All Medsurg questions

the instructor is reviewing pneumonia with the nursing student. Which statement could be included in the conversation? A. Streptococcus pneumonia is the most common causative organism. B. Community acquired pneumonia has a higher mortality than hospital acquired pneumonia C.. All pneumonias can be treated with antibiotics D. Vomiting is a prerequisite for aspiration pneumonia

A

A patient hospitalized for evaluation of unstable angina experiences severe chest pain and calls the nurse. Prioritize the interventions below from 1 (highest) to 5 lowest priority. 1. notify the HCP 2. Assess and medicate as ordered 3. Administer oxygen per nasal cannula 4. obtain a 12 lead ECG 5. check patient's vital signs

1,2,5,4,3

Which clinical indicator does the nurse expect to identify when assessing a patient admitted with a herniated lumbar disk? A. pain radiating to the hip and leg B. Bowel and bladder incontinence C. paralysis of both lower extremities D. overgrowth of tissue on the lower back

A

The nurse suspects a decrease in cardiac output from a dysrhythmia. Which of the following assessment findings best support the nurse's suspicion? (Select All That Apply) A. Thready pulse B. Urine output = 40mL/ 2 hours C. Dry skin D. BP = 128/64 mmHg E. Dizziness

A, B, E Dizziness, Irregular pulse, weak/thready, and cool, clammy skin can be symptoms of a low cardiac output. A regular pulse, warm, dry skin, respiratory rate of 20/min and BP of 128/64 are normal physiological findings. UOP of 30 mL/ hour is the accepted norm.

The patient with a history of severe emphysema and is a known CO2 retainer is admitted to the hospital to have an elective surgery performed tomorrow. Routine baseline ABGs are performed preoperatively. The patient is in no acute distress. Which ABG results are consistent with this scenario (pH---, pCO2--, HCO3--) A. 7.30, 60, 27 B. 7.50, 22, 27 C. 7.35, 65, 35 D. 7.45, 22, 35

C (compensated respiratory acidosis)

A patient is admitted with heart failure. Which findings would be consistent with left sided heart failure? Select all that apply. A. ascites B. JVD C. orthopnea D. productive cough E. hepatomegaly F. crackles

C,D,F

A patient is brought to an emergency department in an unconscious condition. The Hgb level of the patient is 20g/dL. How should teh nurse interpret the lab result? A. The patient is dehydrated B. The patient has anemai C. THe patient has internal hemorrhage D. The patient has fluid volume excess

A

A patient arrives at the ED with a heart rate of 210 beats/minute and the following pattern on the cardiac monitor. The nurse is correct to alert the health care provider that the patient has converted to: A. premature atrial contractions B. atrial flutter C Sinus arrhythmia D. Supraventrical tachycardia

B

A patient in end-stage kidney disease is prescribed epoietin (Epogen). Before administering the first dose, the nurse should: A. Check to see if the patient has any difficulty swallowing B. Assess the Hgb level C. hold the medication if the BUN is elevated D. administer diphenhydramine (Benadryl)

B

A patient is admitted to the hospital with idiopathic aplastic anemia. Which of these collaborative problems will the nurse include when developing the care plan? A. potential complication: siezures B. potential complication: infection C. potential complication: hypokalemia D. potential complication: pulmonary edema

B

The patient is in distress. Stat ABGs are drawn. Results are pH 7.32, pCO2 38, HCO3 19. Which findings in the patient's chart would be consistent with this problem? 1. Uncontrolled diabetes mellitus 2.Uncontrolled vomiting 3. Excessive opioids 4. Uncontrolled anxiety

1

A patient is having major abdominal surgery tomorrow. During preop teaching, the nurse teaches the patient how to do deep breathing exercises after surgery by telling the patient to: A. Hold your abdomen firmly wit ha pillow and take several deep breaths B. Tighten your stomach muscles as you inhale and breathe normally in and out of your mouth C. Raise your shoulders to expand you chest and rib cage. D. Sit in an upright position and perform huff breathing.

A

A 68-year old scheduled for a herniorrhaphy at an ambulatory surgical center expresses concern that he will not have enough care at home and asks if he can stay in the hospital after the surgery. The best response b the nurse is: A. Who is available to help you at home after the surgery? B. I'm sure you will be able to manage at home after surgery. It is a simple procedure. C. We will teach you everything you need to know to be able to care for yourself after surgery.

A

A Female patient's complicated history of signs and symptoms have finally led to the diagnosis of SLE . Which statement demonstrates the patient's need for further teaching about the disease? A. im hoping that surgery will be an option for me in the future. B. Ill try my best to stay out of the sun this summer C. I know that I probably have a high chance of getting arthritis D. I understand that Im going to be vulnerable to getting infections

A

A patient has been taking opiod analgesics for more than 2 weeks to control his post-surgical pain. While the surgeon is pleased with his healing progress, he wants to change the analgesic to a non-opiod drug. He prescribes a gradually lower opiod dose and increasingly larger non-opiod dose and increasingly larger non-opiod drug doses. Why is the surgeon changing medications in this manner? A. to avoid withdrawal symptoms B. To avoid addiction C. to avoid tolerance D. to avoid respiratory depression

A

A patient is prescribed 325mg/day of oral ferrous sulfate. The nurse includes in patient teaching "take your iron pill..." A. 1 hour before breakfast B. with dairy products C. and decrease fruits and juices in your diet D. along with a low residue diet

A

A patient is scheduled for an arteriogram. The nurse should explain to the patient that the arteriogram will confirm the diagnosis of occlusive arterial disease by: A. showing the location of the obstruction and the collateral circulation B. Scanning other affected extremity and identifying the areas of volume changes C. Using ultrasound to estimate the velocity changes in the blood vessels D. mathematical calculations using upper and lower extremity blood pressures

A

A patient who has been newly diagnosed with SLE has been admitted to the medsurg unit. The nurse anticipates which diagnostic finding related to this disease? A. Thrombocytopenia B. Elevated hemoglobin level C. Negative antinuclear antibodies level D. Glucosuria

A

A patient with a suspected dysrhythmia is to wear a Holter monitor for 24 hours at home. What should the nurse instruct the patient to do? A. Keep a record of the day's activities B. avoid going through laser activated doors C. record the pulse and BP q 4 hours D. Delay taking prescribed medications until the monitor is removed.

A

A postmenopausal patient is scheduled for a bone density scan. Which instructions should be included in the pre-procedure teaching? A. the procedure is painless and non invasive B. please consume foods and beverages with a high content of calcium 2 days before the test C. please take 600 mg of calcium carbonate for two weeks before the test D. report any significant back pain to the provider at least 2 days before the test.

A

After receiving change-of-shift report, which patient should the nurse assess first? A. Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating B. Patient who has 30 ml of sanguinous drainage in the wound drain 10 hours after hip replacement surgery. C. Patient who has bibasilar crackles and a temperature of 100 degrees on the first postoperative day after chest surgery. D. Patient who continues to have incisional pain 20 mins after hydrocodone and acetaminophen (Vicodin) was given.

A

The nurse cares for a patient who has SLE. To prevent an exacerbation of the condition, what should the nurse instruct the patient to avoid? A. Becoming fatigued B. Animal dander C. Dairy products D. Nonsteroidal drugs

A

The nurse is assessing the patient who is immediately postoperative from a total knee replacement. Which assessment data would warrant immediate intervention? A. complaints of left calf tenderness upon palpation B. T 99.4 HR 88, RR 20, BP 128/76 C. bowel sounds heard intermittently in four quadrants D. diffuse abdominal cramping and pain

A

The patient diagnosed with OA tells the nurse, "My friend takes steroid pills for her RA. Are steroids used for osteoarthritis too?" what should then nurse explain to the patient? A. Intra-articular corticosteroid injections can be used to treat OA B. oral corticosteroids are used in OA C. A systemic effect is needed on osteoarthritis. D. RA and OA are in fact treated with the same medications

A

The patient has a history of severe epistaxis. Which lab value is of most concern? A. INR= 4.5 B. Hgb= 13.4 C. Hct=41% D. O2 sat= 94%

A

The patient is admitted to the medsurg unit with a fracture of the hip. The provider orders russel traction. This type of traction is: A. skin traction applied to a lower extremity with the extremity suspended above the bed B. skeletal traction applied to al lower extremity C. skin traction applied to an extended lower extremity D. skin traction applied bilaterally to the lower extremities.

A

The patient undergoes a right above the knee amputation with an immediate prosthetic fitting. When the patient arrives to the med-surg floor after surgery, which nursing action takes priority. A. assess the surgical site for bleeding B. remove the prosthesis and wrap the site C. place the patient in a side lying position D. keep the affected abducted at all times

A

The patient with sleep apnea asks why he has to wear an oral appliance every night. The nurse's response is based on the fact that an oral appliance's primary purpose is to: A. Maintain patency of the oropharyngeal area B. Keep the upper and lower teeth from touching C. provide positive pressure to the alveoli D. Reduce tension in the mandibular muscles

A

When developing a plan of care to manage a patient's pain from cancer, What should the nurse plan to do? A. Individualize the pain medication regimen for the patient. B. Select medications that are least likely to lead to addiction. C. Administer pain medication as soon as the patient requests it. D. Change pain medications periodically to avoid drug tolerance.

A

The nurse is caring for an unresponsive patient that has been brought to the emergency room after a motor vehicle crash (MVC). The patient has been diagnosed with an aortic dissection that requires immediate surgical repair. There are no family members present, and the surgeon tells the nurse to assist with the transport to the OR. What should the nurse do about the informed consent? A.Go ahead and take the patient to the OR without the consent signed, there is no one present to sign it. B. Inform the surgeon that the consent is not signed and sign it in place of the patient. C. Call the hospital's legal representative and have them initial the consent, and then sign the document as a witness. D. Contact the emergency room chaplain and have them sign the consent form and then try to locate the next of kin.

A A true medical emergency like an aortic dissection may override the need to obtain consent (particularly if legal next of kin or power of attorney cannot be located).

A nurse is caring for a patient who underwent a lumbar laminectomy 2 days ago. The nurse know that which of the following finding should be reported to the provider? A.The patient is having numbness of the buttocks this morning B.Back pain is worse today, than the first postoperative day C.Urine output is 100 mL for the last 3 hours D.Temperature of 100.2° F up from 99.3 F yesterday

A Although paresthesia is common after surgery, new or progressive weakness, numbness, or paralysis may indicate spinal nerve compression., so the nursing staff will want to monitor carefully , but should notify the provider of the finding An increase in back pain is more common because on the second postoperative day the long-acting local anesthetic, which may have been injected during surgery, will wear off. Urine output is 100 mL for the last 3 hours A mild fever is also common after surgery, and is considered significant only if the temperature reaches 101° F (38.3° C). The trend is going up, and the nursing staff will want to monitor it carefully.

It is 10 am, and the scheduling personnel for the Operating Room has been called and told that there is a patient with a history of GI bleeding, that had an endoscopy this morning and needs surgical intervention. Which of the following responses by the scheduling personnel is the most appropriate? A."If you admit the patient to a floor for observation, we will get them in sometime today." B. "I will put them on the schedule for tomorrow morning, and if nothing emergent comes in they should be in by noon." C. "Since you are seeing the patient as an outpatient, do you think it could wait for another day or two?" D. "Have they been NPO (nothing by mouth) this morning? We can wait and see if anything opens up later this evening."

A GI bleeds, and their stabilization are considered emergency situations—especially if an endoscopy (a scope to look into the GI tract) was completed and the provider felt surgical intervention was needed. That means surgery needs to be done ASAP—ideally within 2 hours, but absolutely within 24—the only answer that confirms that is A. What if an emergency comes in and delays the surgery in the morning—it may push it back too far. D is too vague "wait and see"?? No plan—no guarantee, not best. Also, note, the patient being observed at the hospital until surgery will be a protective measure as well.

The nurse is caring for a patient with Chronic Kidney Disease Stage 3. The nurse assists the patient to get ready for their meal. Which of the following meals would the nurse know is the most appropriate? A. The tray with grilled chicken, corn, mashed potatoes, roll B. The tray with roast beef, salted green beans, protein supplement drink, iced tea C. The tray with eggs, cheese slices, fresh banana, pineapple juice D. The tray with ham, cola beverage, tomato salad

A In patient with kidney disease, the diet should be restricted in potassium, sodium, fluid, and phosphorus, careful with proteins. The diet in A is the most appropriate of the options presented TIP: When answering diet questions—know what needs to be present or avoided and then look at each option and "place it on a scale in your thinking" each one tipping that scale a little more in one direction of "okay to have" or "should not have"—if there is something that is REALLY bad it can have a little more weight, then see which one "weighs" more—this will help because many times diet questions will have some items that would be avoided in each as it is not realistic that people eliminate things completely from their diet.

A patient has a history of osteoarthritis. Which signs and symptoms should the nurse expect to find on physical assessment? A.Joint pain, crepitus, Heberden's nodes B. Hot, inflamed joints; crepitus; joint pain C.Tophi, enlarged joints, Bouchard's nodes D.Swelling, joint pain, and tenderness on palpation

A Joint pain, crepitus & Heberden's nodes all point to osteoarthritis. I don't like "B" - because hot & inflamed is related to RA (not OA). I don't like "C" - because tophi are associated with gout, not OA. I don't like "D" - because OA typically does not involve swelling & tenderness on palpation. (There may be mild joint swelling after excessive activity, but that is not typical.)

A patient is being discharged after 1 week of IV antibiotic therapy for acute osteomyelitis in the right leg. Which information will be included in the discharge teaching? A. how to apply warm packs to the leg to reduce the pain B. how to monitor and care for a long term IV catheter C. the need for daily aerobic exercise to help maintain muscle strength D. The reason for taking oral antibiotics for 7-10 days after discharge

B

An infusion of one unit of packed red blood cells is started at 2:30 AM by the night shift nurse. During the 6:30 AM assessment, the nurse observes that approximately 25% of the unit is left to infuse. The priority action by the nurse in this situation is which of the following? A. Stop the infusion, document the amount of volume infused on the intake/output record B. Send the first voided urine to the lab for analysis, and notify the provider of the situation C.Administer the standing order for acetaminophen (Tylenol) and diphenhydramine (Benadryl) D. Notify the day shift nurse during shift change report that the infusion needs to be completed

A Nothing indicates that there has been a problem with the blood transfusion other than it has been hanging for 4 hours. 4 hours is the max time limit to infuse a unit of blood and it must be taken down. It is always important to document any amount of volume that went into the patient.

The nurse is assessing a patient who is taking alendronate Fosamax for osteoporosis. The nurse knows that this medication: A. helps replace low calcium levels B. can lead to uncontrolled weight gain C. must be taken with a full glass of water D. is always given after primary treatment with estrogen therapy

C

The nurse is caring for a patient with pernicious anemia. The nurse knows that which of the following meal trays would be the best to meet this patient's dietary needs? A.Baked mackerel, a bran muffin, and a glass of milk B. Salad with a whole grain roll, and a glass of orange juice C. Grilled chicken with green beans, and a glass of ice tea D. Liver with a baked potato, a salad and a glass of water

A Pernicious Anemia is a type of B12 anemia So a diet that meets the needs of B12 deficiency would be best: Red meat (liver) Fish (mackerel) Enriched grains (bran) Milk Other dairy Eggs

A nurse preceptor tells the nurse orientee that they will be caring for a patient with lupus for the day. The nurse orientee looks at the list of patients on the floor and knows that which of the following patients is most likely the one with lupus? A.The 34 year old African American female admitted with pain and fatigue. B. The 22 year old Asian male admitted with a red raised rash over his face and torso. C. The 43 year old Caucasian female admitted with confusion and headaches. D. The 28 year old Hispanic male admitted with facial swelling and ulcerations in the mouth.

A SLE strikes nearly 10 times as many women as men Most common in women between ages 20 and 40. SLE affects more black women than white women Frequency of symptoms at onset: Fatigue: 50% Fever: 35% Arthritis (pain): 60s% Skin: 73% Confusion: 20% Mucous membrane lesion: 20% So the Female, 30s, pain, fatigue is the most likely patient with lupus.

Where does bradycardia originate? A. AV node B. left atrial wall C. SA node D. Purkinje fibers

C

The nurse is caring for a patient with chronic kidney disease. The patient is experiencing metabolic acidosis and appears to be symptomatic because of it. The nurse knows that which of the following would be an appropriate response to this condition? A. Sodium bicarbonate supplements B. An anti-anxiety medication C. Normal Saline IV fluids D. An antiemetic medication

A The metabolic acidosis of chronic renal failure usually produces no symptoms and requires no treatment, but if it is symptomatic or if it does need treatment—the appropriate response is sodium bicarbonate supplements. You don't want to give an renal failure person IV fluids (if they can be avoided), no justification for anti anxiety or antiemetic and thinking of acid/base elements—anxiety usually impact respiratory, slowing down breathing (increasing CO2—more acid, more acidosis), antiemetic reduces vomiting and loss of H+ (increasing acid—more acidosis).

A patient was admitted to the hospital yesterday after a reported history of coffee-ground hematemesis. Following the morning assessment, the nurse is concerned that the patient is having acute bleeding. Which of the following clinical manifestations would best support the nurses concern that the patient is bleeding? A. Fatigue with syncopal event B. Weakness with pale appearance C. Jugular vein distention D. Moist mucous membranes

A There are acute and chronic symptoms that can overlap however in the acute onset of bleeding you may have tachycardia, hypotension, angina, and shortness of breath, weak pulses, dry mucous membranes, decreased UOP, etc.

Which HCP order should the nurse implement first? A. explain to the patient the NPO status B. insert the nasogastric tube and hook to suction C. Take the vital signs D. insert the IV and start IVFs

C

An obese patient is having worsening shortness of air (SOA) and chest pain. The provider feels it will be necessary to do a transesophageal echocardiogram (TEE), and explains the procedure to the patient. Which of the following statements by the patients would require follow up by the nurse? (Select All That Apply). A. "I am just so glad I won't have to skip breakfast, I need to eat every 4-6 hours around the clock." B. "I had no idea it was possible to see the function of my heart with a probe." C. "I am worried, I have such a sensitive gag reflex, I will never be able to hold still long enough." D. " I feel better that there is a special lab where this will take place." E. "I think the provider is going to be surprised that my arteries are pretty clogged."

A, C, E A TEE will be able to show the function of the heart with better pictures (especially for obese patients with large amounts of skin on their chest), but it won't look inside the vessels. The patient will need to be NPO for at least 6 hours prior to the exam. They will receive medication to relax so they will not gag and cough during the procedure and it will be done in a vascular lab.

The Nurse Preceptor is talking to the Nurse Orientee about the "PQRST" Assessment of Angina. Which of the following questions by the nurse orientee is an example of "Q" of the assessment. (Select All That Apply). A. Can you describe what the pain feels like? B. Can you tell me what you were doing when the pain started? C. Can you point to where your pain started and where it is hurting now? D. Can you tell me if it is constant ache or a sharp stabbing pain? E. Can you tell me when you first noticed the pain? F. Can you rate the pain for me on a scale from 1-10?

A, D Q is the Quality of the pain—the description of what it feels like, sharp, stabbing, dull, constant, etc. (P = provokes it?; Q = quality?; R = region/radiation?; S = severity; T = timing)

The nurse is preparing an In-Service on the risk factors for Coronary Artery Disease (CAD). Which of the following should be included in the in-service? (Select all that apply). A. A history of Diabetes Mellitus B. Elevated high-density lipoprotein (HDL) levels C. A history of ischemic heart disease D. Current cigarette and cigar smoking E. Weekly alcohol intake, occasionally to excess F. Hypertension and hyperlipidemia

A, D, F Risk factors of CAD: Obesity, smoking, positive family history of CAD, hyperlipidemia, hypertension, PMH of DM. Elevated HDL levels aren't a risk factor for CAD; in fact, increased HDL levels seem to protect against CAD. Ischemic heart disease is another term for CAD, not a risk factor. Alcoholism hasn't been identified as a major risk factor for CAD.

A patient sustains a crushing injury to the lower left leg and a below the knee amputation is performed. for which common clinical manifestations of a pulmonary embolus should the nurse assess this patient? Select all that apply. A. Sharp Chest pain B. acute onset of dyspnea C. pain in the residual limb D. absence of the popliteal pulse E. blanching of the affected extremity

A,B

The nurse is caring for a patient receiving chemotherapy. The patient has developed chemotherapy-induced thrombocytopenia. Which instructions should the nurse provide to the patient and caregiver? Select all that apply. A.Shave only with an electric shaver. B.Avoid blowing the nose forcefully. C.Reduce water intake. D.Use a suppository if required. E.Use an alcohol-based mouthwash.

A,B The nurse should instruct the patient to shave only with an electric shaver and avoid the use of blades. The patient should avoid blowing the nose forcefully; instead, gently pat it with a tissue. The patient should drink plenty of fluids to prevent constipation. The patient should avoid using a suppository without the permission of the health care provider; the patient may be prescribed stool softeners. Alcohol-based mouthwashes should be avoided, as they can dry the gums and increase bleeding.

The nurse is preparing an in-service on acute interventions of pneumonia. The nurse knows to include which of the following statements in the in-service? (Select all that apply.) A.Mobility is very important, so the patient needs to be out of the bed and walking daily. B. Encourage fluids whenever you are in the patient's room, & keep a pitcher of water handy. C.It is okay for the patient to take a nap during the day; this can be part of the healing process. D.Ensure the antibiotics have been ordered for any patient with a pneumonia diagnosis. E. Ensure the patient uses the incentive spirometer, but be sure they are monitored while they do.

A,B,C When thinking of nursing interventions for a patient with pneumonia—remember: ambulation is important. Force fluids and encourage oral intake. Allow for rest and energy conservation in between activities. While most patients will likely be on antibiotics, it is not a must for any and all patients with pneumonia—follow cultures and provider orders appropriately. Good pulmonary toilet is important and that can incorporate the use of incentive spirometer—while the nurse may need to provide instruction and can observe the patient when they are in the room, it is not necessary to monitor the patient, and they should be encouraged to use it, even when no one is present.

A patient diagnosed with heart failure, suddenly develops dyspnea at rest, disorientation, confusion, and crackles in the lying bases on auscultation, what are the important nursing interventions? Select all that apply. A. insert a foley catheter B. monitor urinary output C. administer nasal oxygen D. administer a prescribed rapid-acting diuretic E. place the patient in a modified trendelenburg position F. administer the ordered 500ml IV bolus of normal saline solution

A,B,C,D

A patient is diagnosed with osteoporosis. Which statements would the nurse include when teaching the patient about the disease? Select all that apply. A. Osteoporosis is common in females after menopause B. osteoporosis is degenerative disease characterized by a decrease in bone density C. the disease is inherited caused b an inability to tolerate milk products D. osteoporosis can cause pain and injury E. passive ROM exercises can promote bone growth F. weight bearing exercise would be avoided

A,B,D

The nurse is caring for a patient with CKD stage 4. The nurse is concerned that the patient needs dialysis. Using the principles of SBAR communication, the nurse knows that which of the following would be included in the Background communication to support the nurses assessment that the patient needs dialysis? (Select All That Apply) A. The patient has worsening confusion B. The patient has an increasing number of PVCs C. The patient is complaining of pruritus D. The patient has bilateral crackles on auscultation E. The patient is experiencing flank plan F. The patient has anemia and fatigue

A,B,D -- The patient has worsening confusion which could be a sign of uremia that is a build up of waste products that affect mental status --The patient has an increasing number of PVCs which could likely be related to electrolyte imbalances (hyperkalemia most likely, maybe hypermagnesemia) --The patient is complaining of pruritus—this could be and is likely an expected finding, but does not indicate a need for dialysis --The patient has bilateral crackles on auscultation which could be related to the inability to rid the body of excess fluid --The patient is experiencing flank plan—this could be, and may need follow up, but is not an indication for dialysis --The patient has anemia and fatigue—this could be, and may need intervention, but dialysis will not improve the level of anemia and related fatigue is not an indication for dialysis

The nurse is caring for A patient who has crackles in the lower lobes, 2+ pitting edema, and dyspnea with minimal exertion. The nurse knows that Which of the following findings would correlate with this assessment? (Select all that apply). A. The patient has an elevated preload B. The patient has an elevated B-type natriuretic peptide (BNP) C. The patient has an elevated Troponin level D. The patient has jugular vein distention E. The patient has oliguria

A,B,D,E Preload is the stretch that is felt in the ventricles during diastole and is associated with cardiac volume in the heart. If a patient has excess volume in their vasculature they will have an increased preload BNP is a neurohormone that's released from the ventricles when the ventricles experience increased pressure and stretch, such as in heart failure. A BNP level greater than 51 pg/ml is commonly associated with mild heart failure. As the BNP level increases, the severity of heart failure increases. If there is excess volume in the vasculature—it can cause jugular vein distention Oliguria can result in the decreased perfusion to the kidney secondary to the HF

A patient with laryngeal cancer has undergone a laryngectomy and is now receiving radiation therapy to the head and neck. The nurse would monitor the patient for which adverse effects of external radiation? select all that apply. A. Xerostomia B. Stomatitis C. thrombocytopenia D. cystitis E. mucositis F. leukopenia

A,B,E

The patient is admitted with sinus tachycardia. To treat the dysrhythmia, the nurse will look for potential causes. Which causes will the nurse look for in this patient? Select all that apply. A. sympathomimetic drugs B. Anxiety C. foods with vitamin K D. Hypothermia E. anemia F. beta-blockers

A,B,E

Which findings would the nurse anticipate in a patient with a new diagnosis of osteoarthritis? A. Negative rheumatoid factor RF B. increased erythrocyte sedimentation rate ESR C. no inflammation in joint fluid D. increased serum creatinine E. Increased CRP

A,C

A patient who has apnea during sleep would require which of the following interventions? Select all that apply. A. Refer to primary healthcare provider B. Restrict family members from sleeping in the same room C. Assess sleep routine/hours D. Have the patient keep a sleep diary E. Teach pursed lip breathing

A,C,D

The nurse is caring for a patient with a recent femur fracture. The nurse is concerned that the patient has developed compartment syndrome. Which of the following assessment findings would provide the greatest support this concern? (Select all that apply). A.The inability to perform active movement when asked B.A palpable growth in and around the bone tissue C.Pain rating 9/10, throbbing and unresponsive to analgesics D.Pulses distal to the fracture are obtained by Doppler only E.Capillary refill is 4 seconds in the toenails of the injured leg

A,C,D,E When compartment syndrome is present, the client will not be able to perform active movement A bone tumor will show growth in and around the bone tissue, and is not really specific to compartment syndrome. Symptoms of compartment syndrome include pain, especially pain that does not response to interventions decreased movement and absent (very weak) pulses distal to the fracture site. It would result in a delayed cap. Refill of the extremity not a brisk cap refill—but > 3 seconds.

A nurse is reviewing the laboratory reports of a patient with acute pericarditis. The electrocardiogram report shows an elevated ST segment. What laboratory abnormalities would the nurse expect to find in this patient? Select all that apply. A.Elevated C-reactive protein (CRP) B. Decreased erythrocyte sedimentation rate (ESR) C. Elevated troponin levels D. Decreased hemoglobin count E. Elevated white blood cell count

A,C,E Elevated CRP is a common laboratory finding in acute pericarditis. It is caused by the inflammation of the pericardial sac. Troponin levels are increased with the elevation of the ST segment, which indicates concurrent myocardial damage. Leukocytosis commonly occurs because of inflammation. The ESR is elevated due to inflammation of the pericardial sac. A decreased hemoglobin count is not associated with acute pericarditis.

A nurse is reviewing the laboratory reports of a patient with acute pericarditis. The electrocardiogram report shows an elevated ST segment. What laboratory abnormalities would the nurse expect to find in this patient? Select all that apply. A. elevated CRP B. decreased ESR C. Decreased Hgb D. Elevated WBCs E. Decreased troponin levels

A,D

A patient with a positive Mantoux test result is taking isoniazid INH for treatment of TB. In assessing for side effects of this medication, the nurse should specifically include which of the following during the clinic visit? A. Scleral assessment B. Assess for peripheral edema C. Assess for dyspnea D. note return rate of capillary refill

A.

Which of the following dysrhythmias is most likely to be associated with a reduction in cardiac output and loss of atrial kick? A. sinus arrhythmia B. premature atrial contractions C. atrial fibrillation D. sinus tachycardia

C

A patient who is to receive external radiation for cancer says to the nurse, "My family and friends say that I will get a radiation burn." Which response by the nurse is best? A. Daily application an emollient will prevent the burn B. A localized skin reaction does usually occur C. It will be no worse than a sunburn D. They may be misinformed

B

A 92 year old woman has bilateral osteoarthritis of the knees. THe nurse teaches the patient that the most beneficial measure to protect the joints is to: A. Use a wheelchair to avoid walking as much as possible B. Exercise regularly and maintain a well balanced diet C. Use a cane for ambulation to relieve the pressure on the hips D. Avoid sitting at a 90 degree angle or full flexion of the knees.

B

A HCP admits a patient with a history of IV drug abuse to the medical surgical unit for evaluation for infective endocarditis. Nursing assessment is most likely to reveal that this patient has: A. retrosternal pain that worsens during supine position B. oslers nodes and splinter hemorrhages C. pulsus paradoxus D. a scratchy pericardial friction rub

B

A nurse is checking lab values on a patient who has crackles in the lower lobes 2+ pitting edema and dyspnea with minimal exertion. Which lab value does the nurse expect to be abnormal? A. Potassium B. Btype natriuretic peptide C. C reactive protien D. erythrocite sedimentation rate

B

A nurse is reviewing the medical record of a male patient with cancer. The health care provider has prescribed filgrastim 400 mcg subQ once daily. The nurse reviews the laboratory report and determines treatment has been effective when: A. Hgb> 12g/dl B. WBC>3,500/mm3 C. Platelets>92,000/mm3 D. Hct>35%

B

A woman of african descent is admitted to the hospital after sustaining a hip fracture. she is 5 feet 4 inches tall and weighs 96lbs. She has five children. She reports tht she just stepped forward and fell. The results of her bone density tests indicate she has osteoporosis. Which is the greatest risk factor for osteoporosis? A. her race B. her weight C. her parity (how many children she had D. her balance

B

After undergoing surgery the previous day for a total knee replacement, a patient states that he doesn't feel ready to ambulate yet. What should the nurse do? A. notify the provider of the patient's refusal to ambulate B. discuss the complications that the patient may experience if he doesn't cooperate with the care plan C. do nothing because the patient has the ultimate right to determine his degree of participation D. document the patient's refusal to ambulate

B

Five minutes after receiving the ordered preoperative midazolam (Versed) by IV injection, the patient asks to get up to go to the bathroom to urinate. Which action by the nurse is most appropriate? a. Assist the patient to the bathroom and stay with the patient to prevent falls. b. Offer a urinal or bedpan and position the patient in bed to promote voiding. c. Allow the patient up to the bathroom because medication onset is 10 minutes. d. Ask the patient to wait because catheterization is performed just before the surgery.

B

The female patient diagnosed with osteoporosis tells the nurse that she is going to perform swim aerobics for 30 mins every day. Which response would be most appropriate by the nurse? A. praise the patient for committing to do this activity B. explain that walking 30 minutes a day is a better activity C. encourage the patient to swim every other day instead of daily. D. discuss that sedentary activities help prevent osteoporosis.

B

The nurse teaches a patient with osteoporosis about dietary modifications to improve calcium intake. which patient food choices indicate the need for additional teaching? A. one glass of milk, cottage cheese, and one cup yogurt B. boiled egg, carrot and lettuce salad, and a fresh cut apple C. spinach soup and roasted salmon with cheddar cheese dip D. steamed broccoli salad, steamed oysters, and one cup ice cream

B

The nurse teaches the patient to perform isometric exercises to strengthen the leg muscles after arthroplasty. Isometric exercises are particularly effective for this patient because they: A. do not require specialized equipment B. strengthen the muscles while keeping the joints stationary. C. involve patients in their own care and thus improve morale D. prevent joint stiffness

B

The nursing student is reviewing facts about the Shiley trach to the patient and his wife, as he is undergoing a tracheostomy in the morning. Which statement could be included in the discussion? A. "Shiley trachs are metal." B. "Shiley trachs have a string with an inflatable balloon attached." C. "Shiley trachs have a reusable inner cannula." D. "shiley trachs do not need an obturator to be inserted."

B

The patient has undergone a posterior hip arthroplasty. Which of the following assessment findings should be reported to the provider? A. A total of 100 ml of red drainage in the auto-transfusion drainage system. B. urinary output of 60ml of clear yellow urine in the past three hours C. moderate pain relief after using the PCA D. Cool toes, distal pulses palpable and pale nail beds bilaterally

B

The patient with chronic bronchitis is admitted to the medsurg unit. To best help this patient maintain a patent airway and achieve maximal gas exchange, the nurse should: A. administer scheduled anxiolytics daily to control related anxiety B. Instruct the patient to drink 2 L of fluid daily C. Administer pain medication as ordered D. Maintain the patient on bedrest.

B

What should the nurse include in the plan of care for a patient who just had a posterior lumbar laminectomy? A. encourage the patient to cough B. reposition the patient by log rolling C. Assess the patient for indications of peritonitis D. instruct the patient to bend the knees when turning

B

When caring for a patient with SLE, the nurse recognizes which is the most serious complication of the disorder? A. Polycythemia B. renal failure C. hepatitis D. Hypothyroidism

B

Which symptom indicates the patient with TB is contagious? A. + Mantoux test B. Sputum + for AFB C. Weight loss and night sweats D. Calcification noted on CXR

B

A patient is admitted to the telemetry floor following myocardial infarction. The following vital signs are seen: A heart rate of 45 beats per minute with a BP of 115/65 mmHg. The patient is awake and alert when doing the physical exam. Which of the following interventions would be the highest priority for the nurse in this scenario? A. Initiate CPR B. Insert an intravenous line C. Bring the defibrillator to the bedside D. Prepare for pacemaker insertion

B Atropine is the drug of choice for symptomatic bradycardia. At this point in time, the nurse does not know if the patient will become symptomatic or not. Inserting an intravenous line will permit the administration of Atropine should symptoms occur. Cardiopulmonary resuscitation is not indicated with this information and a ventricular dysrhythmia has not been documented, therefore, CPR and defibrillation are not options. A pacemaker may be needed if Atropine or other medications are not successful in increasing heart rate—it is to early to tell and the patient is stable, so this is not the priority

The nurse is talking with a patient that is scheduled for surgery in 3 hours. The nurse asks the patient if they have remained NPO (nothing by mouth) overnight. The patient replies that they had some coffee for breakfast, but they didn't eat any food. The nurse knows that which of the following responses is correct? A. "Oh no, nothing by mouth—means, nothing. I will contact the team. I am afraid we may have to postpone your surgery." B. "That should be fine as long as the coffee was black. Did you use any cream or sugar in it?" C. "Your stomach need to remain empty for at least 6 hours after having fluids. I think we can switch your time, but I have to check." D. "Was it more than 8 oz? If so, we will probably have to cancel the surgery for today."

B Preoperative fasting recommendations for a patient that had black coffee are a minimum of 2 hours (but in the "real world" clinical setting, surgery teams will likely prefer a little longer -more like 6-8 hours—know your foundational information for exam purposes and you will know the correct answers.)

A patient with gout asks the nurse why a low-purine diet is recommended. What explanation should the nurse provide? A.Purine causes the joint pain associated with gout. B.The metabolism of purine results in the formation of uric acid. C.Urine retention can result from a high purine level and thus increase the uric acid level. D.Limiting purine can decrease the incidence of headaches and dizziness that occur with gout.

B Purine, an end product of protein digestion, breaks down into uric acid. The uric acid then acts to form crystals in joints, usually beginning the great toe, which produces intense pain. Purine does not cause the joint pain of gout. Urine retention will not result in an increased uric acid level. Limiting purine will not relieve headaches or dizziness.

The nurse is caring for a patient with a lower respiratory infection. The current patient vital signs are as follows: T: 102 F (38.8 C), HR: 110 bpm, BP: 122/72 mmHg RR: 32 breaths/min SpO2: 86% on 2L nc. The nurse notes circumoral cyanosis. What should be the priority action by the nurse caring for this patient? A.Encourage coughing and deep breathing B. Increase the supplemental oxygen per order C.Place the patient in a side lying position D. Instruct the patient to use pursed lip breathing

B The immediate needs of this patient are oxygenation. Due to the cyanosis and decreased oxygen saturation, increasing the oxygen will immediately improve gas exchange. Encouraging deep breathing and coughing, and maintaining in a side-lying position, will not improve breathing and may exacerbate the situation. Pursed-lip breathing may be appropriate for a client with COPD—there was nothing to indicate that in the stem.

Upon hearing a murmur at the mitral area, the nurse interprets that incomplete closure of this valve results in backflow of the blood from the: A. Left atrium to the pulmonic artery B. Left ventricle to the left atrium C. Right atrium to the superior vena cava D. Right ventricle to the right atrium

B The mitral valve lies between the left atrium & left ventricle. (The tricuspid valve lies between the right atrium & right ventricle. The pulmonic valve lies between the right ventricle & pulmonary artery. The aortic valve lies between the left ventricle and the aorta.)

The nurse is completing the pre-op admission assessment of a patient that will be having gastric by-pass surgery. The patient says, "I have been waiting for years to have this surgery so that there wouldn't be any real risks to it." Which of the following statements by the nurse would be the most appropriate? A."I am sure you must be excited now that the time has come." B. "Can you tell me a little more about what risks you are aware of?" C. "I think I better call the surgeon and have them come and talk to you again." D. "Are you sure you aren't nervous about anything?"?"

B The nurse should evaluate the patient's understanding of the procedure. The patient may or may not be aware of the risks. If they are not aware, then the surgeon would need to be contacted to come and speak with the patient again. The nurse would not just want to support and agree with the patient without follow-up. Asking an open-ended question is better than an yes/no The question—aren't you nervous about anything? Might actually make the patient a little scared.

Which of the following findings would be expected in a patient with chest trauma, rib fractures, and respiratory acidosis? A. Kussmaul respirations due to inability to take deep breaths B. A massive diffusion disturbance due to the rib fractures C. Hypoventilation due to inability to take deep breaths because of pain D. Hyperventilation due to inability to take deep breaths, so short fast breaths are more comfortable

C

A patient has just returned to their room with a cast on their leg after an open reduction of a fractured femur. The nurse notes a 6 cm by 10 cm area of blood on the splint. What is the priority action by the nurse? A.Use gauze pads to reinforce the bloody area B.Obtain a complete set of vital signs C.Alert the provider of post-operative hemorrhage D.Document the size and location of the drainage

B The priority action for the nurse to take is to assess the patient's vital signs for evidence of hemorrhage, such as tachycardia and hypotension. After the nurse has assessed the patient, the provider should be notified with the findings. Gauze pads may be placed over the bloody drainage after the patient is assessed and the provider notified. The size of the bloody drainage should be documented after the patient is assessed and the provider notified.

The nurse is caring for a patient that was admitted with peptic ulcer disease. The patient reports being nauseated most of the day and is now feeling light-headed and dizzy. Based upon these findings, which of the following would be the priority nursing action? A. Administer the prn (as needed) antacid that is ordered B. Obtain a complete set of patient vital signs C. Document the findings and reassess in an hour D. Notify the provider of the patient's symptoms

B The symptoms of nausea and dizziness in a patient with peptic ulcer disease may be indicative of hemorrhage and should not be ignored. prompt intervention is essential in a patient who is potentially experiencing a gastrointestinal hemorrhage. The appropriate nursing actions at this time are for the nurse to monitor the patient's vital signs and notify the HCP of the patient's symptoms. To administer an antacid hourly or to wait 1 hour to reassess the patient would be inappropriate

The nurse has just finished teaching a patient with osteoporosis about a variety of activities they could do that would help build the density in their bone. Which of the following statements by the patient indicates the teaching has been successful? Select all that apply. A. "I had no idea swimming was such a good activity for my bones." B. "I understand that on days when my joints are sore, walking would be okay instead of running." C. "I have a friend that does aerobics at the gym, I could go with them to a class sometime." D. "My spouse is always asking me to go on bike rides with them, this will be great." E. I will incorporate weight lifting into my weekly schedule of exercise."

B, C, E Swimming, biking, and other non-weight-bearing exercises do not maintain bone mass. (Bicycling does not qualify as weight-bearing exercise because you don't support your weight against gravity.) Walking and running, which are weight-bearing exercises, do maintain bone mass.

The nurse is caring for a patient that has just had a plaster cast applied for a fractured radius. The patient is stable and able to be discharged home. Which of the following instructions should the nurse include in the discharge teaching? (Select All That Apply). A."Use a hair dryer to dry the cast more quickly once you are home." B."Refrain from strenuous activities for the first few days." C."Pay attention to the movement and sensation of your fingers." D."You can take acetaminophen (Tylenol) if you have mild discomfort." E."You may apply very small amounts of powder to the inside of the cast if you want." F."Avoid using a hanger or something sharp inside the cast, but a straw would be okay."

B,C,D Use of a hair dryer to complete the drying of the cast is not encouraged because the hair dryer only dries the outside of the cast, it dries the cast unevenly, can cause burns to the tissue, and can crack the cast, causing poor alignment to the injured bone. For the first few days after application of a plaster or fiberglass cast, the patient should not engage in strenuous activities, to minimize swelling that would cause the cast to become too tight. Movement and sensation of the fingers need to be checked several times a day for the first few days. It is appropriate to take acetaminophen every 4 to 6 hours, for discomfort. Powder should not be used, because it can cake under the cast. The nurse should instruct the patient not to place sharp objects, such as straws or hangers, down the inside of the cast to avoid the risk of impairing the skin and causing infection.

Surgery is not without risks. Therefore, patients receive a lot of information and pre-operative teaching to try and limit complications. Which of the statements below is correct in regards to pre-operative teaching? (select all that apply) A.If you have a latex allergy, you will need to be pre-medicated with diphenhydramine (Benadryl) prior to surgery B. If you smoke, you should stop smoking at least 6 weeks prior to surgery C. The only way to know if you will have malignant hyperthermia, is to actually have a surgery D. Occasional alcohol use is not necessary to mention, but illicit drug use is important to be honest about E. It is okay to share anything that seems important to you, even if it isn't asked about specifically

B,C,E If you have a latex allergy, you will want to tell the staff and they will have an OR that is free of latex products. If you smoke, you should stop smoking at least 6 weeks prior to surgery. Though a family history can be an indicator of a risk for malignant hyperthermia, the only way to know if you have malignant hyperthermia, is to have a surgery and monitor closely. Occasional alcohol use should also be mentioned to the team, along with illicit drug use—just so the team knows all parts of your personal puzzle pieces. It is always okay to share anything that seems important to you, even if it isn't asked about specifically

The nurse had just completed teaching a patient with newly diagnosed peptic ulcer disease about dietary modifications they will need to make. Which of the following statements by the patient indicates an understanding of that teaching? (Select All that Apply.) A. "I understand that I will need to eat a bland, soft diet from now on." B. "I should make sure that my last meal is small and an hour before I lay down." C. " I will be sure to drink several glasses of milk with each meal." D. "There goes my coffee in the morning and my wine in the evening." E. "I am so disappointed, I love strawberries and almonds for my snack at work."

B,D Caffeinated beverages and alcohol should be avoided because they stimulate gastric acid production and irritate gastric mucosa. Eating smaller meals is a good rule of thumb, but it is important to wait a few hours prior to laying down. The patient should avoid foods that cause discomfort; however, there is no need to follow a soft, bland diet. Milk in large quantities and at each meal is not recommended because it actually stimulates further production of gastric acid. There is no reason that a patient cannot have berries and/or nuts for a snack.

A nurse is caring for a patient that has a hiatal hernia. The patient says they have abdominal and sternal pain after eating and when lying down. Which of the following statements by the nurse would be appropriate? Select all that apply. A. Avoid all activity 30 minutes after eating B. Limit caffeinated beverages and spicy foods C. Eat three evenly spaced meals everyday D. Sleep with their head elevated on two pillows E. Maintain weight at an ideal BMI

B,D,E A hiatal hernia occurs when a portion of the stomach pushes through the diaphragm. A hiatal hernia may cause abdominal and sternal pain after eating. The discomfort is associated with reflux of gastric contents. To reduce gastric reflux, the nurse would instruct the client to: avoid caffeine, and spicy foods; sleep with the upper body elevated; lose weight, if obese; remain upright for 2 hours after eating, but no need to avoid ALL activity; eat small, frequent meals.

The nurse is caring for a patient that is nervous about having a MRI (magnetic resonance imaging) to evaluate the status of a lung mass that was detected on a previous x-ray. The nurse explains the procedure to the patient. Which of the statements by the patient requires follow-up? (Select all that apply). A."I don't like small spaces, but I think the medication will make that easier." B. "I know this will be worth it, when they can finally get the tissue they need for a diagnosis." C. "I have heard it is pretty loud, it is nice to know they have ways to lessen the noise." D."I have a sensitive gag reflux, I am glad I will be asleep before they put the scope down my throat." E. "It is a good thing I don't have an iodine allergy, or I couldn't have this procedure at all."

B,D,E MRIs can be used in patient with lung masses to further assess for metastasis, but no tissue will be removed at this time for a biopsy. While contrast may be used—it is not iodine based, and so the allergy is irrelevant in this case. Closed MRIs can be distressing; especially to those with claustrophobia, and often a sedative can be used to assist with this. MRIs can be loud and distracting to patients, but there are headphones/ear plugs and other interventions used to lessen this aspect. Scopes are used in bronchoscopy and other procedures but are not a part of the MRI.

A nurse is caring for a patient who has developed dysphagia and is unable to swallow. The patient is receiving around the clock opioid pain medications for cancer pain, and hospice has recently begum caring for the patient. What is the best nursing intervention in preparing for the patient's discharge? A. Contact the patient's HCP to ask to substitute a liquid form of medications for the pill form B. Teach the patient and family members to crush the pills and administer them with applesauce. C. contact the patient's HCP to discuss use of transdermal medications for pain control D. Teach the patient and family members about addiction that may occur as a result of regular opioid use.

C

A patient has a bone marrow aspiration performed. After the procedure, what is the first nursing action? A. Position the patient on the affected side B. Cleanse the site with an antiseptic solution C. Briefly apply pressure over the aspiration site D. Begin frequent monitoring of the patient's vital signs

C

A patient has a right above the knee amputation after trauma sustained in a work related accident. Upon awakening from surgery the pateint states "what happened to me? I dont remember a thing?" A. Tell me what you think happened B. you will remember more as you get better C. You were in a work related accident this morning D. It was necessary to amputate your leg after the accident

C

A patient in the telemetry unit is on a cardiac monitor The monitor technician notices there are no ECG complexes and the alarm sounds. What is the first action by the nurse? A. Begin CPR B. call the rapid response team C. Assess the patient and check lead placement D. Press the record button to get an EKG strip

C

A patient is 5 hours s/p abdominal surgery. The oncoming nurse notes in report that there has been no drainage noted from the Hemovac since surgery. Which finding may explain the absence of the drainage? A. The patient has been lying on his side for 2 hours with the drain positioned upwards. B. The patient has a NG tube in place that drained 400 mLs C. The hemovac drain isn't compressed; instead its fully expanded D. There is a moderate amount of dry drainage on the outside of the dressing.

C

A patient underwent a below the knee amputation secondary to sever arterial insufficiency. When instructing the patient in residula limb care, which statement by the nurse is correct? A. you should inspect the incision carefully when you change the dressing every other day B. You should wash the incision, dry it, and apply moisturizing lotion daily. C. You should rewrap the stump as often as needed D. you should elevate the stump on pillows at all times to decrease swelling.

C

A patient with SLE is getting ready for discharge. The nurse knows the patient has understood the patient teaching when the patient states she needs to what? A. Get as much exposure to sunlight as possible to help control skin rashes B. Be as active as possible between flare-ups C. Monitor body temp regularly D. Stop her corticosteroids when symptoms are relieved.

C

A patient with gout should be assessed by the nurse for which complication? A. Cirrhosis B. Gastric ulcer C. Renal calculi D. Pulmonary emboli

C

A patient with many home related responsibilities is diagnosed with osteoarthritis. She tells the nurse she is concerned that the disease will prevent her from doing her chores. Which suggestion should the nurse offer. A. Do all your chores in the morning when pain and stiffness are least pronounced B. do all your chores right after performing morning exercises to loosen up. C. Pace yourself and rest frequently especially after activities D. Do all your chores in the evening when pain and stiffness are least pronounced

C

After 3 months of supplemental iron therapy, there is no significant increase in the patient's Hgb level. Iron dextran is prescribed. What is the best way for the nurse to administer this medication? A. with a transdermal needle B. by massaging the injection site C. with the use of z-track injection D. by administering at a 45 degree angle

C

After a right total knee replacement, the patient's right leg is placed in a continuous passive motion machine. Nursing responsibilities when caring for a patient with this apparatus should include: A. adjusting the settings as needed to prevent patient discomfort B. anticipate increasing the range of motion settings at least every 8 hours. C. maintaining proper positioning of the leg on the CPM machine D. discontinuing the CPM therapy if the patient complains of pain with movement

C

On admission of a patient to the postanesthesia care unit (PACU) the BP is 122/72 mm Hg. Thirty minutes after admission, the BP is 114/62 with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate? A. Increase the IV fluid rate B. Notify the anesthesia care provider. C. continue to take vital signs every 15 minutes. D. Administer oxygen therapy at 100% per mask.

C

The nurse is assessing a patient in PACU who is recovering postoperatively from general anesthesia. The patient can give his name but is not sure about where he is or the time of day. What should the nurse do next? A. Notify the surgeon B. Rub the patient's sternum to arouse the patient C. tell the patient where he is and the time of day D. take the patient's blood pressure

C

The nurse is caring for a patient on the orthopedics floor why had an open reduction internal fixation two days ago for an open displaced tibial fracture. Which nursing diagnosis currently takes priority for this patient? A. Activity intolerance related to reconditioning B. Risk for constipation related to prolonged bed rest and side effects of opioids C. Risk for infection related to disruption in skin integrity D. Risk for impaired skin integrity related to immobility

C

The nurse is caring for a patient receiving a chemotherapy drug in a peripheral line that is a potential vesicant. The patient is currently not a candidate for a central line, The patient c/o pain at insertion site; redness noted. Which nursing action would be included in the follow-up care? A. Slow the infusion rate while notifying the HCP. B. Restart the infusion distal to the dc'd IV site. C. Assess the patient for skin sloughing. D. hold the site below the level of the heart.

C

The nurse is evaluating the pin insertion site of a patient's skeletal traction. which finding indicates a complication? A. presence of crusts around the pin insertion site B. serous drainage on the dressing C. prn moves slightly at insertion site D. patient does not feel pain at insertion site

C

The nurse is making patient rounds following shift report . which patient should the nurse assess first? A. A 38 year old woman receiving internal radiation therapy for cervical cancer B. A 77 year old man with lung cancer hospitalized for induction of high dose chemo therapy C. A 75 year old man with metastatic prostate cancer with a pathologic fracture of the femur who is in pain D. A 33 year old woman with cancer undergoing surgery for placement of a central venous catheter

C

The patient is being discharged with a long arm cast after a fall that resulted in a comminuted left forearm fracture. Which information would the nurse include? A. keep the left shoulder elevated on a pillow or two B. Avoid taking non steroidal anti inflammatory drugs. C. call the health care provider for numbness of the left hand D. keep the left hand immobile to prevent soft tissue swelling.

C

What is the most important assessment for the nurse to make when assessing peripheral pulses on a patient who has a fractured lower left extremity? A.Strong contractility and rate of pulse of the unaffected limb B. Color of the skin and rhythm of pulse above the affected fracture site C. Amplitude and symmetry of pulses in both extremities D. local temperature and visible pulsations bilaterally

C

When the nurse observes the patient's HR increase during inspiration and decrease during expiration, the nurse reports that the patient is demonstrating: A. normal sinus rhythm B.sinus bradycardia C. sinus arrhythmia D. sinus tachycardia

C

A patient is receiving IV therapy through a non-tunneled subclavian CVC. The patient is reporting pain in the chest and shoulder. Upon taking V.S., the nurse notes: T - 101.2; P - 116 & thready; R - 24 & dyspneic; BP has dropped to 86/48. What complication would the nurse suspect? A. Circulatory overload due to infusion of fluid B. Air embolism C. Systemic infection D. Infiltration at the site of insertion

C Infection should be suspected because of the increase in temperature, BP & respirations. (Remember "CLABSI"?) The decrease in BP & thread pulse could be pointing to shock - which happens if infection is severe enough. There is no indication of excess fluid, so circulatory overload is not the issue. Nor are there signs and symptoms of an air embolus or infiltration at the intravenous site.

The nurse preceptor is explaining the reasoning behind the most important reasons to type and cross-match a patient prior to giving them any blood products. Which of the following statements by the nurse orientee demonstrates their understanding of this explanation? A."This will eliminate the need to monitor vital signs closely once the blood transfusion begins." B. "With blood supply shortages, patients cannot receive universal donor blood if they are not in the ED." C. "Acute hemolytic reactions can be reduced if patients are type and crossed and the blood is checked carefully." D. "Most patients don't know what blood type they are, and the cross match is the way to find that out."

C It is always necessary to monitor vital signs closely, especially for the first 15 minutes of the transfusion. The most important reason to type and cross is to try to reduce (if not eliminate) the risk of the acute hemolytic reaction in patients. If people have an acute crisis (even on the floor) and they do not have a type and cross ready—universal donor blood can be given until other is ready. While many patients may not know their blood type: 1. That is not a most important reason to do this, and 2. The cross match wouldn't give you that information anyway.

The nurse is caring for a patient with a Shiley trach. The patient's spouse asks if the patient will be able to speak with the trach. The nurse knows that which of the following is the most correct response? A. It is hard to say, the provider would really have to answer that question for you. B. It is not possible to speak with a Shiley trach in because a Shiley trach has a cuff. C. We can have a Passy-Muir valve brought to the room and see how it goes. D. If the respiratory therapist changes the trach to a Jackson trach, the patient will be able to speak.

C It is within the scope of a nurse to educate a family member about the ability of a person to talk with a trach. A person can have a Passy Muir valve with a trach—Shiley or Jackson, it just has to have the cuff deflated. Passy Muir valves can be sent up from material management and the nurse can place it on the trach and assess how the patient does.

The patient is going to surgery tomorrow. The nurse collaborates with the patient when developing the teaching plan. What is the primary purpose of preoperative teaching? A. To determine whether the patient is psychologically ready for the surgery. B. To discuss the types of anesthesia that will be used for the surgery. C. To reduce the risk of postop complications. D. To explain the risks associated with the surgery.

C Preoperative teaching helps reduce the risk of postoperative complications by telling the patient what to expect and providing a chance for him to practice, before surgery, any required postoperative activities, such as breathing and leg exercises. It is the anesthesiologist's responsibility to teach about the anesthesia, not the nurse. The surgeon — not the nurse — is responsible for determining the patient's psychological readiness for surgery. The surgeon should describe alternative treatments and explain the risks to the patient when obtaining informed consent.

The nurse is caring for a patient that is scheduled for tonsillectomy because of frequent infections. The nurse knows that this surgery is semi-elective based on which of the following statements? A. This is an urgent medical condition, and needs to be completed within 2 hours B. There will be significant complications if not completed within 24 hours C.Though a priority, this is a low mortality risk surgery D. This surgery is only being done because the patient wants to have it

C Semi-Elective is a priority surgery that has a relative low morbidity and mortality risk, but does not have to be done within 24 hour. Elective Surgery is done at the patient's discretion to improve quality of life and timing is not an essential, low morbidity and low mortality risks Urgent surgeries—are done within 24 hours and complications can occur to the patient if delayed Emergency surgeries—are medically urgent and should not be delayed, ideally, they would be scheduled within 2 hours

The nurse is caring for a patient that has an external fixation device on their arm following repair of a complex radius fracture. The patient is complaining of pain. When looking at the fixation device, the nurse notes some redness and warmth around the pin sites. Using SBAR communication, which of the following statements would be included in "A" assessment? A."I think the patient needs increased pain medication for uncontrolled pain." B."The patient has an external fixation device on their arm." C."I am concerned that the patient may have an infection." D"I noticed warmth and redness around the pin sites."

C The assessment portion of SBAR is what conclusion the nurse draws about a situation. That means that both the statements of redness and warmth and external fixation are part of the background (story or picture). Feeling the pain may be uncontrolled is an assessment in SBAR, but does not have enough support in this question as it is unclear what the pain is, where it is, if it has been attempted to treat, what meds are orders, are they prn vs. scheduled, etc. The concern of infection is valid secondary to pain, redness, and warmth experienced by the patient. There may/may not be an infection, but the patient is at risk due to the external fixation and is experiencing some possible s/s of infection.

During a follow-up visit, a nurse finds that flexion contractures have developed in a patient with osteoarthritis (OA). Which factor may have led to this condition? A.Wearing shoes without insoles B.Elevating the legs 8 to 12 inches C.Using large pillows under the knees or head D.Placing the patient in prone position once daily.

C The use of large pillows under the knees or head may result in flexion contractures that keep the patient from straightening the knees (or neck) fully. Wearing shoes without insoles may result in pressure on painful metatarsal joints - though it has nothing to do with flexion contractures. The legs may be elevated 8 to 12 inches to reduce back discomfort associated with OA. Placing a patient in prone would serve to "extend" the hip flexors - so would be a good thing/not a bad thing.

The nurse is caring for a patient in skeletal traction with a Thomas leg splint and Pearson attachment. To help promote independence in the area of eating, which of the following meal selections would they recommend to the patient? A.A roast beef dinner with mashed potatoes and gravy, peas, and a cup of water. B.Tomato soup, grilled cheese sandwich, coleslaw, and a glass of iced tea. C.Chicken tenders with sauce, apple slices, ice cream sandwich, and milk in a carton. D.Spaghetti and meat sauce, carrot sticks, cherry cobbler, and apple juice in a can.

C To promote independent, self-feeding, the nurse should provide the patient with foods that can be eaten with the fingers or that do not spill easily. Fluids should be provided in containers with straws to prevent spills. Gravies, small round vegetables, and soups can easily spill from a spoon or fork—in traction, the patient is likely in a position that is less than ideal and certainly unfamiliar to their normal eating. Spaghetti can be very difficult to eat in traction (without dropping or spilling quite a bit).

The patient is in atrial fibrillation. The clinical instructor explains to the nursing student that with a-fib: A.The pulse always originates in the AV node. B. The impulse creates a saw-tooth effect on the telemetry monitor. C. There are multiple ectopic foci that want to be the initiator of the impulse. D. The patient will always exhibit some sort of hemodynamic instability upon assessment.

C With atrial fibrillation, there is total disorganization of atrial electrical activity due to multiple ectopic foci, resulting in loss of effective atrial contraction (kick) Atrial rate > 400 bpm R to R intervals are irregularly irregular The impulse originates in the atria, not the AV node. The saw tooth morphology is consistent with atrial flutter (not fib). If the ventricular rate is controlled, the patient will not likely exhibit hemodynamic compromise.

The nurse is caring for a patient that has been diagnosed with nephrotic syndrome. The nurse knows to anticipate which of the following findings? (Select All That Apply). A. Weight Loss B. Hematuria C. Proteinuria D. Peripheral Edema E. Elevated Serum Albumin

C, D Nephrotic syndrome is characterized by massive proteinuria caused by increased glomerular membrane permeability. Other symptoms include: peripheral edema, hyperlipidemia, hypoalbuminemia. Because of the edema, clients retain fluid and may gain weight. Hematuria is not a symptom related to nephrotic syndrome.

Which non-pharmacologic interventions should be included in the plan of care for a patient who has moderate rheumatoid arthritis? Select all that apply. A.Massaging inflamed joints B.Avoiding range-of-motion (ROM) exercises C.Applying splints to inflamed joints D.Using assistive devices as needed E.Selecting clothing that has Velcro fasteners

C,D,E Applying splints to inflamed joints, using assistive devices & selecting clothing that has Velcro fasteners are good strategies for the patient with rheumatoid arthritis. Massaging inflamed joints would only serve to aggravate the pain and is contraindicated. Active range-of-motion would be encouraged - not avoided - as prolonged avoiding of movement would only serve to aggravate the possibility of contractures.

A patient admitted with acute pericarditis is reporting severe sharp chest pain. To assist the patient to feel more comfortable the nurse should encourage the patient to assume which position? A. semi fowler's B. lie on side with knees sharply flexed C. flat on back with pillow under knees D. sit up and lean forward

D

A patient arrives in the emergency department reporting intense pain in the abdomen and tells the nurse that it feels like a heartbeat in the abdomen. Which nursing assessment would indicate potential rupture of an aortic aneurysm? A. The blood pressure and pulse are within normal limits, but the patient's skin color is pale and slightly diaphoretic B. The patient reports feeling nauseated C. The patient has been taking an antihypertensive for the past 3 years but forgot to take it today D. the patient reports increasing severe back pain

D

A patient hospitalized with osteomyelitis has a prescription for bed rest with bathroom privileges, with the affected foot elevated on two pillows. The nurse would place highest priority on which intervention? A. ambulate the patient to the bathroom every one to two hours B. ask the patient about preferred activities to relieve boredom C> allow the patient to dangle legs at the bedside every one to tow hours D. perform frequent position changes and ROM exercises

D

A patient with atherosclerosis is admitted with atrial fibrillation and is started on continuous heparin drip. What clinical finding enables the nurse to conclude that the anticoagulant therapy is effective? A. an elevated prothrombin time B/ An absence of the ecchymotic areas C/ A decreased viscosity of the blood D. An activated partial thromboplastin twice the usual value.

D

A patient with heart failure must be monitored closely after starting diuretic therapy. The best indicator for the nurse to monitor is: A. fluid intake and output B. urine specific gravity C. vital signs D. weight

D

A patient with pernicious anemia is receiving parenteral vitamin B12 therapy. Which patient statement indicates effective teaching about this therapy? A. "I will receive parenteral vitamin B12 therapy until my signs and symptoms disappear." B. "I will receive parenteral vitamin B12 therapy until my vitamin B12 level returns to normal." C. "I will receive parenteral vitamin B12 therapy monthly for 6 months to a year." D. "I will receive parenteral vitamin b12 for the rest of my life."

D

A white male age 43 with a tentative diagnosis of infective endocarditis is admitted to an acute acre facility. His medical history reveals diabetes mellitus hypertension and pernicious anemia; he underwent an appendectomy 20 years earlier and an aortic valve replacement 3 years before this admission. Which history finding is a major risk factor for infective endocarditis? A. Race B. age C. history of diabetes mellitus D. history of aortic valve replacement

D

After a knee replacement, the patient has a sequential compression device. What is a related nursing action with these devices? A. Elevate the SCD on 3 pillows. B. Change the settings on the SCD to make the patient more comfortable. C. Stop the SCD to remove dressings and bathe the leg. D. Discontinue the SCF when the patient is ambulatory.

D

An obese, malnourished patient has undergone abdominal surgery. While ambulating on the fourth postoperative day, she complains to the nurse that her dressing is saturated with drainage. Before this activity, the dressing was dry and intact. Which is the best initial action for the nurse to take? A. Splint the abdomen with a pillow and call the surgeon. B. Administer oxygen per nasla cannula C. Reinforce the existing dressing with another dressing D. Lift the dressing to assess the wound

D

The nurse is caring for a patient with RA who is receiving NSAIDS. Which intervention included in the care plan will help the nurse provide safe and effective care? A. Provide a potassium rich diet B. Administer vitamin C supplements C. Teach deep breathing and kegel exercises D. Monitor for symptoms of GI distress

D

The nurse is caring for an elderly patient with a history of chronic osteomyelitis of the left hip. The nurse knows that the most appropriate way to identify the causative microorganism is: A. blood culture B. wound culture C. magnetic resonance imaging of the hip D. bone or soft tissue biopsy

D

The nurse is providing teaching to a patient going home with an external fixation device in place. What should be included in the discussion? A. You will need someone to help you carefully remove the external fixator for your daily shower B. you will remain on bed rest with only bathroom privileges until the bone healing is over 50% complete C. you will need to take these prophylactic antibiotics daily until the fixator is removed D. you will need to check and clean the pin insertion sites every day.

D

The nurse receives evening report on a patient who underwent posterior nasal packing for epistaxis earlier in the day. The first assessment of the patient the nurse should make is the: A. patient's temp B. the level of the patient's pain C. the drainage on the nasal dressing D. The oxygen saturation by pulse oximetry

D

The teaching plan for the patient with RA includes rest promotion. What position of the involved joints should the nurse tell the patient to avoid when at rest? A. keeping all joints aligned B. Elevating the affected joints C. lying in a prone postion D. maintaining the joints in a flexed position

D

Which statement by a patient undergoing external radiation therapy indicates the need for further teaching? A. Ill wash my skin with mild soap and water only B. Ill not use my heating pad during my treatment C. Ill wear protective clothing when outside D. Im worried ill expose my family members to radiation.

D

what is the primary purpose of wrapping the residual limb with an elastic bandage postoperative? A. limits formation of blood clots B. Decreases likelihood of phantom limb sensation C. prevents hemorrhage and covers the incision D. supports the soft tissue and minimizes postop swelling

D

Which nursing intervention most likely prevents footdrop in a patient with osteomyelitis? A.Elevating the foot with the use of pillows B. Consistently plantar-flexing the affected extremity C. Encouraging the patient to change positions frequently D. Neutral positioning of the foot with the use of a foot splint

D A patient with osteomyelitis is at an increased risk for footdrop, which results in an abnormal gait. Neutral positioning of the foot with the use of a foot splint can reduce the risk of footdrop in the patient with osteomyelitis. Elevating the patient's foot on pillows can reduce the risk of edema. Asking the patient with osteomyelitis to plantar-flex the affected extremity does not help prevent foot drop. Encouraging the patient with osteomyelitis to change positions helps prevent complications associated with immobility and promotes comfort; does not directly prevent foot drop.

The nurse is caring for a patient with heart failure (HF) who is unable to answer multiple questions in a row. The spouse is present and trying to describe some of the symptoms. The nurse knows that this patient has orthopnea based on which of the following statements? A. "We don't even go out to eat anymore, he has such anxiety that he won't have enough oxygen." B. " He usually wakes up 2-3 times a night and can't catch his breath." C. "We could never take a trip out west, he has such terrible dependent edema." D. "He doesn't even come to bed any more, he just sleeps in his chair."

D Orthopnea is when there is shortness of air (SOA) in a supine position—CHF patients with this symptom will not want to lay flat. The airplane trip is describing trouble with dependent edema, maybe fatigue. The waking up multiple times a night is describing paroxysmal nocturnal dyspnea and staying at home all the time is describing exhaustion and fatigue.

A patient with an above-the-knee amputation asks why the residual limb needs to be wrapped with an elastic bandage. The nurse explains the purpose of doing this is to: A.Limit formation of blood clots. B.Decrease phantom limb sensation. C.Prevent hemorrhage and cover the incision. D.Support the soft tissues and minimize swelling

D Pressure supports tissue, promotes venous return, and limits edema, thus promoting shrinkage of the distal part of the residual limb. Although it may limit clot formation, its primary purpose is to promote venous return, prevent edema & shrink distal part of limb. Bandaging does not decrease occurrence of phantom limb sensation. Although pressure may prevent hemorrhage, it is not its primary purpose in this case.

The nurse is caring for a very sick patient that has received the following: 50 Grams of Albumin, 3 units packed red blood cells (PRBC) 2 units of platelets (PTL) 2 of fresh frozen plasma (FFP). The provider is concerned that the patient has had a transfusion reaction and orders Lasix (furosemide), increased supplemental O2, and for the HOB to be at least 45 degrees. The nurse knows that based on these orders the provider is concerned about which transfusion reaction? A. Sepsis Reaction B. Anaphylactic Reaction C. Non-hemolytic Reaction D. Circulatory Overload Reaction

D The clue is in the question—based on these orders: so what reaction is treated with diuretics, oxygen and placing the person upright? Circulatory overload. Then, take into account the person is very sick—a high risk person possible, then look at all the volume they were given over a short amount of time--, then consider what their blood pressure likely was if they were requiring that much fluid and blood products...

A nurse is reviewing the laboratory reports of four patients. Which patient most likely has rheumatoid arthritis? A.Uric acid elevated B.C-reactive protein decreased C.Positive Anti-DNA antibody D.Erythrocyte sedimentation rate (ESR) elevated

D The erythrocyte sedimentation rate (ESR) or "sed rate" is a non-specific index of inflammation. Thus, would be elevated with a patient who has RA. Elevated uric acid levels are associated with gout, not RA. C-reactive protein (CRP) would be increased, not decreased. Positive anti-DNA antibody test is the most specific test for SLE (not RA). (If the question had read, "Anti-CCP" - it would be correct, as THAT is the important diagnostic for RA.)

A patient diagnosed with kidney failure is receiving peritoneal dialysis. Which assessment finding warrants immediate nursing intervention? A. The effluent is straw colored B. The patient reports mild back pain during the dwell cycle C. There is no bruit detected over the catheter insertion site D. The dialysate instilled into the patient equals the amount of fluid that is drained

D The purpose of peritoneal dialysis is to remove excess water, waste products, and electrolytes from the body. Output should be greater than input. If it is not this is a concern that requires immediate follow up. Normal effluent (liquid waste product) is clear or straw colored and clear. Mild back pain is expected as large amounts of fluid are instilled into the abdomen. The patient receiving peritoneal dialysis does not have a graft and there is no bruit to be assessed.

The nurse is caring for a patient that has just undergone an above the knee (ATK) amputation. While the patient is sleeping the spouse tells the nurse, "I am worried that things will come up at home and I won't know what to I can do to help." Which response by the nurse is the most appropriate to address the spouse's concern? A."You have nothing to worry about, written instructions on health care information will be given to you both." B."You just need to explain to your spouse what you can do to assist them, and what your limitations are." C."Before discharge, let's set up a plan for meeting your spouse's daily needs." D."It will be important for you to talk to your spouse about what they need, and ask how you can be of assistance."

D There will be times where the best strategy for the spouse (support person) to use is to ask the patient what they need, and request that they identify how the spouse can best facilitate assistance and support in that specific situation. Although written information and the creation of a plan of care can be helpful, and likely will be provided and developed--it is best to provide the spouse with a general guideline to use since various situations, so they will know how to handle things that may not be covered. Focusing on the spouse's limitations may limit communication and make the patient hesitant to ask for assistance.

The patient who has been hospitalized for four weeks is receiving TPN through a central venous catheter (CVC). The patient asks the nurse why this type of catheter is being used instead of a regular peripheral IV. Which is the best nursing response for this patient? A. "A central venous catheter was inserted because your peripheral veins could no longer be used." B. "The central venous catheter allows nutrients to be administered at a much higher rate." C."The TPN solution is hypotonic and can be given only through a central venous catheter." D."The nutrients that are being administered are too concentrated for a peripheral IV."

D Total parenteral nutrition (TPN) solutions contain dextrose 15-25% - (which is very concentrated). The solution would be very irritating to the peripheral blood vessels due to their small diameter (& lack of good, turbulent blood flow). The other answers are incorrect because the principal reason for the central venous catheter in this patient is to provide concentrated nutrition. TPN is hypertonic (not hypotonic). IVF rate is not impacted by location of catheter tip (central vs. peripheral). And - even though a CVC is sometimes necessary if no peripheral line can be accessed, in this patient (in the scenario) - the primary reason he has it is r/t the concentration of the TPN.

The nurse is caring for a 68 year old patient that underwent a Percutaneous Coronary Intervention (PCI) 2 hours ago for a myocardial infarction. The patient's current vital signs are: HR of 97 bpm, BP of 112/78 mmHg, RR of 20 bpm, 02 Sat. of 96% on 2L nc. The patient is now experiencing dysrhythmias. Using SBAR communication, the nurse knows that which of the following would be most appropriate "R." (select all that apply). A. The patient had a percutaneous coronary intervention B. The patient's HR is 97 bpm C. The dysrhythmias are an expected finding D. I will continue to monitor the patient every hour E. I will check electrolytes F. I will prepare the patient for the operating room

D and E "R" is the recommendations for action/response to the situation that the nurse is communicating. In this case it is about the dysrhythmias the patient experiences— This is an expected finding after a PCI and with the patient being stable at this time, it would be appropriate to continue to monitor every hour at this time It would also be appropriate to suggest sending electrolytes off to ensure they are within normal limits to try and limit the risk of dysrhythmias related to that cause.

A patient is treated with radiation therapy for lung cancer. The nurse finds that the patient has dry desquamation of the skin due to the radiation therapy. How should the nurse prevent infection and facilitate healing of the skin? Select all that apply. A. Apply ice packs as needed. B.Allow for brief periods of direct exposure to sunlight. C.Encourage swimming in salt water. D.Avoid rubbing the affected area. E.Avoid the use of heating pads.

D,E Rubbing the area & applying heating pads would likely aggravate (not heal) the tender skin associated with dry desquamation. Along the same line of "no heating pads" - ice packs are not a good idea either. (No temperature extremes.) While providing "open air" is a good idea for the area, direct sunlight should be avoided. Salt & chlorine swimming should be avoided. These could aggravate the tender skin. (As noted in Lewis.)

The nurse is caring for an elderly patient that has been admitted with pneumonia. The nurse knows that the pneumonia had an atypical presentation based on which of the following patient statements? A."I wake up in the middle of the night just drenched in sweat." B."I feel horrible and there is such pain every time I breathe in." C."I get so mixed up and can't remember basic things about my day." D."The most annoying thing is this dry, hacking cough, it is miserable."

D. Atypical pneumonia is characterized by a gradual onset of symptoms, such as dry cough, headache, sore throat, fatigue, nausea, and vomiting. Typical pneumonia is characterized by tachypnea, fever, chills, and productive cough with purulent sputum. Also Note in the elderly: confusion is considered a typical presentation.