the cuff inflated.
A 20-year-old has a mandatory electrocardiogram (ECG) before participating on a college soccer team and is found to have sinus bradycardia, rate 52. Blood pressure (BP) is 114/54, and the student denies any health problems. What action by the nurse is most appropriate? a. Allow the student to participate on the soccer team. b. Refer the student to a cardiologist for further diagnostic testing. c. Tell the student to stop playing immediately if any dyspnea occurs. d. Obtain more detailed information about the student's family health history.
Allow the student to participate on the soccer team.
Which individual would least likely suffer from a disturbance in fluid volume, electrolyte, or acid-base balance?
An elderly client suffering from a type I decubitus
In which order will the nurse take these steps to prepare NPH 20 units and regular insulin 2 units using the same syringe? (Put a comma and a space between each answer choice [A, B, C, D, E]). a. Rotate NPH vial. b. Withdraw regular insulin. c. Withdraw 20 units of NPH. d. Inject 20 units of air into NPH vial. e. Inject 2 units of air into regular insulin vial.
Ans A,D,E,B,C
Which question during the assessment of a diabetic patient will help the nurse identify autonomic neuropathy? a. Do you feel bloated after eating? b. Have you seen any skin changes? c. Do you need to increase your insulin dosage when you are stressed? d. Have you noticed any painful new ulcerations or sores on your feet?
Ans A; Do you feel bloated after eating? Autonomic neuropathy can cause delayed gastric emptying, which results in a bloated feeling for the patient. The other questions are also appropriate to ask but would not help in identifying autonomic neuropathy.
The nurse has administered 4 oz of orange juice to an alert patient whose blood glucose was 62 mg/dL. Fifteen minutes later, the blood glucose is 67 mg/dL. Which action should the nurse take next? a. Give the patient 4 to 6 oz more orange juice. b. Administer the PRN glucagon (Glucagon) 1 mg IM. c. Have the patient eat some peanut butter with crackers. d. Notify the health care provider about the hypoglycemia.
Ans A; Give the patient 4 to 6 oz more orange juice. The rule of 15 indicates that administration of quickly acting carbohydrates should be done 2 to 3 times for a conscious patient whose glucose remains less than 70 mg/dL before notifying the health care provider. More complex carbohydrates and fats may be used once the glucose has stabilized. Glucagon should be used if the patients level of consciousness decreases so that oral carbohydrates can no longer be given.
A 54-year-old patient is admitted with diabetic ketoacidosis. Which admission order should the nurse implement first? a. Infuse 1 liter of normal saline per hour. b. Give sodium bicarbonate 50 mEq IV push. c. Administer regular insulin 10 U by IV push. d. Start a regular insulin infusion at 0.1 units/kg/hr.
Ans A; Infuse 1 liter of normal saline per hour. The most urgent patient problem is the hypovolemia associated with diabetic ketoacidosis (DKA), and the priority is to infuse IV fluids. The other actions can be done after the infusion of normal saline is initiated.
A 27-year-old patient admitted with diabetic ketoacidosis (DKA) has a serum glucose level of 732 mg/dL and serum potassium level of 3.1 mEq/L. Which action prescribed by the health care provider should the nurse takefirst? a. Place the patient on a cardiac monitor. b. Administer IV potassium supplements. c. Obtain urine glucose and ketone levels. d. Start an insulin infusion at 0.1 units/kg/hr.
Ans A; Place the patient on a cardiac monitor. Hypokalemia can lead to potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation, which would be detected with electrocardiogram (ECG) monitoring. Because potassium must be infused over at least 1 hour, the nurse should initiate cardiac monitoring before infusion of potassium. Insulin should not be administered without cardiac monitoring because insulin infusion will further decrease potassium levels. Urine glucose and ketone levels are not urgently needed to manage the patients care.
Which action should the nurse take after a 36-year-old patient treated with intramuscular glucagon for hypoglycemia regains consciousness? a. Assess the patient for symptoms of hyperglycemia. b. Give the patient a snack of peanut butter and crackers. c. Have the patient drink a glass of orange juice or nonfat milk. d. Administer a continuous infusion of 5% dextrose for 24 hours.
Ans B; Give the patient a snack of peanut butter and crackers. Rebound hypoglycemia can occur after glucagon administration, but having a meal containing complex carbohydrates plus protein and fat will help prevent hypoglycemia. Orange juice and nonfat milk will elevate blood glucose rapidly, but the cheese and crackers will stabilize blood glucose. Administration of IV glucose might be used in patients who were unable to take in nutrition orally. The patient should be assessed for symptoms of hypoglycemia after glucagon administration.
An unresponsive patient with type 2 diabetes is brought to the emergency department and diagnosed with hyperosmolar hyperglycemic syndrome (HHS). The nurse will anticipate the need to a. give a bolus of 50% dextrose. b. insert a large-bore IV catheter. c. initiate oxygen by nasal cannula. d. administer glargine (Lantus) insulin.
Ans B; insert a large-bore IV catheter. HHS is initially treated with large volumes of IV fluids to correct hypovolemia. Regular insulin is administered, not a long-acting insulin. There is no indication that the patient requires oxygen. Dextrose solutions will increase the patients blood glucose and would be contraindicated.
After change-of-shift report, which patient will the nurse assess first? a. 19-year-old with type 1 diabetes who was admitted with possible dawn phenomenon b. 35-year-old with type 1 diabetes whose most recent blood glucose reading was 230 mg/dL c. 60-year-old with hyperosmolar hyperglycemic syndrome who has poor skin turgor and dry oral mucosa d. 68-year-old with type 2 diabetes who has severe peripheral neuropathy and complains of burning foot pain
Ans C; 60-year-old with hyperosmolar hyperglycemic syndrome who has poor skin turgor and dry oral mucosa The patients diagnosis of HHS and signs of dehydration indicate that the nurse should rapidly assess for signs of shock and determine whether increased fluid infusion is needed. The other patients also need assessment and intervention but do not have life-threatening complications.
The health care provider suspects the Somogyi effect in a 50-year-old patient whose 6:00 AM blood glucose is 230 mg/dL. Which action will the nurse teach the patient to take? a. Avoid snacking at bedtime. b. Increase the rapid-acting insulin dose. c. Check the blood glucose during the night d. Administer a larger dose of long-acting insulin.
Ans C; Check the blood glucose during the night If the Somogyi effect is causing the patients increased morning glucose level, the patient will experience hypoglycemia between 2:00 and 4:00 AM. The dose of insulin will be reduced, rather than increased. A bedtime snack is used to prevent hypoglycemic episodes during the night.
A patient who was admitted with diabetic ketoacidosis secondary to a urinary tract infection has been weaned off an insulin drip 30 minutes ago. The patient reports feeling lightheaded and sweaty. Which action should the nurse take first? a. Infuse dextrose 50% by slow IV push. b. Administer 1 mg glucagon subcutaneously. c. Obtain a glucose reading using a finger stick. d. Have the patient drink 4 ounces of orange juice.
Ans C; Obtain a glucose reading using a finger stick. The patients clinical manifestations are consistent with hypoglycemia and the initial action should be to check the patients glucose with a finger stick or order a stat blood glucose. If the glucose is low, the patient should ingest a rapid-acting carbohydrate, such as orange juice. Glucagon or dextrose 50% might be given if the patients symptoms become worse or if the patient is unconscious.
A 26-year-old patient with diabetes rides a bicycle to and from work every day. Which site should the nurse teach the patient to administer the morning insulin? a. thigh. b. buttock. c. abdomen. d. upper arm.
Ans C; abdomen Patients should be taught not to administer insulin into a site that will be exercised because exercise will increase the rate of absorption. The thigh, buttock, and arm are all exercised by riding a bicycle.
The nurse provides information to a patient who was exposed to anthrax by inhalation. The nurse determines the teaching has been successful if the patient makes which statement? A. "Anthrax can be spread by person-to-person contact." B. "It is not necessary to receive the anthrax vaccine." C. "An antibiotic will be prescribed for 2 months." D. "Antibiotics are only indicated for an active infection."
Answer: C. "An antibiotic will be prescribed for 2 months." Rationale: Postexposure prophylaxis includes a 60-day course of antibiotics. Ciprofloxacin (Cipro) is the treatment of choice. Anthrax is not spread by person-to-person contact; anthrax is spread by direct contact with the bacteria and its spores. The patient may receive the anthrax vaccine (three doses); if vaccinated, the course of antibiotic therapy is reduced to 30 days. Antibiotics are indicated after exposure to inhaled anthrax. Ch. 69
Which patient should the nurse prepare to transfer to a regional burn center? A. A 53-year-old patient with a chemical burn to the anterior chest and neck B. A 25-year-old pregnant patient with a carboxyhemoglobin level of 1.5% C. A 42-year-old patient who is scheduled for skin grafting of a burn wound D. A 39-year-old patient with a partial-thickness burn to the right upper arm
Answer: A. A 53-year-old patient with a chemical burn to the anterior chest and neck Rationale: The American Burn Association (ABA) has established referral criteria to determine which burn injuries should be treated in burn centers where specialized facilities and personnel are available to handle this type of trauma (see Table 25-3). Patients with chemical burns should be referred to a burn center. A normal serum carboxyhemoglobin level for nonsmokers is 0% to 1.5% and for smokers is 4% to 9%. Skin grafting for burn wound management is not a criteria for a referral to a burn center. Partial-thickness burns greater than 10% total body surface area (TBSA) should be referred to a burn center; a burn to the right upper arm is 4% TBSA. Ch. 25
The nurse is caring for a 71 kg patient during the first 12 hours after a thermal burn injury. Which outcomes if observed by the nurse would indicate adequate fluid resuscitation (select all that apply)? A. Heart rate is 94 beats/minute. B. Mean arterial pressure is 54 mm Hg. C. Urine output is 46 mL/hour. D. Urine specific gravity is 1.040. E. Systolic blood pressure 88 mm Hg
Answer: A. Heart rate is 94 beats/minute. C. Urine output is 46 mL/hour. Rationale: Assessment of the adequacy of fluid resuscitation is best made using either urine output or cardiac factors. Urine output should be 0.5 to 1 mL/kg/hr (or 75 to 100 mL/hr for an electrical burn patient with evidence of hemoglobinuria/myoglobinuria). Cardiac factors include a mean arterial pressure (MAP) greater than 65 mm Hg, systolic blood pressure (BP) greater than 90 mm Hg, heart rate less than 120 beats/minute. Normal range for urine specific gravity is 1.003 to 1.030. Ch. 25
A nurse manager educates the emergency department staff about their roles during a disaster with mass casualties. Which primary responsibility should the nurse manager discuss with the staff? A. Learn the hospital emergency response plan. B. Report acts of violence to security personnel. C. Contact the American Red Cross for assistance. D. Notify local, state, and national authorities.
Answer: A. Learn the hospital emergency response plan. Rationale: All health care providers need to be prepared for a mass casualty incident; the priority responsibility is to know the agency's emergency response plan. Ch. 69
The nurse is planning to change the dressing covering a deep partial-thickness burn of the right lower leg. Which prescribed medication should the nurse administer 30 minutes before the scheduled dressing change? A. zolpidem (Ambien) B. morphine sulfate C. sertraline (Zoloft) D. enoxaparin (Lovenox)
Answer: B. morphine sulfate Rationale: Deep partial-thickness burns result in severe pain related to nerve injury. The nurse should plan to administer analgesics before the dressing change to promote patient comfort. Morphine sulfate is a common opioid used for pain control. Sedative/hypnotics and antidepressant agents can also be given with analgesics to control the anxiety, insomnia, and/or depression that patients may experience. Zolpidem promotes sleep; sertraline is an antidepressant; and enoxaparin is an anticoagulant. Ch. 25
The nurse is caring for a patient who sustained a deep partial thickness burn to the anterior chest area. Which statement would be appropriate for the nurse to include when documenting the appearance of this type of burn? ]A. Skin is hard with a dry, waxy white appearance with visible venous patterns. B. Skin blanches with pressure and is red with delayed blister formation. C. Skin is red and shiny with the presence of clear fluid-filled blisters. D. Skin is charred and leathery with visible muscles, tendons, and bones
Answer: C. Skin is red and shiny with the presence of clear fluid-filled blisters. Rationale: Deep partial thickness burns have fluid-filled vesicles that are red and shiny; may appear wet (if vesicles have ruptured); and mild to moderate edema may be present. Deep partial thickness burns result in severe pain related to nerve injury. Superficial partial thickness burns are red and blanch with pressure; pain and mild edema are present. Superficial partial thickness burns may have vesicles that appear 24 hours after the burn injury. Full-thickness burns are dry, waxy white, leathery, or hard; thrombosed vessels may be visible. Full-thickness burns result in an insensitivity to pain because of nerve destruction, and there may be involvement of muscles, tendons, and bones. Ch. 25
A patient arrives in the emergency department after ingesting 8 g of acetaminophen (Tylenol). Which question is most important for the nurse to ask? A. Have you tried to commit suicide before? B. Do you feel like you have a fever? C. What time did you take the Tylenol? D. Are you experiencing any abdominal pain?
Answer: C. What time did you take the Tylenol? Rationale: Acetaminophen will bind to activated charcoal and pass through the gastrointestinal tract without being absorbed. Activated charcoal is most effective if administered within 1 hour of ingestion of acetaminophen and other select poisons. Ch. 69
The nurse is providing emergent care for a patient with a possible inhalation injury sustained in a house fire. The patient is anxious and disoriented, and the skin is a cherry red color. Which action should the nurse take first? A. Assist the patient to a high Fowler's position. B. Teach the patient deep breathing exercises. C. Allow the patient to verbalize feelings. D. Administer 100% humidified oxygen.
Answer: D. Administer 100% humidified oxygen. Rationale: Carbon monoxide (CO) poisoning may occur in house fires; CO displaces oxygen on the hemoglobin molecule resulting in hypoxia. High levels of CO in the blood result in a skin color that is described as cherry red. Hypoxia may cause anxious behaviors and altered mental status. Emergency treatment for inhalation injury and CO poisoning includes the immediate administration of 100% humidified oxygen. The other interventions are appropriate for inhalation injury but are not as emergent as oxygen administration. Ch. 25
After receiving change-of-shift report on a heart failure unit, which patient should the nurse assess first? a. Patient who is taking carvedilol (Coreg) and has a heart rate of 58 b. Patient who is taking digoxin and has a potassium level of 3.1 mEq/L c. Patient who is taking isosorbide dinitrate/hydralazine (BiDil) and has a headache d. Patient who is taking captopril (Capoten) and has a frequent nonproductive cough
B
A patient is admitted to the emergency department with cold exposure and a core body temperature of 86.6o F (30.3o C). Which action is most appropriate for the nurse to take? A. Immerse the extremities in a water bath (102° to 108° F) [38.9° to 42.2° C]) B. Place an air-filled warming blanket on the patient. C. Position patient under a radiant heat lamp. D. Administer warmed intravenous (IV) fluids.
Answer: D. Administer warmed intravenous (IV) fluids. Rationale: A patient with a core body temperature of 86.6o F (30.3o C) has moderate hypothermia. Active core rewarming is used for moderate to severe hypothermia and includes administration of warmed IV fluids (109.4° F [43° C]). Patients with moderate to severe hypothermia should have the core warmed before the extremities to prevent after drop (or further drop in core temperature). This occurs when cold peripheral blood returns to the central circulation. Use passive or active external rewarming for mild hypothermia. Active external rewarming involves fluid-filled warming blankets or radiant heat lamps. Immersion of extremities in a water bath is indicated for frostbite. Ch. 69
A nurse is performing triage in the emergency department. Which patient should the nurse see first? A. 18-year-old patient with type 1 diabetes mellitus who has a 4-cm laceration on right leg. B. 32-year-old patient with drug overdose who is unresponsive with poor respiratory effort. C. 56-year-old patient with substernal chest pain who is diaphoretic with shortness of breath. D. 78-year-old patient with right hip fracture who is confused; blood pressure is 98/62 mm Hg.
Answer: B. 32-year-old patient with drug overdose who is unresponsive with poor respiratory effort. Rationale: Patient with drug overdose is unstable and needs to be seen immediately. Patient with chest pain (possible myocardial infarction) should be seen second. Patient with hip fracture should be seen third. Patient with laceration is the most stable and should be seen last. Ch. 69
A patient develops sinus bradycardia at a rate of 32 beats/minute, has a blood pressure (BP) of 80/42 mm Hg, and is complaining of feeling faint. Which actions should the nurse take next? a. Recheck the heart rhythm and BP in 5 minutes. b. Have the patient perform the Valsalva maneuver. c. Give the scheduled dose of diltiazem (Cardizem). d. Apply the transcutaneous pacemaker (TCP) pads.
Apply the transcutaneous pacemaker (TCP) pads.
To evaluate the effectiveness of ordered interventions for a patient with ventilatory failure, which diagnostic test will be most useful to the nurse?
Arterial blood gas
A 19-year-old student comes to the student health center at the end of the semester complaining that, "My heart is skipping beats." An electrocardiogram (ECG) shows occasional premature ventricular contractions (PVCs). What action should the nurse take next? a. Start supplemental O2 at 2 to 3 L/min via nasal cannula. b. Ask the patient about current stress level and caffeine use. c. Ask the patient about any history of coronary artery disease. d. Have the patient taken to the hospital emergency department (ED).
Ask the patient about current stress level and caffeine use.
When assessing a patient with chronic obstructive pulmonary disease (COPD), the nurse finds a new onset of agitation and confusion. Which action should the nurse take first?
Assess oxygenation using pulse oximetry
When a patient is admitted to the emergency department after a submersion injury, which assessment will the nurse obtain first? a. Apical pulse b. Lung sounds c. Body temperature d. Level of consciousness
B The priority assessment data are how well the patient is oxygenating, so lung sounds should be assessed first. The other data also will be collected rapidly but are not as essential as the lung sounds.
The nurse is preparing to teach a 43-year-old man who is newly diagnosed with type 2 diabetes about home management of the disease. Which action should the nurse take first? Ask the patient's family to participate in the diabetes education program. Assess the patient's perception of what it means to have diabetes mellitus. Demonstrate how to check glucose using capillary blood glucose monitoring. Discuss the need for the patient to actively participate in diabetes management.
B - Before planning teaching, the nurse should assess the patient's interest in and ability to self-manage the diabetes. After assessing the patient, the other nursing actions may be appropriate, but planning needs to be individualized to each patient.
Which patient action indicates good understanding of the nurse's teaching about administration of aspart (NovoLog) insulin? A. The patient avoids injecting the insulin into the upper abdominal area. B. The patient cleans the skin with soap and water before insulin administration. C. The patient stores the insulin in the freezer after administering the prescribed dose. D. The patient pushes the plunger down while removing the syringe from the injection site.
B - Cleaning the skin with soap and water or with alcohol is acceptable. Insulin should not be frozen. The patient should leave the syringe in place for about 5 seconds after injection to be sure that all the insulin has been injected. The upper abdominal area is one of the preferred areas for insulin injection.
The nurse identifies a need for additional teaching when the patient who is self-monitoring blood glucose A. Washes the puncture site using warm water and soap. B. Chooses a puncture site in the center of the finger pad. C. Hangs the arm down for a minute before puncturing the site. D. Says the result of 120 mg indicates good blood sugar control.
B - The patient is taught to choose a puncture site at the side of the finger pad because there are fewer nerve endings along the side of the finger pad. The other patient actions indicate that teaching has been effective.
Which information will the nurse include when teaching a 50-year-old patient who has type 2 diabetes about glyburide (Micronase, DiaBeta, Glynase)? A. Glyburide decreases glucagon secretion from the pancreas. B. Glyburide stimulates insulin production and release from the pancreas. C. Glyburide should be taken even if the morning blood glucose level is low. D. Glyburide should not be used for 48 hours after receiving IV contrast media.
B - The sulfonylureas stimulate the production and release of insulin from the pancreas. If the glucose level is low, the patient should contact the health care provider before taking the glyburide, because hypoglycemia can occur with this class of medication. Metformin should be held for 48 hours after administration of IV contrast media, but this is not necessary for glyburide. Glucagon secretion is not affected by glyburide.
After admitting a patient from home to the medical unit with a diagnosis of pneumonia, which physician orders will the nurse verify have been completed before administering a dose of cefuroxime (Ceftin) to the patient? A. Orthostatic blood pressures B. Sputum culture and sensitivity C. Pulmonary function evaluation D. Serum laboratory studies ordered for AM
B. Sputum culture and sensitivity The nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory before administering the cefuroxime as this is community-acquired pneumonia. It is important that the organisms are correctly identified (by the culture) before the antibiotic takes effect. The test will also determine whether the proper antibiotic has been ordered (sensitivity testing). Although antibiotic administration should not be unduly delayed while waiting for the patient to expectorate sputum, orthostatic BP, pulmonary function evaluation, and serum laboratory tests will not be affected by the administration of antibiotics.
A patient who is receiving dobutamine (Dobutrex) for the treatment of acute decompensated heart failure (ADHF) has the following nursing interventions included in the plan of care. Which action will be most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Assess the IV insertion site for signs of extravasation. b. Teach the patient the reasons for remaining on bed rest. c. Monitor the patient's blood pressure and heart rate every hour. d. Titrate the rate to keep the systolic blood pressure >90 mm Hg.
C
A patient with a history of chronic heart failure is admitted to the emergency department (ED) with severe dyspnea and a dry, hacking cough. Which action should the nurse do first? a. Auscultate the abdomen. b. Check the capillary refill. c. Auscultate the breath sounds. d. Assess the level of orientation.
C
A patient with chronic heart failure who is taking a diuretic and an angiotensin-converting enzyme (ACE) inhibitor and who is on a low-sodium diet tells the home health nurse about a 5-pound weight gain in the last 3 days. The nurse's priority action will be to a. have the patient recall the dietary intake for the last 3 days. b. ask the patient about the use of the prescribed medications. c. assess the patient for clinical manifestations of acute heart failure. d. teach the patient about the importance of restricting dietary sodium.
C
A patient with heart failure has a new order for captopril (Capoten) 12.5 mg PO. After administering the first dose and teaching the patient about the drug, which statement by the patient indicates that teaching has been effective? a. "I will be sure to take the medication with food." b. "I will need to eat more potassium-rich foods in my diet." c. "I will call for help when I need to get up to use the bathroom." d. "I will expect to feel more short of breath for the next few days."
C
The nurse working on the heart failure unit knows that teaching an older female patient with newly diagnosed heart failure is effective when the patient states that a. she will take furosemide (Lasix) every day at bedtime. b. the nitroglycerin patch is applied when any chest pain develops. c. she will call the clinic if her weight goes from 124 to 128 pounds in a week. d. an additional pillow can help her sleep if she is feeling short of breath at night.
C
Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute shortness of breath has heart failure? a. Serum troponin b. Arterial blood gases c. B-type natriuretic peptide d. 12-lead electrocardiogram
C
Which topic will the nurse plan to include in discharge teaching for a patient with systolic heart failure and an ejection fraction of 33%? a. Need to begin an aerobic exercise program several times weekly b. Use of salt substitutes to replace table salt when cooking and at the table c. Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors d. Importance of making an annual appointment with the primary care provider
C
While admitting an 82-year-old with acute decompensated heart failure to the hospital, the nurse learns that the patient lives alone and sometimes confuses the "water pill" with the "heart pill." When planning for the patient's discharge the nurse will facilitate a a. consult with a psychologist. b. transfer to a long-term care facility. c. referral to a home health care agency. d. arrangements for around-the-clock care.
C
While assessing a 68-year-old with ascites, the nurse also notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. The nurse knows this finding indicates a. decreased fluid volume. b. jugular vein atherosclerosis. c. increased right atrial pressure. d. incompetent jugular vein valves.
C
n outpatient who has chronic heart failure returns to the clinic after 2 weeks of therapy with metoprolol (Toprol XL). Which assessment finding is most important for the nurse to report to the health care provider? a. 2+ pedal edema b. Heart rate of 56 beats/minute c. Blood pressure (BP) of 88/42 mm Hg d. Complaints of fatigue
C
The emergency department (ED) triage nurse is assessing four victims of an automobile accident. Which patient has the highest priority for treatment? a. A patient with absent pedal pulses b. A patient with an open femur fracture c. A patient with a sucking chest wound d. A patient with bleeding of facial lacerations
C Most immediate deaths from trauma occur because of problems with ventilation, so the patient with a sucking chest wound should be treated first. Face and head fractures can obstruct the airway, but the patient with facial injuries has lacerations only. The other two patients also need rapid intervention but do not have airway or breathing problems.
Which statement by a nurse to a patient newly diagnosed with type 2 diabetes is correct? A. Insulin is not used to control blood glucose in patients with type 2 diabetes. B. Complications of type 2 diabetes are less serious than those of type 1 diabetes. C. Changes in diet and exercise may control blood glucose levels in type 2 diabetes. D. Type 2 diabetes is usually diagnosed when the patient is admitted with a hyperglycemic coma.
C - For some patients with type 2 diabetes, changes in lifestyle are sufficient to achieve blood glucose control. Insulin is frequently used for type 2 diabetes, complications are equally severe as for type 1 diabetes, and type 2 diabetes is usually diagnosed with routine laboratory testing or after a patient develops complications such as frequent yeast infections.
When a patient who takes metformin (Glucophage) to manage type 2 diabetes develops an allergic rash from an unknown cause, the health care provider prescribes prednisone (Deltasone). The nurse will anticipate that the patient may A. Need a diet higher in calories while receiving prednisone. B. Develop acute hypoglycemia while taking the prednisone. C. Require administration of insulin while taking prednisone. D. Have rashes caused by metformin-prednisone interactions.
C - Glucose levels increase when patients are taking corticosteroids, and insulin may be required to control blood glucose. Hypoglycemia is not a side effect of prednisone. Rashes are not an adverse effect caused by taking metformin and prednisone simultaneously. The patient may have an increased appetite when taking prednisone, but will not need a diet that is higher in calories.
The nurse determines a need for additional instruction when the patient with newly diagnosed type 1 diabetes says which of the following? A. "I can have an occasional alcoholic drink if I include it in my meal plan." B. "I will need a bedtime snack because I take an evening dose of NPH insulin." C. "I can choose any foods, as long as I use enough insulin to cover the calories." D. "I will eat something at meal times to prevent hypoglycemia, even if I am not hungry."
C - Most patients with type 1 diabetes need to plan diet choices very carefully. Patients who are using intensified insulin therapy have considerable flexibility in diet choices but still should restrict dietary intake of items such as fat, protein, and alcohol. The other patient statements are correct and indicate good understanding of the diet instruction.
A 48-year-old male patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dL (6.7 mmol/L). The nurse will plan to teach the patient about A. Self-monitoring of blood glucose. B. Using low doses of regular insulin. C. Lifestyle changes to lower blood glucose. D. Effects of oral hypoglycemic medications.
C - The patient's impaired fasting glucose indicates prediabetes, and the patient should be counseled about lifestyle changes to prevent the development of type 2 diabetes. The patient with prediabetes does not require insulin or oral hypoglycemics for glucose control and does not need to self-monitor blood glucose.
The nurse is assessing a 22-year-old patient experiencing the onset of symptoms of type 1 diabetes. Which question is most appropriate for the nurse to ask? A. "Are you anorexic?" B. "Is your urine dark colored?" C. "Have you lost weight lately?" D. "Do you crave sugary drinks?"
C - Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy. The patient is thirsty but does not necessarily crave sugar-containing fluids. Increased appetite is a classic symptom of type 1 diabetes. With the classic symptom of polyuria, urine will be very dilute.
Your patient had 200 mL of ice chips and 900 mL intravenous (IV) fluid during your shift. Which total intake should you record?
C. 1000 mL
Which clinical manifestation should the nurse expect to find during assessment of a patient admitted with pneumonia? A. Hyperresonance on percussion B. Vesicular breath sounds in all lobes C. Increased vocal fremitus on palpation D. Fine crackles in all lobes on auscultation
C. Increased vocal fremitus on palpation A typical physical examination finding for a patient with pneumonia is increased vocal fremitus on palpation. Other signs of pulmonary consolidation include bronchial breath sounds, egophony, and crackles in the affected area. With pleural effusion, there may be dullness to percussion over the affected area.
A patient's cardiac monitor shows sinus rhythm, rate 64. The P-R interval is 0.18 seconds at 1:00 AM, 0.22 seconds at 2:30 PM, and 0.28 seconds at 4:00 PM. Which action should the nurse take next? a. Place the transcutaneous pacemaker pads on the patient. b. Administer atropine sulfate 1 mg IV per agency dysrhythmia protocol. c. Document the patient's rhythm and assess the patient's response to the rhythm. d. Call the health care provider before giving the next dose of metoprolol (Lopressor).
Call the health care provider before giving the next dose of metoprolol (Lopressor).
The nurse is caring for a patient with hyperkalemia. Which body system would be most important for the nurse plan to monitor closely?
Cardiac
A patient who has just been admitted with pulmonary edema is scheduled to receive the following medications. Which medication should the nurse question before giving? a. Furosemide (Lasix) 60 mg b. Captopril (Capoten) 25 mg c. Digoxin (Lanoxin) 0.125 mg d. Carvedilol (Coreg) 3.125 mg
D
Following an acute myocardial infarction, a previously healthy 63-year-old develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about a. digitalis preparations. b. b-adrenergic blockers. c. calcium channel blockers. d. angiotensin-converting enzyme (ACE) inhibitors.
D
The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best indicator that the treatment has been effective? a. Weight loss of 2 pounds in 24 hours b. Hourly urine output greater than 60 mL c. Reduction in patient complaints of chest pain d. Reduced dyspnea with the head of bed at 30 degrees
D
When teaching the patient with newly diagnosed heart failure about a 2000-mg sodium diet, the nurse explains that foods to be restricted include a. canned and frozen fruits. b. fresh or frozen vegetables. c. eggs and other high-protein foods. d. milk, yogurt, and other milk products.
D
A hospitalized diabetic patient received 38 U of NPH insulin at 7:00 AM. At 1:00 PM, the patient has been away from the nursing unit for 2 hours, missing the lunch delivery while awaiting a chest x-ray. To prevent hypoglycemia, the best action by the nurse is to A. Save the lunch tray for the patient's later return to the unit. B. Ask that diagnostic testing area staff to start a 5% dextrose IV. C. Send a glass of milk or orange juice to the patient in the diagnostic testing area. D. Request that if testing is further delayed, the patient be returned to the unit to eat.
D - Consistency for mealtimes assists with regulation of blood glucose, so the best option is for the patient to have lunch at the usual time. Waiting to eat until after the procedure is likely to cause hypoglycemia. Administration of an IV solution is unnecessarily invasive for the patient. A glass of milk or juice will keep the patient from becoming hypoglycemic but will cause a rapid rise in blood glucose because of the rapid absorption of the simple carbohydrate in these items.
A patient with type 2 diabetes is scheduled for a follow-up visit in the clinic several months from now. Which test will the nurse schedule to evaluate the effectiveness of treatment for the patient? A. Urine dipstick for glucose B. Oral glucose tolerance test C. Fasting blood glucose level D. Glycosylated hemoglobin level
D - The glycosylated hemoglobin (A1C or HbA1C) test shows the overall control of glucose over 90 to 120 days. A fasting blood level indicates only the glucose level at one time. Urine glucose testing is not an accurate reflection of blood glucose level and does not reflect the glucose over a prolonged time. Oral glucose tolerance testing is done to diagnose diabetes, but is not used for monitoring glucose control once diabetes has been diagnosed.
The nurse has been teaching a patient with type 2 diabetes about managing blood glucose levels and taking glipizide (Glucotrol). Which patient statement indicates a need for additional teaching? A. "If I overeat at a meal, I will still take the usual dose of medication." B. "Other medications besides the Glucotrol may affect my blood sugar." C. "When I am ill, I may have to take insulin to control my blood sugar." D. "My diabetes won't cause complications because I don't need insulin."
D - The patient should understand that type 2 diabetes places the patient at risk for many complications and that good glucose control is as important when taking oral agents as when using insulin. The other statements are accurate and indicate good understanding of the use of glipizide.
A 28-year-old male patient with type 1 diabetes reports how he manages his exercise and glucose control. Which behavior indicates that the nurse should implement additional teaching? A. The patient always carries hard candies when engaging in exercise. B. The patient goes for a vigorous walk when his glucose is 200 mg/dL. C. The patient has a peanut butter sandwich before going for a bicycle ride. D. The patient increases daily exercise when ketones are present in the urine.
D - When the patient is ketotic, exercise may result in an increase in blood glucose level. Type 1 diabetic patients should be taught to avoid exercise when ketosis is present. The other statements are correct.
Which of the following assessments would indicate that a patient's IV has infiltrated? (Select all that apply.)
Edema of the extremity near the insertion site Skin discolored or bruised in appearance Skin cool to the touch Numbness or loss of sensation
The nurse evaluates that discharge teaching for a patient hospitalized with pneumonia has been effective when the patient makes which statement about measures to prevent a relapse? A. "I will seek immediate medical treatment for any upper respiratory infections." B. "I should continue to do deep-breathing and coughing exercises for at least 12 weeks." C. "I will increase my food intake to 2400 calories a day to keep my immune system well." D. "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution."
D. "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution." The follow-up chest x-ray will be done in 6 to 8 weeks to evaluate pneumonia resolution. A patient should seek medical treatment for upper respiratory infections that persist for more than 7 days. It may be important for the patient to continue with coughing and deep breathing exercises for 6 to 8 weeks, not 12 weeks, until all of the infection has cleared from the lungs. Increased fluid intake, not caloric intake, is required to liquefy secretions.
What is the priority nursing intervention in helping a patient expectorate thick lung secretions? A. Humidify the oxygen as able. B. Administer cough suppressant q4hr. C. Teach patient to splint the affected area. D. Increase fluid intake to 3 L/day if tolerated.
D. Increase fluid intake to 3 L/day if tolerated. Although several interventions may help the patient expectorate mucus, the highest priority should be on increasing fluid intake, which will liquefy the secretions so that the patient can expectorate them more easily. Humidifying the oxygen is also helpful but is not the primary intervention. Teaching the patient to splint the affected area may also be helpful in decreasing discomfort but does not assist in expectoration of thick secretions.
The health care provider's order is 1000 mL 0.9% NaCl with 20 mEq K+ intravenously over 8 hours. Which assessment finding causes you to clarify the order with the health care provider before hanging this fluid?
D. Oliguria
The nurse is caring for a 78-year-old patient who was hospitalized 2 days earlier with community-acquired pneumonia. Which assessment information is most important to communicate to the health care provider?
Decreased oxygen saturation to 90% with 100% O2 by non-rebreather mask.
A patient with respiratory failure has a respiratory rate of 6 breaths/minute and an oxygen saturation (SpO2) of 88%. The patient is increasingly lethargic. Which intervention will the nurse anticipate?
Endotracheal intubation and positive pressure ventilation
You teach patients to replace sweat, vomiting, or diarrhea fluid losses with which type of fluid?
Fluid that has sodium (salt) in it
A nurse is assessing a patient who is receiving a blood transfusion and finds that the patient is anxiously fidgeting in bed. The patient is afebrile and dyspneic. The nurse auscultates crackles in both lung bases and sees jugular vein distention. The nurse recognizes that the patient is experi-encing which transfusion complication?
Fluid volume overload
A patient with acute respiratory distress syndrome (ARDS) and acute kidney injury has the following medications ordered. Which medication should the nurse discuss with the health care provider before giving?
Gentamicin (Garamycin) 60 mg IV
Which action should the nurse perform when preparing a patient with supraventricular tachycardia for cardioversion who is alert and has a blood pressure of 110/66 mm Hg? a. Turn the synchronizer switch to the "off" position. b. Give a sedative before cardioversion is implemented. c. Set the defibrillator/cardioverter energy to 360 joules. d. Provide assisted ventilations with a bag-valve-mask device.
Give a sedative before cardioversion is implemented.
A patient who is on the progressive care unit develops atrial flutter, rate 150, with associated dyspnea and chest pain. Which action that is included in the hospital dysrhythmia protocol should the nurse do first? a. Obtain a 12-lead electrocardiogram (ECG). b. Notify the health care provider of the change in rhythm. c. Give supplemental O2 at 2 to 3 L/min via nasal cannula. d. Assess the patient's vital signs including oxygen saturation.
Give supplemental O2 at 2 to 3 L/min via nasal cannula.
An elderly patient was hydrated with lactated Ringer's solution in the emergency room for the last hour. During the most recent evaluation of the patient by the nurse, a finding of a rapid bounding pulse and shortness of breath were noted. Reporting this episode to the physician, the nurse suspects that the patient now shows signs of:
Hypervolemia, and need the fluids adjusted
A patient has ST segment changes that support an acute inferior wall myocardial infarction. Which lead would be best for monitoring the patient? a. I b. II c. V2 d. V6
II
After the nurse gives IV atropine to a patient with symptomatic type 1, second-degree atrioventricular (AV) block, which finding indicates that the medication has been effective? a. Increase in the patient's heart rate b. Increase in strength of peripheral pulses c. Decrease in premature atrial contractions d. Decrease in premature ventricular contractions
Increase in the patient's heart rate
While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient's oxygen saturation (SpO2) from 94% to 88%. Which action should the nurse take next?
Increase oxygen flow rate
Which action by a new registered nurse (RN) who is orienting to the progressive care unit indicates a good understanding of the treatment of cardiac dysrhythmias? a. Injects IV adenosine (Adenocard) over 2 seconds to a patient with supraventricular tachycardia b. Obtains the defibrillator and quickly brings it to the bedside of a patient whose monitor shows asystole c. Turns the synchronizer switch to the "on" position before defibrillating a patient with ventricular fibrillation d. Gives the prescribed dose of diltiazem (Cardizem) to a patient with new-onset type II second degree AV block
Injects IV adenosine (Adenocard) over 2 seconds to a patient with supraventricular tachycardia
Which nursing interventions included in the care of a mechanically ventilated patient with acute respiratory failure can the registered nurse (RN) delegate to an experienced licensed practical/vocational nurse (LPN/LVN) working in the intensive care unit?
Insert an indwelling urinary catheter
Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown origin? a. Instruct the patient to call for assistance before getting out of bed. b. Explain the association between various dysrhythmias and syncope. c. Educate the patient about the need to avoid caffeine and other stimulants. d. Tell the patient about the benefits of implantable cardioverter-defibrillators.
Instruct the patient to call for assistance before getting out of bed.
Approximately two thirds of the body's total water volume exists in the _____ fluid.
Intracellular
When discontinuing a peripheral IV access, the nurse should (Select all that apply.)
Keep the catheter parallel to the skin while removing it. Stop the infusion before removing the IV catheter. Apply pressure to the site for 2 to 3 minutes after removal.
The nurse notes that a patient's endotracheal tube (ET), which was at the 22-cm mark, is now at the 25-cm mark and the patient is anxious and restless. Which action should the nurse take next?
Listen to the patient's breath sounds.
A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a right pneumothorax. Which action will the nurse anticipate taking next?
Lower the positive end-expiratory pressure (PEEP).
The nurse responds to a ventilator alarm and finds the patient lying in bed holding the endotracheal tube (ET). Which action should the nurse take next?
Manually ventilate the patient with 100% oxygen
Which of the following activities can you delegate to nursing assistive personnel (NAP)? (Select all that apply.)
Measuring oral intake and urine output Reporting an IV container that is low in fluid
A patient who is receiving positive pressure ventilation is scheduled for a spontaneous breathing trial (SBT). Which finding by the nurse is most important to discuss with the health care provider before starting the SBT?
New ST segment elevation is noted on the cardiac monitor.
Which nursing action can the registered nurse (RN) delegate to experienced unlicensed assistive personnel (UAP) working as a telemetry technician on the cardiac care unit? a. Decide whether a patient's heart rate of 116 requires urgent treatment. b. Monitor a patient's level of consciousness during synchronized cardioversion. c. Observe cardiac rhythms for multiple patients who have telemetry monitoring. d. Select the best lead for monitoring a patient admitted with acute coronary syndrome.
Observe cardiac rhythms for multiple patients who have telemetry monitoring.
Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires immediate action by the nurse?
Only continuous IV opioids have been ordered
A nurse is caring for a patient with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation using synchronized intermittent mandatory ventilation (SIMV). The settings include fraction of inspired oxygen (FIO2) 80%, tidal volume 450, rate 16/minute, and positive end-expiratory pressure (PEEP) 5 cm. Which assessment finding is most important for the nurse to report to the health care provider?
Oxygen saturation 99%
To determine whether there is a delay in impulse conduction through the atria, the nurse will measure the duration of the patient's a. P wave. b. Q wave. c. P-R interval. d. QRS complex.
P wave.
Which laboratory value should the nurse examine when evaluating uncompensated respiratory alkalosis?
PaCO2
After change-of-shift report, which patient should the progressive care nurse assess first?
Patient who is receiving IV heparin for a venous thromboembolism and has a partial thromboplastin time (PTT) of 98 sec
After change-of-shift report on a ventilator weaning unit, which patient should the nurse assess first?
Patient who was successfully weaned and extubated 4 hours ago and now has no urine output for the last 6 hours
A patient's cardiac monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious and pulseless. Which action should the nurse take first? a. Perform immediate defibrillation. b. Give epinephrine (Adrenalin) IV. c. Prepare for endotracheal intubation. d. Give ventilations with a bag-valve-mask device.
Perform immediate defibrillation.
Which assessment finding should cause a nurse to question administering a sodium-containing isotonic intravenous fluid?
Pitting edema
The nurse is assessing a patient and finds crackles in the lung bases and neck vein distention. The nurse gives the patient a diuretic. What electrolyte imbalance is the nurse most concerned about?
Potassium imbalance
A patient who was admitted with a myocardial infarction experiences a 45-second episode of ventricular tachycardia, then converts to sinus rhythm with a heart rate of 98 beats/minute. Which of the following actions should the nurse take next? a. Immediately notify the health care provider. b. Document the rhythm and continue to monitor the patient. c. Perform synchronized cardioversion per agency dysrhythmia protocol. d. Prepare to give IV amiodarone (Cordarone) per agency dysrhythmia protocol.
Prepare to give IV amiodarone (Cordarone) per agency dysrhythmia protocol.
Which actions should the nurse initiate to reduce the risk for ventilator-associated pneumonia (VAP) (select all that apply)?
Provide a "sedation holiday" daily; Elevate the head of the bed to at least 30°; Give prescribed pantoprazole (Protonix); E. Provide oral care with chlorhexidine (0.12%) solution daily.
When analyzing the rhythm of a patient's electrocardiogram (ECG), the nurse will need to investigate further upon finding a(n) a. isoelectric ST segment. b. P-R interval of 0.18 second. c. Q-T interval of 0.38 second. d. QRS interval of 0.14 second.
QRS interval of 0.14 second.
The nurse is caring for a patient who is intubated and receiving positive pressure ventilation to treat acute respiratory distress syndrome (ARDS). Which finding is most important to report to the health care provider?
Red-brown drainage from orogastric tube
A patient with a cardiac history is taking the diuretic furosemide (Lasix) and is seen in the emergency department for muscle weakness. Which laboratory value do you assess first?
Serum potassium
Which laboratory result for a patient with multifocal premature ventricular contractions (PVCs) is most important for the nurse to communicate to the health care provider? a. Blood glucose 243 mg/dL b. Serum chloride 92 mEq/L c. Serum sodium 134 mEq/L d. Serum potassium 2.9 mEq/L
Serum potassium 2.9 mEq/L
The nurse knows that the most abundant cation in the blood is
Sodium
A patient whose heart monitor shows sinus tachycardia, rate 132, is apneic and has no palpable pulses. What is the first action that the nurse should take? a. Perform synchronized cardioversion. b. Start cardiopulmonary resuscitation (CPR). c. Administer atropine per agency dysrhythmia protocol. d. Provide supplemental oxygen via non-rebreather mask.
Start cardiopulmonary resuscitation (CPR).
A patient had an acute intravascular hemolytic reaction to a blood transfusion. After discontinu-ing the blood transfusion, what is the nurse's next action?
Start normal saline at TKO rate using new tubing.
The nurse notes premature ventricular contractions (PVCs) while suctioning a patient's endotracheal tube. Which action by the nurse is a priority?
Stop and ventilate the patient with 100% oxygen
A nurse is preparing to administer a blood transfusion. Which assessment finding would the nurse report immediately?
Temp 101.3
The nurse educator is evaluating the care that a new registered nurse (RN) provides to a patient receiving mechanical ventilation. Which action by the new RN indicates the need for more education?
The RN positions the patient with the head of bed at 10 degrees.
The nurse educator is evaluating the performance of a new registered nurse (RN) who is providing care to a patient who is receiving mechanical ventilation with 15 cm H2O of peak end-expiratory pressure (PEEP). Which action indicates that the new RN is safe?
The RN uses a closed-suction technique to suction the patient.
A patient with respiratory failure has arterial pressure-based cardiac output (APCO) monitoring and is receiving mechanical ventilation with peak end-expiratory pressure (PEEP) of 12 cm H2O. Which information indicates that a change in the ventilator settings may be required?
The arterial pressure is 90/46.
Which intervention by a new nurse who is caring for a patient who has just had an implantable cardioverter-defibrillator (ICD) inserted indicates a need for more education about care of patients with ICDs? a. The nurse assists the patient to do active range of motion exercises for all extremities. b. The nurse assists the patient to fill out the application for obtaining a Medic Alert ID. c. The nurse gives amiodarone (Cordarone) to the patient without first consulting with the health care provider. d. The nurse teaches the patient that sexual activity usually can be resumed once the surgical incision is healed.
The nurse assists the patient to do active range of motion exercises for all extremities.
When admitting a patient with possible respiratory failure with a high PaCO2, which assessment information should be immediately reported to the health care provider?
The patient is somnolent (lethargic,drowsy).
A nurse is weaning a 68-kg male patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation. Which patient assessment finding indicates that the weaning protocol should be stopped?
The patient respiratory rate is 32 breaths/min
The nurse is caring for a 33-year-old patient who arrived in the emergency department with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action?
The patient's PaO2 is 45 mm Hg.
A patient with acute respiratory distress syndrome (ARDS) is placed in the prone position. When prone positioning is used, which information obtained by the nurse indicates that the positioning is effective?
The patient's PaO2 is 89 mm Hg, and the SaO2 is 91%.
A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department complaining of shortness of breath and dyspnea on minimal exertion. Which assessment finding by the nurse is most important to report to the health care provider?
The patient's pulse oximetry indicates an O2 saturation of 91%.
Which assessment finding obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning?
The patient's respiratory rate is 32 breaths/minute
Which information will the nurse include when teaching a patient who is scheduled for a radiofrequency catheter ablation for treatment of atrial flutter? a. The procedure will prevent or minimize the risk for sudden cardiac death. b. The procedure will use cold therapy to stop the formation of the flutter waves. c. The procedure will use electrical energy to destroy areas of the conduction system. d. The procedure will stimulate the growth of new conduction pathways between the atria.
The procedure will use electrical energy to destroy areas of the conduction system.
During change-of-shift report on a medical unit, the nurse learns that a patient with aspiration pneumonia who was admitted with respiratory distress has become increasingly agitated. Which action should the nurse take first?
Use pulse oximetry to check the oxygen saturation.
The nurse needs to quickly estimate the heart rate for a patient with a regular heart rhythm. Which method will be best to use? a. Count the number of large squares in the R-R interval and divide by 300. b. Print a 1-minute electrocardiogram (ECG) strip and count the number of QRS complexes. c. Calculate the number of small squares between one QRS complex and the next and divide into 1500. d. Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10.
Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10.
The nurse notes that a patient's cardiac monitor shows that every other beat is earlier than expected, has no visible P wave, and has a QRS complex that is wide and bizarre in shape. How will the nurse document the rhythm? a. Ventricular couplets b. Ventricular bigeminy c. Ventricular R-on-T phenomenon d. Multifocal premature ventricular contractions
Ventricular bigeminy
A patient who is orally intubated and receiving mechanical ventilation is anxious and is "fighting" the ventilator. Which action should the nurse take next?
Verbally coach the patient to breathe with the ventilator
The physician asks the nurse to monitor the fluid volume status of a congestive heart failure patient and a patient at risk for clinical dehydration. What is the most effective nursing interven-tion for monitoring both of these patients?
Weigh the patients every morning before breakfast.
The nurse would select the dorsal venous plexus of the foot as an IV site for which patient? A 2-year-old child
a 2 year old child
The nurse selects appropriate tubing for a blood transfusion by ensuring that the tubing has
a filter to ensure that clots do not enter the patient
A young adult patient who denies any history of smoking is seen in the clinic with a new diagnosis of chronic obstructive pulmonary disease (COPD). The nurse should plan to teach the patient about a. Alpha 1-antitrypsin testing. b. leukotriene modifiers. c. use of the nicotine patch. d. continuous pulse oximetry.
a. Alpha 1-antitrypsin testing.
Which finding in a patient hospitalized with bronchiectasis is most important to report to the health care provider? a. Cough productive of bloody, purulent mucus b. Scattered crackles and wheezes heard bilaterally c. Complaint of sharp chest pain with deep breathing d. Respiratory rate 28 breaths/minute while ambulating
a. Cough productive of bloody, purulent mucus
A patient who is experiencing an acute asthma attack is admitted to the emergency department. Which assessment should the nurse complete first? a. Listen to the patient's breath sounds. b. Ask about inhaled corticosteroid use. c. Determine when the dyspnea started. d. Obtain the forced expiratory volume (FEV) flow rate.
a. Listen to the patient's breath sounds.
A patient who has been experiencing an asthma attack develops bradycardia and a decrease in wheezing. Which action should the nurse take first? a. Notify the health care provider. b. Document changes in respiratory status. c. Encourage the patient to cough and deep breathe. d. Administer IV methylprednisolone (Solu-Medrol).
a. Notify the health care provider.
Which nursing action for a patient with chronic obstructive pulmonary disease (COPD) could the nurse delegate to experienced unlicensed assistive personnel (UAP)? a. Obtain O2 saturation using pulse oximetry. b. Monitor for increased O2 need with exercise. c. Teach the patient about safe use of O2 at home. d. Adjust O2 to keep saturation in prescribed parameters.
a. Obtain O2 saturation using pulse oximetry.
The nurse in the emergency department receives arterial blood gas results for four recently admitted patients with obstructive pulmonary disease. The results for which patient will require the most rapid action by the nurse? a. pH 7.28, PaCO2 50 mm Hg, and PaO2 58 mm Hg b. pH 7.48, PaCO2 30 mm Hg, and PaO2 65 mm Hg c. pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg d. pH 7.31, PaCO2 58 mm Hg, and PaO2 64 mm Hg
a. pH 7.28, PaCO2 50 mm Hg, and PaO2 58 mm Hg
A nurse is caring for a patient whose ECG presents with changes characteristic of hypokalemia. Which assessment finding would the nurse expect?
abdominal distention
A nurse is caring for a diabetic patient with a bowel obstruction and has orders to ensure that the volume of intake matches the output. In the past 4 hours, the patient received dextrose 5% with 0.9% sodium chloride through a 22-gauge catheter infusing at 4 mL/hr and has eaten 200 mL of ice chips. The patient also has an NG suction tube set to low continuous suction that had 300 mL output. The patient has voided 400 mL of urine. After reporting these values to the physician, what orders does the nurse anticipate?
add a potassium supplement to replace loss from output
A patient with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. The priority teaching needed for this patient would include information about a. anticoagulant therapy. b. permanent pacemakers. c. electrical cardioversion. d. IV adenosine (Adenocard).
anticoagulant therapy.
The nurse provides dietary teaching for a patient with chronic obstructive pulmonary disease (COPD) who has a low body mass index (BMI). Which patient statement indicates that the teaching has been effective? a. "I will drink lots of fluids with my meals." b. "I can have ice cream as a snack every day." c. "I will exercise for 15 minutes before meals." d. "I will decrease my intake of meat and poultry."
b. "I can have ice cream as a snack every day."
A young adult female patient with cystic fibrosis (CF) tells the nurse that she is considering getting married and wondering about having children. Which initial response by the nurse is best? a. "Are you aware of the normal lifespan for patients with CF?" b. "Would like more information to help you with that decision?" c. "Many women with CF do not have difficulty conceiving children." d. "You will need to have genetic counseling before making a decision."
b. "Would like more information to help you with that decision?"
The nurse receives a change-of-shift report on the following patients with chronic obstructive pulmonary disease (COPD). Which patient should the nurse assess first? a. A patient with loud expiratory wheezes b. A patient with a respiratory rate of 38 breaths/min c. A patient who has a cough productive of thick, green mucus d. A patient with jugular venous distention and peripheral edema
b. A patient with a respiratory rate of 38 breaths/min
A patient with severe chronic obstructive pulmonary disease (COPD) tells the nurse, "I wish I were dead! I'm just a burden on everybody." Based on this information, which nursing diagnosis is most appropriate? a. Complicated grieving related to expectation of death b. Chronic low self-esteem related to physical dependence c. Ineffective coping related to unknown outcome of illness d. Deficient knowledge related to lack of education about COPD
b. Chronic low self-esteem related to physical dependence
A patient with chronic obstructive pulmonary disease (COPD) has poor gas exchange. Which action by the nurse would support the patient's ventilation? a. Have the patient rest in bed with the head elevated to 15 to 20 degrees. b. Encourage the patient to sit up at the bedside in a chair and lean forward. c. Ask the patient to rest in bed in a high-Fowler's position with the knees flexed. d. Place the patient in the Trendelenburg position with pillows behind the head.
b. Encourage the patient to sit up at the bedside in a chair and lean forward.
Which assessment finding in a patient who has received omalizumab (Xolair) is most important to report immediately to the health care provider? a. Pain at injection site b. Flushing and dizziness c. Peak flow reading 75% of normal d. Respiratory rate 24 breaths/minute
b. Flushing and dizziness
A patient in the clinic with cystic fibrosis (CF) reports increased sweating and weakness during the summer months. Which action by the nurse would be most appropriate? a. Teach the patient signs of hypoglycemia. b. Have the patient add dietary salt to meals. c. Suggest decreasing intake of dietary fat and calories. d. Instruct the patient about pancreatic enzyme replacements.
b. Have the patient add dietary salt to meals.
The clinic nurse makes a follow-up telephone call to a patient with asthma. The patient reports having a baseline peak flow reading of 600 L/min, and the current peak flow is 420 L/min. Which action should the nurse take first? a. Tell the patient to go to the hospital emergency department. b. Instruct the patient to use the prescribed albuterol (Ventolin HFA). c. Ask about recent exposure to any new allergens or asthma triggers. d. Question the patient about use of the prescribed inhaled corticosteroids.
b. Instruct the patient to use the prescribed albuterol (Ventolin HFA).
A patient is receiving 35% O2 via a Venturi mask. To ensure the correct amount of O2 delivery, which action by the nurse is important? a. Teach the patient to keep the mask on during meals. b. Keep the air entrainment ports clean and unobstructed. c. Give a high enough flow rate to keep the bag from collapsing. d. Drain moisture condensation from the corrugated tubing every hour.
b. Keep the air entrainment ports clean and unobstructed.
The nurse is admitting a patient diagnosed with an acute exacerbation of chronic obstructive pulmonary disease (COPD). How should the nurse determine the appropriate O2 flow rate? a. Minimize O2 use to avoid O2 dependency. b. Maintain the pulse oximetry level at 90% or greater. c. Administer O2 according to the patient's level of dyspnea. d. Avoid administration of O2 at a rate of more than 2 L/min.
b. Maintain the pulse oximetry level at 90% or greater.
The emergency department nurse is evaluating the effectiveness of therapy for a patient who has received treatment during an asthma attack. Which assessment finding is the best indicator that the therapy has been effective? a. No wheezes are audible. b. O2 saturation is >90%. c. Accessory muscle use has decreased. d. Respiratory rate is 16 breaths/minute.
b. O2 saturation is >90%.
Which finding by the nurse for a patient with a nursing diagnosis of impaired gas exchange will be most useful in evaluating the effectiveness of treatment? a. Even, unlabored respirations b. Pulse oximetry reading of 92% c. Absence of wheezes or crackles d. Respiratory rate of 18 breaths/min
b. Pulse oximetry reading of 92%
The home health nurse is visiting a patient with chronic obstructive pulmonary disease (COPD). Which nursing action is appropriate to implement for a nursing diagnosis of impaired breathing pattern related to anxiety? a. Titrate O2 to keep saturation at least 90%. b. Teach the patient how to use pursed-lip breathing. c. Discuss a high-protein, high-calorie diet with the patient. d. Suggest the use of over-the-counter sedative medications.
b. Teach the patient how to use pursed-lip breathing.
A patient with chronic obstructive pulmonary disease (COPD) has coarse crackles throughout the lung fields and a chronic, nonproductive cough. Which nursing intervention will be most effective? a. Change the O2 flow rate to the highest prescribed rate. b. Teach the patient to use the Flutter airway clearance device. c. Reinforce the ongoing use of pursed-lip breathing techniques. d. Teach the patient about consistent use of inhaled corticosteroids.
b. Teach the patient to use the Flutter airway clearance device.
The nurse teaches a patient about pursed-lip breathing. Which action by the patient would indicate to the nurse that further teaching is needed? a. The patient inhales slowly through the nose. b. The patient puffs up the cheeks while exhaling. c. The patient practices by blowing through a straw. d. The patient's ratio of inhalation to exhalation is 1:3.
b. The patient puffs up the cheeks while exhaling.
The nurse teaches a patient with chronic bronchitis about a new prescription for Advair Diskus (combined fluticasone and salmeterol). Which action by the patient would indicate to the nurse that teaching about medication administration has been successful? a. The patient shakes the device before use. b. The patient rapidly inhales the medication. c. The patient attaches a spacer to the Diskus. d. The patient performs huff coughing after inhalation.
b. The patient rapidly inhales the medication.
A 55-yr-old patient with increasing dyspnea is being evaluated for a possible diagnosis of chronic obstructive pulmonary disease (COPD). When teaching a patient about pulmonary spirometry for this condition, what is the most important question the nurse should ask? a. "Are you claustrophobic?" b. "Are you allergic to shellfish?" c. "Have you taken any bronchodilators today?" d. "Do you have any metal implants or prostheses?"
c. "Have you taken any bronchodilators today?"
Which instruction should the nurse include in an exercise teaching plan for a patient with chronic obstructive pulmonary disease (COPD)? a. "Avoid upper body exercise to prevent dyspnea." b. "Stop exercising if you start to feel short of breath." c. "Use the bronchodilator before you start to exercise." d. "Breathe in and out through the mouth while you exercise."
c. "Use the bronchodilator before you start to exercise."
A patient seen in the asthma clinic has recorded daily peak flow rates that are 75% of the baseline. Which action will the nurse plan to take next? a. Increase the dose of the leukotriene inhibitor. b. Teach the patient about the use of oral corticosteroids. c. Administer a bronchodilator and recheck the peak flow. d. Instruct the patient to keep the scheduled follow-up appointment.
c. Administer a bronchodilator and recheck the peak flow.
Postural drainage with percussion and vibration is ordered twice daily for a patient with chronic bronchitis. Which intervention should the nurse include in the plan of care? a. Schedule the procedure 1 hour after the patient eats. b. Maintain the patient in the lateral position for 20 minutes. c. Give the prescribed albuterol (Ventolin HFA) before the therapy. d. Perform percussion before assisting the patient to the drainage position.
c. Give the prescribed albuterol (Ventolin HFA) before the therapy.
A patient hospitalized with chronic obstructive pulmonary disease (COPD) is being discharged home on O2 therapy. Which instruction should the nurse include in the discharge teaching? a. Travel is not possible with the use of O2 devices. b. O2 flow should be increased if the patient has more dyspnea. c. O2 use can improve the patient's prognosis and quality of life. d. Storage of O2 requires large metals tanks that each last 4 to 6 hours.
c. O2 use can improve the patient's prognosis and quality of life.
A patient with chronic obstructive pulmonary disease (COPD) has a nursing diagnosis of imbalanced nutrition: less than body requirements. Which intervention would be most appropriate for the nurse to include in the plan of care? a. Encourage increased intake of whole grains. b. Increase the patient's intake of fruits and fruit juices. c. Offer high-calorie protein snacks between meals and at bedtime. d. Assist the patient in choosing foods with high vegetable content.
c. Offer high-calorie protein snacks between meals and at bedtime.
The nurse is caring for a patient with cor pulmonale. The nurse should monitor the patient for which expected finding? a. Chest pain b. Finger clubbing c. Peripheral edema d. Elevated temperature
c. Peripheral edema
A patient newly diagnosed with asthma is being discharged. The nurse anticipates including which topic in the discharge teaching? a. Use of long-acting Beta-adrenergic medications b. Side effects of sustained-release theophylline c. Self-administration of inhaled corticosteroids d. Complications associated with O2 therapy
c. Self-administration of inhaled corticosteroids
A patient with cystic fibrosis (CF) has blood glucose levels that are consistently between 180 to 250 mg/dL. Which nursing action will the nurse plan to implement? a. Discuss the role of diet in blood glucose control. b. Evaluate the patient's use of pancreatic enzymes. c. Teach the patient about administration of insulin. d. Give oral hypoglycemic medications before meals.
c. Teach the patient about administration of insulin.
The nurse teaches a patient how to administer formoterol (Perforomist) through a nebulizer. Which action by the patient indicates good understanding of the teaching? a. The patient attaches a spacer before using the inhaler. b. The patient coughs vigorously after using the inhaler. c. The patient removes the facial mask when misting stops. d. The patient activates the inhaler at the onset of expiration.
c. The patient removes the facial mask when misting stops.
The nurse interviews a patient with a new diagnosis of chronic obstructive pulmonary disease (COPD). Which information is most specific in confirming a diagnosis of chronic bronchitis? a. The patient tells the nurse about a family history of bronchitis. b. The patient indicates a 30 pack-year cigarette smoking history. c. The patient reports a productive cough for 3 months every winter. d. The patient denies having respiratory problems until the past 12 months.
c. The patient reports a productive cough for 3 months every winter.
The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). Which information obtained from the patient would prompt the nurse to consult with the health care provider before administering the prescribed theophylline? a. The patient reports a recent 15-lb weight gain. b. The patient denies shortness of breath at present. c. The patient takes cimetidine (Tagamet HB) daily. d. The patient complains of coughing up green mucus.
c. The patient takes cimetidine (Tagamet HB) daily.
The nurse assesses a patient with a history of asthma. Which assessment finding indicates that the nurse should take immediate action? a. Pulse oximetry reading of 91% b. Respiratory rate of 26 breaths/min c. Use of accessory muscles in breathing d. Peak expiratory flow rate of 240 L/min
c. Use of accessory muscles in breathing
A patient is scheduled for spirometry. Which action should the nurse take to prepare the patient for this procedure? a. Give the rescue medication immediately before testing. b. Administer oral corticosteroids 2 hours before the procedure. c. Withhold bronchodilators for 6 to 12 hours before the examination. d. Ensure that the patient has been NPO for several hours before the test.
c. Withhold bronchodilators for 6 to 12 hours before the examination.
The nurse receives the patient's most recent blood work results. Which laboratory value is of greatest concern?
calcium of 17.5 mg/dL
The nurse would expect a patient with respiratory acidosis to have an excessive amount of
carbon dioxide
A young adult patient with cystic fibrosis (CF) is admitted to the hospital with increased dyspnea. Which intervention should the nurse include in the plan of care? a. Schedule a sweat chloride test. b. Arrange for a hospice nurse visit. c. Place the patient on a low-sodium diet. d. Perform chest physiotherapy every 4 hours.
d. Perform chest physiotherapy every 4 hours.
A patient develops increasing dyspnea and hypoxemia 2 days after heart surgery. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by heart failure, the nurse will plan to assist with
insertion of a pulmonary artery catheter.
The nurse understands that administering a hypertonic solution to a patient will shift water from the _____ to the _____ space.
intracellular; extracellular
The nurse teaches a patient who has asthma about peak flow meter use. Which action by the patient indicates that teaching was successful? a. The patient inhales rapidly through the peak flow meter mouthpiece. b. The patient takes montelukast (Singulair) for peak flows in the red zone. c. The patient calls the health care provider when the peak flow is in the green zone. d. The patient uses an albuterol (Ventolin HFA) inhaler for peak flows in the yellow zone.
d. The patient uses an albuterol (Ventolin HFA) inhaler for peak flows in the yellow zone.
The nurse completes an admission assessment on a patient with asthma. Which information given by patient is indicates a need for a change in therapy? a. The patient uses albuterol (Ventolin HFA) before aerobic exercise. b. The patient says that the asthma symptoms are worse every spring. c. The patient's heart rate increases after using the albuterol (Ventolin HFA) inhaler. d. The patient's only medications are albuterol (Ventolin HFAl) and salmeterol (Serevent).
d. The patient's only medications are albuterol (Ventolin HFAl) and salmeterol (Serevent).
Which information will the nurse include in the asthma teaching plan for a patient being discharged? a. Use the inhaled corticosteroid when shortness of breath occurs. b. Inhale slowly and deeply when using the dry powder inhaler (DPI). c. Hold your breath for 5 seconds after using the bronchodilator inhaler. d. Tremors are an expected side effect of rapidly acting bronchodilators.
d. Tremors are an expected side effect of rapidly acting bronchodilators.
The nurse develops a teaching plan to help increase activity tolerance at home for an older adult with severe chronic obstructive pulmonary disease (COPD). Which instructions would be appropriate for the nurse to include in the plan of care? a. Stop exercising when you feel short of breath. b. Walk until pulse rate exceeds 130 beats/minute. c. Limit exercise to activities of daily living (ADLs). d. Walk 15 to 20 minutes a day at least 3 times/week.
d. Walk 15 to 20 minutes a day at least 3 times/week.
Four hours after mechanical ventilation is initiated for a patient with chronic obstructive pulmonary disease (COPD), the patient's arterial blood gas (ABG) results include a pH of 7.51, PaO2 of 82 mm Hg, PaCO2 of 26 mm Hg, and HCO3- of 23 mEq/L (23 mmol/L). The nurse will anticipate the need to
decrease the respiratory rate.
The nurse would expect a patient with increased levels of serum calcium to also have _____ levels.
decreased phosphate
A patient has a normal cardiac rhythm and a heart rate of 72 beats/minute. The nurse determines that the P-R interval is 0.24 seconds. The most appropriate intervention by the nurse would be to a. notify the health care provider immediately. b. give atropine per agency dysrhythmia protocol. c. prepare the patient for temporary pacemaker insertion. d. document the finding and continue to monitor the patient.
document the finding and continue to monitor the patient.
A patient with a lower respiratory infection has pH of 7.25, PaCO2 of 55 mm Hg, and HCO3- of 20 mEq/L. The physician has been notified. Which is the priority nursing intervention for this patient?
encourage the patient to increase respirations
A patient was admitted for hypovolemia and has intravenous fluid running at 250 mL/hr. The patient complains of burning at the IV insertion site. Upon assessment, the nurse does not find redness, swelling, heat, or coolness. The nurse suspects that the
fluid is infusing too quickly
The nurse knows that an imbalance of which ion causes acid-base impairment?
hydrogen
The nurse knows that edema in a patient who has venous congestion from right heart failure is facilitated by an imbalance with regard to _____ pressure.
hydrostatic
The nurse is caring for a patient with a subarachnoid hemorrhage who is intubated and placed on a mechanical ventilator with 10 cm H2O of peak end-expiratory pressure (PEEP). When monitoring the patient, the nurse will need to notify the health care provider immediately if the patient develops
increased jugular venous distention.
To maintain proper cuff pressure of an endotracheal tube (ET) when the patient is on mechanical ventilation, the nurse should
inject air into the cuff until a slight leak is heard only at peak inflation
The process of passively moving water from an area of lower particle concentration to an area of higher particle concentration is known as
osmosis
The nurse is caring for a diabetic patient in renal failure. Which laboratory findings would the nurse expect?
pH 7.3; PaCO2 36 mm Hg; HCO3- 19 mEq/L
A patient was admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent suction for the past 3 days. The patient's respiratory rate has decreased to 12 breaths per minute. The nurse would expect the patient to have which of the following arterial blood gas values? . pH 7.52, PaCO2 48 mm Hg, HCO3- 28 mEq/L
ph 7.25, PaCO2 48 mm Hg, HCO3-28 mEq/L
Which organ system is responsible for compensation of respiratory acidosis?
renal
A nurse is caring for a cancer patient who presents with anorexia, blood pressure 100/60, elevated white blood cell count, and oral candidiasis. The nurse knows that the purpose of starting total parenteral nutrition (TPN) is to
replace fluid, electrolytes, and nutrients in the patient
A 2-year-old child was brought into the emergency department after ingesting several morphine tablets from a bottle in his mother's purse. The nurse knows that the child is at greatest risk for which acid-base imbalance? Respiratory acidosis
respiratory acidosis
The nurse would not expect full compensation to occur for which acid-base imbalance?
respiratory alkalosis
The nurse knows that intravenous fluid therapy has been effective for a patient with hyper-natremia when
serum sodium concentration return to normal
A nurse is caring for a patient who is in hypertensive crisis. When the nurse is flushing the patient's peripheral IV, the patient complains of pain. Upon assessment, the nurse notices a red streak that is warm to the touch. What is the nurse's initial action?
start a new IV line
While receiving a blood transfusion, your patient develops chills, tachycardia, and flushing. What is your priority action?
stop the transfusion
Which assessment finding would the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL?
tingling of the extremities and tetany
To verify the correct placement of an oral endotracheal tube (ET) after insertion, the best initial action by the nurse is to
use an end-tidal CO2 monitor to check for placement in the trachea.
The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, P-R interval not measurable, ventricular rate 162, R-R interval regular, and QRS complex wide and distorted, QRS duration 0.18 second. The nurse interprets the patient's cardiac rhythm as a. atrial flutter. b. sinus tachycardia. c. ventricular fibrillation. d. ventricular tachycardia.
ventricular tachycardia.
A client taking lasix (furosemide) for congestive heart failure is seeing the physician for a potassium value of 3.0. An order for oral potassium taken daily is written and discussed with the client. In addition, potassium-rich foods should be eaten. The nurse educator meets with this client and has the client identify all of the following foods as potassium-rich except:
white bread