Cardio Practice questions, Neuro NCLEX, NCLEX Neuro disorders, Lewis Chapter 48, Endocrine, Liver Failure, Hepatitis, cholecystitis, pancreatitis, NCLEX, Urinary NCLEX Questions, Med-surg Test #3, Urinary NCLEX QUESTIONS, Fluids and Electrolytes_Test...
T or F The most common cause of superficial thrombophlebitis in the legs is IV therapy.
False, thrombophlebitis should be varicose veins
The primary function of the kidney is:
Filtration of water and blood products
When the home health RN is planning care for a patient with a seizure disorder, which nursing action can be delegated to an LPN/LVN?
Place medications in the home medication organizer. rational: LPN/LVN education includes administration of medications. The other activities require RN education and scope of practice.
What is the short term treatment for diagnosis of myasthenia gravis? And for long term?
Short term is TENSILON. Long term treatment is PROSTIGMIN, an airway medication and MESTINON.
What statement by the patient indicates the need for further teaching before renal angiography?
"I'm glad I don't have to stay in bed after the test."
A client with pheochromocytoma is scheduled for surgery and says to the nurse, "I'm not sure that surgery is the best thing to do." Which response by the nurse is appropriate?
"You have concerns about the surgical treatment for your condition?"
When caring for a client diagnosed with pheochromocytoma, what information should the nurse know when assisting with planning care? 1. Profound hypotension may occur. 2. Excessive catecholamines are released. 3. The condition is not curable and is treated symptomatically. 4. Hypoglycemia is the primary presenting symptom.
*2. Excessive catecholamines are released.* *rationale* Pheochromocytoma is a catecholamine-producing tumor of the adrenal gland and causes secretion of excessive amounts of epinephrine and norepinephrine. Hypertension is the principal manifestation, and the client has episodes of a high blood pressure accompanied by pounding headaches. The excessive release of catecholamine also results in excessive conversion of glycogen into glucose in the liver. Consequently, hyperglycemia and glucosuria occur during attacks. Pheochromocytoma is curable. The primary treatment is surgical removal of one or both of the adrenal glands, depending on whether the tumor is unilateral or bilateral.
A nurse is caring for a postoperative parathyroidectomy client. Which of the following would require the nurse's immediate attention? 1. Incisional pain 2. Laryngeal stridor 3. Difficulty voiding 4. Abdominal cramps
*2. Laryngeal stridor* *rationale* During the postoperative period, the nurse carefully observes the client for signs of hemorrhage, which cause swelling and the compression of adjacent tissue. Laryngeal stridor is a harsh, high-pitched sound heard on inspiration and expiration that is caused by the compression of the trachea and that leads to respiratory distress. It is an acute emergency situation that requires immediate attention to avoid the complete obstruction of the airway.
A nurse is collecting data from a client who is being admitted to the hospital for a diagnostic workup for primary hyperparathyroidism. The nurse understands that which client complaint would be characteristic of this disorder? 1. Diarrhea 2. Polyuria 3. Polyphagia 4. Weight gain
*2. Polyuria* *rationale* Hypercalcemia is the hallmark of hyperparathyroidism. Elevated serum calcium levels produce osmotic diuresis (polyuria). This diuresis leads to dehydration and the client would lose weight. Options 1, 3, and 4 are gastrointestinal (GI) symptoms but are not associated with the common GI symptoms typical of hyperparathyroidism (nausea, vomiting, anorexia, constipation).
A nurse assists in developing a plan of care for a client with hyperparathyroidism receiving calcitonin-human (Cibacalcin). Which outcome has the highest priority regarding this medication? 1. Relief of pain 2. Absence of side effects 3. Reaching normal serum calcium levels 4. Verbalization of appropriate medication knowledge
*3. Reaching normal serum calcium levels* *rationale* Hypercalcemia can occur in clients with hyperparathyroidism, and calcitonin is used to lower plasma calcium level. The highest priority outcome in this client situation would be a reduction in serum calcium level. Option 1 is unrelated to this medication. Although options 2 and 4 are expected outcomes, they are not the highest priority for administering this medication.
56. Which could be a complication of cryotherapy surgery for cancer of the prostate? 1. The urethra could become scarred and cause retention. 2. The client could have ejaculation difficulties and be impotent. 3. Bone marrow suppression could occur from the chemotherapy. 4. Chronic vomiting and diarrhea causing electrolyte imbalance could occur.
1. Cryotherapy involves placing freezing probes into the prostate to freeze the cancer cells. An indwelling catheter is placed into the urethra, and warm water is circulated through the catheter to try to prevent the urethra from freezing. If the urethra scars, then the lumen will constrict, causing retention of urine.
54. Which statement indicates discharge teaching has been effective for the client who is postoperative TURP? 1. "I will call the surgeon if I experience any difficulty urinating." 2. "I will take my Proscar daily, the same as before my surgery." 3. "I will continue restricting my oral fluid intake." 4. "I will take my pain medication routinely even if I do not hurt."
1. This indicates the teaching is effective.
11. The client who has had a mastectomy tells the nurse, "My husband will leave me now since I am not a whole woman anymore." Which response by the nurse is most therapeutic? 1. "You're afraid your husband will not find you sexually appealing?" 2. "Your husband should be grateful you will be able to live and be with him." 3. "Maybe your husband would like to attend a support group for spouses." 4. "You don't know that is true. You need to give him a chance."
1. This is restating the client's feelings and is a therapeutic response.
Arterial or Venous disease? Decreased peripheral pulses
A
The health-care provider prescribes an ACE inhibitor for the client diagnosed with essential hypertension. Which statement is the most appropriate rationale for administering this medication?
ACE inhibitors decrease blood pressure by relaxing vascular smooth muscle
Which information will the nurse include when teaching a patient with acute low back pain (select all that apply)? a. Sleep in a prone position with the legs extended. b. Keep the knees straight when leaning forward to pick something up. c. Avoid activities that require twisting of the back or prolonged sitting. d. Symptoms of acute low back pain frequently improve in a few weeks. e. Ibuprofen (Motrin, Advil) or acetaminophen (Tylenol) can be used to relieve pain.
ANS: C, D, E Acute back pain usually starts to improve within 2 weeks. In the meantime, the patient should use medications such as nonsteroidal antiinflammatory drugs (NSAIDs) or acetaminophen to manage pain and avoid activities that stress the back. Sleeping in a prone position and keeping the knees straight when leaning forward will place stress on the back, and should be avoided
A surgical patient received a volatile liquid as an inhalation anesthetic during surgery. Postoperatively the nurse should monitor the patient for a. tachypnea. b. myoclonia. c. hypertension. d. incisional pain.
ANS: D Because volatile liquid inhalation agents are rapidly metabolized, postoperative pain occurs soon after surgery. Hypertension and tachypnea are not associated with general anesthetics. Myoclonia may occur with nonbarbiturate hypnotics but not with the inhaled inhalation agents.
A critical action by the nurse caring for a patient with an acute exacerbation of polycythemia vera is to a. place the patient on bed rest. b. administer iron supplements. c. avoid use of aspirin products. d. monitor fluid intake and output.
ANS: D Monitoring hydration status is important during an acute exacerbation because the patient is at risk for fluid overload or underhydration. Aspirin therapy is used to decrease risk for thrombosis. The patient should be encouraged to ambulate to prevent deep vein thrombosis (DVT). Iron is contraindicated in patients with polycythemia vera
During postoperative care of the patient with an ileoconduit, which finding represents an emergency?
Absence of bowel sounds
Which assessment data would require immediate intervention by the nurse for the client who is six (6) hours post-operative abdominal aortic aneurysm repair?
Absent bilateral pedal pulses
Which medication does the nurse plan to administer before the procedure?
Acetylcysteine (Mucosil) This client has kidney impairment demonstrated by increased creatinine. Acetylcysteine (an antioxidant) may be used to prevent contrast-induced nephrotoxic effects.
ACTH stimulation test is to assess for
Addison's disease
A client who is admitted with urolithiasis reports "spasms of intense flank pain, nausea, and severe dizziness." Which intervention does the nurse implement first
Administer morphine sulfate 4 mg IV.
Leuprolide
Advanced Prostate Cancer
What is sensory aphasia?
Also known as RECEPTIVE APHASIA, a patient cannot understand oral or written forms of communication.
The most important factor to foster patient compliance with the treatment plan is to provide te patient with:
An active role in the planning
The patient with ESRD receiving hemodialysis is at risk for:
Anemia
Which of the following symptoms would the nurse expect to find in the patient diagnosed with bladder cancer? A) Dysuria and urgency B) Painless hematuria C) Suprapubic pain with nausea and vomiting D) Pyuria and incontinence
Answer: B. Painless gross hematuria is the most common symptom of bladder cancer. Dysuria and urgency are common findings in UTI. Suprapubic pain with nausea and vomiting may be found with nephrolithiasis (kidney stones). Pyuria and incontinence are not associated with bladder cancer.
Which problem constitutes a medical emergency?
Anuria
The nurse is reviewing the postoperative prescriptions for a client who had a transsphenoidal hypophysectomy. Which health care provider's prescription noted on the record indicates the need for clarification?
Apply a loose dressing if any clear drainage is noted.
A client diagnosed with a brain tumor experiences a generalized seizure while sitting in a chair. How should the nurse intervene first?
Assist the client to a side-lying position on the floor, and protect her with linens.
A client with a history of epilepsy is admitted to the medical-surgical unit. While assisting the client from the bathroom, the nurse observes the start of a tonic-clonic seizure. Which nursing interventions are appropriate for this client?
Assist the client to the floor. Turn the client to his side. Place a pillow under the client's head.
A patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care?
Assist with active range of motion. rational: ALS causes progressive muscle weakness, but assisting the patient to perform active ROM will help to maintain strength as long as possible. Psychotic symptoms such as agitation and paranoia are not associated with ALS. Cognitive function is not affected by ALS, and the patient's ability to understand procedures will not be impaired. Muscle relaxants will further increase muscle weakness and depress respirations.
Doxazosin
BPH-relaxes smooth muscle in bladder neck
Tamsulosin
BPH-relaxes smooth muscle in bladder neck
A patient with a head injury has admission vital signs of blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse?
Blood pressure 156/60, pulse 55, respirations 12 rational: Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad and indicate that the intracranial pressure (ICP) has increased, and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process.
A patient has the following ABG results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. The nurse interprets these results as a. respiratory acidosis. b. respiratory alkalosis. c. metabolic acidosis. d. metabolic alkalosis.
Correct Answer: C Rationale: The pH and HCO3 indicate that the patient has a metabolic acidosis. The ABGs are inconsistent with the other responses.
The most comon cause of renal failure is:
DM
The health-care provider ordered a femoral angiogram for the client diagnosed with atrial occlusive disease. Which intervention should the nurse implement?
Discuss with the client that he or she will be on bed rest with bathroom
Uniform, circumferential dilation of artery?
Fusiform aneurysm
How can you keep your patient safe during seizure?
Have airway open, clear harmful objects, assess respirations and then pulse. Do not restrain patient during seizure. Do not try to open clenched jaw. Do not move unless it is unsafe not to move. Do not suction until motor activity stops.
May be administered IV or Subq
Heparin
Protamine sulfate is antidote
Heparin
Activated partial thromboplastin time
Heparin, Hirudin derivatives, and Thrombin inhibitor
b) No antidote for anticoagulant effect
Hirudin derivatives
The client is diagnosed with an abdominal aortic aneurysm. Which statement would the nurse expect the client to make during the admission assessment?
I don't have any abdominal pain or any type of problems
The nurse is teaching the Dietary Approaches to Stop Hypertension (DASH) diet to a client diagnosed with essential hypertension. Which statement indicates that the client understands the client teaching concerning DASH diet?
I should eat at least for (4) to (5) servings of vegetables a day
A client is admitted for extracorporeal shock wave lithotripsy (ESWL). What information obtained on admission is most critical for a nurse to report to the health care provider before the ESWL procedure begins?
I take over-the-counter naproxen (Aleve) twice a day for joint pain." Because a high risk for bleeding during ESWL has been noted, clients should not take nonsteroidal anti-inflammatory drugs before this procedure; the ESWL will have to be rescheduled for this client.
Which urinary assessment information for a client indicates the potential need for increased fluids?
Increased blood urea nitrogen Increased blood urea nitrogen can indicate dehydration. Increased creatinine indicates kidney impairment.
In a client with amyotrophic lateral sclerosis and respiratory distress, which finding is the earliest sign of reduced oxygenation?
Increased restlessness
Which nursing diagnosis takes highest priority for a client with Parkinson's crisis?
Ineffective airway clearance
To determine glomerular filtration rate for a patient with chronic renal disease, the nurse plans to:
Initate a 24-hour collection of the patient's urine.
Which action will the nurse take when evaluating a patient who is taking phenytoin (Dilantin) for adverse effects of the medication?
Inspect the oral mucosa. rational: Phenytoin can cause gingival hyperplasia, but does not affect bowel tones, lung sounds, or pupil reaction to light.
An unconscious patient has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care?
Keep the head of the bed elevated to 30 degrees. rational: The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to help reduce ICP. Flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions increases ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic pressure and ICP.
What drug is commonly taken to help Parkinson's symptoms? What are the Considerations?
LEVODOPA. Watch for hypotension and place TED hose on your patient to prevent further complications.
Is administered subcutaneously only
LMWH
Routine coagulation tests not usually required
LMWH
A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. In this syndrome, polyneuritis leads to progressive motor, sensory, and cranial nerve dysfunction. On admission, which assessment is most important for this client?
Lung auscultation and measurement of vital capacity and tidal volume
When caring for a client with uremia, the nurse assesses for which symptom?
Manifestations of uremia include anorexia, nausea, vomiting, weakness, and fatigue.
A client with hypoparathyroidism has hypocalcemia. The nurse avoids giving the client the prescribed vitamin and calcium supplement with which liquid?
Milk
A client with tonic-clonic seizure disorder is being discharged with a prescription for phenytoin (Dilantin). Which instructions about phenytoin should the nurse give this client?
Monitor for skin rash. Perform good oral hygiene, including daily brushing and flossing., Periodic follow-up blood work is necessary. Report to the physician problems with walking and coordination, slurred speech, or nausea.
Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?
Monitoring the patency of an indwelling urinary catheter
What are the risk factors for Guillain Barre Syndrome?
More common among the 20-50 age group, associated with swine flu immunizations, frequently preceded by mild respiratory or intestinal infection.
A 26-year-old patient with a T3 spinal cord injury asks the nurse about whether he will be able to be sexually active. Which initial response by the nurse is best?
Multiple options are available to maintain sexuality after spinal cord injury. rational: Although sexuality will be changed by the patient's spinal cord injury, there are options for expression of sexuality and for fertility. The other information also is correct, but the choices will depend on the degrees of injury and the patient's individual feelings about sexuality.
the nurse visualizes blood clots in a client's urinary catheter after a cystoscopy. What nursing intervention does the nurse perform first?
Notify the health care provider. Bleeding and/or blood clots are potential complications of cystoscopy and may obstruct the catheter and decrease urine output. The nurse should monitor urine output and notify the health care provider of obvious blood clots or a decreased or absent urine output.
Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses? Are there any collaborative problems?
Nursing diagnosis: Acute pain r/t compression of internal structures with blood Decreased cardiac output r/t hypovolemia Deficient knowledge r/t lack of information about surgical aneurysm repair and postoperative care Collaborative: Potential complications: organ ischemia; hypovolemic shock; myocardial infarction
When a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter, which information obtained by the nurse is most important to communicate to the health care provider?
Oral temperature 101.6° F rational: Infection is a serious consideration with ICP monitoring, especially with intraventricular catheters. The temperature indicates the need for antibiotics or removal of the monitor. The ICP, arterial pressure, and apical pulse are all borderline high but require only ongoing monitoring at this time.
Oxybutynin
Overactive bladder, urinary ugency
The nurse is collecting data from a client who is being admitted to the hospital for a diagnostic workup for primary hyperparathyroidism. The nurse understands that which client complaint would be characteristic of this disorder?
Polyuria
Which nursing activity illustrates proper aseptic technique during catheter care?
Positioning the collection bag below the height of the bladder
The nurse is caring for a client with a diagnosis of hypoparathyroidism. The nurse reviews the client's laboratory results and notes that the calcium level is extremely low. The nurse should expect to note which sign/symptom on data collection?
Positive Trousseau's sign
A patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse plan to take?
Prepare the patient for immediate craniotomy. rational: The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation. If intracranial pressure (ICP) is elevated after surgery, furosemide or high-dose barbiturate therapy may be needed, but these will not be of benefit unless the hematoma is removed. Minimal blood loss occurs with head injuries, and transfusion is usually not necessary.
The teaching priority for the patient with acute renal failure is:
Prevention of infection
Flutamide
Prostate Cancer
Episodes include white, blue, and red color of the finger tips
R
Frequently associated with autoimmune disorders
R
Indicate whether the following manifestations and treatments are characteristics of thromboangititis obliterans (Buerger's disease) (B) or arteriospastic disease (Raynaud's phenomenon) (R) a) involves small cutaneous arteries of the fingers and toes
R
Precipitated by exposure to cold, caffeine, and tobacco
R
Predominant in young females
R
Treated with calcium-channel blockers, especially nifedipine (Procardia)
R
Which medical treatment would be prescribed for the client with an AAA less than 3 cm?
Repair of abdominal aortic aneurysm
A pouch-like bulge of an artery?
Saccular Aneurysm
The nurse is caring for a client with hypothyroidism who is overweight. Which food items should the nurse suggest to include in the plan?
Skim milk, apples, whole-grain bread, and cereal
A patient admitted with bacterial meningitis and a temperature of 102° F (38.8° C) has orders for all of these collaborative interventions. Which action should the nurse take first?
Swap the nasopharyngeal mucosa for cultures. rational: Antibiotic therapy should be instituted rapidly in bacterial meningitis, but cultures must be done before antibiotics are started. As soon as the cultures are done, the antibiotic should be started. Hypothermia therapy and acetaminophen administration are appropriate but can be started after the other actions are implemented.
A patient with VTE is to be discharged on long-term warfarin therapy and is taught about prevention and continuing treatment of VTE. The nurse determines that discharge teaching for the patient has been effective when the patient states...
Swimming is a good activity to include in my exercise program to increase my circulation
A client is having a tonic-clonic seizure. What should the nurse do first?
Take measures to prevent injury.
Which nursing action will the home health nurse include in the plan of care for a patient with paraplegia in order to prevent autonomic dysreflexia?
Teach the purpose of a prescribed bowel program. rational: Fecal impaction is a common stimulus for autonomic dysreflexia. The other actions may be included in the plan of care but will not reduce the risk for autonomic dysreflexia.
The nurse and an unlicensed nursing assistant are bathing a bedfast client. Which action by the assistant warrants immediate intervention?
The assistant begins to massage and rub lotion into the clients calf
What should you document for a seizure occurrence?
The time it occurred and lasted and what parts of the body were affected.
T or F A patient with VTE is scheduled for surgical treatment. The nurse recognizes that surgery is most commonly performed for this condition to insert a vena cava interruption device to prevent pulmonary embolism.
True
Ciprofloxacin
UTI
The clinical findings in the oliguric phase of acute renal failure include:
Urinary output increases
Bethanzhol
Urinary retention
Tolterodine
Urinary urgency
The nurse obtains these assessment findings for a patient who has a head injury. Which finding should be reported rapidly to the health care provider?
Urine output of 800 mL in the last hour rational: The high urine output indicates that diabetes insipidus may be developing and interventions to prevent dehydration need to be rapidly implemented. The other data do not indicate a need for any change in therapy.
The nurse is planning care for a client with multiple sclerosis. Which three problems should the nurse expect the client to experience?
Visual disturbances Balance problems Mood disorders
How is multiple sclerosis treated?
With steroids when active. Patient then becomes immunocompromised.
The wife of a client with arterial occlusive disease tells the nurse, "My husband says he is having rest pain. What does that mean?" Which statement by the nurse would be most appropriate?
You are concerned that your husband is having rest pain
What information will the nurse provide to a client who is scheduled for extracorporeal shock wave lithotripsy? (Select all that apply.)
Your urine will be strained after the procedure." Correct "Be sure to finish all of your antibiotics." "Remember to drink at least 3 liters of fluid a day to promote urine flow."
Identify the prophylactic immunologic agents that are used for the following: a. pre-exposure protection to HBV b. post-exposure protection to HBV
a. hepatitis B vaccine (Recombivax HB) b. hepatitis B immune globulin (HBIG) and hepatitis B vaccine
The increased risk for falls in the older adult is most likely due to a.changes in balance. b.decrease in bone mass. c.loss of ligament elasticity. d.erosion of articular cartilage.
a.changes in balance Aging can cause changes in a person's sense of balance, making the person unsteady, and proprioception may be altered. The risk for falls also increases in older adults partly because of a loss of strength.
chvosteks sigh is seen with
abnormal facial twitch when touching the facial nerve in front of the ear
Identify at least one observation made by the nurse that would indicate the presence of the following complications of aortic aneurysm repair. c. Bowel infarction
absent bowel sounds, abdominal distention, diarrhea, bloody stools
In patients with primary adrenal insufficiency will have this result from ACTH stimulation test
absent or very decreased
when is calcium likely to be impaired
as a complication of thyroid removal
A 42-year-old patient who was adopted at birth is diagnosed with early Huntington's disease (HD). When teaching the patient, spouse, and children about this disorder, the nurse will provide information about the ______________
availability of genetic testing to determine the HD risk for the patient's children. rational: Genetic testing is available to determine whether an asymptomatic individual has the HD gene. The patient and family should be informed of the benefits and problems associated with genetic testing. Sinemet will increase symptoms of HD given that HD involves an increase in dopamine. Antibiotic therapy will not reduce the risk for aspiration. There are no effective treatments or lifestyle changes that delay the progression of symptoms in HD.
A patient is scheduled for an electromyogram (EMG). The nurse explains that this diagnostic test involves a.incision or puncture of the joint capsule. b.insertion of small needles into certain muscles. c.administration of a radioisotope before the procedure. d.placement of skin electrodes to record muscle activity.
b.insertion of small needles into certain muscles Electromyography (EMG) is an evaluation of electrical potential associated with skeletal muscle contraction. Small-gauge needles are inserted into certain muscles and attached to leads that record electrical activity of muscle. Results provide information related to lower motor neuron dysfunction and primary muscle disease
the client is in the preicteric phase of hepatitis. which s/s should the nurse expect the client to exhibit during this phase? 1. clay colored stools and jaundice 2. normal appetite and pruritus 3. being afebrile and left upper quadrant pain 4. c/o fatigue and diarrhea
c/o fatigue and diarrhea: flu like symptoms are the first complaints of the client in the preicteric phase of hepatitis, which is the initial phase and may begin abruptly or insidiously
parathyroid gland regulates
calcium, phospherus and magnesium balance within blood and bone
thyroid storm can quickly cause
congestive heart failure and pulmonary edema
ACTH adrenocorticotropic hormone measures
corticol response to to ACTH
A client is admitted to the hospital with a medical DX of hyperthyroidism. When taking a history which information would be most significant? A. edema, intolerance to cold, lethargy b. peri-orbital edema, lethargy mask like face c. weight loss, intolerance to cold, muscle wasting d. weight loss, intolerance to heat, exophthalmos
d. weight loss, intolerance to heat, exophthalmos
how propanolol is used in treatment of thyroid storm
decrease rapid heart rate caused by excessive thyroid stimulation
demopressin acetate (DDVAP) is prescribed for the treatment of diabetes insipidus. The nurse monitors the client after medication administration for which therapeutic response
decreased urine output it (promotes renal conservation)
The water deprivation test is used to diagnose
diabetes insipidus.
SIADH is caused by
excessive release of ADH
pheochromocytoma symptoms are
headache, sweating, fast heartbeat, with markedly high blood pressure
which statement by the client dx with hepatitis warrants immediate intervention by the clinic nurse? 1. i will not drink any type of beer or mixed drink 2. i will get adequate rest so i dont get exhausted 3. i had a big hearty breakfast this morning 4. i took some cough syrup for this nasty head cold
i took some cough syrup for this nasty head cold: the client needs to understand some types of cough syrup have alcohol and all alcohol must be avoided to prevent further injury to the liver, therefore, this statement requires intervention
expected finding for patient with diabetes insipidus
increased Hct level
Identify at least one observation made by the nurse that would indicate the presence of the following complications of aortic aneurysm repair. d. Graft infection
increased temperature and WBC; surgical sit inflammation or drainage
When performing an assessment on a client the nurse notes tenderness to blunt percussion of the costovertebral angle. What might this finding suggest?
inflammation of the kidneys
the nurse is administering a pancreatic enzyme to the client dx with chronic pancreatitis. which statement best explains the rationale for administering this med? 1. it is an exogenous source of protease, amylase, and lipase 2. this enzyme increases the number of bowel movements 3. this medication breaks down in the stomach to help with digestion 4. pancreatic enzymes help break down fat in the small intestine
it is an exogenous source of protease, amylase, and lipase: pancreatic enzymes enhance the digestion of starches (carbohydrates) in the gastrointestinal tract by supplying an exogenous (outside) source of the pancreatic enzymes protease, amylase and lipase
Management of mild hyperparathyroidism includes increasing oral fluid intake to prevent
kidney stones from developing
A 24-year-old patient is hospitalized with the onset of Guillain-Barré syndrome. During this phase of the patient's illness, the most essential assessment for the nurse to carry out is ______________
observing respiratory rate and effort. rational: The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse should monitor respiratory function continuously. The other assessments also will be included in nursing care, but they are not as important as respiratory assessment.
The nurse is assessing the client for urinary incontinence. The client is at risk for
psychosocial problems
Surgery for PAD is indicated when the patient has limb pain during _______.
rest
a client has acute pancreatitis. to determine its severity, the nurse would look at which lab test? 1. serum transaminase 2. serum amylase 3. serum sodium 4. serum magnesium
serum amylase: severity of pancreatitis is directly correlated to the level of amylase, a pancreatic enzyme
During the nursing assessment of the patient with a distal descending aortic dissection, the nurse would expect the patient to manifest what?
severe ripping back or abdominal pain with decreasing urine output
the client dx with liver failure is experiencing pruritus secondary to severe jaundice. which action by the unlicensed assistive personnel warrants intervention by the nurse? 1. the UAP is assisting the client to take a hot soapy shower 2. the UAP applies an emollient to the clients legs and back 3. the UAP puts mittens on both hands of the client 4. the cUAP pats the clients skin dry with a clean towel
the UAP is assisting the client to take a hot soapy shower: hot water increases pruritus and soap will cause dry skin, which increases pruritus, therefore, the nurse should discuss this with the UAP
The water deprivation test DETERMINES
the cause of polydipsia and polyuria - central diabetes insipidus (DI), nephrogenic DI, or psychogenic polydipsia.
When communicating with a client who has sensory (receptive) aphasia, the nurse should:
use short, simple sentences.
The nurse and an unlicensed nursing assistant are caring for a 64-year-old client who four (4) hours post-operative bilateral femoral-popliteal bypass surgery. Which nursing task should be delegated to the unlicensed nursing assistant?
Feed the client the evening meal
f) Pregnancy
Venous stasis
The nurse is caring for a 63-year-old with a possible pituitary tumor who is scheduled for a computed tomography (CT) scan with contrast. Which information about the patient is most important to discuss with the health care provider before the test? a. History of renal insufficiency b. Complains of chronic headache c. Recent bilateral visual field loss d. Blood glucose level of 134 mg/dL
a. History of renal insufficiency
The nurse has reinforced dietary instructions to a client with a diagnosis of hypoparathyroidism. The nurse instructs the client to include which item in the diet?
Vegetables
a nurse is teaching a client about choledocholithiasis. the nurse explains that the term means 1. infection of the bile duct 2. stones in the hepatic and bile duct 3. inflammation of the gallbladder 4. stones in the gallbladder
stones in the hepatic and bile duct
The nurse is teaching a class on coronary artery disease. Which modifiable risk factors should the nurse discuss when teaching about atherosclerosis?
stress
thyroid storm s/s
tachycardia, hypertension, fever, sweating, restlessness, tremors, abdominal pain
During the evening following a partial gastrectomy, a clients oral temp is 100F. other data include a bp of 134/68, pulse of 88, and resp rate of 18. the nurse should: 1. notify the physician immediately 2. take temp every hour until it is normal 3. perform a respiratory assesment 4. remove the dressing and check the operative site
take temp every hour until its normal: the temp needs to be observed frequently to rule out some cause other than the inflammatory process
purpose of 24 hour urine collection in patient with pheochromocytoma
measure levels of catecholamines and metanephrines
An elderly female tells the nurse "I wish I could have a good night's sleep without having to get up every two hours to urinate." The nurse realizes that the client is experiencing
nocturia
for a patient taking desmopressin in the treatment of diabetes insipidus, adjustment is needed in the medication dosage for
nocturia
Two serious complications of PAD that frequently lead to lower limb amputation are ______________ and ___________.
non-healing ischemic ulcers and gangrene
The client diagnosed with peripheral vascular disease is overweight, has smoked two (2) packs of cigarettes a day for 20 years, and sits behind a desk all day. What is the strongest factor in the development of atherosclerotic lesions?
sedentary lifestyle
The nurse teaches the patient with any venous disorder that the best way to prevent venous stasis and increase venous return is to...
walk
When teaching patients who are at risk for Bell's palsy because of previous herpes simplex infection, which information should the nurse include?
"Call the doctor if pain or herpes lesions occur near the ear." rational: Pain or herpes lesions near the ear may indicate the onset of Bell's palsy and rapid corticosteroid treatment may reduce the duration of Bell's palsy symptoms. Antiviral therapy for herpes simplex does not reduce the risk for Bell's palsy. Corticosteroid therapy will be most effective in reducing symptoms if started before paralysis is complete but will still be somewhat effective when started later. Facial exercises do not prevent Bell's palsy.
What is the therapeutic level of DILANTIN?
"Dial at Ten" 10-20 = therapeutic level
in HHS the patient produces enough insulin to prevent ketosis but not enough to prevent
hyperglycemia; pH will be normal but glucose will be over 600
graves disease is also known as
hyperthyroidism and causes insomnia and anxiety
chvostek's sign & trousseau sign are both expected findings of
hypocalcemia in which there is evidence of latent tetany
The nurse is preparing a client for a computed tomography (CT) scan, which requires infusion of radiopaque dye. Which question is important for the nurse to ask?
"Are you allergic to seafood or iodine?"
When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction?
"Avoid hot baths and showers."
A client is scheduled for an EEG after having a seizure for the first time. Client preparation for this test should include which instruction?
"Avoid stimulants and alcohol for 24 to 48 hours before the test."
When teaching a client about levodopa and carbidopa (Sinemet) therapy for Parkinson's disease, the nurse should include which instruction?
"Be aware that your urine may appear darker than usual."
The nursing instructor asks a student to describe the pathophysiology that occurs in Cushing's disease. Which statement by the student indicates an accurate understanding of this disorder?
"Cushing's disease is characterized by an oversecretion of glucocorticoid hormones."
A client with multiple sclerosis who is unable to bathe herself complains that other staff members haven't been bathing her. How should the nurse respond to this client's complaint?
"I'm sorry you haven't been bathed. I'm available to bathe you now."
A client who was diagnosed with multiple sclerosis 3 years ago now presents with lower extremity weakness and heaviness. During the admission process, the client presents her advance directive, which states that she doesn't want intubation, mechanical ventilation, or tube feedings should her condition deteriorate. How should the nurse respond?
"It's important for us to have this information. You should review the document with your physician at every admission."
A client with idiopathic seizure disorder is being discharged with a prescription for phenytoin (Dilantin). Client teaching about this drug should include which instruction?
"Schedule follow-up visits with your physician for blood tests."
The physician has talked to te patient and his wife about the treatment plan for his bladder cancer. Later, the patient tells the nurse he does not understand what the doctor is going to do. The most appropriate response by the nurse would be:
"Tell me what you know abot the treatment."
A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. What should the nurse tell the client about the paralysis?
"The paralysis caused by this disease is temporary."
When caring for a patient who experienced a T1 spinal cord transsection 2 days ago, which collaborative and nursing actions will the nurse include in the plan of care:
-Urinary catheter care -Continuous cardiac monitoring -Avoidance of cool room temperature -Administration of H2 receptor blockers rational: The patient is at risk for bradycardia and poikilothermia caused by sympathetic nervous system dysfunction and should have continuous cardiac monitoring and maintenance of a relatively warm room temperature. Gastrointestinal (GI) motility is decreased initially and NG suctioning is indicated. To avoid bladder distention, a urinary retention catheter is used during this acute phase. Stress ulcers are a common complication but can be avoided through the use of the H2 receptor blockers such as famotidine.
A patient with Parkinson's disease is admitted to the hospital for treatment of an acute infection. Which nursing interventions will be included in the plan of care:
-Use an elevated toilet seat -Cut patient's food into small pieces -Place an arm chair at the patient's bedside rational: Since the patient with Parkinson's has difficulty chewing, food should be cut into small pieces. An armchair should be used when the patient is seated so that the patient can use the arms to assist with getting up from the chair. An elevated toilet seat will facilitate getting on and off the toilet. High protein foods will decrease the effectiveness of L-dopa. Parkinson's is a steadily progressive disease without acute exacerbations.
the nurse is to administer promethazine 12.5 mg IM and has 50mg/mL on hand. how many mL should be drawn up?
0.25mL
What treatment is done for seizure patients?
1) Anticonvulsants: Phebobarbital, Carbamazepine (Tegretol) or Phenytoin (Dilantin). 2) Evaluate consciousness, safety, avoid alcohol. 3) Reduce activities that stimulate and reduce stimuli; no strobe lights because it is repetitive. 4) Reorient client after seizure.
77. The nurse is planning the care of a postoperative client with an ileal conduit. Which intervention should be included in the plan of care? 1. Provide meticulous skin care and pouching. 2. Apply sterile drainage bags daily. 3. Monitor the pH of the urine weekly. 4. Assess the stoma site every day.
1. Urine is acidic, and the abdominal wall tissue is not designed to tolerate acidic environments. The stoma is pouched so urine will not touch the skin.
60. The nurse is preparing the care plan for a 45-year-old client who has had a radical prostatectomy. Which psychosocial and physiological problem should be included in the plan? 1. Altered coping. 2. High risk for hemorrhage. 3. Sexual impotence. 4. Risk for electrolyte imbalance.
3. This problem has both physiological and psychosocial implications.
For a client with a head injury whose neck has been stabilized, the preferred bed position is:
30-degree head elevation.
23. The client diagnosed with CKD is receiving peritoneal dialysis. Which assessment data warrant immediate intervention by the nurse? 1. Inability to auscultate a bruit over the fistula. 2. The client's abdomen is soft, is nontender, and has bowel sounds. 3. The dialysate being removed from the client's abdomen is clear. 4. The dialysate instilled was 1,500 mL and removed was 1,500 mL.
4. Because the client is in ESRD, fluid must be removed from the body, so the output should be more than the amount instilled. These assessment data require intervention by the nurse.
51. Which data support to the nurse the client's diagnosis of acute bacterial prostatitis? 1. Terminal dribbling. 2. Urinary frequency. 3. Stress incontinence. 4. Sudden fever and chills.
4. Clients with acute bacterial prostatitis will frequently experience a sudden onset of fever and chills. Clients with chronic prostatitis have milder symptoms.
8. A nurse is caring for a client following thyroidectomy and is monitoring for complications. Which of the following if noted in the client, would indicate a need for physician notification? a) surgical pain in the neck area b) voice hoarseness c) numbness and tingling around the mouth d) weakness of the voice
8) C - Hypocalcemia can develop after thyroidectomy if the parathyroid glands are accidentally removed or traumatized during surgery. If the client develops numbness and tingling around the mouth or in the fingertips or toes, muscle spasms, or twitching, the physician should be called immediately. A hoarse or weak voice may occur temporarily if there has been unilateral injury to the laryngeal nerve during surgery. Pain is expected in the postoperative period. Calcium gluconate ampules should be available at the bedside, and the client should have a patent intravenous (IV) line in the event that hypocalcemic tetany occurs
When scheduling the administration of furosemide (Lasix), it would be in the patient's best interest to schedule the medication to be given at:
9 AM
9. Persons at increased risk of developing Hashimoto's disease include all of the following except: a. Persons with vitiligo b. Asian-Americans c. Persons with rheumatoid arthritis d. Persons with Addison's disease
9. B: Along with the above-mentioned groups, persons with type 1 diabetes and persons suffering from pernicious anemia (insufficient vitamin b12) are at increased risk of developing Hashimoto's disease. Because it tends to run in families, there is likely a genetic susceptibility as well. Environmental factors such as excessive iodine consumption and selected drugs also have been implicated as potential risk factors.
A 36-year-old male patient in the outpatient clinic is diagnosed with acute hepatitis C (HCV) infection. Which action by the nurse is appropriate? a. Schedule the patient for HCV genotype testing. b. Administer the HCV vaccine and immune globulin. c. Teach the patient about ribavirin (Rebetol) treatment. d. Explain that the infection will resolve over a few months.
A
A complication of the hyperviscosity of polycythemia is: A. thrombosis B. cardiomyopathy C. pulmonary edema D. disseminated intravascular coagulation (DIC)
A
Arterial or Venous disease? Pallor on elevation of the legs
A
Arterial or Venous disease? Paresthesia
A
Arterial or Venous disease? Thickened, brittle nails
A
Arterial or Venous disease? Ulcers over bony prominences on toes and feet
A
The nurse administering alpha-interferon and ribavirin (Rebetol) to a patient with chronic hepatitis C will plan to monitor for a. leukopenia. b. hypokalemia. c. polycythemia. d. hypoglycemia.
A
In educating a client, the nurse is likely to explain the following is the cause of Hashimoto's disease: Answers: A. Antibodies attacking the thyroid gland B. Inflammation in the kidneys C. An adenocarcinoma in the brain D. Overactivation of the pituitary gland
A Hashimoto's disease is caused by autoimmunity to the thyroid gland, often involving antibodies.
The patient with cirrhosis is being taught self-care. Which statement indicates the patient needs more teaching? a. "If I notice a fast heart rate or irregular beats, it is normal for cirrhosis." b. "I need to take good care of my belly and ankle skin where it is swollen." c. "A scrotal support may be more comfortable when I have scrotal edema." d. "I can use pillows to support my head to help me breathe when I am in bed."
A If the patient with cirrhosis experiences a fast or irregular heart rate, it may be indicative of hypokalemia and should be reported to the health care provider, because this is not normal for cirrhosis. Edematous tissue is subject to breakdown and needs meticulous skin care. A scrotal support may improve comfort if there is scrotal edema. Pillows and a semi-Fowler's or Fowler's position will increase respiratory efficiency. Text Reference - p. 1024
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.
The nurse is discussing the pathophysiology of atherosclerosis with a client whose high-density lipoprotein (HDL) level is 68 mg/dL. Which information should the nurse discuss with the client concerning HDL?
A normal HDL is good because it has a protective action in the body
After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first?
A patient whose right pupil is 10 mm and unresponsive to light rational: The dilated and nonresponsive pupil may indicate an intracerebral hemorrhage and increased intracranial pressure. The other patients are not at immediate risk for complications such as herniation.
Which of the following is a nursing priority when caring for a male patient with a condom catheter? A) Preventing the tubing from kinking to maintain free urinary drainage B) Not removing the catheter for any reason C) Fastening the condom tightly to prevent the possible ability of leakage D) Maintaining bed rest at all times to prevent the catheter from slipping off
A) Preventing the tubing from kinking to maintain free urinary drainage The catheter should be allowed to drain freely through toothing that is not king. It also should be removed daily to prevent skin excoriation And should not be fastened to tightly or restriction of blood vessels in the area is likely. Confining a patient to bed rest increases the risk for other hazards related to immobility
Nursing interventions for a patient with severe anemia related to peptic ulcer disease would include (select all that apply): A. monitoring stools for guaiac B. instruction for a high iron diet C. taking vital signs every 8 hours D. teaching self injection of erythropoietin E. administration of cobalamin (vit B12) injections
A, B
12. Nurse Louie is developing a teaching plan for a male client diagnosed with diabetes insipidus. The nurse should include information about which hormone lacking in clients with diabetes insipidus? a. antidiuretic hormone (ADH). b. thyroid-stimulating hormone (TSH). c. follicle-stimulating hormone (FSH). d. luteinizing hormone (LH).
A. ADH is the hormone clients with diabetes insipidus lack. The client's TSH, FSH, and LH levels won't be affected.
4. A nurse is caring for a client who has cirrhosis. Which of the following medications can the nurse expect to administer to this client? (Select all that apply.) A. Diuretic B. Beta-blocking agent C. Opioid analgesic D. Lactulose (Cephulac) E. Sedative
A. CORRECT: Diuretics facilitate excretion of excess fluid from the body in a client who has cirrhosis. B. CORRECT: Beta-blocking agents are prescribed for a client who has cirrhosis to prevent bleeding from varices. D. CORRECT: Lactulose (Cephulac) is prescribed for a client who has cirrhosis to aid in the elimination of ammonia in the stool.
Which finding from a patient's right knee arthrocentesis will be of concern to the nurse? a. Cloudy fluid b. Scant thin fluid c. Pale yellow fluid d. Straw-colored fluid
A. The presence of purulent fluid suggests a possible joint infection. Normal synovial fluid is scant in amount and pale yellow/straw-colored.
The nurse is preparing the patient for a diagnostic procedure to remove pleural fluid for analysis. The nurse would prepare the patient for which test? A. Thoracentesis B. Bronchoscopy C. Pulmonary angiography D. Sputum culture and sensitivity
A. Thoracentesis Thoracentesis is the insertion of a large-bore needle through the chest wall into the pleural space to obtain specimens for diagnostic evaluation, remove pleural fluid, or instill medication into the pleural space.
During the assessment in the ED, the nurse is palpating the patient's chest. Which finding is a medical emergency? A. Trachea moved to the left B. Increased tactile fremitus C. Decreased tactile fremitus D. Diminished chest movement
A. Trachea moved to the left Tracheal deviation is a medical emergency when it is caused by a tension pneumothorax. Tactile fremitus increases with pneumonia or pulmonary edema and decreases in pleural effusion or lung hyperinflation. Diminished chest movement occurs with barrel chest, restrictive disease, and neuromuscular disease.
Which nursing action is correct when performing the straight-leg raising test for an ambulatory patient with back pain? a. Raise the patient's legs to a 60-degree angle from the bed. b. Place the patient initially in the prone position on the exam table. c. Have the patient dangle both legs over the edge of the exam table. d. Instruct the patient to elevate the legs and tense the abdominal muscles.
A. When performing the straight leg-raising test, the patient is in the supine position and the nurse passively lifts the patient's legs to a 60-degree angle. The other actions would not be correct for this test.
In severely anemic patients, the nurse would expect to find: A. dyspnea and tachycardia B. cyanosis and pulmonary edema C. cardiomegaly and pulmonary fibrosis D. ventricular dysrhythmia and wheezing
A. dyspnea and tachycardia
1. A patient is to receive an infusion of 250 mL of platelets over 2 hours through tubing that is labeled: 1 mL equals 10 drops. How many drops per minute will the nurse infuse?
ANS: 21 To infuse 250 mL over 2 hours, the calculated drip rate is 20.8 drops/minute or 21 drops/minute.
Which client problem would be priority for client who is one (1) day postoperative? 1. Potential for hemorrhaging. 2. Potential for injury. 3. Potential for fluid volume excess. 4. Potential for infection.
ANS: 1 All clients who undergo surgery are at risk for hemorrhaging, which is the priority problem.
When developing the plan of care for the surgical client having sedation, which intervention has highest priority for the nurse? 1. Assess the client's respiratory status. 2. Monitor the client's urinary output. 3. Take a 12-lead ECG prior to injection. 4. Attempt to keep the client focused.
ANS: 1 Assessing the respiratory rate, rhythm, and depth is the most important action.
The68-year-old client scheduled for intestinal surgery does not have clear fecal contents after three tap water enemas. Which intervention should the nurse implement first? 1. Notify the surgeon of the client's status. 2. Continue giving enemas until clear. 3. Increase the client's IV fluid rate. 4. Obtain stat serum electrolytes.
ANS: 1 The nurse should contact the surgeon because the client is at risk for fluid and electrolyte imbalance after three (3) enemas. Clients who are NPO, elderly clients, and pediatric clients are more likely to have these imbalances.
Which statement would be an expected outcome when the circulating nurse evaluates the goal of the intraoperative client? 1. The client has no injuries from the OR equipment. 2. The client has no postoperative infection. 3. The client has stable vital signs during surgery. 4. The client recovers from anesthesia.
ANS: 1 This expected outcome addresses the safety of the client while in the OR.
The client is complaining of left shoulder pain. Which response would be best for the nurse to assess the pain? 1. Request that the client describe the pain. 2. Inquire if the pain is intense, throbbing, or stabbing. 3. Ask if the client wants pain medication. 4. Instruct the client to complete the pain questionnaire.
ANS: 1 This request allows the client to use terms and descriptions so that the nurse can eval- uate the pain and the effectiveness of the treatment.
When the water absorption in the renal tubules becomes greater than normal, the nurse anticipates that the urine will become: 1. more concentrated 2. less concentrated 3. more alkaline 4. less alkaline
ANS: 1 When more water is kept back in the body, the water left to form urine is less; therefore, the urine is more concentrated.
When administering an opioid narcotic, which interventions should the nurse imple- ment to provide for client safety? Select all that apply. 1. Compare the hospital number on the MAR to the client's bracelet. 2. Have a witness verify the wasted portion of the narcotic. 3. Assess the client's vital signs prior to administration. 4. Determine if the client has any allergies to medications. 5. Clarify all orders with the health-care provider.
ANS: 1,3,4 1.This procedure ensures client safety by preventing medication from being given to the wrong client. 3. This intervention would prevent giving a narcotic to a client who is unstable or compromised. 4. Determining allergies addresses client safety.
The nurse assesses that the patient's urine has become much more concentrated, which results from the effect of: 1. adrenaline. 2. aldosterone. 3. antidiuretic hormone (ADH). 4. insulin.
ANS: 2 Aldosterone acts on the kidney tubules, affecting water retention and its attendant urine concentration.
The nurse must obtain surgical consent forms for the following clients who are scheduled for surgery. Which client would not be able to consent to surgery? 1. The 65-year-old client who cannot read or write. 2. The 30-year-old client who does not understand English. 3. The 16-year-old client who has a fractured ankle. 4. The 80-year-old client who is not oriented to the day.
ANS: 3 A 16-year-old client is not legally able to give permission for surgery unless the adolescent is given an emancipated status by a judge. This information was not given in the stem.
The charge nurse is making the shift assignments. Which postoperative client would be the most appropriate assignment to the graduate nurse? 1. The four (4)-year-old client who had a tonsillectomy and is swallowing frequently. 2. The 74-year-old client with a repair of the left hip who is unable to ambulate. 3. A 24-year-old client who had an uncomplicated appendectomy the previous day. 4. An 80-year-old client with small bowel obstruction and congestive heart failure.
ANS: 3 A young client who had an appendectomy would require routine postoperative care and would be the most appropriate client to assign to the inexperienced nurse.
Which assessment data indicate the postoperative client who had spinal anesthesia is suffering a complication of the anesthesia? 1. Loss of sensation on the lumbar (L5) dermatome. 2. Absence of the client's posterior tibial pulse. 3. The client has a respiratory rate of eight (8). 4. The blood pressure is within 20% of client's baseline.
ANS: 3 If the effects of the spinal anesthesia move up rather than down the spinal cord, respirations can be depressed and even blocked.
While working in the operating room the circulating nurse observes the surgical scrub technician remove a sponge from the edge of the sterile field with a clamp and place the sponge and clamp in a designated area. Which action should the nurse implement? 1. Place the sponge back where it was. 2. Tell the technician not to waste supplies. 3. Do nothing because this is the correct procedure. 4. Take the sponge out of the room immediately.
ANS: 3 The technician followed the correct procedure. Sponges are counted to maintain client safety, so all sponges must be kept together to repeat the count before the incision site is sutured. The sponge must be removed, not used, and placed in a desig- nated area to be counted later.
Which laboratory result would require immediate intervention by the nurse for the client scheduled for surgery? 1. Calcium 9.2 mg/dL. 2. Bleeding time 2 minutes. 3. Hemoglobin 15 gm/dL. 4. Potassium 2.4 mEq/L.
ANS: 4 This potassium level is low and should be reported to the health-care provider because potassium is important for muscle function, including the cardiac muscle.
The nurse is obtaining the health history for a patient who is scheduled for outpatient knee surgery. Which statement by the patient is most important to report to the health care provider? a. "I had a heart valve replacement last year." b. "I had bacterial pneumonia 6 months ago." c. "I have knee pain whenever I walk or jog." d. "I have a strong family history of breast cancer."
ANS: A A patient with a history of valve replacement is at risk for endocarditis associated with invasive procedures and may need antibiotic prophylaxis. A current respiratory infection may affect whether the patient should have surgery, but a history of pneumonia is not a reason to postpone surgery. The patient's knee pain is the likely reason for the surgery. A family history of breast cancer does not have any implications for the current surgery.
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).
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.
17. The clinic nurse teaches a patient with a 42 pack-year history of cigarette smoking about lung disease. Which information will be most important for the nurse to include? a. Options for smoking cessation b. Reasons for annual sputum cytology testing c. Erlotinib (Tarceva) therapy to prevent tumor risk d. Computed tomography (CT) screening for lung cancer
ANS: A Because smoking is the major cause of lung cancer, the most important role for the nurse is teaching patients about the benefits of and means of smoking cessation. CT scanning is currently being investigated as a screening test for high-risk patients. However, if there is a positive finding, the person already has lung cancer. Erlotinib may be used in patients who have lung cancer, but it is not used to reduce the risk of developing cancer.
25. An appropriate nursing intervention for a patient with non-Hodgkin's lymphoma whose platelet count drops to 18,000/µL during chemotherapy is to a. check all stools for occult blood. b. encourage fluids to 3000 mL/day. c. provide oral hygiene every 2 hours. d. check the temperature every 4 hours.
ANS: A Because the patient is at risk for spontaneous bleeding, the nurse should check stools for occult blood. A low platelet count does not require an increased fluid intake. Oral hygiene is important, but it is not necessary to provide oral care every 2 hours. The low platelet count does not increase risk for infection, so frequent temperature monitoring is not indicated.
26. The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment would best evaluate the effectiveness of the therapies? a. Observe for distended neck veins. b. Auscultate for crackles in the lungs. c. Palpate for heaves or thrills over the heart. d. Review hemoglobin and hematocrit values.
ANS: A Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations of right ventricular failure such as peripheral edema, jugular venous distention, and right upper-quadrant abdominal tenderness would be expected. Crackles in the lungs are likely to be heard with left-sided heart failure. Findings in cor pulmonale include evidence of right ventricular hypertrophy on electrocardiogram ECG and an increase in intensity of the second heart sound. Heaves or thrills are not common with cor pulmonale. Chronic hypoxemia leads to polycythemia and increased total blood volume and viscosity of the blood. The hemoglobin and hematocrit values are more likely to be elevated with cor pulmonale than decreased.
3. A patient with bacterial pneumonia has rhonchi and thick sputum. What is the nurse's most appropriate action to promote airway clearance? a. Assist the patient to splint the chest when coughing. b. Teach the patient about the need for fluid restrictions. c. Encourage the patient to wear the nasal oxygen cannula. d. Instruct the patient on the pursed lip breathing technique.
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.
On auscultation of a patient's 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
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).
2. Which menu choice indicates that the patient understands the nurse's teaching about best dietary choices for iron-deficiency anemia? a. Omelet and whole wheat toast b. Cantaloupe and cottage cheese c. Strawberry and banana fruit plate d. Cornmeal muffin and orange juice
ANS: A Eggs and whole grain breads are high in iron. The other choices are appropriate for other nutritional deficiencies but are not the best choice for a patient with iron-deficiency anemia.
Which menu choice indicates that the patient understands the nurse's teaching about best dietary choices for iron-deficiency anemia? a. Omelet and whole wheat toast b. Cantaloupe and cottage cheese c. Strawberry and banana fruit plate d. Cornmeal muffin and orange juice
ANS: A Eggs and whole grain breads are high in iron. The other choices are appropriate for other nutritional deficiencies but are not the best choice for a patient with iron-deficiency anemia.
Which information obtained by the nurse assessing a patient admitted with multiple myeloma is most important to report to the health care provider? a. Serum calcium level is 15 mg/dL. b. Patient reports no stool for 5 days. c. Urine sample has Bence-Jones protein. d. Patient is complaining of severe back pain.
ANS: A Hypercalcemia may lead to complications such as dysrhythmias or seizures, and should be addressed quickly. The other patient findings will also be discussed with the health care provider, but are not life threatening
45. Which information obtained by the nurse assessing a patient admitted with multiple myeloma is most important to report to the health care provider? a. Serum calcium level is 15 mg/dL. b. Patient reports no stool for 5 days. c. Urine sample has Bence-Jones protein. d. Patient is complaining of severe back pain.
ANS: A Hypercalcemia may lead to complications such as dysrhythmias or seizures, and should be addressed quickly. The other patient findings will also be discussed with the health care provider, but are not life threatening.
A patient with acute osteomyelitis of the left femur is hospitalized for regional antibiotic irrigation. Which intervention will be included in the initial plan of care? a. Immobilization of the left leg b. Positioning the left leg in flexion c. Assisted weight-bearing ambulation d. Quadriceps-setting exercise repetitions
ANS: A Immobilization of the affected leg helps decrease pain and reduce the risk for pathologic fractures. Weight-bearing exercise increases the risk for pathologic fractures. Flexion of the affected limb is avoided to prevent contractures.
2. 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.
Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate? a. "I will call my health care provider if my stools turn black." b. "I will take a stool softener if I feel constipated occasionally." c. "I should take the iron with orange juice about an hour before eating." d. "I should increase my fluid and fiber intake while I am taking iron tablets."
ANS: A It is normal for the stools to appear black when a patient is taking iron, and the patient should not call the doctor about this. The other patient statements are correct.
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.
11. 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.
Which action will the nurse take when caring for a patient with osteomalacia? a. Teach about the use of vitamin D supplements. b. Educate about the need for weight-bearing exercise. c. Discuss the use of medications such as bisphosphonates. d. Emphasize the importance of sunscreen use when outside.
ANS: A Osteomalacia is caused by inadequate intake or absorption of vitamin D. Weight-bearing exercise and bisphosphonate administration may be used for osteoporosis but will not be beneficial for osteomalacia. Because ultraviolet light is needed for the body to synthesize vitamin D, the patient might be taught that 20 minutes/day of sun exposure is beneficial.
33. 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/L. 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/L 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.
The nurse assesses a patient who has numerous petechiae on both arms. Which question should the nurse ask the patient? a. "Do you take salicylates?" b. "Are you taking any oral contraceptives?" c. "Have you been prescribed antiseizure drugs?" d. "How long have you taken antihypertensive drugs?"
ANS: A Salicylates interfere with platelet function and can lead to petechiae and ecchymoses. Antiseizure drugs may cause anemia, but not clotting disorders or bleeding. Oral contraceptives increase a person's clotting risk. Antihypertensives do not usually cause problems with decreased clotting.
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.
What is the priority nursing diagnosis for the client newly diagnosed with hyperthyroidism? A. Decreased cardiac output related to tachycardia B. Disturbed Body Image related to weight loss C. Hyperthermia related to hypermetabolism D. Fatigue related to energy depletion
ANS: A The cardiac problems of hyperthyroidism include increased systolic blood pressure, a widened pulse pressure, tachycardia, and other dysrhythmias. The goals of nonsurgical management are to decrease the effect of thyroid hormone on cardiac function and to reduce thyroid hormone secretion.
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.
The nurse caring for a patient with type A hemophilia being admitted to the hospital with severe pain and swelling in the right knee will a. immobilize the joint. b. apply heat to the knee. c. assist the patient with light weight bearing. d. perform passive range of motion to the knee.
ANS: A The initial action should be total rest of the knee to minimize bleeding. Ice packs are used to decrease bleeding. Range of motion (ROM) and weight-bearing exercise are contraindicated initially, but after the bleeding stops, ROM and physical therapy are started.
47. The nurse has obtained the health history, physical assessment data, and laboratory results shown in the accompanying figure for a patient admitted with aplastic anemia. Which information is most important to communicate to the health care provider? a. Neutropenia b. Increasing fatigue c. Thrombocytopenia d. Frequent constipation
ANS: A The low white blood cell count indicates that the patient is at high risk for infection and needs immediate actions to diagnose and treat the cause of the leucopenia. The other information may require further assessment or treatment, but does not place the patient at immediate risk for complications.
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.
42. A patient who was admitted the previous day with pneumonia complains of a sharp pain of 7 (based on 0 to 10 scale) "whenever I take a deep breath." Which action will the nurse take next? a. Auscultate breath sounds. 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.
The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action should the nurse include in the plan of care? a. Avoid intramuscular injections. b. Encourage increased oral fluids. c. Check temperature every 4 hours. d. Increase intake of iron-rich foods.
ANS: A Thrombocytopenia is a decreased number of platelets, which places the patient at high risk for bleeding. Neutropenic patients are at high risk for infection and sepsis and should be monitored frequently for signs of infection. Encouraging fluid intake and iron-rich food intake is not indicated in a patient with thrombocytopenia
50. 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.
A patient arrives at the ambulatory surgery center for a scheduled outpatient surgery. Which information is of most concern to the nurse? a. The patient has not had outpatient surgery before. b. The patient is planning to drive home after surgery. c. The patient's insurance does not cover outpatient surgery. d. The patient had a glass of water a few hours before arriving.
ANS: B After outpatient surgery, the patient should not drive home and will need assistance with transportation and home care. The patient's experience with outpatient surgery is assessed, but it does not have as much application to the patient's physiologic safety. The patient's insurance coverage is important to establish, but this is not usually the nurse's role or a priority in nursing care. Having clear liquids a few hours before surgery does not usually increase risk for aspiration.
A diabetic patient who uses insulin to control blood glucose has been NPO since midnight before having a mastectomy. The nurse will anticipate the need to a. withhold the usual scheduled insulin dose because the patient is NPO. b. obtain a blood glucose measurement before any insulin administration. c. give the patient the usual insulin dose because stress will increase the blood glucose. d. administer a lower dose of insulin because there will be no oral intake before surgery.
ANS: B Preoperative insulin administration is individualized to the patient, and the current blood glucose will provide the most reliable information about insulin needs. It is not possible to predict whether the patient will require no insulin, a lower dose, or a higher dose without blood glucose monitoring.
When the nurse caring for a patient before surgery has a question about a sedative medication to be given before sending the patient to the surgical suite, the nurse will communicate with the a. surgeon. b. anesthesiologist. c. circulating nurse. d. registered nurse first assistant (RNFA).
ANS: B The anesthesiologist is responsible for prescribing preoperative medications. The RNFA and surgeon are responsible for the surgery, but not for the preoperative sedation. The circulating nurse does not have authority to make a change in any medication.
Which of these actions included in the perioperative patient plan of care can the perioperative nurse delegate to a surgical technologist? a. Complete the patient's admission assessment. b. Pass sterile instruments and supplies to the surgeon. c. Teach the patient about what to expect in the operating room (OR). d. Give the postoperative report to the postanesthesia care unit (PACU) nurse.
ANS: B The education and certification for a surgical technologist includes the scrub and circulating functions in the OR. Patient teaching, communication with other departments about a patient's condition, and the admission assessment require RN level education and scope of practice.
A postoperative patient has not voided for 7 hours after return to the postsurgical unit. Which action should the nurse take first? a. Notify the surgeon. b. Perform a bladder scan. c. Assist the patient to ambulate to the bathroom. d. Insert a straight catheter as indicated on the PRN order.
ANS: B The initial action should be to assess the bladder for distention. If the bladder is distended, providing the patient with privacy (by walking with them to the bathroom) will be helpful. Catheterization should only be done after other measures have been tried without success because of the risk for urinary tract infection. There is no indication to notify the surgeon about this common postoperative problem unless all measures to empty the bladder are unsuccessful.
A patient is seen at the health care provider's office several weeks before hip surgery for preoperative assessment. The patient reports use of echinacea, saw palmetto, and glucosamine/chondroitin. The nurse should a. ascertain that there will be no interactions with anesthetic agents. b. discuss the supplement use with the patient's health care provider. c. teach the patient that these products may be continued preoperatively. d. advise the patient to stop the use of all herbs and supplements at this time.
ANS: B The nurse should discuss the medication use with the patient's health care provider because saw palmetto is used to decrease prostatic hyperplasia, and the patient may need to continue taking the medication or a prescription medication to prevent urinary retention. The nurse should not advise the patient to stop the supplements or to continue them without consulting with the health care provider. Determining the interactions between the supplements and anesthetics is not within the nurse's scope of practice.
What is the major hormone secreted by the adrenal medulla? A. Dopamine B. Epinephrine C. Norepinephrine D. Aldosterone
ANS: B The adrenal medulla secretes norepinephrine and epinephrine in proportions of 15% and 85%, respectively.
17. A 28-year-old man with von Willebrand disease is admitted to the hospital for minor knee surgery. The nurse will review the coagulation survey to check the a. platelet count. b. bleeding time. c. thrombin time. d. prothrombin time.
ANS: B The bleeding time is affected by von Willebrand disease. Platelet count, prothrombin time, and thrombin time are normal in von Willebrand disease.
A 28-year-old man with von Willebrand disease is admitted to the hospital for minor knee surgery. The nurse will review the coagulation survey to check the a. platelet count. b. bleeding time. c. thrombin time. d. prothrombin time.
ANS: B The bleeding time is affected by von Willebrand disease. Platelet count, prothrombin time, and thrombin time are normal in von Willebrand disease.
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.
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.
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.
44. A patient who has non-Hodgkin's lymphoma is receiving combination treatment with rituximab (Rituxan) and chemotherapy. Which patient assessment finding requires the most rapid action by the nurse? a. Anorexia b. Vomiting c. Oral ulcers d. Lip swelling
ANS: D Lip swelling in angioedema may indicate a hypersensitivity reaction to the rituximab. The nurse should stop the infusion and further assess for anaphylaxis. The other findings may occur with chemotherapy, but are not immediately life threatening.
46. Which intervention will the nurse include in the plan of care for a patient who is diagnosed with a lung abscess? a. Teach the patient to avoid the use of over-the-counter expectorants. b. Assist the patient with chest physiotherapy and postural drainage. c. Notify the health care provider immediately about any bloody or foul-smelling sputum. d. Teach about the need for prolonged antibiotic therapy after discharge from the hospital.
ANS: D Long-term antibiotic therapy is needed for effective eradication of the infecting organisms in lung abscess. Chest physiotherapy and postural drainage are not recommended for lung abscess because they may lead to spread of the infection. Foul smelling and bloody sputum are common clinical manifestations in lung abscess. Expectorants may be used because the patient is encouraged to cough.
A client has just been admitted with a diagnosis of myxedema coma. If all of the following interventions were prescribed, the nurse should place highest priority on completing which action first?
Administering oxygen
Megestrol
Advanced endometrial and breast cancer
14. Which of these assessment findings in a patient with a hiatal hernia who returned from a laparoscopic Nissen fundoplication 4 hours ago is most important for the nurse to address immediately? a. The patient has absent breath sounds throughout the left lung. b. The patient complains of 6/10 (of a 0-10 scale) abdominal pain. c. The patient has decreased bowel sounds in all four quadrants. d. The patient is experiencing intermittent waves of nausea.
Answer: A Rationale: Decreased breath sounds on one side may indicate a pneumothorax, which requires rapid diagnosis and treatment. The abdominal pain and nausea should also be addressed but are not as high priority as the patient's respiratory status. The patient's decreased bowel sounds are expected after surgery and require ongoing monitoring but no other action. Cognitive Level: Application Text Reference: p. 1008 Nursing Process: Assessment NCLEX: Physiological Integrity
8. The nurse is admitting a patient who has been diagnosed with squamous cell carcinoma of the buccal mucosa. When interviewing the patient for the health history, the nurse will ask about a. any use of tobacco by the patient. b. any history of streptococcal throat infection. c. chronic overexposure to the sun. d. recurrent herpes simplex (HSV) infections.
Answer: A Rationale: Tobacco use greatly increases the risk for oral cancer. History of acute infections such as strep throat is not a risk factor for oral cancer, although chronic irritation of the oral mucosa does increase risk. Sun exposure does not increase the risk for cancers of the buccal mucosa. Human papillomavirus infection (HPV) infection may be associated with increased risk, but HSV infection is not a risk factor for oral cancer. Cognitive Level: Comprehension Text Reference: pp. 1001-1002 Nursing Process: Assessment NCLEX: Physiological Integrity
20. A patient who is nauseated and vomiting up blood streaked fluid is admitted to the hospital with acute gastritis. When obtaining the admission health history, it will be most important for the nurse to ask the patient about a. frequency of nonsteroidal antiinflammatory drug (NSAID) use. b. family history of gastric problems. c. recent weight gain or loss. d. the amount of fat in the diet.
Answer: A Rationale: Use of an NSAID is associated with damage to the gastric mucosa, which can result in acute gastritis. Family history, recent weight gain or loss, and fatty foods are not risk factors for acute gastritis. Cognitive Level: Application Text Reference: p. 1013 Nursing Process: Assessment NCLEX: Physiological Integrity
The nurse is teaching the female client how to perform self-catheterization. Which of the following instructions is incorrect? A) It is important to maintain ascetic technique when performing this process. B) The catheterization should be performed every 4-6 hours C) If you have the urge to void in the middle of the night, try to pea. If that doesn't work, you may self-catheterize. D) Always dispose of the catheter after use
Answer: A. Patients who self-catheterize are instructed to use clean technique as aseptic technique is not feasible or as needed in the home setting. Catheterization should be performed at regular intervals. It can be performed in the middle of the night as necessary. The catheter should be disposed of after use, never reused.
1. Which information about a patient who has just been admitted to the hospital with nausea and vomiting will require the most rapid intervention by the nurse? a. The patient has been vomiting several times a day for the last 4 days. b. The patient is lethargic and difficult to arouse. c. The patient's chart indicates a recent resection of the small intestine. d. The patient has taken only sips of water.
Answer: B Rationale: A lethargic patient is at risk for aspiration, and the nurse will need to position the patient to decrease aspiration risk. The other information is also important to collect, but it does not require as quick action as the risk for aspiration. Cognitive Level: Application Text Reference: p. 991 Nursing Process: Assessment NCLEX: Physiological Integrity
7. When the nurse is assessing the mouth of a patient who uses smokeless tobacco for signs of oral cancer, which finding will be of most concern? a. A 3-mm ulcer on the floor of the mouth b. A red, velvety patch on the buccal mucosa c. White, curdlike plaques on the back of the tongue d. Painful blisters at the border of the lips
Answer: B Rationale: A red, velvety patch suggests erythroplasia, which has a high incidence (greater than 50%) of progression to squamous cell carcinoma. The other lesions are suggestive of acute processes (aphthous stomatitis, oral candidiasis, and herpes simplex). Cognitive Level: Comprehension Text Reference: p. 1001 Nursing Process: Assessment NCLEX: Physiological Integrity
5. All the following orders are received for a patient who has been admitted with dehydration after 3 days of nausea and vomiting. Which order will the nurse act on first? a. Provide oral care with moistened swabs. b. Infuse normal saline at 250 ml/hr. c. Insert a 16-gauge nasogastric (NG) tube. d. Administer IV ondansetron (Zofran).
Answer: B Rationale: Because the patient has severe dehydration, rehydration with IV fluids is the priority. The other orders should be accomplished as quickly as possible after the IV fluids are initiated. Cognitive Level: Application Text Reference: pp. 993-994 Nursing Process: Implementation NCLEX: Physiological Integrity
43. The nurse suspects the possibility of Escherichia coli O157:H7 food poisoning when several individuals who have eaten in the same restaurant develop a. fever and chills. b. hemorrhagic diarrhea. c. muscular incoordination. d. nausea and vomiting.
Answer: B Rationale: E. coli O157:H7 causes hemorrhagic colitis with bloody diarrhea. Fever and chills are not typical clinical manifestations of food poisoning. Muscular incoordination is seen with botulism. Nausea and vomiting are common with some forms of food poisoning, but not with E. coli O157:H7. Cognitive Level: Comprehension Text Reference: p. 1031 Nursing Process: Assessment NCLEX: Physiological Integrity
4. A patient who has been NPO during treatment for nausea and vomiting caused by gastric irritation is to start oral intake. Which of these should the nurse offer to the patient? a. A glass of orange juice b. A bowl of hot chicken broth c. A dish of lemon gelatin d. A cup of coffee with cream
Answer: C Rationale: Clear liquids are usually the first foods started after a patient has been nauseated. Acidic foods such as orange juice, very hot foods, and coffee are poorly tolerated when patients have been nauseated. Cognitive Level: Comprehension Text Reference: pp. 992, 995 Nursing Process: Implementation NCLEX: Physiological Integrity
37. Which information will be best for the nurse to include when teaching a patient with PUD about dietary management of the disease? a. "You should avoid eating many raw fruits and vegetables." b. "High-protein foods are least likely to cause pain." c. "Avoid foods that cause pain after you eat them." d. "You will need to remain on a bland diet indefinitely."
Answer: C Rationale: The best information is that each individual should choose foods that are not associated with postprandial discomfort. Raw fruits and vegetables may irritate the gastric mucosa, but chewing well seems to decrease this and some patients may tolerate these well. High-protein foods help to neutralize acid, but they also stimulate hydrochloric (HCl) acid secretion and may increase discomfort for some patients. Bland diets may be recommended during an acute exacerbation of PUD, but there is little scientific evidence to support their use. Cognitive Level: Application Text Reference: p. 1021 Nursing Process: Implementation NCLEX: Physiological Integrity
41. The nurse will instruct the patient with GERD who is being discharged after a Stretta procedure that a. acetaminophen (Tylenol) tablets can be used for pain. b. postoperative nausea is an expected symptom. c. gelatin, clear broth, and tea are appropriate foods for the next 24 hours. d. intake and output should be measured and reported to the health care provider.
Answer: C Rationale: The patient should remain on clear liquids for the first 24 hours after the Stretta procedure. Liquid medications, rather than tablets, are used to decrease irritation at the site. The patient is instructed to notify the health care provider if nausea or vomiting occurs. There is no need for the patient to monitor intake and output. Cognitive Level: Application Text Reference: p. 1007 Nursing Process: Implementation NCLEX: Physiological Integrity
13. After the nurse teaches a patient with GERD about recommended dietary modifications, which diet choice for a snack 2 hours before bedtime indicates that the teaching has been effective? a. Chocolate pudding b. Glass of low-fat milk c. Peanut butter sandwich d. Cherry gelatin and fruit
Answer: D Rationale: Gelatin and fruit are low fat and will not decrease lower esophageal sphincter (LES) pressure. Foods like chocolate are avoided because they lower LES pressure. Milk products increase gastric acid secretion. High-fat foods such as peanut butter decrease both gastric emptying and LES pressure. Cognitive Level: Application Text Reference: p. 1005 Nursing Process: Evaluation NCLEX: Physiological Integrity
When caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury, which nursing action has the highest priority?
Assessment of respiratory rate and depth rational: Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function. The other actions also are appropriate but are not as important as assessment of respiratory effort.
When assessing a patient with a urinary tract infection, where would the nurse percuss to assess for possible pyelonephritis?
At the Costovertebral angle (CVA) (on back/flank between the twelfth rib and the vertebral column). Tenderness with percussion suggests pyelonephritis or polycystic kidney disease.
A patient found in a tonic-clonic seizure reports afterward that the seizure was preceded by numbness and tingling of the arm. The nurse knows that this finding indicates what type of seizure?
Atonic rational: The initial symptoms of a partial seizure involve clinical manifestations that are localized to a particular part of the body or brain. Symptoms of an absence seizure are staring and a brief loss of consciousness. In an atonic seizure, the patient loses muscle tone and (typically) falls to the ground. Myoclonic seizures are characterized by a sudden jerk of the body or extremities.
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.
A patient with varicose veins has been prescribed compression stockings. How should the nurse teach the patient to use these? A. "Try to keep your stockings on 24 hours a day, as much as possible." B. "While you're still lying in bed in the morning, put on your stockings." C. "Dangle your feet at your bedside for 5 minutes before putting on your stockings." D. "Your stockings will be most effective if you can remove them for a few minutes several times a day."
B. "While you're still lying in bed in the morning, put on your stockings." The patient with varicose veins should apply stockings in bed, before rising in the morning. Stockings should not be worn continuously, but they should not be removed several times daily. Dangling at the bedside prior to application is likely to decrease their effectiveness.
Tamoxifen
Breast Cancer
Miss Jones is alert, ambulatory, older nursing home resident, who frequently has difficulty making it to the bathroom in time. The nurse planning her care is aware of the following? A) Incontinence is to be expected and a woman of Mrs Jones age. B)One of every 10 nursing home residents is incontinent C) Keagle exercises performed at regular intervals throughout the day maybe helpful D) An indwelling catheter should be inserted as soon as possible
C) Keagle exercises performed at regular intervals throughout the day maybe helpful Keagle exercises may help "pt" Regain control of the micturition process. Incontinence is not a normal consequence of aging, And at least half of nursing home residents may be incontinent. An indwelling catheter is the last choice of treatment
When caring for a patient with autoimmune hepatitis, the nurse recognizes that, unlike viral hepatitis, the patient a. does not manifest hepatomegaly or jaundice b. experiences less liver inflammation and damage c. is treated with corticosteroids or other immunosuppressant agents d. is usually an older adult who has used a wide variety of prescription and over the counter drugs
C- Immunosuppressive agents are indicated i hepatitis associated with immune disorders to decrease liver damage caused by autoantibodies. Autoimmune hepatitis is similar to viral hepatitis in presenting signs and symptoms and may become chronic and lead to cirrhosis.
The care plan for a patient who has increased intracranial pressure and a ventriculostomy includes the following nursing actions. Which action can the nurse delegate to nursing assistive personnel (NAP) who regularly work in the intensive care unit?
Check capillary blood glucose level every 6 hours. rational: Experienced NAP can obtain capillary blood glucose levels when they have been trained and evaluated in the skill. Monitoring and documentation of cerebrospinal fluid (CSF) color and intracranial pressure (ICP) require RN-level education and scope of practice. Although repositioning patients is frequently delegated to NAP, repositioning a patient with a ventriculostomy is complex and should be done by the RN.
Following hypophysectomy, a client complains of being very thirsty and having to urinate frequently. Which is the initial nursing action?
Check the urine specific gravity.
When teaching a patient with renal failure about a low-phosphate diet, the nurse will include information to restrict a. intake of green, leafy vegetables. b. the amount of high-fat foods. c. ingestion of dairy products. d. the quantity of fruits and juices.
Correct Answer: C Rationale: Foods high in phosphate include milk and other dairy products, so these are restricted on low-phosphate diets. Green, leafy vegetables, high-fat foods, and fruits/juices are not high in phosphate and are not restricted.
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.
The doctor walks into the patient room and says. "You have pheochromocytoma" and leaves. The patient begins to cry and says, "What does that mean?" What is the best response by the nurse? A) It is a tumor in your pituitary gland. You are probably going to die. B) You seem upset. Tell me how you are feeling. C) Pheochromocytoma is a disorder of the adrenal glands where too little steroids are released into the blood stream D) This is a caused by a benign tumor in certain glands in your body located above your kidneys
D This is a caused by a benign tumor in certain glands in your body located above your kidneys
Data must be collected to evaluate the effectiveness of a plan to reduce urinary incontinence and a older adult patient. Of the information below, which is the least important for the evaluation process? A) The incontinence pattern B) State of physical mobility C) Medications being taken D) Age of patient
D) Age of patient Incontinence is not a natural consequence of the aging process. All the other factors are necessary information for the plan of care.
A thoracic aortic aneurysm is found when a patient has a routine chest radiograph. The nurse anticipates that additional diagnostic testing to determine the size and structure of the aneurysm will include... A) angiography B) Ultrasonography C) echocardiography D) CT scan
D) CT scan, The most accurate test to determine the diameter of the aneurysm and whether a thrombus is present. The other tests may also be used, but the CT yields the most descriptive results.
The most common type of leukemia in older adults is: A. acute myelocytic leukemia B. acute lymphocytic leukemia C. chronic myelocytic leukemia D. chronic lymphocytic leukemia
D. chronic lymphocytic leukemia
Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient with acute pancreatitis? a. Nausea and vomiting b. Hypotonic bowel sounds c. Abdominal tenderness and guarding d. Muscle twitching and finger numbness
D: Muscle twitching and finger numbness indicate hypocalcemia,
A patient who has right-sided weakness after a stroke is attempting to use the left hand for feeding and other activities. The patient's wife insists on feeding and dressing him, telling the nurse, "I just don't like to see him struggle." Which nursing diagnosis is most appropriate for the patient?
Disabled family coping related to inadequate understanding by patient's spouse rational: The information supports the diagnosis of disabled family coping because the wife does not understand the rehabilitation program. There are no data supporting low self-esteem, and the patient is attempting independence. The data do not support an interruption in family processes because this may be a typical pattern for the couple. There is no indication that the patient has impaired nutrition.
The nurse is teaching a group of older adult women about the signs and symptoms of urinary tract infection (UTI). Which concepts does the nurse explain in the presentation? (Select all that apply.)
Dysuria Correct Frequency Correct Nocturia Correct Urgency
Which action should the nurse take when assessing a patient with trigeminal neuralgia?
Examine the mouth and teeth thoroughly. rational: Oral hygiene is frequently neglected because of fear of triggering facial pain. Having the patient clench the facial muscles will not be useful because the sensory branches of the nerve are affected by trigeminal neuralgia. Light touch and palpation may be triggers for pain and should be avoided.
A client with seizure disorder comes to the physician's office for a routine checkup. Knowing that the client takes phenytoin (Dilantin) to control seizures, the nurse assesses for which common adverse drug reaction?
Excessive gum tissue growth
Match the following anticoagulant drugs with their characteristics. Can choose unfractionated heparin, LMWH, Hirudin derivatives, Warfarin (Coumadin), Thrombin inhibitor (argatroban (Acova)) a) Is only administered IV
Hirudin derivatives and Thrombin inhibitor
A patient who has numbness and weakness of both feet is hospitalized with Guillain-Barré syndrome. The nurse will anticipate the need to teach the patient about _____________
IV infusion of immunoglobulin (Sandoglobulin). rational: Because the Guillain-Barré syndrome is in the earliest stages (as evidenced by the symptoms), use of high-dose immunoglobulin is appropriate to reduce the extent and length of symptoms. Mechanical ventilation and tube feedings may be used later in the progression of the syndrome but are not needed now. Corticosteroid use is not helpful in reducing the duration or symptoms of the syndrome.
A client is diagnosed with hyperparathyroidism. The nurse teaching the client about dietary alterations to manage the disorder tells the client to limit which food in the diet?
Ice cream
Acromegaly is NOT the result of excess growth hormone secretion in children, IT IS IN ADULTS
In children, too much growth hormone causes gigantism, resulting in an abnormal increase in height and bone growth. Acromegaly occurs in adulthood.
A client has an endocrine system dysfunction of the pancreas. The nurse anticipates that the client will exhibit impaired secretion of which substance?
Insulin
What is multiple sclerosis?
It is a progressive neurological disease with an onset among those who are at their 20's through 40's. It has a hereditary link and occurs most commonly among women. It involves the hardening of multiple nerves, and is aggravated by stress. It limits changes.
Careful preparation of the patient for an IVP is necessary. Nursing interventions would include:
NPO for about 12 hours before examination. Giving prescribed bowel prep. Instructing patient concerning IVP.
A patient with right-sided weakness that started 90 minutes earlier is admitted to the emergency department and all these diagnostic tests are ordered. Which test should be done first?
Noncontrast computed tomography (CT) scan rational: Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the smaller the area of brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.
Which of these nursing actions for a patient with Guillain-Barré syndrome is most appropriate for the nurse to delegate to an experienced nursing assistant?
Passive range of motion to extremities q8hr rational: Assisting a patient with movement is included in nursing assistant education and scope of practice. Administration of tube feedings, administration of ordered medications, and assessment are skills requiring more education and scope of practice, and the RN should perform these skills.
The nursing care plan includes teaching the patient Kegel exercises. The nurse teaches the patient to alternately tighten and relax which group of muscles?
Perineal floor
The collection of subjective and objective data for the patient with acute glomerulonephritis could include:
Periorbital edema. Anorexia. Frankly sanguineous urine.
When caring for a patient with left-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care during the acute period of the stroke?
Place objects needed for activities of daily living on the patient's right side. rational: During the acute period, the nurse should place objects on the patient's unaffected side. Since there is a visual defect in the left half of each eye, an eye patch is not appropriate. The patient should be approached from the right side. The visual deficit may not resolve, although the patient can learn to compensate for the defect.
A client with amyotrophic lateral sclerosis (ALS) tells the nurse, "Sometimes I feel so frustrated. I can't do anything without help!" This comment best supports which nursing diagnosis?
Powerlessness
A health care provider has prescribed propylthiouracil (PTU) for a client with hyperthyroidism, and the nurse assists in developing a plan of care for the client. Which nursing measure would be included in the plan regarding this medication?
Signs and symptoms of hypothyroidism
What kinds of food or vitamins should someone with Parkinson's avoid? Why?
Spinach, bananas, fish and pepper. Also, Vitamin B6, because they all deactivate LEVODOPA, the precursor to the neurotransmitters dopamine, norepinephrine (noradrenaline), and epinephrine (adrenaline) collectively known as catecholamines
Renal calculi may result from:
Stasis of urine caused by obstruction or quadriplegia. Infections of urinary tract. Hyperparathyroidism, which causes increase in calcium metabolism.
The certified Wound, Ostomy, and Continence Nurse or enterostomal therapist teaches a client who has had a cystectomy about which care principles for the client's post-discharge activities?
Stoma and pouch care
Which nursing intervention or practice is most effective in helping to prevent urinary tract infection (UTI) in hospitalized clients?
Studies have shown that re-evaluating the need for indwelling catheters in clients is the most effective way to prevent UTIs in the hospital setting.
A patient with multiple sclerosis (MS) has urinary retention caused by a flaccid bladder. Which action will the nurse plan to take?
Teach the patient how to use the Credé method. rational: The Credé method can be used to improve bladder emptying. Decreasing fluid intake will not improve bladder emptying and may increase risk for urinary tract infection (UTI) and dehydration. The use of incontinence briefs and frequent toileting will not improve bladder emptying.
Which assessment finding alarms the nurse immediately after a client returns from the operating room for cystoscopy performed under conscious sedation?
Temperature of 100.8° F sign of infection!!!!
2. These crystals are uremic frost resulting from irritating toxins deposited in the client's tissues. Bathing in cool water will remove the crystals, promote client comfort, and decrease the itching resulting from uremic frost.
The UAP tells the nurse the client with ARF has a white crystal-like layer on top of the skin. Which intervention should the nurse implement? 1.Have the assistant apply a moisture barrier cream to the skin. 2.Instruct the UAP to bathe the client in cool water. 3.Tell the UAP not to turn the client in this condition. 4.Explain this is normal and do not do anything for the client.
client with acute kidney failure who is receiving a protein restricted diet
The amount of protein permitted in the diet (usually less than 50 g) depends on the extent of kidney function; excess protein causes an increase in urea concentration, which should be avoided Adequate calories are provided to prevent tissue catabolism that also results in an increase in metabolic waste products. In kidney failure the kidneys are unable to eliminate the waste products of a high-protein diet. The body is able to synthesize the nonessential amino acids. Urea is a waste product of protein metabolism; the body is able to synthesize the nonessential amino acids.
3. Regular insulin, along with glucose, will drive potassium into the cells,thereby lowering serum potassium levels temporarily.
The client diagnosed with ARF is experiencing hyperkalemia. Which medication should the nurse prepare to administer to help decrease the potassium level? 1.Erythropoietin. 2.Calcium gluconate. 3.Regular insulin. 4.Osmotic diuretic.
2. Bed rest reduces exertion and the metabolic rate, thereby reducing catabolism and subsequent release of potassium and accumulation of endogenous waste products (urea and creatinine).
The client diagnosed with ARF is placed on bed rest. The client asks the nurse, "Why do I have to stay in bed? I don't feel bad." Which scientific rationale supports the nurse's response? 1.Bed rest helps increase the blood return to the renal circulation. 2.Bed rest reduces the metabolic rate during the acute stage. 3.Bed rest decreases the workload of the left side of the heart. 4.Bed rest aids in reduction of peripheral and sacral edema.
2. Assessment is the first part of the nursing process and is priority. The renal colic pain can be so intense it can cause a vasovagal response, with resulting hypotension and syncope.
The client diagnosed with renal calculi is admitted to the medical unit. Which intervention should the nurse implement first? 1.Monitor the client's urinary output. 2.Assess the client's pain and rule out complications. 3.Increase the client's oral fluid intake. 4.Use a safety gait belt when ambulating the client.
4. The white blood cell count is elevated;normal is 5,000 to 10,000/mm3.
The client had surgery to remove a kidney stone. Which laboratory assessment data warrant immediate intervention by the nurse? 1.A serum potassium level of 3.8 mEq/L. 2.A urinalysis shows microscopic hematuria. 3.A creatinine level of 0.8 mg/100 mL. 4.A white blood cell count of 14,000/mm3.
3. Dehydration results in concentrated serum, causing laboratory values to increase because the blood has normal constituents but not enough volume to dilute the values to within normal range or possibly lower.
The client is admitted to a nursing unit from a long-term care facility with a hematocrit of 56% and a serum sodium level of 152 mEq/L. Which condition is a cause for these findings? 1.Overhydration. 2.Anemia. 3.Dehydration. 4.Renal failure.
1. Preventing and treating shock with blood and fluid replacement will prevent acute renal failure from hypoperfusion of the kidneys.Significant blood loss is expected in the client with a gunshot wound.
The client is admitted to the emergency department after a gunshot wound to the abdomen. Which nursing intervention should the nurse implement first to prevent ARF? 1.Administer normal saline IV. 2.Take vital signs. 3.Place client on telemetry. 4.Assess abdominal dressing.
3. Venison, sardines, goose, organ meats,and herring are high-purine foods, which should be eliminated from the diet to help prevent uric acid stones.
The client is diagnosed with a uric acid stone. Which foods should the client eliminate from the diet to help prevent re-occurrence? 1.Beer and colas. 2.Asparagus and cabbage. 3.Venison and sardines. 4.Cheese and eggs.
4. Pain is priority. The pain can be so severe a sympathetic response may occur, causing nausea; vomiting; pallor;and cool, clammy skin.
The client is diagnosed with an acute episode of ureteral calculi. Which client problem is priority when caring for this client? 1.Fluid volume loss. 2.Knowledge deficit. 3.Impaired urinary elimination. 4.Alteration in comfort.
3. A urinalysis can assess for hematuria,the presence of white blood cells,crystal fragments, or all three, which can determine if the client has a urinary tract infection or possibly a renal stone, with accompanying signs/symptoms of UTI.
The client with a history of renal calculi calls the clinic and reports having burning on urination, chills, and an elevated temperature. Which instruction should the nurse discuss with the client? 1.Increase water intake for the next 24 hours. 2.Take two (2) Tylenol to help decrease the temperature. 3.Come to the clinic and provide a urinalysis specimen. 4.Use a sterile 4 × 4 gauze to strain the client's urine.
4. No special preparation is needed for this noninvasive, nonpainful test. A conductive gel is applied to the back or flank and then a transducer is applied which produces sound waves, resulting in a picture.
The client with possible renal calculi is scheduled for a renal ultrasound. Which intervention should the nurse implement for this procedure? 1.Ask if the client is allergic to shellfish or iodine. 2.Keep the client NPO eight (8) hours prior to the ultrasound. 3.Ensure the client has a signed informed consent form. 4.Explain the test is noninvasive and there is no discomfort.
the client is one (1) day post-operative abdominal aortic aneurysm repair. Which information from the unlicensed nursing assistant would require immediate intervention from the nurse?
The clients urinary output is 90 mL in six (6) hours.
2 Some clients develop a chronic infection and must receive antibiotic therapy as a routine daily medication to suppress the bacterial growth. The prescription will be refilled after the 90 days and continued.
The clinic nurse is caring for a client diagnosed with chronic pyelonephritis who is prescribed trimethoprim-sulfamethoxazole (Bactrim), a sulfa antibiotic, twice a day for 90 days. Which statement is the scientific rationale for prescribing this medication? 1.The antibiotic will treat the bladder spasms that accompany a urinary tract infection. 2.If the urine cannot be made bacteria free, the Bactrim will suppress bacterial growth. 3.In three (3) months, the client should be rid of all bacteria in the urinary tract. 4.The HCP is providing the client with enough medication to treat future infections.
4 Coffee, tea, cola, and alcoholic beverages are urinary tract irritants.
The female client in an outpatient clinic is being sent home with a diagnosis of urinary tract infection (UTI). Which instruction should the nurse teach to prevent a recurrence of a UTI? 1.Clean the perineum from back to front after a bowel movement. 2.Take warm tub baths instead of hot showers daily. 3.Void immediately preceding sexual intercourse. 4.Avoid coffee, tea, colas, and alcoholic beverages.
Priority Decision: What is the first priority in this patient's care?
The first priority is to control the bleeding, which will require immediate surgical repair of the aneurysm. Fatal hemorrhage is likely if the bleeding is not controlled.
The nurse is caring for a client following a thyroidectomy. The client tells the nurse that she is concerned because of voice hoarseness. The client asks the nurse whether the hoarseness will subside. Which statement by the nurse regarding the hoarseness is accurate?
The hoarseness is normal and will gradually subside.
3. Dietary changes for preventing renal stones include reducing the intake of the primary substance forming the calculi. In this case, limiting vitamin D will inhibit the absorption of calcium from the gastrointestinal tract.
The laboratory data reveal a calcium phosphate renal stone for a client diagnosed with renal calculi. Which discharge teaching intervention should the nurse implement? 1.Encourage the client to eat a low-purine diet and limit foods such as organ meats. 2.Explain the importance of not drinking water two (2) hours before bedtime. 3.Discuss the importance of limiting vitamin D-enriched foods. 4.Prepare the client for extracorporeal shock wave lithotripsy (ESWL).
3. After the initial administration of erythropoietin, a client's antihypertensive medications may need to be adjusted. Therefore, this complaint requires notification of the HCP. Erythropoietin therapy is contraindicated in clients with uncontrolled hypertension.
The male client diagnosed with CKD has received the initial dose of erythropoietin,a biologic response modifier, 1 week ago. Which complaint by the client indicates the need to notify the health-care provider? 1.The client complains of flu-like symptoms. 2.The client complains of being tired all the time. 3.The client reports an elevation in his blood pressure. 4.The client reports discomfort in his legs and back.
2. Reflecting the client's feelings and re-stating them are therapeutic responses the nurse should use when addressing the client's issues.
The male client diagnosed with CKD secondary to diabetes has been receiving dialysis for 12 years. The client is notified he will not be placed on the kidney transplant list. The client tells the nurse he will not be back for any more dialysis treatments. Which response by the nurse is most therapeutic? 1."You cannot just quit your dialysis. This is not an option." 2."Your angry at not being on the list, and you want to quit dialysis?" 3."I will call your nephrologist right now so you can talk to the HCP." 4."Make your funeral arrangements because you are going to die."
4. Medications such as non-steroidal anti-inflammatory drugs (NSAIDs) and some herbal remedies are nephrotoxic;therefore, asking about medications is appropriate.
The nurse is admitting a client diagnosed with acute renal failure (ARF). Which question is most important for the nurse to ask during the admission interview? 1."Have you recently traveled outside the United States?" 2."Did you recently begin a vigorous exercise program?" 3."Is there a chance you have been exposed to a virus?" 4."What over-the-counter medications do you take regularly?"
4. The client with urethral strictures will report a decrease in force and stream during voiding. The stricture is treated by dilation using small filiform bougies.
The nurse is assessing a client diagnosed with urethral strictures. Which data support the diagnosis? 1.Complaints of frequency and urgency. 2.Clear yellow drainage from the urethra. 3.Complaints of burning during urination. 4.A diminished force and stream during voiding.
3. The lungs attempt to increase the blood pH level by blowing off the carbon dioxide (carbonic acid).
The nurse is caring for a client diagnosed with diabetic ketoacidosis (DKA). Which statement best explains the scientific rationale for the client's Kussmaul's respirations? 1.The kidneys produce excess urine and the lungs try to compensate. 2.The respirations increase the amount of carbon dioxide in the bloodstream. 3.The lungs speed up to release carbon dioxide and increase the pH. 4.The shallow and slow respirations will increase the HCO3 in the serum.
2. Hypotension, which causes a decreased blood supply to the kidney, is one of the most common causes of pre-renal failure(before the kidney).
The nurse is caring for a client diagnosed with rule-out ARF. Which condition predisposes the client to developing prerenal failure? 1.Diabetes mellitus. 2.Hypotension. 3.Aminoglycosides. 4.Benign prostatic hypertrophy
3. The classic sign/symptom of nephrotic syndrome is dependent edema located on the client's sacrum and ankles.
The nurse is caring for a client diagnosed with rule-out nephrotic syndrome. Which intervention should be included in the plan of care? 1.Monitor the urine for bright-red bleeding. 2.Evaluate the calorie count of the 500-mg protein diet. 3.Assess the client's sacrum for dependent edema. 4.Monitor for a high serum albumin level.
2. Bladder spasms are common, but being relieved with medication indicates the condition is improving.
The nurse is caring for a client with a TURP. Which expected outcome indicates the client's condition is improving? 1.The client is using the maximum amount allowed by the PCA pump. 2.The client's bladder spasms are relieved by medication. 3.The client's scrotum is swollen and tender with movement. 4.The client has passed a large, hard, brown stool this morning.
1 A pregnant client diagnosed with a UTI will be admitted for aggressive IV antibiotic therapy. After symptoms subside, the client will be sent home to complete the course of treatment with oral medications.
The nurse is caring for a pregnant client diagnosed with acute pyelonephritis. Which scientific rationale supports the client being hospitalized for this condition? 1.The client must be treated aggressively to prevent maternal/fetal complications. 2.The nurse can force the client to drink fluids and avoid nausea and vomiting. 3.The client will be dehydrated and there won't be sufficient blood flow to the baby. 4.Pregnant clients historically are afraid to take the antibiotics as ordered.
4. Excess fluid volume is priority because of the stress placed on the heart and vessels, which could lead to heart failure, pulmonary edema,and death.
The nurse is developing a nursing care plan for the client diagnosed with CKD. Which nursing problem is priority for the client? 1.Low self-esteem. 2.Knowledge deficit. 3.Activity intolerance. 4.Excess fluid volume.
2. Treatment includes diuretics to eliminate dependent edema, usually in the ankles and sacrum. Medication teaching is an appropriate intervention.
The nurse is preparing a teaching care plan for the client diagnosed with nephrotic syndrome. Which intervention should the nurse include? 1.Stop steroids if a moon face develops. 2.Provide teaching for taking diuretics. 3.Increase the intake of dietary sodium. 4.Report a decrease in daily weight.
2. The client or family needs to contact the surgeon if the client develops chills, flank pain, decreased urinary output, or fever.
The nurse is preparing the discharge teaching plan for the male client with a left-sided nephrectomy. Which statement indicates the teaching is effective? 1."I can't wait to start back to work next week, I really need the money." 2."I will take my temperature and if it is above 101 I will call my doctor." 3."I am glad I won't have to keep track of how much I urinate in the day." 4."I am happy I will be able eat what I usually eat, I don't like this food."
1. Polycystic kidney disease poses an increased risk for rupture of the kidney, and therefore sports activities or occupations with risks for trauma should be avoided.
The nurse is providing discharge teaching to the client diagnosed with polycystic kidney disease. Which statement made by the client indicates the teaching has been effective? 1."I need to avoid any activity causing a risk for injury to my kidney." 2."I should avoid taking medications for high blood pressure." 3."When I urinate there may be blood streaks in my urine." 4."I may have occasional burning when I urinate with this disease."
2. Clients who have been diagnosed with tuberculosis of the renal tract should use condoms to prevent transmission of the mycobacterium. If the infection is located in the penis or urethra,abstaining from sexual activity is recommended.
The nurse is teaching the female client diagnosed with tuberculosis of the urinary tract prior to discharge. Which information should the nurse include specific to this diagnosis? 1.Instruct the client to take the medication with food. 2.Explain condoms should be used during treatment. 3.Discuss the need for follow-up chest x-rays. 4.Encourage a well-balanced diet and fluid intake.
2. Increasing the irrigation fluid will flush out the clots and blood.
The nurse observes red urine and several large clots in the tubing of the normal saline continuous irrigation catheter for the client who is one (1) day postoperative TURP. Which intervention should the nurse implement? 1.Remove the indwelling catheter. 2.Titrate the NS irrigation to run faster. 3.Administer protamine sulfate IVP. 4.Administer vitamin K slowly.
620 mL The amount of sterile normal saline is subtracted from the total volume removed from the catheter.
The nurse performs bladder irrigation through an indwelling catheter. The nurse instilled 90 mL of sterile normal saline. The catheter drained 710 mL. What is the client's output? ________
2. Fluid volume excess refers to an isotonic expansion of the extracellular fluid by an abnormal expansion of water and sodium. Therefore, sodium is restricted to allow the body to excrete the extra volume.
The nurse writes the client problem of "fluid volume excess" (FVE). Which intervention should be included in the plan of care? 1.Change the IV fluid from 0.9% NS to D5W. 2.Restrict the sodium in the client's diet. 3.Monitor blood glucose levels. 4.Prepare the client for hemodialysis.
While caring for a patient who has just been admitted with meningococcal meningitis, the RN observes all of the following. Which one requires action by the RN?
The nursing assistant goes into the patient's room without a mask. rational: Meningococcal meningitis is spread by respiratory secretions, so it is important to maintain respiratory isolation as well as standard precautions. Because the patient may be confused and weak, bedrails should be elevated at both the food and head of the bed. Low light levels in the room decrease pain caused by photophobia. Nutrition is an important aspect of care in a patient with meningitis.
What steps, if any, could have been taken to prevent the rupture of the AAA?
The only effective treatment for AAA is surgery, and the only way to prevent rupture is to repair the aneurysm surgically before it ruptures. Patients with AAAs should have close medical observation to detect increases in aneurysm size because surgical repair is generally required when the aneurysm is >5.5cm for men and >5 cm for women
The health care provider is considering the use of sumatriptan (Imitrex) for a patient with migraine headaches. Which information obtained by the nurse is most important to report to the health care provider?
The patient has a history of a recent acute myocardial infarction. rational: The triptans cause coronary artery vasoconstriction and should be avoided in patients with coronary artery disease. The other information will be reported to the health care provider, but none of it is an indication that sumatriptan would be an inappropriate treatment.
When assessing a patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider?
The patient's blood pressure is 86/42 mm Hg. rational: Shock is a serious complication of meningitis, and the patient's low blood pressure indicates the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernig's sign are expected with bacterial meningitis. The nurse should intervene to lower the temperature, but this is not as life threatening as the hypotension.
The nurse is monitoring a client following a thyroidectomy for signs/symptoms of hypocalcemia. Which sign/symptom noted in the client indicates the presence of hypocalcemia?
Tingling around the mouth
The nurse is teaching a client how to provide a clean-catch urine specimen. Which statement by the client indicates that teaching was effective?
To provide a clean-catch urine sample, the client should initiate voiding, then stop, then resume voiding into the container.
The nurse caring for a client scheduled for a transsphenoidal hypophysectomy to remove a tumor in the pituitary gland assists in developing a plan of care for the client. The nurse suggests including which specific information in the preoperative teaching plan?
Toothbrushing will not be permitted for at least 2 weeks following surgery.
Trimethoprim & Sulfamethoxazole
UTI
Nitrofurantoin
UTI-turns urine brown
Phenazopyridine
UTI-turns urine brown
1. Assessing the rate and volume of intravenous fluid is the most important intervention for the client who has one(1) kidney because an overload of fluids can result in pulmonary edema.
Which intervention is most important for the nurse to implement for the client with a left nephrectomy? 1.Assess the intravenous fluids for rate and volume. 2.Change surgical dressing every day at the same time. 3.Monitor the client's PT/PTT/INR level daily. 4.Monitor the percentage of each meal eaten.
4. The nephrostomy tube should never be clamped or have kinks because an obstruction can cause pyelonephritis.
Which intervention should the nurse implement when caring for the client with a nephrostomy tube? 1.Change the dressing only if soiled by urine. 2.Clean the end of the connecting tubing with Betadine. 3.Clean the drainage system every day with bleach and water. 4.Assess the tube for kinks to prevent obstruction.
1. An increased fluid intake ensuring 2 to 3 L of urine a day prevents the stone-forming salts from becoming concentrated enough to precipitate.
Which statement indicates the client diagnosed with calcium phosphate renal calculi understands the discharge teaching for ways to prevent future calculi formation? 1."I should increase my fluid intake, especially in warm weather. "2."I should eat foods containing cocoa and chocolate." 3."I will walk about a mile every week and not exercise often." 4."I should take one (1) vitamin a day with extra calcium."
Is someone with aphasia still considered competent?
YES
A female patient being admitted with pneumonia has a history of neurogenic bladder as a result of a spinal cord injury. Which action will the nurse plan to take first? a. Ask about the usual urinary pattern and any measures used for bladder control. b. Assist the patient to the toilet at scheduled times to help ensure bladder emptying. c. Check the patient for urinary incontinence every 2 hours to maintain skin integrity. d. Use intermittent catheterization on a regular schedule to avoid the risk of infection.
a
trousseau sign is seen with
a carpal spasm occurs when the upper arm is compressed, as by a tourniquet or a blood pressure cuff.
the nurse reinforces teaching for a pt after a cholecystectomy on a low fat diet. the nurse will know that the pt understands the diet if which of the following menu items is selected? a. roast chick rice gelatin dessert b. cream of chick soup, milk, gelatin dessert c. meat loaf, mashed potatoes with small amount of gravy, green beans d. turkey and cheese sandwich on whole grain bread, apply, milk
a: roast chicken, rice, and gelatin dessert is a low fat meal
a 44 y/o client has cirrhosis of the liver with sever ascites. the nurse plans for the following intervention? 1. apply prolonged pressure to injection sites 2. administer aspirin for headache as needed 3. measure abdominal girth weekly 4. provide a low protein, high carb diet
apply prolonged pressure to injection sites: the client may have a tendency to bleed easily bc clotting factors are formed in the liver
The mother of a 2 year old tells the nurse her child was born deaf. The most appropriate action for the nurse is to
assess the child's urinary elimination patterns
A patient who has had a stroke has a new order to attempt oral feedings. The nurse should assess the gag reflex and then _____________
assist the patient into a chair. rational: The patient should be as upright as possible before attempting feeding to make swallowing easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient. Pureed diets are not recommended because the texture is too smooth. The patient may have a poor appetite, but the oral feeding should be attempted regardless.
Which test is most specific for renal function? a. Renal scan b. Serum creatinine c. Creatinine clearance d. Blood urea nitrogen (BUN)
c. The rate at which creatinine is cleared from the blood and eliminated in the urine approximates the GFR and is the most specific test of renal function. The renal scan is useful in showing the location, size, and shape of the kidney and general blood perfusion.
Which additional information will the nurse need to consider when reviewing the laboratory results for a patient's total calcium level? a. The blood glucose is elevated. b. The phosphate level is normal. c. The serum albumin level is low. d. The magnesium level is normal.
c. The serum albumin level is low.
Which laboratory value should the nurse review to determine whether a patient's hypothyroidism is caused by a problem with the anterior pituitary gland or with the thyroid gland? a. Thyroxine (T4) level b. Triiodothyronine (T3) level c. Thyroid-stimulating hormone (TSH) level d. Thyrotropin-releasing hormone (TRH) level
c. Thyroid-stimulating hormone (TSH) level
the nurse is completing discharge teaching to the client dx with acute pancreatitis. which instruction should the nurse discuss with the client? 1. instruct client to decrease alcohol intake 2. explain the need to avoid all stress 3. discuss the importance of stopping smoking 4. teach the correct way to take pancreatic enzymes
discuss the importance of stopping smoking: smoking stimulates the pancreas to release pancreatic enaymes and should be stopped
the client has end stage liver failure secondary to alcoholic cirrhosis. which complication indicates the client is at risk for developing hepatic encephalopathy? 1. gastrointestinal bleeding 2. hypoalbuminemia 3. splenomegaly 4. hyperaldosteronism
gastrointestinal bleeding: blood in the intestinal tract is digested as a protein, which increases serum ammonia levels and increases the risk of developing hepatic encephalopathy
acute adrenal insufficiency requires treatment with
hydrocortisone sodium succinate
The nurse expects that management of the patient who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects will include ______________
oral administration of low dose aspirin therapy. rational: The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA.
adverse effects of long term corticosteroid therapy include
osteroperosis, moon face, increased risk of infection, weigt gain, blurred vision
Graves' disease - an autoimmune disorder that leads to
overactivity of the thyroid gland.
The nurse evaluates that treatment for the patient with an uncomplicated aortic dissection is successful when...
pain is relieved
After having a craniectomy and left anterior fossae incision, a patient has a nursing diagnosis of impaired physical mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is to ______________
perform range-of-motion (ROM) exercises every 4 hours. rational: ROM exercises will help to prevent the complications of immobility. Patients with anterior craniotomies are positioned with the head elevated. The patient with a craniectomy should not be turned to the operative side. When the patient is weak, clustering nursing activities may lead to more fatigue and weakness.
When evaluating a patient with trigeminal neuralgia who has had a glycerol rhizotomy, the nurse will ______________
question the patient about social activities with family and friends. rational: Because withdrawal from social activities is a common manifestation of trigeminal neuralgia, asking about social activities will help in evaluating whether the patient's symptoms have improved. Glycerol rhizotomy does not damage the corneal reflex or motor functions of the trigeminal nerve, so there is no need to use an eye shield, do facial exercises, or take precautions with chewing.
hyperosmolar hyperglycemic state (HHS)
rare but deadly metabolic state is more common in the elderly with type 2 DM. HHS is characterized by hyperglycemia and severe dehydration without ketoacidosis.
Major complications of aortic aneurysm repair are associated with involvement or obstruction of the _______ arteries.
renal
A ________ aneurysm may be surgically treated by excising only the weakened area and suturing the artery closed.
saccular
which type of precaution should the nurse implement to protect from being exposed to any of the hepatitis viruses? 1. airborne precautions 2. standard precautions 3. droplet precautions 4. exposure precautions
standard precautions: standard precautions apply to blood, all body fluids, secretions, and excretions, except sweat, regardless of whether they contain visible blood
An elderly client reports that is she incontinent of urine when she coughs of sneezes. The client is experiencing
stress incontinence
The mother of a 4 year old boy states "I can't believe he's still wetting the bed at night". The nurse tells the mother
this is not unusual for children of his age
The physician suspects myasthenia gravis in a client with chronic fatigue, muscle weakness, and ptosis. Myasthenia gravis is associated with:
thymus gland hyperplasia.
thyroid storm usually follows
thyroid removal or acute stress, trauma, infection or hyperthyroidism
an indication of hypocalcemia following a thyroidectomy
tingling in hands & feet (paresthesia); cool, clammy, nervous, tachycardia, anxiety, confusion
A client has a history of painful, continuous muscle spasms. He has taken several skeletal muscle relaxants without experiencing relief. His physician prescribes diazepam (Valium), 2 mg by mouth twice daily. In addition to being used to relieve painful muscle spasms, diazepam also is recommended for:
treatment of spasticity associated with spinal cord lesions.
When assessing a patient with newly diagnosed trigeminal neuralgia, the nurse will ask the patient about _______________
triggers that lead to facial pain. rational: The major clinical manifestation of trigeminal neuralgia is severe facial pain that is triggered by cutaneous stimulation of the nerve. Ptosis, loss of taste, and facial weakness are not characteristics of trigeminal neuralgia.
One of the nurse's roles is talking to adult clients about urinary and sexual hygiene. Which words does the nurse use when referring to the client's reproductive body parts?
use words the client uses.
test used to screen for pheochromocytoma
vanillylmandellic acid test
b) prolonged immobilization
venous stasis
After teaching a patient about management of migraine headaches, the nurse determines that the teaching has been effective when the patient says, _____________
"I will try to lie down someplace dark and quiet when the headaches begin." rational: It is recommended that the patient with a migraine rest in a dark, quiet area. Topiramate (Topamax) is used to prevent migraines and must be taken for several months to determine effectiveness. Aspirin or other nonsteroidal anti-inflammatory medications can be taken with the triptans. Alcohol may precipitate migraine headaches.
A patient who sustained a spinal cord injury a week ago becomes angry, telling the nurse "I want to be transferred to a hospital where the nurses know what they are doing!" Which reaction by the nurse is best?
Ask for the patient's input into the plan for care. rational: The patient is demonstrating behaviors consistent with the anger phase of the mourning process, and the nurse should allow expression of anger and seek the patient's input into care. Expression of anger is appropriate at this stage and should be tolerated by the nurse. Reassurance about the competency of the staff will not be helpful in responding to the patient's anger. Ignoring the patient's comments will increase the patient's anger and sense of helplessness.
A patient found in a tonic-clonic seizure reports afterward that the seizure was preceded by numbness and tingling of the arm. The nurse knows that this finding indicates what type of seizure?
Atonic rational: The initial symptoms of a partial seizure involve clinical manifestations that are localized to a particular part of the body or brain. Symptoms of an absence seizure are staring and a brief loss of consciousness. In an atonic seizure, the patient loses muscle tone and (typically) falls to the ground. Myoclonic seizures are characterized by a sudden jerk of the body or extremities.
Which nursing action will the home health nurse include in the plan of care for a patient with paraplegia in order to prevent autonomic dysreflexia?
Teach the purpose of a prescribed bowel program. rational: Fecal impaction is a common stimulus for autonomic dysreflexia. The other actions may be included in the plan of care but will not reduce the risk for autonomic dysreflexia.
The client diagnosed with essential hypertension is taking a loop diuretic daily. Which assessment data would require immediate intervention by the nurse?
The client has a weight gain of 2kg within 1-2days
When assessing a patient with a possible stroke, the nurse finds that the patient's aphasia started 3.5 hours previously and the blood pressure is 170/92 mm Hg. Which of these orders by the health care provider should the nurse question?
Titrate labetolol (Normodyne) drip to keep BP less than 140/90 mm Hg. rational: Because elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if mean arterial pressure (MAP) is >130 mm Hg or systolic pressure is >220 mm Hg. Fluid intake should be 1500 to 2000 mL daily to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees, unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient meets the other criteria for tPA use.
Which information about a patient who is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease is most important for the nurse to report to the health care provider?
Uncontrolled head movement rational: Dyskinesia is an adverse effect of the Sinemet, indicating a need for a change in medication or decrease in dose. The other findings are typical with Parkinson's disease.
When teaching a patient with myasthenia gravis (MG) about management of the disease, the nurse advises the patient to ______________
perform physically demanding activities in the morning. rational: Muscles are generally strongest in the morning, and activities involving muscle activity should be scheduled then. Plasmapheresis is not routinely scheduled but is used for myasthenia crisis or for situations in which corticosteroid therapy should be discontinued. There is no decrease in sensation with MG, and muscle atrophy does not occur because muscles are used during part of the day.
A patient is seen in the health clinic with symptoms of a stooped posture, shuffling gait, and pill rolling-type tremor. The nurse will anticipate teaching the patient about _______________
antiparkinsonian drugs. rational: The diagnosis of Parkinson's is made when two of the three characteristic signs of tremor, rigidity, and bradykinesia are present. The confirmation of the diagnosis is made on the basis of improvement when antiparkinsonian drugs are administered. This patient has symptoms of tremor and bradykinesia; the next anticipated step will be treatment with medications. MRI and EEG are not useful in diagnosing Parkinson's disease, and corticosteroid therapy is not used to treat it.
A patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information will the nurse include in patient teaching?
How to draw up and administer injections of the medication rational: Copaxone is administered by self-injection. Oral contraceptives are an appropriate choice for birth control. There is no need to avoid driving or drink large fluid volumes when taking glatiramer.
A patient who has numbness and weakness of both feet is hospitalized with Guillain-Barré syndrome. The nurse will anticipate the need to teach the patient about _____________
IV infusion of immunoglobulin (Sandoglobulin). rational: Because the Guillain-Barré syndrome is in the earliest stages (as evidenced by the symptoms), use of high-dose immunoglobulin is appropriate to reduce the extent and length of symptoms. Mechanical ventilation and tube feedings may be used later in the progression of the syndrome but are not needed now. Corticosteroid use is not helpful in reducing the duration or symptoms of the syndrome.
Which interventions should the nurse discuss with the client diagnosed with atherosclerosis?
Include significant other in the discussion, stop smoking or using any type of tobacco products, avoid stressful situations
To evaluate the effectiveness of IV methylprednisolone (Solu-Medrol) given to a patient with a T4 spinal cord injury, which information is most important for the nurse to obtain?
Leg strength and sensation rational: The purpose of methylprednisolone administration is to help preserve motor function and sensation. Therefore the nurse will assess this patient for lower extremity function. The other data also will be collected by the nurse, but they do not reflect the effectiveness of the methylprednisolone.
The client receiving low molecular weight heparin (LMWH) subcutaneously to prevent DVT following hip replacement surgery complains to the nurse that there are small purple hemorrhaged areas on the upper abdomen. Which action should the nurse implement?
Notify the HCP immediately
When the nurse is developing a rehabilitation plan for a patient with a C6 spinal cord injury, an appropriate patient goal is that the patient will be able to _____________
push a manual wheelchair on flat, smooth surfaces. rational: The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn independently in bed.
The client diagnosed with a DVT is on heparin drip at 1400 units per hour. Which intervention should the nurse implement FIRST?
Check the PT/INR
A patient with a history of a T2 spinal cord injury tells the nurse, "I feel awful today. My head is throbbing, and I feel sick to my stomach." Which action should the nurse take first?
Check the blood pressure (BP). rational: The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine whether autonomic dysreflexia is occurring. Notification of the patient's health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated after autonomic dysreflexia is ruled out as the cause of the nausea. The nurse may assess for a fecal impaction, but this should be done after checking the BP and lidocaine jelly should be used to prevent further increases in the BP.
The nurse is teaching the client diagnosed with arterial occlusive disease. Which interventions should the nurse include in the teaching?
Wash legs and feet daily in warm water, apply moisturizing cream to feet, wear clean white cotton socks
function of aldosterone is to
helps maintain BP, help the kidney maintain the water/sodium balance and excrete potassium.
the public health nurse is teaching day care workers. which type of hepatitis is transmitted byt he fecal oral route via contaminated food, water, or direct contact with an infected person? 1. hep a 2. hep b 3. hep c 4. hep d
hep a: the hep a virus is in the stool of infected ppl and takes up to two weeks before symptoms develop
in patients with pheochromocytoma there is a release of
high levels of epinephrine and norepinephrine
a 32 y/o client had a cholecystectomy 2 hrs ago. the client weighs 250 lbs and had general anesthesia. the client is c/o pain. priority nursing dx at this time: 1. alteration in comfort 2. high risk for airway impairment 3. alteration in fluid volume 4. knowledge deficit
high risk for airway impairment: the airway is of highest priority in postop clients after general anesthesia
hyperthyroid expected findings
palpitations, heat intolerance, tremor, diaphoresis, insomnia
Progestins
Endometrial Carnicoma
The disruption of all layers of an artery with bleeding?
Pseudoaneurysm
The goal for peritoneal dialysis is to:
Remove toxins and metabolic waste
What are the people with myasthenia gravis always at risk for?
Respiratory Distress
Assessment of the patient with a urinary disorder may be complicated by:
Social taboos surrounding sexuality
pheochromocytoma is a
tumor of the adrenal glands
What are the signs and symptoms of Parkinson's Disease?
1. Mask like blank expression 2. pill rolling 3. Shuffling gait 4. propulsive gait 5. tremors 6. bradykinesia 7. loss of ability to swallow 8. decreased blinking 9. muscle rigidity
47. The nurse is preparing an in-service for women in the community. Which primary nursing intervention should the nurse discuss regarding the development of ovarian cancer? 1. Instruct the clients not to use talcum powder on the perineum. 2. Encourage the clients to consume diets with a high fat content. 3. Teach the women to have a lower pelvic sonogram yearly. 4. Discuss the need to be aware of the family history of cancer.
1. Research has shown the use of talcum powder perineally increases the risk for developing ovarian cancer, although there is no explanation known for this occurrence. Other risk factors include a high-fat diet, nulliparity, infertility, older age (70 to 80 years) has the greatest incidence, mumps before menarche, and family history of ovarian cancer.
26. The client in the gynecology clinic asks the nurse, "What are the risk factors for developing cancer of the cervix?" Which statement is the nurse's best response? 1. "The earlier the age of sexual activity and the more partners, the greater the risk." 2. "Eating fast foods high in fat and taking birth control pills are risk factors." 3. "A Chlamydia trachomatis infection can cause cancer of the cervix." 4. "Having yearly Pap smears will protect you from developing cancer."
1. Risk factors for cancer of the cervix include sexual activity before the age of 20 years; multiple sexual partners; early childbearing; exposure to the human papillomavirus; HIV infection; smoking; and nutritional deficits of folates, beta carotene, and vitamin C.
49. Which is the American Cancer Society's recommendation for the early detection of cancer of the prostate? 1. A yearly PSA level and DRE beginning at age 50. 2. A biannual rectal examination beginning at age 40. 3. A semiannual alkaline phosphatase level beginning at age 45. 4. A yearly urinalysis to determine the presence of prostatic fluid
1. The American Cancer Society recommends all men have a yearly prostatespecific antigen (PSA) blood level, followed by a digital rectal examination (DRE) beginning at age 50. Men in the high-risk group, including all African American men, should begin at age 45.
9. The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a medical floor. Which nursing task is most appropriate for the nurse to delegate? 1. Collect a clean voided midstream urine specimen. 2. Evaluate the client's 8-hour intake and output. 3. Assist in checking a unit of blood prior to hanging. 4. Administer a cation-exchange resin enema.
1. The UAP can collect specimens. Collecting a midstream urine specimen requires the client to clean the perineal area, to urinate a little, and then collect the rest of the urine output in a sterile container.
38. The nurse is caring for a client newly diagnosed with Stage IV ovarian cancer. What is the scientific rationale for detecting the tumors at this stage? 1. The client's ovaries lie deep within the pelvis and early symptoms are vague. 2. The client has regular gynecological examinations and this helps with detection. 3. The client had a history of dysmenorrhea and benign ovarian cysts. 4. The client had a family history of breast cancer and was being checked regularly.
1. The ovaries are anatomically positioned deep within the pelvis, and because of this, signs and symptoms of cancer are vague and nonspecific. Symptoms include increased abdominal girth, pelvic pressure, indigestion, bloating, flatulence, and pelvic and leg pain. Increasing abdomen size as a result of accumulation of fluid is the most common sign. Many women ignore the symptoms because they are so nonspecific.
65. The nurse is caring for a client who is eight (8) hours postoperative unilateral orchiectomy for cancer of the testes. Which intervention should the nurse implement? 1. Provide an athletic supporter before ambulating. 2. Encourage the client to delay use of pain medications. 3. Place client on a clear liquid diet for the first 48 hours. 4. Monitor the PT/INR levels and have vitamin K ready.
1. The scrotum will require support during ambulation. An athletic supporter is designed to provide support in this area.
84. The female client diagnosed with bladder cancer who has a cutaneous urinary diversion states, "Will I be able to have children now?" Which statement is the nurse's best response? 1. "Cancer does not make you sterile, but sometimes the therapy can." 2. "Are you concerned you can't have children?" 3. "You will be able to have as many children as you want." 4. "Let me have the chaplain come to talk with you about this."
1. This client is asking for information and should be provided factual information. The surgery will not make the client sterile, but chemotherapy can induce menopause and radiation therapy to the pelvis can render a client sterile.
71. The client diagnosed with cancer of the testes calls and tells the nurse he is having low back pain which does not go away with acetaminophen, a nonnarcotic analgesic. Which action should the nurse implement? 1. Ask the client to come in to see the HCP for an examination. 2. Tell the client to use a nonsteroidal anti-inflammatory drug instead. 3. Inform the client this means the cancer has metastasized. 4. Encourage the client to perform lower back-strengthening exercises.
1. This information could signal the onset of symptoms of metastasis to the retroperitoneum. The HCP should see the client and discuss follow-up diagnostic tests.
What are the signs and symptoms of multiple sclerosis?
1. tinnitus 2. decreased hearing 3. urinary retention 4. spastic bladder 5. constipation 6. nystagmus 7. diplopia 8. blurred vision 9. dysarthria 10. dysphagia 11. numbness 12. tingling 13. weakness 14. paralysis 15. muscle spasticity 16. ataxia 17. vertigo
A client who's receiving phenytoin (Dilantin) to control seizures is admitted to the health care facility for observation. The physician orders measurement of the client's serum phenytoin level. Which serum phenytoin level is therapeutic?
10 to 20 mcg/ml
Which client is at risk for developing thyrotoxicosis?
A client with Graves' disease who is having surgery
Which medication should the nurse expect the health-care provider to order for a client diagnosed with arterial occlusive disease?
An antiplatelet medication
What is Guillain Barre Syndrome?
An autoimmune disease of the nervous system due to damage of myelin sheath around the nerves., progresses rapidly or over 2-3 weeks, characterized by muscle weakness or symmetrical paralysis. Pig Head. Also, Landry's paralysis, an acute polyneuropathy affecting the PNS. The most typical symptoms cause change in sensation or pain, as well as dysfunction of the ANS. It can cause complications, in particularly in the respiratory muscles if the ANS is involved. It is usually triggered by an infection.
transurethral resection of the prostate
An indwelling urethral catheter is used because surgical trauma can cause edema and urinary retention, leading to additional complications, such as bleeding. Urinary control is not lost in most cases; loss of control usually is temporary if it does occur. Sexually ability usually is not affected; sexual ability is maintained if the client was able to perform before surgery. A cystotomy tube is not used if a client has a transurethral resection; however, it is used if a suprapubic resection is done.
The nurse will plan to teach the patient diagnosed with acute hepatitis B about a. side effects of nucleotide analogs. b. measures for improving the appetite. c. ways to increase activity and exercise. d. administering alpha-interferon (Intron A).
B: Maintaining adequate nutritional intake is important for regeneration of hepatocytes.
The nurse who notes that a 59-year-old female patient has lost 1 inch in height over the past 2 years will plan to teach the patient about a. discography studies. b. myelographic testing. c. magnetic resonance imaging (MRI). d. dual-energy x-ray absorptiometry (DXA).
D. The decreased height and the patient's age suggest that the patient may have osteoporosis and that bone density testing is needed. Discography, MRI, and myelography are typically done for patients with current symptoms caused by musculoskeletal dysfunction and are not the initial diagnostic tests for osteoporosis.
A 54-year-old patient is about to have a bone scan. In teaching the patient about this procedure, the nurse should include what information? A. Two additional follow-up scans will be required. B. There will be only mild pain associated with the procedure. C. The procedure takes approximately 15 to 30 minutes to complete. D. The patient will be asked to drink increased fluids after the procedure.
D. The patient will be asked to drink increased fluids after the procedure. Patients are asked to drink increased fluids after a bone scan to aid in excretion of the radioisotope, if not contraindicated by another condition. No follow-up scans and no pain are associated with bone scans that take 1 hour of lying supine.
The client is diagnosed with a small abdominal aortic aneurysm. Which interventions should be included in the discharge teaching?
Encourage the client to eat a low-fat, low-cholesterol diet, discuss with the client the importance of losing weight
What is the medical treatment for TRIGEMINAL NEURALGIA? What is the surgical treatment?
DILANTIN or TEGRETOL. For surgical, local nerve blocks or slow nerve transmission to decrease pain.
What is important to teach pregnant women about DILANTIN?
DO NOT TAKE, because it causes birth defects.
The nurse is discussing the importance of exercising with a client who is diagnosed with CAD. Which statement best describes the scientific rationale for encouraging 30 minutes of walking daily to help prevent complications of atherosclerosis?
Daily exercise helps prevent plaque from developing in the vessel
Which patient report indicates that phenazopyridine hydrochloride (Pyridium) is being effective?
Decrease in buring
Which age-related change can cause nocturia?
Decreased ability to concentrate urine Nocturia may result from decreased kidney-concentrating ability associated with aging.
The nurse is collecting data on a client with a diagnosis of hypothyroidism. Which of these behaviors, if present in the client's history, should the nurse determine as being likely related to the symptoms of this disorder?
Depression
The nurse is caring for a child with a diagnosis of diabetes insipidus. The nurse anticipates that the health care provider will prescribe which medications?
Desmopressin acetate (DDAVP)
A client with a suspected brain tumor is scheduled for computed tomography (CT). What should the nurse do when preparing the client for this test?
Determine whether the client is allergic to iodine, contrast dyes, or shellfish.
A patient with a stroke experiences right-sided arm and leg paralysis and facial drooping on the right side. When admitting the patient, which clinical manifestation will the nurse expect to find?
Difficulty in understanding commands rational: Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and use of language. The left-side reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a right-side stroke.
Alprostadil
ED
Reason the dialysis solution is warmed to body temperature before it is instilled into the peritoneal cavity
Encouraging the removal of serum urea by preventing constriction of peritoneal blood vessels promotes vasodilation so that urea, a large-molecular substance, is shifted from the body into the dialyzing solution. Heat does not affect the shift of potassium into the cells. The removal of metabolic wastes is affected in kidney failure, not the metabolic processes. Excess serum potassium is removed by dialyzing with a potassium-free solution, not by heat.
The nurse making rounds discovers that there is no urine drainage from a postoperative patient's Foley catheter. The first nursing action is to:
Ensure patency
The nurse recognizes tha the most common causative organism in pyelonephritis is:
Escherichia coli.
A client is hospitalized with Guillain-Barré syndrome. Which data collection finding is most significant?
Even, unlabored respirations
Which action should the nurse take when assessing a patient with trigeminal neuralgia?
Examine the mouth and teeth thoroughly. rational: Oral hygiene is frequently neglected because of fear of triggering facial pain. Having the patient clench the facial muscles will not be useful because the sensory branches of the nerve are affected by trigeminal neuralgia. Light touch and palpation may be triggers for pain and should be avoided.
Which signs/symptoms should the nurse expect to note when collecting data on a client with Addison's disease?
Hypotension and vomiting
A nurse is reviewing discharge teaching with a client you has Cushing's syndrome. Which statement made by the client indicates that the instructions related to dietary management were understood
I can eat foods that contain potassium
A community health nurse visit a client at home. Prednisone 10 mg orally daily has been prescribed for a client and the nurse reinforces teaching for the client about the medication. What statement made by the client indicates that further teaching is necessary
I can take aspirin or my antihistamine if I need it
What is the proper way to give DILANTIN?
IV Push: (not compatible with IV solutions), give closest insertion site, flush/push/flush
Shortly after admission to an acute care facility, a client with a seizure disorder develops status epilepticus. The physician orders diazepam (Valium), 10 mg I.V. stat. How soon can the nurse administer a second dose of diazepam, if needed and prescribed?
In 10 to 15 minutes
A patient with right-sided weakness that started 90 minutes earlier is admitted to the emergency department and all these diagnostic tests are ordered. Which test should be done first?
Noncontrast computed tomography (CT) scan rational: Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the smaller the area of brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.
A patient has an incomplete right spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which nursing action should be included in the plan of care?
Positioning the patient's right leg when turning the patient rational: The patient with Brown-Séquard syndrome has loss of motor function on the ipsilateral side and will require the nurse to move the right leg. Pain sensation will be lost on the patient's left leg. Left arm weakness will not be a problem for a patient with a T7 injury. The patient will retain position sense for the left leg.
A patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse plan to take?
Prepare the patient for immediate craniotomy. rational: The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation. If intracranial pressure (ICP) is elevated after surgery, furosemide or high-dose barbiturate therapy may be needed, but these will not be of benefit unless the hematoma is removed. Minimal blood loss occurs with head injuries, and transfusion is usually not necessary.
Which information about a patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse?
Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg rational: The PbtO2 should be 20 to 40 mm Hg. Lower levels indicate brain ischemia. An intracranial pressure (ICP) of 15 mm Hg is at the upper limit of normal. CSF is produced at a rate of 20 to 30 mL/hour. The reason for the sinus tachycardia should be investigated, but the elevated heart rate is not as concerning as the decrease in PbtO2.
Which information about a patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse?
Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg rational: The PbtO2 should be 20 to 40 mm Hg. Lower levels indicate brain ischemia. An intracranial pressure (ICP) of 15 mm Hg is at the upper limit of normal. CSF is produced at a rate of 20 to 30 mL/hour. The reason for the sinus tachycardia should be investigated, but the elevated heart rate is not as concerning as the decrease in PbtO2.
The nurse is administering neostigmine to a client with myasthenia gravis. Which nursing intervention should the nurse implement?
Schedule the medication before meals.
Which action will the nurse in the outpatient clinic include in the plan of care for a patient with mild cognitive impairment (MCI)?
Schedule the patient for more frequent appointments. rational: Ongoing monitoring is recommended for patients with MCI. MCI does not interfere with activities of daily living, acetylcholinesterase drugs are not used for MCI, and an assisted living facility is not indicated for MCI.
The nurse has instructed a patient who is receiving hemodialysis about dietary manageent. Which diet choices by the patient indicate that the teaching has been successful?
Scrambled eggs, English muffin, and apple juice.
What is DILANTIN used for?
Seizure prevention
Which S/S make the nurse suspect that C.S. has a ruptured AAA rather than a nonruptured AAA?
Severe back pain and the shock Sx of BP 88/68, cool, clammy extremities
Which assessment information will the nurse collect to determine whether a patient is developing postconcussion syndrome?
Short-term memory rational: Decreased short-term memory is one indication of postconcussion syndrome. The other data may be assessed but are not indications of postconcussion syndrome.
How is the diagnosis of myasthenia gravis made versus cholinergic crisis?
Since both are present with the same symptoms, administer TENSILON to differentiate one from the other. If the symptoms improve, then it is myasthenia gravis. A lack of medication, PROSTIGMIN, would then be the problem. So, increase medication. If the symptoms get worse, then it is a cholinergic crisis. Too much medication is the problem with increased Prostigmin. So provide an antidote which is ATROPIN.
C.S. is a 73 year old man who was brought to the local emergency department complaining of severe back pain. Subjective Data: *Has a known AAA, which has been followed with yearly abdominal ultrasounds *Has smoked a pack of cigarettes per day for 52 years *Has had occasional bouts of angina for the past 3 years Objective Data: *Has a pulsating abdominal mass *BP: 88/68 *Extremities are cool and clammy What are C.S.'s risk factors for AAA?
Smoker, Male, Age, Hx of atherosclerosis with CAD
a postop cholecystectomy client is receiving a clear liquid diet. which foods are allowed? 1. jello, cream of chick soup, milk 2. oatmeal, oj, vanilla pudding 3. water, coffee or tea, sherbert, pureed bananas 4. a grape popsicle, plain gelatin, apple juice, water
a grape popsicle, plain gelatin, apple juice, water
1. The nurse should place the client's chair with the head lower than thebody, which will shunt blood to the brain; this is the Trendelenburg position.
The client receiving dialysis is complaining of being dizzy and light-headed. Which action should the nurse implement first? 1.Place the client in the Trendelenburg position. 2.Turn off the dialysis machine immediately. 3.Bolus the client with 500 mL of normal saline. 4.Notify the health-care provider as soon as possible.
3. Uremic frost, which results when the skin attempts to take over the function of the kidneys, causes itching, which can lead to scratching possibly resulting in a break in the skin.
The client receiving hemodialysis is being discharged home from the dialysis center. Which instruction should the nurse teach the client? 1.Notify the HCP if oral temperature is 102˚F or greater. 2.Apply ice to the access site if it starts bleeding at home. 3.Keep fingernails short and try not to scratch the skin. 4.Encourage significant other to make decisions for the client.
A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by:
a positive edrophonium (Tensilon) test.
A patient has a new prescription for bromocriptine (Parlodel) to control symptoms of Parkinson's disease. Which information obtained by the nurse may indicate a need for a decrease in the dose?
The patient's blood pressure is 90/46 mm Hg. rational: Hypotension is an adverse effect of bromocriptine, and the nurse should check with the health care provider before giving the medication. Diarrhea, cough, and deep vein thrombosis are not associated with bromocriptine use.
3. The drainage bag should be kept below the level of the bladder to prevent reflux of urine into the renal system; it should not be placed on the bed.
The nurse is observing the UAP providing direct care to a client with an indwelling catheter. Which data warrant immediate intervention by the nurse? 1.The UAP secures the tubing to the client's leg with tape. 2.The UAP provides catheter care with the client's bath. 3.The UAP puts the collection bag on the client's bed. 4.The UAP cares for the catheter after washing the hands.
3 A long-term complication of glomerulonephritis is it can become chronic if unresponsive to treatment,and this can lead to end-stage renal disease. Maintaining renal function is an appropriate long-term goal.
The nurse is preparing a plan of care for the client diagnosed with acute glomerulonephritis. Which statement is an appropriate long-term goal? 1.The client will have a blood pressure within normal limits. 2.The client will show no protein in the urine. 3.The client will maintain normal renal function. 4.The client will have clear lung sounds.
When admitting a patient with a possible coup-contracoup injury after a car accident to the emergency department, the nurse obtains the following information. Which finding is most important to report to the health care provider?
The patient takes warfarin (Coumadin) daily. rational: The use of anticoagulants increases the risk for intracranial hemorrhage and should be immediately reported. The other information would not be unusual in a patient with a head injury who had just arrived to the ED.
A hospitalized 24-year-old patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first?
Start the ordered PRN oxygen at 6 L/min. rational: Acute treatment for cluster headache is administration of 100% oxygen at 6 to 8 L/min. If the patient obtains relief with the oxygen, there is no immediate need to notify the health care provider. Cluster headaches last only 60 to 90 minutes, so oral pain medications have minimal effect. Hot packs are helpful for tension headaches but are not as likely to reduce pain associated with a cluster headache.
A 22-year-old patient is being seen in the clinic with increased secretion of the anterior pituitary hormones. The nurse would expect the laboratory results to show a. increased urinary cortisol. b. decreased serum thyroxine. c. elevated serum aldosterone levels. d. low urinary catecholamines excretion.
a. increased urinary cortisol.
What is the nurse's role in assisting the family in this critical situation?
The patient will most likely be taken to surgery from the emergency department, and ED are not the most private or supportive environments. It is important for the nurse to provide privacy as much as possible and allow the patient and family to be together and ask questions as necessary. The nurse should also provide explanations of the procedures and interventions that are being implemented and be supportive during this critical time. The
A nurse is preparing a diet plan for a 50 yr old with simple goiter. Which of the following should be included in the clients diet to decrease the enlargement of he thyroid gland? a. iodine b. sodium c. potassium d. calcium
a. iodine
Which information about a patient who is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease is most important for the nurse to report to the health care provider?
Uncontrolled head movement rational: Dyskinesia is an adverse effect of the Sinemet, indicating a need for a change in medication or decrease in dose. The other findings are typical with Parkinson's disease.
The nurse is caring for a client who underwent a lumbar laminectomy 2 days ago. Which finding should the nurse consider abnormal?
Urine retention or incontinence
In postoperative care of the patient with an arteriovenous shunt, the nurse should:
Use strict surgical asepsis for dressing changes.
What should you watch for with TEGETROL?
Used as an anticonvulsant for seizure prevention. Monitor CBC d/t bone marrow suppression and watch for infection
Arterial or Venous disease? Ulceration around the medial malleolus
V
The nurse is collecting data on a 38-year-old client diagnosed with multiple sclerosis. Which of the following symptoms would the nurse expect to find?
Vision changes
A preoperative client is scheduled for adrenalectomy to remove a pheochromocytoma. The nurse should most closely monitor which assessment in the preoperative period?
Vital signs
International normalized ration (INR)
Warfarin
Is only administered orally
Warfarin
Vitamin K is antidote
Warfarin
A hospitalized 24-year-old patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first?
Start the ordered PRN oxygen at 6 L/min. rational: Acute treatment for cluster headache is administration of 100% oxygen at 6 to 8 L/min. If the patient obtains relief with the oxygen, there is no immediate need to notify the health care provider. Cluster headaches last only 60 to 90 minutes, so oral pain medications have minimal effect. Hot packs are helpful for tension headaches but are not as likely to reduce pain associated with a cluster headache.
A client is scheduled for electroconvulsive therapy (ECT). Before ECT begins, the nurse expects which neuromuscular blocking agent to be administered?
Succinylcholine (Anectine)
A client with respiratory complications of multiple sclerosis (MS) is admitted to the medical-surgical unit. Which equipment is most important for the nurse to keep at the client's bedside?
Suction machine with catheters
1. This indicates the teaching is effective.
Which statement indicates discharge teaching has been effective for the client who is postoperative TURP? 1."I will call the surgeon if I experience any difficulty urinating." 2."I will take my Proscar daily, the same as before my surgery." 3."I will continue restricting my oral fluid intake." 4."I will take my pain medication routinely even if I do not hurt."
A patient with Parkinson's disease has a nursing diagnosis of impaired physical mobility related to bradykinesia. Which action will the nurse include in the plan of care?
Suggest that the patient rock from side to side to initiate leg movement. rational: Rocking the body from side to side stimulates balance and improves mobility. The patient will be encouraged to continue exercising because this will maintain functional abilities. Maintaining a wide base of support will help with balance. The patient should lift the feet and avoid a shuffling gait.
A patient with paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. Which action will the nurse include in the plan of care?
Teach the patient how to self-catheterize. rational: Because the patient's bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty. The Credé method is more appropriate for a bladder that is flaccid, such as occurs with a reflexic neurogenic bladder. Catheterization after voiding will not resolve the patient's incontinence.
Cisplatin
Testicular and ovarian cancer, bladder cancer (advanced)
Cushing syndrome
a disorder that occurs when the body is exposed to high levels of the hormone cortisol.
A patient is admitted to the hospital with dysphasia and right-sided weakness that resolves in a few hours. The nurse will anticipate teaching the patient about ____________
aspirin (Ecotrin). rational: Following a TIA, patients typically are started on medications such as aspirin to inhibit platelet function and decrease stroke risk. tPA is used for acute ischemic stroke. Coumadin is usually used for patients with atrial fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage.
The nurse witnesses a patient with a seizure disorder as the patient suddenly jerks the arms and legs, falls to the floor, and regains consciousness immediately. It will be most important for the nurse to _________________
assess the patient for a possible head injury. rational: The patient who has had a myoclonic seizure and fall is at risk for head injury and should be evaluated and treated for this possible complication first. Documentation of the seizure, notification of the seizure, and administration of antiseizure medications also are appropriate actions, but the initial action should be assessment for injury.
When the nurse applies a painful stimulus to the nail beds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as _____________
decorticate posturing. rational: Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is generalized, it does not indicate localization of pain or flexion withdrawal.
the client is dx with acute pancreatitis. which health care providers admitting order should the nurse question? 1. bedrest with bathroom privleges. 2. initiate iv therapy of D5W at 125 mL/hr 3. weigh client daily 4. low fat, low carb diet
low fat, low carb diet: the client will be NPO, which will decrease stimulation of the pancreatic enzymes, resulting in decreased autodigestion of the pancreas, therefore decreasing pain
A 24-year-old patient is hospitalized with the onset of Guillain-Barré syndrome. During this phase of the patient's illness, the most essential assessment for the nurse to carry out is ______________
observing respiratory rate and effort. rational: The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse should monitor respiratory function continuously. The other assessments also will be included in nursing care, but they are not as important as respiratory assessment.
A patient has chronic atrial fib and develops an acute occlusion at the iliac artery bifurcation. What are the six P's of acute arterial occlusion the nurse may find in the patient?
pain, pallor, pulselessness, parathesia, paralysis, poikilothermia
in patient with pheochromocytoma avoid
palpating the abdomen and provide darkened room to promote rest
the client dx with acute pancreatitis is in pain. which position should the nurse assist the client to assume to help decrease the pain? 1. recommend lying in the prone position with legs extended 2. maintain a tripod position over the bedside table 3. place in side lying position with knees flexed 4. encourage a supine position with a pillow under the knees
place in side lying position with knees flexed: this fetal lposition decreases pain caused by the stretching of the peritoneum as a result of edema
A client with epilepsy is having a seizure. During the active seizure phase, the nurse should:
place the client on his side, remove dangerous objects, and protect his head.
The nurse is teaching a client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to:
rest in a room set at a comfortable temperature.
d) orthopedic surgery
venous stasis
the client dx with end stage liver failure. the client asks the nurse,, why is my dr decreasing the dose of my meds? which statement is the nurses best response? 1. you are worried bc your dr has decreased the dosage 2. you really should ask your dr. i am sure there is a good reason 3. you may have an overdose of the meds because your liver is damaged 4. the half life of the meds is altered bc the liver is damaged
you may have an overdose of the meds bc your liver is damaged: this is the main reason the hcp decreases the clients medication dose and is an explanation appropriate for the client
When evaluating for hypovolemic shock, the nurse should be aware of which of the following clinical manifestations? a) Hypertension b) Bradycardia c) Bounding pulse d) Hypotension
Hypotension Explanation: The nurse should be alert to a weak pulse (thread), decreased blood pressure, decreased urine output, rapid, shallow respirations, and elevated heart rate.
a 38 y/o woman was admitted with a medical dx of cholecystitis. the nurse would expect the hx of her present illness to include intolerance to which nutrient? 1.carbohydrates 2. fat 3. protein 4. vitamin c
fat: inflammation of the gallbladder, presence of gallstones, or both interfere with movement of the bile from the liver or gallbladder into the small intestine, where it promotes the digestion of fats
a nurse is teaching a client with newly dx hep A. the client asks how did i catch this? the best response is what? 1. blood or contaminated needles 2. body fluids 3. sexual intercourse 4. feces or contaminated food or water
feces or contaminated food or water
The most important measure in the treatment of venous stasis ulcers is...
extrinsic compression
When teaching patients who are at risk for Bell's palsy because of previous herpes simplex infection, which information should the nurse include?
"Call the doctor if pain or herpes lesions occur near the ear." rational: Pain or herpes lesions near the ear may indicate the onset of Bell's palsy and rapid corticosteroid treatment may reduce the duration of Bell's palsy symptoms. Antiviral therapy for herpes simplex does not reduce the risk for Bell's palsy. Corticosteroid therapy will be most effective in reducing symptoms if started before paralysis is complete but will still be somewhat effective when started later. Facial exercises do not prevent Bell's palsy.
Which instruction does the nurse give a client who needs a clean-catch urine specimen?
"Do not touch the inside of the container." A clean-catch specimen is used to obtain urine for culture and sensitivity of organisms present; contamination by the client's hands will render the specimen invalid and alter results.
Which statement by a patient who is being discharged from the emergency department (ED) after a head injury indicates a need for intervention by the nurse?
"I am going to drive home and go to bed." rational: Following a head injury, the patient should avoid operating heavy machinery. Retrograde amnesia is common after a concussion. The patient can take acetaminophen for headache and should return if symptoms of increased intracranial pressure such as dizziness or nausea occur.
The nurse is reinforcing discharge teaching with a client who has Cushing's syndrome. Which statement by the client indicates that the instructions related to dietary management were understood?
"I can eat foods that contain potassium."
A patient with diabetes is admitted for evaluation of kidney function becasue of recent fatigue, weakness, and elevated BUN and serum creatinine levels. While obtaining a nursing history, the nurse identifies an early symptoms of renal insufficiency when the patient states:
"I get up several times every night to urinate."
The nurse has reinforced instructions to the client with hyperparathyroidism regarding home care measures related to exercise. Which statement by the client indicates a need for further teaching? Select all that apply.
"I need to limit playing football to only the weekends." "I should exercise in the evening to encourage a good sleep pattern."
The nurse is reinforcing home care instructions to a client with a diagnosis of Cushing's syndrome. Which client statement reflects a need for further teaching?
"I need to read the labels on any over-the-counter medications I purchase."
The nurse is obtaining a focused respiratory assessment of a 44-year-old female patient who is in severe respiratory distress 2 days after abdominal surgery. What is most important for the nurse to assess? A. Auscultation of bilateral breath sounds B. Percussion of anterior and posterior chest wall C. Palpation of the chest bilaterally for tactile fremitus D. Inspection for anterior and posterior chest expansion
A. Auscultation of bilateral breath sounds Important assessments obtained during a focused respiratory assessment include auscultation of lung (breath) sounds. Assessment of tactile fremitus has limited value in acute respiratory distress. It is not necessary to assess for both anterior and posterior chest expansion. Percussion of the chest wall is not essential in a focused respiratory assessment.
A frail 82-year-old female patient develops sudden shortness of breath while sitting in a chair. What location on the chest should the nurse begin auscultation of the lung fields? A. Bases of the posterior chest area B. Apices of the posterior lung fields C. Anterior chest area above the breasts D. Midaxillary on the left side of the chest
A. Bases of the posterior chest area Baseline data with the most information is best obtained by auscultation of the posterior chest, especially in female patients because of breast tissue interfering with the assessment or if the patient may tire easily (e.g., shortness of breath, dyspnea, weakness, fatigue). Usually auscultation proceeds from the lung apices to the bases unless it is possible the patient will tire easily. In this case the nurse should start at the bases.
2. A nurse is reviewing nutrition teaching for a client who has cholecystitis. Which of the following food choices can trigger cholecystitis? A. Brownie with nuts B. Bowl of mixed fruit C. Grilled turkey D. Baked potato
A. CORRECT: Foods that are high in fat, such as a brownie with nuts, can cause cholecystitis.
A patient with type 2 diabetes and cirrhosis asks the nurse if it would be okay to take silymarin (milk thistle) to help minimize liver damage. The nurse responds based on what knowledge? A. Milk thistle may affect liver enzymes and thus alter drug metabolism. B. Milk thistle is generally safe in recommended doses for up to 10 years. C. There is unclear scientific evidence for the use of milk thistle in treating cirrhosis. D. Milk thistle may elevate the serum glucose levels and is thus contraindicated in diabetes.
A. Milk thistle may affect liver enzymes and thus alter drug metabolism. There is good scientific evidence that there is no real benefit from using milk thistle to protect the liver cells from toxic damage in the treatment of cirrhosis. Milk thistle does affect liver enzymes and thus could alter drug metabolism. Therefore patients will need to be monitored for drug interactions. It is noted to be safe for up to 6 years, not 10 years, and it may lower, not elevate, blood glucose levels.
The patient with Parkinson's disease has a pulse oximetry reading of 72%, but he is not displaying any other signs of decreased oxygenation. What is most likely contributing to his low SpO2 level? A. Motion B. Anemia C. Dark skin color D. Thick acrylic nails
A. Motion Motion is the most likely cause of the low SpO2 for this patient with Parkinson's disease. Anemia, dark skin color, and thick acrylic nails as well as low perfusion, bright fluorescent lights, and intravascular dyes may also cause an inaccurate pulse oximetry result. There is no mention of these or reason to suspect these in this question.
The nurse is performing a musculoskeletal assessment of an 81-year-old female patient whose mobility has been progressively decreasing in recent months. How should the nurse best assess the patient's range of motion (ROM) in the affected leg? A. Observe the patient's unassisted ROM in the affected leg. B. Perform passive ROM, asking the patient to report any pain. C. Ask the patient to lift progressive weights with the affected leg. D. Move both of the patient's legs from a supine position to full flexion.
A. Observe the patient's unassisted ROM in the affected leg. Passive ROM should be performed with extreme caution and may be best avoided when assessing older patients. Observing the patient's active ROM is more accurate and safe than asking the patient to lift weights with her legs.
A patient has a new order for magnetic resonance imaging (MRI) to evaluate for left femur osteomyelitis after a hip replacement surgery. Which information indicates that the nurse should consult with the health care provider before scheduling the MRI? a. The patient has a pacemaker. b. The patient is claustrophobic. c. The patient wears a hearing aid. d. The patient is allergic to shellfish.
A. Patients with permanent pacemakers cannot have MRI because of the force exerted by the magnetic field on metal objects. An open MRI will not cause claustrophobia. The patient will need to be instructed to remove the hearing aid before the MRI, but this does not require consultation with the health care provider. Because contrast medium will not be used, shellfish allergy is not a contraindication to MRI.
The patient's arterial blood gas results show the PaO2 at 65 mmHg and the SaO2 at 80%. What early manifestations should the nurse expect to observe in this patient? A. Restlessness, tachypnea, tachycardia, and diaphoresis B. Unexplained confusion, dyspnea at rest, hypotension, and diaphoresis C. Combativeness, retractions with breathing, cyanosis, and decreased output D. Coma, accessory muscle use, cool and clammy skin, and unexplained fatigue
A. Restlessness, tachypnea, tachycardia, and diaphoresis With inadequate oxygenation, early manifestations include restlessness, tachypnea, tachycardia, and diaphoresis, decreased urinary output, and unexplained fatigue. The unexplained confusion, dyspnea at rest, hypotension, and diaphoresis; combativeness, retractions with breathing, cyanosis, and decreased urinary output; coma, accessory muscle use, cool and clammy skin, and unexplained fatigue occur as later manifestations of inadequate oxygenation.
The nurse should question an order written for Percocet for a patient exhibiting which clinical manifestation? A. Severe jaundice B. Oral candidiasis C. Increased urine output D. Elevated blood glucose
A. Severe jaundice Acetaminophen and oxycodone are the ingredients in Percocet. Because acetaminophen is metabolized in the liver, the patient could develop acetaminophen toxicity in the presence of severe liver disease (evidenced by jaundice). The prudent nurse would question the order before administration.
When caring for a patient with a biliary obstruction, the nurse will anticipate administering which vitamin supplements (select all that apply)? A. Vitamin A B. Vitamin D C. Vitamin E D. Vitamin K E. Vitamin B
A. Vitamin A B. Vitamin D C. Vitamin E D. Vitamin K Biliary obstruction prevents bile from entering the small intestine and thus prevents the absorption of fat-soluble vitamins. Vitamins A, D, E, and K are all fat-soluble and thus would need to be supplemented in a patient with biliary obstruction.
Cyclophosphamide
Breast and ovarian cancer
5. Nurse Oliver should expect a client with hypothyroidism to report which health concerns? a. Increased appetite and weight loss b. Puffiness of the face and hands c. Nervousness and tremors d. Thyroid gland swelling
B. Hypothyroidism (myxedema) causes facial puffiness, extremity edema, and weight gain. Signs and symptoms of hyperthyroidism (Graves' disease) include an increased appetite, weight loss, nervousness, tremors, and thyroid gland enlargement (goiter).
The patient with right upper quadrant abdominal pain has an abdominal ultrasound that reveals cholelithiasis. What should the nurse expect to do for this patient? A. Prevent all oral intake. B. Control abdominal pain. C. Provide enteral feedings. D. Avoid dietary cholesterol.
B. Control abdominal pain. Patients with cholelithiasis can have severe pain, so controlling pain is important until the problem can be treated. NPO status may be needed if the patient will have surgery but will not be used for all patients with cholelithiasis. Enteral feedings should not be needed, and avoiding dietary cholesterol is not used to treat cholelithiasis
Which nursing intervention is most appropriate when preparing to administer an opioid analgesic agent? A. Give the medication on an empty stomach. B. Count the number of doses on hand before administration. C. Give the medication with a glass of juice or other cold beverage. D. Assess the patient for allergies to aspirin before administration.
B. Count the number of doses on hand before administration. Because opioid analgesics are controlled substances, the nurse needs to count the number of doses and check that it matches the number recorded before removing and administering the medication.
The nurse notes crackling sounds and a grating sensation with palpation of an older patient's elbow. How will this finding be documented? a. Torticollis b. Crepitation c. Subluxation d. Epicondylitis
B. Crackling sounds and a grating sensation that accompany movement are described as crepitus or crepitation. Torticollis is a twisting of the neck to one side, subluxation is a partial dislocation of the joint, and epicondylitis is an inflammation of the elbow that causes a dull ache that increases with movement.
Which action can the nurse delegate to unlicensed assistive personnel (UAP) who are working in the orthopedic clinic? a. Grade leg muscle strength for a patient with back pain. b. Obtain blood sample for uric acid from a patient with gout. c. Perform straight-leg-raise testing for a patient with sciatica. d. Check for knee joint crepitation before arthroscopic surgery.
B. Drawing blood specimens is a common skill performed by UAP in clinic settings. The other actions are assessments and require registered nurse (RN)-level judgment and critical thinking.
Which of the following would the nurse most expect to find in the patient with hypoparathyroidism? A) Hypertension and cramps in extremities B) Dysphagia and stiffness in hands or feet C) Positive Trousseau's sign and profuse sweating D) Increased Phosphorous levels and tremors
B. Dysphagia related to laryngeal spasms and stiffness or camping in extremities would be expected signs and symptoms of hypoparathyroidism. Hypertension, profuse sweating, and increased phosphorous levels would not be expected with this condition.
After administering acetaminophen and oxycodone (Percocet) for pain, which intervention would be of highest priority for the nurse to complete before leaving the patient's room? A. Leave the overbed light on at low setting. B. Ensure that the upper two side rails are raised. C. Offer to turn on the television to provide distraction. D. Ensure that documentation of intake and output is accurate.
B. Ensure that the upper two side rails are raised. Percocet has acetaminophen and oxycodone as ingredients. Since the medication contains an opioid analgesic with sedative properties, the nurse must ensure patient safety before leaving the room, such as leaving the top two bedrails raised. This will help prevent the patient from falling from bed, while not restraining the patient (as four side rails would do). Leaving the light or television on will not provide a positive environment for healing sleep.
A 73-year-old man with dementia has a venous ulcer related to chronic venous insufficiency. The nurse should provide education on which type of diet for this patient and his caregiver? A. Low-fat diet B. High-protein diet C. Calorie-restricted diet D. High-carbohydrate diet
B. High-protein diet A patient with a venous ulcer should have a balanced diet with adequate protein, calories, and micronutrients; this type of diet is essential for healing. Nutrients most important for healing include protein, vitamins A and C, and zinc. Foods high in protein (e.g., meat, beans, cheese, tofu), vitamin A (green leafy vegetables), vitamin C (citrus fruits, tomatoes, cantaloupe), and zinc (meat, seafood) must be provided. Restricting fat or calories is not helpful for wound healing or in patients of normal weight. For overweight individuals with no active venous ulcer, a weight-loss diet should be considered.
The postoperative patient is receiving epidural fentanyl for pain relief. For which common side effects should the nurse monitor the patient (select all that apply)? A. Ataxia B. Itching C. Nausea D. Urinary retention E. Gastrointestinal bleeding
B. Itching C. Nausea D. Urinary retention Common side effects of intraspinal opioids include nausea, itching, and urinary retention. Ataxia is a common side effect of intraspinal clonidine.
A patient was just diagnosed with acute arterial ischemia in the left leg secondary to atrial fibrillation. Which early clinical manifestation must be reported to the physician immediately to save the patient's limb? A. Paralysis B. Paresthesia C. Crampiness D. Referred pain
B. Paresthesia The physician must be notified immediately if any of the six Ps of acute arterial ischemia occur to prevent ischemia from quickly progressing to tissue necrosis and gangrene. The six Ps are paresthesia, pain, pallor, pulselessness, and poikilothermia, with paralysis being a very late sign indicating the death of nerves to the extremity. Crampy leg sensation is more common with varicose veins. The pain is not referred.
67-year-old man with peripheral artery disease is seen in the primary care clinic. Which symptom reported by the patient would indicate to the nurse that the patient is experiencing intermittent claudication? A. Patient complains of chest pain with strenuous activity. B. Patient says muscle leg pain occurs with continued exercise. C. Patient has numbness and tingling of all his toes and both feet. D. Patient states the feet become red if he puts them in a dependent position.
B. Patient says muscle leg pain occurs with continued exercise. Intermittent claudication is an ischemic muscle ache or pain that is precipitated by a consistent level of exercise, resolves within 10 minutes or less with rest, and is reproducible. Angina is the term used to describe chest pain with exertion. Paresthesia is the term used to describe numbness or tingling in the toes or feet. Reactive hyperemia is the term used to describe redness of the foot; if the limb is in a dependent position the term is dependent rubor.
After assisting at the bedside with a thoracentesis, the nurse should continue to assess the patient for signs and symptoms of what? A. Bronchospasm B. Pneumothorax C. Pulmonary edema D. Respiratory acidosis
B. Pneumothorax Because thoracentesis involves the introduction of a catheter into the pleural space, there is a risk of pneumothorax. Thoracentesis does not carry a significant potential for causing bronchospasm, pulmonary edema, or respiratory acidosis.
Uh oh, the patient records got scrambled up. You need to go in and see each of the patients in the clinic to see which problem they have. Which of the following patients does the nurse suspect to be the patient with hyperparathyroidism? A) The patient with shakiness in his hands and c/o numbness and tingling in fingers and toes B) The patient c/o back pain and abdominal cramping with nausea C) The patient with a BP of 167/87 and HR 110 with profuse sweating D) The patient c/o of fatigue and depression with bronze skin pigmentation
B. Remember, the patient with hyperparathyroidism is experiencing symptoms r/t too much calcium in the bloodstream. That means they will have issues with Stones (Renal), Bones (bone pain, joint pain, osteoporosis), Moans (GI upset, abdominal cramps), and psychic moans (mental changes). Patient A might be a patient with hypoparathyroidism. Patient C might be a patient with Pheochromocytoma. Patient D might be a patient with Addison's disease
A 62-year-old Hispanic male patient with diabetes mellitus has been diagnosed with peripheral artery disease (PAD). The patient is a smoker and has a history of gout. What should the nurse focus her teaching on to prevent complications for this patient? A. Gender B. Smoking C. Ethnicity D. Co-morbidities
B. Smoking Smoking is the most significant factor for this patient. PAD is a marker of advanced systemic atherosclerosis. Therefore tobacco cessation is essential to reduce PAD progression, CVD events, and mortality. Diabetes mellitus and hyperuricemia are also risk factors. Being male or Hispanic are not risk factors for PAD.
To reduce the risk of adverse effects, what should the nurse do when caring for a patient receiving morphine sulfate via patient-controlled analgesia (PCA)? A. Instruct the patient not to push the button too frequently. B. Teach the caregiver not to push the button for the patient. C. Ask the patient to do deep breathing exercises every hour. D. Administer medications to prevent the occurrence of diarrhea.
B. Teach the caregiver not to push the button for the patient. It is important to teach the caregiver not to push the button for the patient because it is only the patient who can determine the need for the medication. If the caregiver pushes the button, the patient could receive more of a dose than is actually needed, and this increases the risk of adverse effects.
A 42-year-old male patient complains of shoulder pain when the nurse moves his arm behind the back. Which question should the nurse ask? a. "Are you able to feed yourself without difficulty?" b. "Do you have difficulty when you are putting on a shirt?" c. "Are you able to sleep through the night without waking?" d. "Do you ever have trouble lowering yourself to the toilet?"
B. The patient's pain will make it more difficult to accomplish tasks like putting on a shirt or jacket. This pain should not affect the patient's ability to feed himself or use the toilet because these tasks do not involve moving the arm behind the patient. The arm will not usually be positioned behind the patient during sleeping.
The nurse is counseling the patient with hypoparathyroidism about nutrition choices r/t her disease process. Which of the following trays demonstrates correct understanding of the teaching? A) Yogurt, cream of chicken soup, and apple sauce with sweet tea B) Fried salmon, green beans, and a white wheat bread roll C) Sausage and egg sandwich with whole wheat bread and coffee with creamer D) Turkey sandwich with lettuce, tomato, fruit cup and a glass of milk
B. The recommended diet for patients with hypoparathyroidism includes foods that are high in calcium yet low in phosphorous (remember the balancing act) Fish, green beans, and white wheat are recommended foods because they are low in phosphorous. Milk and dairy products, while are high in calcium are also high in phosphorous and are thus restricted. Hypoparathyroidism is as much an issue with too much phosphorus as calcium (although s/s are r/t hypocalcemia) Other restricted foods include eggs and spinach. Other foods encouraged include broccoli, cucumbers, and nondairy creamer.
In assessment of the patient with acute respiratory distress, what should the nurse expect to observe (select all that apply)? A. Cyanosis B. Tripod position C. Kussmaul respirations D. Accessory muscle use E. Increased AP diameter
B. Tripod position D. Accessory muscle use Tripod position and accessory muscle use indicate moderate to severe respiratory distress. Cyanosis may be related to anemia, decreased oxygen transfer in the lungs, or decreased cardiac output. Therefore it is a nonspecific and unreliable indicator of only respiratory distress. Kussmaul respirations occur when the patient is in metabolic acidosis to increase CO2 excretion. Increased AP diameter occurs with lung hyperinflation from COPD, cystic fibrosis, or with advanced age.
The nurse is caring for a group of patients. Which patient is at highest risk for pancreatic cancer? A. A 38-year-old Hispanic female who is obese and has hyperinsulinemia B. A 23-year-old who has cystic fibrosis-related pancreatic enzyme insufficiency C. A 72-year-old African American male who has smoked cigarettes for 50 years D. A 19-year-old who has a 5-year history of uncontrolled type 1 diabetes mellitus
C. A 72-year-old African American male who has smoked cigarettes for 50 years Risk factors for pancreatic cancer include chronic pancreatitis, diabetes mellitus, age, cigarette smoking, family history of pancreatic cancer, high-fat diet, and exposure to chemicals such as benzidine. African Americans have a higher incidence of pancreatic cancer than whites. The most firmly established environmental risk factor is cigarette smoking. Smokers are two or three times more likely to develop pancreatic cancer as compared with nonsmokers. The risk is related to duration and number of cigarettes smoked.
5. A nurse in a clinic is reviewing the laboratory reports of a client who has suspected cholelithiasis. Which of the following is an expected finding? A. Serum albumin 4.1 g/dL B. WBC 9,511/uL C. Direct bilirubin 2.1 mg/dL D. Serum cholesterol 171 mg/dL
C. CORRECT: This finding is outside the expected reference range and is increased in the client who has cholelithiasis.
The nurse is caring for a patient who has been receiving warfarin (Coumadin) and digoxin (Lanoxin) as treatment for atrial fibrillation. Because the warfarin has been discontinued before surgery, the nurse should diligently assess the patient for which complication early in the postoperative period until the medication is resumed? A. Decreased cardiac output B. Increased blood pressure C. Cerebral or pulmonary emboli D. Excessive bleeding from incision or IV sites
C. Cerebral or pulmonary emboli Warfarin is an anticoagulant that is used to prevent thrombi from forming on the walls of the atria during atrial fibrillation. Once the medication is terminated, thrombi could again form. If one or more thrombi detach from the atrial wall, they could travel as cerebral emboli from the left atrium or pulmonary emboli from the right atrium.
The nurse, when auscultating the lower lungs of the patient, hears these breath sounds. How should the nurse document these sounds? A. Stridor B. Rhonchi C. Coarse crackles D. Bronchovesicular
C. Coarse crackles Coarse crackles are a series of long-duration, discontinuous, low-pitched sounds caused by air passing through an airway intermittently occluded by mucus, an unstable bronchial wall, or a fold of mucosa. Coarse crackles are evident on inspiration and at times expiration. Stridor is a continuous crowing sound of constant pitch from partial obstruction of larynx or trachea. Rhonchi are a continuous rumbling, snoring, or rattling sound from obstruction of large airways with secretions. Bronchovesicular sounds are normal sounds heard anteriorly over the mainstem bronchi on either side of the sternum and posteriorly between the scapulae with a medium pitch and intensity.
A patient admitted with metastatic lung cancer is ordered to receive morphine sulfate for pain. Which side effect of this medication should the nurse try to prevent with oral intake and medication? A. Diarrhea B. Agitation C. Constipation D. Urinary incontinence
C. Constipation Morphine sulfate is an opioid analgesic that can lead to constipation as a side effect, and tolerance to opioid-induced constipation does not develop. It is very important to use measures, such as increased fiber and fluids in the diet, and exercise when possible, to prevent this side effect. A gentle stimulant laxative plus a stool softener are also frequently needed to prevent constipation in a patient who is likely to develop this side effect.
You the nurse are taking care of the patient with hypoparathyroidism. Based on your knowledge of the disease process. Which of the following do you expect to be your priority in planning care for this patient? A) Acute Pain B) Fluid Volume Deficit C) Ineffective Airway Maintenance D) Impaired Cerebral Perfusion
C. Due to bronchospasm that can be caused by decreased calcium levels, it is important for the nurse to assess airway and breathing pattern. Signs associated with hypoparathyroidism are d/t hypocalcemia and the number one sign is tetany.
The nurse will teach a patient with chronic pancreatitis to take the prescribed pancrelipase (Viokase) a. at bedtime. b. in the morning. c. with each meal. d. for abdominal pain.
C: Pancreatic enzymes are used to help with digestion of nutrients and should be taken with every meal.
Which medication information will the nurse identify as a concern for a patient's musculoskeletal status? a. The patient takes a daily multivitamin and calcium supplement. b. The patient takes hormone therapy (HT) to prevent "hot flashes." c. The patient has severe asthma and requires frequent therapy with oral corticosteroids. d. The patient has migraine headaches treated with nonsteroidal antiinflammatory drugs (NSAIDs).
C. Frequent or chronic corticosteroid use may lead to skeletal problems such as avascular necrosis and osteoporosis. The use of HT and calcium supplements will help prevent osteoporosis. NSAID use does not increase the risk for musculoskeletal problems.
The condition of a patient who has cirrhosis of the liver has deteriorated. Which diagnostic study would help determine if the patient has developed liver cancer? A. Serum α-fetoprotein level B. Ventilation/perfusion scan C. Hepatic structure ultrasound D. Abdominal girth measurement
C. Hepatic structure ultrasound Correct Hepatic structure ultrasound, CT, and MRI are used to screen and diagnose liver cancer. Serum α-fetoprotein level may be elevated with liver cancer or other liver problems. Ventilation/perfusion scans do not diagnose liver cancer. Abdominal girth measurement would not differentiate between cirrhosis and liver cancer.
The nurse is caring for a patient receiving morphine sulfate 10 mg IV push when necessary for pain. Upon assessment, the nurse finds the patient obtunded with a respiratory rate of 8/minute. Which medication would the nurse prepare to administer to treat these symptoms? A. Atropine sulfate B. Protamine sulfate C. Naloxone (Narcan) D. Neostigmine bromide (Prostigmin)
C. Naloxone (Narcan) Naloxone is the antidote or reversal agent for opioid analgesics, such as morphine. Excessive sedation and respiratory depression are symptoms of overdose and/or severe adverse effects that must be reversed for patient safety.
Which clinical manifestation should the nurse attribute to adverse effects of morphine sulfate administered via PCA? A. Diarrhea B. Urinary incontinence C. Nausea and vomiting D. Increased blood pressure
C. Nausea and vomiting Morphine sulfate promotes nausea and vomiting by directly stimulating the chemoreceptor trigger zone in the medulla. Other common side effects include constipation, sedation, respiratory depression, decreased blood pressure, and pruritus.
The nurse would determine that a postoperative patient is not receiving the beneficial effects of enoxaparin (Lovenox) after noting what during a routine shift assessment? A. Generalized weakness and fatigue B. Crackles bilaterally in the lung bases C. Pain and swelling in lower extremity D. Abdominal pain with decreased bowel sounds
C. Pain and swelling in lower extremity Enoxaparin is a low-molecular-weight heparin used to prevent the development of deep vein thromboses (DVTs) in the postoperative period. Pain and swelling in the lower extremity can indicate development of DVT and therefore may signal ineffective medication therapy.
The nurse is caring for a preoperative patient who has an order for vitamin K by subcutaneous injection. The nurse should verify that which laboratory study is abnormal before administering the dose? A. Hematocrit (Hct) B. Hemoglobin (Hgb) C. Prothrombin time (PT) D. Partial thromboplastin time (PTT)
C. Prothrombin time (PT) Vitamin K counteracts hypoprothrombinemia and/or reverses the effects of warfarin (Coumadin) and thus decreases the risk of bleeding. High values for either the prothrombin time (PT) or the international normalized ratio (INR) demonstrates the need for this medication.
Which assessment is of highest priority for the nurse to complete before administration of morphine? A. Pain rating B. Blood pressure C. Respiratory rate D. Level of consciousness
C. Respiratory rate A decreased respiratory rate below 12/min is a sign of opioid toxicity. Using the ABC approach in prioritization of care, a patent airway is always the first priority and is important to assess as a baseline before and during the administration of morphine.
The patient with Addison's disease presents to the clinic saying "I've gained five pounds in the past week!" You note some edema in both lower extremities. What does the nurse suspect to be the problem? A) Precipitation of Addisonian Crisis B) Heart Failure d/t end stage Addison's disease C) Excessive hormone replacement dose D) Adrenocarcinoma development
C. Signs of too high a corticosteroid dose include edema and weight gain. S/S of an Addisonian crisis include hypotension, tachycardia, cyanosis, pallor, and tachypnea. Heart failure is not associated with Addison's disease. There is no evidence of a tumor in the adrenal glands based on these symptoms.
A 45-year-old woman who had abdominal surgery yesterday received IV pain medication 30 minutes ago. Which assessment by the nurse would most accurately determine the effectiveness of the medication? A. The patient is resting quietly with eyes closed and is not grimacing. B. The patient is talking with visitors and intermittently watching the television. C. The patient states the pain has decreased from an 8 to a 3 on a 0 to 10 pain scale. D. The patient's heart rate is 78 beats/minute with a blood pressure of 122/76 mm Hg.
C. The patient states the pain has decreased from an 8 to a 3 on a 0 to 10 pain scale. Pain is a subjective experience. The patient is the best judge of his or her own pain and is the expert on the effectiveness of treatment of the pain.
Which information obtained during the nurse's assessment of a 30-year-old patient's nutritional-metabolic pattern may indicate the risk for musculoskeletal problems? a. The patient takes a multivitamin daily. b. The patient dislikes fruits and vegetables. c. The patient is 5 ft 2 in and weighs 180 lb. d. The patient prefers whole milk to nonfat milk.
C. The patient's height and weight indicate obesity, which places stress on weight-bearing joints. The use of whole milk, avoiding fruits and vegetables, and use of a daily multivitamin are not risk factors for musculoskeletal problems.
An 82-year-old patient is frustrated by her flabby belly and rigid hips. What should the nurse tell the patient about these frustrations? A. "You should go on a diet and exercise more to feel better about yourself." B. "Something must be wrong with you because you should not have these problems." C. "You have arthritis and need to go on nonsteroidal antiinflammatory drugs (NSAIDs)." D. "Decreased muscle mass and strength and increased hip rigidity are normal changes of aging."
D. "Decreased muscle mass and strength and increased hip rigidity are normal changes of aging." The musculoskeletal system's normal changes of aging include decreased muscle mass and strength; increased rigidity in the hips, neck, shoulders, back, and knees; decreased fine motor dexterity; and slowed reaction times. Going on a diet and exercising will help but not stop these changes. Telling the patient "Something must be wrong with you..." will not be helpful to the patient's frustrations.
Which effect should the nurse instruct a patient receiving NSAIDs to report? A. Blurred vision B. Nasal stuffiness C. Urinary retention D. Black or tarry stools
D. Black or tarry stools Black, tarry stools could indicate GI bleeding, which is a risk associated with NSAIDs. For this reason, the patient should be taught to report this sign and other signs of bleeding immediately.
Which assessment finding of the respiratory system does the nurse interpret as abnormal? A. Inspiratory chest expansion of 1 in B. Percussion resonance over the lung bases C. Symmetric chest expansion and contraction D. Bronchial breath sounds in the lower lung fields
D. Bronchial breath sounds in the lower lung fields Bronchial or bronchovesicular sounds heard in the peripheral lung fields are abnormal breath sounds.
After swallowing, a 73-year-old patient is coughing and has a wet voice. What changes of aging could be contributing to this abnormality? A. Decreased response to hypercapnia B. Decreased number of functional alveoli C. Increased calcification of costal cartilage D. Decreased respiratory defense mechanisms
D. Decreased respiratory defense mechanisms These manifestations are associated with aspiration, which more easily occur in the right lung as the right mainstem bronchus is shorter, wider, and straighter than the left mainstem bronchus. Aspiration occurs more easily in the older patient related to decreased respiratory defense mechanisms (e.g., decreases in immunity, ciliary function, cough force, sensation in pharynx). Changes of aging include a decreased response to hypercapnia, decreased number of functional alveoli, and increased calcification of costal cartilage, but these do not increase the risk of aspiration.
The patient is receiving fentanyl (Duragesic) patch for control of chronic cancer pain. What should the nurse observe for in the patient as a potential adverse effect of this medication? A. Hypertension B. Pupillary dilation C. Urinary incontinence D. Decreased respiratory rate
D. Decreased respiratory rate Respiratory depression is a potentially life-threatening adverse effect of fentanyl (Duragesic), which is an opioid analgesic, via any route.
What should the nurse inspect when assessing a patient with shortness of breath for evidence of long-standing hypoxemia? A. Chest excursion B. Spinal curvatures C. Respiratory pattern D. Fingernails and their base
D. Fingernails and their base Clubbing, a sign of long-standing hypoxemia, is evidenced by an increase in the angle between the base of the nail and the fingernail to 180 degrees or more, usually accompanied by an increase in the depth, bulk, and sponginess of the end of the finger.
The nurse is preparing to administer a scheduled dose of enoxaparin (Lovenox) 30 mg subcutaneously. What should the nurse do to administer this medication correctly? A. Remove the air bubble in the prefilled syringe. B. Aspirate before injection to prevent IV administration. C. Rub the injection site after administration to enhance absorption. D. Pinch the skin between the thumb and forefinger before inserting the needle.
D. Pinch the skin between the thumb and forefinger before inserting the needle. The nurse should gather together or "bunch up" the skin between the thumb and the forefinger before inserting the needle into the subcutaneous tissue. The nurse should not remove the air bubble in the prefilled syringe, aspirate, nor rub the site after injection.
A patient with a respiratory condition asks "how does air get into my lungs?". The nurse bases her answer on her knowledge that air moves into the lungs because of: A. contraction of the accessory abdominal muscles. B. increased carbon dioxide and decreased oxygen in the blood. C. stimulation of the respiratory muscles by the chemoreceptors. D. decrease in intrathoracic pressure relative to pressure at the airway.
D. decrease in intrathoracic pressure relative to pressure at the airway. During inspiration, the diaphragm contracts, increasing intrathoracic volume and pushing the abdominal contents downward. At the same time, the external intercostal muscles and scalene muscles contract, increasing the lateral and anteroposterior dimension of the chest. This causes the size of the thoracic cavity to increase and intrathoracic pressure to decrease, which enables air to enter the lungs.
The HCP prescribes an HMG-COA reductase inhibitor (statin) medication to a client with CAD. Which should the nurse teach the client about this medication?
This medication should be taken in the evening
The charge nurse observes an inexperienced staff nurse who is caring for a patient who has had a craniotomy for a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene?
The staff nurse suctions the patient every 2 hours. rational: Suctioning increases intracranial pressure and is done only when the patient's respiratory condition indicates it is needed. The other actions by the staff nurse are appropriate.
Choose all of the correct patient teachings for the patient with cystitis.
Teach the patient to drink cranberry juice to treat and prevent UTIs. Teach the female patient to cleanse the perineal area from anterior to posterior to prevent rectal E. Coli contamination of the urethra. Encourage the patient to drink 2000 ml of fluid per day, unless contraindicated.
Which assessment finding in a patient who was admitted the previous day with a basilar skull fracture is most important to report to the health care provider?
Temperature of 101.5° F (38.6° C) rational: Patients who have basilar skull fractures are at risk for meningitis, so the elevated temperature should be reported to the health care provider. The other findings are typical of a patient with a basilar skull fracture.
expected finding in patient with adrenal insufficiency
high calcium
diet requirements for Addison's patient
high salt, carbs, and protein with low potassium
which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel? 1. draw the serum liver function test 2. evaluate the clients intake and output 3. perform the bedside glucometer check 4. help the ward clerk transcribe orders
perform the bedside glucometer check: the UAP can perform a bedside glucometer check but the nurse must evaluate the result and determine any action needed
a client has been given a dx of hep A. the nurse would use which precautions for preventing the transmission of the disease to self and others? 1. reverse isolation 2. mask and gown 3. universal precautions 4. isolation precautions for trash
universal precautions
A patient diagnosed with ESRD is treated with conservative management, including erythropoietin injections. After teaching the patient about management of ESRD, the nurse determiness teaching has been effective when the patient states:
"I wil measure my urinary output each day to help calculate the amount I drink."
The nurse is instructing a client with Addison's disease about a newly prescribed medication, fludrocortisone acetate (Florinef). Which statement by the client indicates a need for further teaching?
"I will be glad to gain weight."
The nurse educates a group of women who have had frequent urinary tract infections (UTIs) about how to avoid recurrences. Which client statement shows a correct understanding of what the nurse has taught?
"I should be drinking at least 1.5 to 2.5 liters of fluids every day."
he nurse is instructing an older adult female client about interventions to decrease the risk for cystitis. Which client comment indicates that the teaching was effective?
"I should drink 2½ liters of fluid every day."
A client with Parkinson's disease visits the physician's office for a routine checkup. The nurse notes that the client takes benztropine (Cogentin), 0.5 mg by mouth daily, and asks when the client takes the drug each day. Which response indicates that the client understands when to take benztropine?
"I take the medication at bedtime."
The nurse is teaching a client who is scheduled for a neobladder and a Kock pouch. Which client statement indicates a correct understanding of these procedures?
"I will have to drain my pouch with a catheter."
The nurse is teaching a client with trigeminal neuralgia how to minimize pain episodes. Which comments by the client indicate that he understands the instructions?
"I'll try to chew my food on the unaffected side." "Drinking fluids at room temperature should reduce pain.", "If brushing my teeth is too painful, I'll try to rinse my mouth instead."
A 28-year-old woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. Which response by the nurse is accurate?
"MS symptoms may be worse after the pregnancy." rational: During the postpartum period, women with MS are at greater risk for exacerbation of symptoms. There is no increased risk for congenital defects in infants born of mothers with MS. Symptoms of MS may improve during pregnancy. Onset of labor is not affected by MS.
An elementary teacher who has just been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse, "I cannot teach anymore, it will be too upsetting if I have a seizure at work." Which response by the nurse is best?
"Most patients with epilepsy are well controlled with antiseizure medications." rational: The nurse should inform the patient that most patients with seizure disorders are controlled with medication. The other information may be necessary if the patient seizures persist after treatment with antiseizure medications is implemented.
The health care provider recommends a carotid endarterectomy for a patient with carotid atherosclerosis and a history of transient ischemic attacks (TIAs). The patient asks the nurse to describe the procedure. Which response by the nurse is appropriate?
"The carotid endarterectomy involves surgical removal of plaque from an artery in the neck." rational: In a carotid endarterectomy, the carotid artery is incised and the plaque is removed. The response beginning, "The diseased portion of the artery in the brain is removed" describes an arterial graft procedure. The answer beginning, "A catheter with a deflated balloon is positioned at the narrow area" describes an angioplasty. The final response beginning, "A wire is threaded through the artery" describes the MERCI procedure.
When family members ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring for a patient, which response by the nurse is best?
"The monitoring system helps show whether blood flow to the brain is adequate." rational: Short and simple explanations should be given to patients and family members. The other explanations are either too complicated to be easily understood or may increase the family member's anxiety.
A nurse is reviewing discharge teaching with a client who has Cushing's syndrome. Which statement by the client indicates that the instructions related to dietary management were understood? 1. "I can eat foods that contain potassium." 2. "I will need to limit the amount of protein in my diet." 3. "I am fortunate that I can eat all the salty foods I enjoy." 4. "I am fortunate that I do not need to follow any special diet."
*1. "I can eat foods that contain potassium."* *rationale* A diet that is low in calories, carbohydrates, and sodium but ample in protein and potassium content is encouraged for a client with Cushing's syndrome. Such a diet promotes weight loss, the reduction of edema and hypertension, the control of hypokalemia, and the rebuilding of wasted tissue.
Which statement by the client would cause the nurse to suspect that the thyroid test results drawn on the client this morning may be inaccurate? 1. "I had a radionuclide test done 3 days ago." 2. "When I exercise I sweat more than normal." 3. "I drank some water before the blood was drawn." 4. "That hamburger I ate before the test sure tasted good."
*1. "I had a radionuclide test done 3 days ago."* *rationale* Option 1 indicates that a recent radionuclide scan had been performed. Recent radionuclide scans performed before the test can affect thyroid laboratory results. No food, fluid, or activity restrictions are required for this test, so options 2, 3, and 4 are incorrect.
A client has just been admitted with a diagnosis of myxedema coma. If all of the following interventions were prescribed, the nurse would place highest priority on completing which of the following first? 1. Administering oxygen 2. Administering thyroid hormone 3. Warming the client 4. Giving fluid replacement
*1. Administering oxygen* *rationale* As part of maintaining a patent airway, oxygen would be administered first. This would be quickly followed by fluid replacement, keeping the client warm, monitoring vital signs, and administering thyroid hormones.
A nurse is collecting data on a client with a diagnosis of hypothyroidism. Which of these behaviors, if present in the client's history, would the nurse determine as being likely related to the manifestations of this disorder? 1. Depression 2. Nervousness 3. Irritability 4. Anxiety
*1. Depression* *rationale* Hypothyroid clients experience a slow metabolic rate, and its manifestation includes apathy, fatigue, sleepiness, and depression. Options 2, 3, and 4 identify the clinical manifestations of hyperthyroidism.
A nurse is reviewing a plan of care for a client with Addison's disease. The nurse notes that the client is at risk for dehydration and suggests nursing interventions that will prevent this occurrence. Which nursing intervention is an appropriate component of the plan of care? *Select all that apply.* 1. Encouraging fluid intake of at least 3000 mL/day 2. Encouraging an intake of low-protein foods 3. Monitoring for changes in mental status 4. Monitoring intake and output 5. Maintaining a low-sodium diet
*1. Encouraging fluid intake of at least 3000 mL/day* *3. Monitoring for changes in mental status* *4. Monitoring intake and output* *rationale* The client at risk for deficient fluid volume should be encouraged to eat regular meals and snacks and to increase the intake of sodium, protein, and complex carbohydrates. Oral replacement of sodium losses is necessary, and maintenance of adequate blood glucose levels is required.
A client with Addison's disease asks the nurse how a newly prescribed medication, fludrocortisone acetate (Florinef), will improve the condition. When formulating a response, the nurse should incorporate that a key action of this medication is to: 1. Help restore electrolyte balance. 2. Make the body produce more cortisol. 3. Replace insufficient circulating estrogens. 4. Alter the body's immune system functioning.
*1. Help restore electrolyte balance.* *rationale* Fludrocortisone acetate is a long-acting oral medication with mineralocorticoid and moderate glucocorticoid activity. It is prescribed for the long-term management of Addison's disease. Mineralocorticoids cause renal reabsorption of sodium and chloride ions and the excretion of potassium and hydrogen ions. These actions help restore electrolyte balance in the body. The other options are incorrect.
In planning nutrition for the client with hypoparathyroidism, which diet would be appropriate? 1. High in calcium and low phosphorous 2. Low in vitamins A, D, E, and K 3. High in sodium with no fluid restriction 4. Low in water and insoluble fiber
*1. High in calcium and low phosphorous* *rationale* Hypocalcemia is the end result of hypoparathyroidism resulting from either a lack of parathyroid hormone (PTH) secretion or ineffective PTH influence on tissue. Calcium is the major controlling factor of PTH secretion. Because of this, the diet needs to be high in calcium but low in phosphorus because these two electrolytes must exist in inverse proportions in the body. The other options are not dietary interventions with hypoparathyroidism.
A client with hypoparathyroidism has hypocalcemia. The nurse avoids giving the client the prescribed vitamin and calcium supplement with which of the following liquids? 1. Milk 2. Water 3. Iced tea 4. Fruit juice
*1. Milk* *rationale* Milk products are high in phosphates, which should be avoided by a client with hypoparathyroidism. Otherwise, calcium products are best absorbed with milk because the vitamin D in the milk promotes calcium absorption.
A nurse notes in the medical record that a client with Cushing's syndrome is experiencing fluid overload. Which interventions should be included in the plan of care? *Select all that apply.* 1. Monitoring daily weight 2. Monitoring intake and output 3. Maintaining a low-potassium diet 4. Monitoring extremities for edema 5. Maintaining a low-sodium diet
*1. Monitoring daily weight* *2. Monitoring intake and output* *4. Monitoring extremities for edema* *5. Maintaining a low-sodium diet* *rationale* The client with Cushing's syndrome experiencing fluid overload should be maintained on a high-potassium and low-sodium diet. Decreased sodium intake decreases renal retention of sodium and water. Monitoring weight, intake, output, and extremities for edema are all appropriate interventions for such a nursing diagnosis.
A nurse is caring for a client with a diagnosis of hypoparathyroidism. The nurse reviews the laboratory results drawn on the client and notes that the calcium level is extremely low. The nurse would expect to note which of the following on data collection of the client? 1. Positive Trousseau's sign 2. Negative Chvostek's sign 3. Unresponsive pupils 4. Hyperactive bowel sounds
*1. Positive Trousseau's sign* *rationale* Hypoparathyroidism is related to a lack of parathyroid hormone secretion or to a decreased effectiveness of parathyroid hormone on target tissues. The end result of this disorder is hypocalcemia. When serum calcium levels are critically low, the client may exhibit positive Chvostek's and Trousseau's signs, which indicate potential tetany. Options 2, 3, and 4 are not related to the presence of hypocalcemia.
A health care provider has prescribed propylthiouracil (PTU) for a client with hyperthyroidism, and the nurse assists in developing a plan of care for the client. A priority nursing measure to be included in the plan regarding this medication is to monitor the client for: 1. Signs and symptoms of hypothyroidism 2. Signs and symptoms of hyperglycemia 3. Relief of pain 4. Signs of renal toxicity
*1. Signs and symptoms of hypothyroidism* *rationale* Excessive dosing with propylthiouracil may convert the client from a hyperthyroid state to a hypothyroid state. If this occurs, the dosage should be reduced. Temporary administration of thyroid hormone may be required. Propylthiouracil is not used for pain and does not cause hyperglycemia or renal toxicity.
A nurse is preparing to discharge a client who has had a parathyroidectomy. When teaching the client about the prescribed oral calcium supplement, what information should the nurse include? 1. Take the calcium 30 to 60 minutes following a meal. 2. Avoid sunlight because it can cause skin color change. 3. Store the calcium in the refrigerator to maintain potency. 4. Check the pulse daily and hold the dosage if it is below 60 beats per minute.
*1. Take the calcium 30 to 60 minutes following a meal.* *rationale* Oral calcium supplements can be taken 30 to 60 minutes after meals to enhance their absorption and decrease gastrointestinal irritation. All the other options are unrelated to oral calcium therapy.
An older client with a history of hyperparathyroidism and severe osteoporosis is hospitalized. The nurse caring for the client plans first to address which problem? 1. The possibility of injury 2. Constipation 3. Urinary retention 4. Need for teaching about the disorder
*1. The possibility of injury* *rationale* The client with severe osteoporosis as a result of hyperparathyroidism is at risk for injury as a result of pathological fractures that can occur from bone demineralization. The client may also have a risk for constipation from the disease process but this is a lesser priority than client safety. The client may or may not have urinary elimination problems, depending on other factors in the client's history. There is no information in the question to support whether the client needs teaching.
A nurse is monitoring a client following a thyroidectomy for signs of hypocalcemia. Which of the following signs, if noted in the client, likely indicates the presence of hypocalcemia? 1. Tingling around the mouth 2. Negative Chvostek's sign 3. Flaccid paralysis 4. Bradycardia
*1. Tingling around the mouth* *rationale* Following a thyroidectomy, the nurse assesses the client for signs of hypocalcemia and tetany. Early signs include tingling around the mouth and fingertips, muscle twitching or spasms, palpitations or dysrhythmias, and positive Chvostek's and Trousseau's signs. Options 2, 3, and 4 are not signs of hypocalcemia.
During routine postoperative assessment of a client who has undergone hypophysectomy, the client complains of thirst and frequent urination. Knowing the expected complications of this surgery, the nurse would next check the: 1. Urine specific gravity 2. Serum glucose 3. Respiratory rate 4. Blood pressure
*1. Urine specific gravity* *rationale* Following hypophysectomy, diabetes insipidus can occur temporarily because of antidiuretic hormone (ADH) deficiency. This deficiency is related to surgical manipulation. The nurse should assess specific gravity and notify the registered nurse if the results are less than 1.005. Although options 2, 3, and 4 may be components of the assessment, the nurse would next check urine specific gravity.
A nurse has reinforced dietary instructions to a client with a diagnosis of hypoparathyroidism. The nurse instructs the client to include which of the following items in the diet? 1. Vegetables 2. Meat 3. Fish 4. Cereals
*1. Vegetables* *rationale* The client with hypoparathyroidism is instructed to follow a calcium-rich diet and to restrict the amount of phosphorus in the diet. The client should limit meat, poultry, fish, eggs, cheese, and cereals. Vegetables are allowed in the diet.
A nurse is caring for a client with pheochromocytoma. The client is scheduled for an adrenalectomy. During the preoperative period, the priority nursing action would be to monitor the: 1. Vital signs 2. Intake and output 3. Blood urea nitrogen (BUN) level 4. Urine for glucose and acetone
*1. Vital signs* *rationale* Hypertension is the hallmark of pheochromocytoma. Severe hypertension can precipitate a brain attack (stroke) or sudden blindness. Although all of the options are accurate nursing interventions for the client with pheochromocytoma, the priority nursing action is to monitor the vital signs, particularly the blood pressure.
A nurse is collecting data on a client with hyperparathyroidism. Which of the following questions would elicit the accurate information about this condition from the client? 1. "Do you have tremors in your hands?" 2. "Are you experiencing pain in your joints?" 3. "Have you had problems with diarrhea lately?" 4. "Do you notice swelling in your legs at night?"
*2. "Are you experiencing pain in your joints?"* *rationale* Hyperparathyroidism causes an oversecretion of parathyroid hormone (PTH), which causes excessive osteoblast growth and activity within the bones. When bone reabsorption is increased, calcium is released from the bones into the blood, causing hypercalcemia. The bones suffer demineralization as a result of calcium loss, leading to bone and joint pain, and pathological fractures.
A nursing instructor asks a student to describe the pathophysiology that occurs in Cushing's disease. Which statement by the student indicates an accurate understanding of this disorder? 1. "Cushing's disease is characterized by an oversecretion of insulin." 2. "Cushing's disease is characterized by an oversecretion of glucocorticoid hormones." 3. "Cushing's disease is characterized by an undersecretion of corticotropic hormones." 4. "Cushing's disease is characterized by an undersecretion of glucocorticoid hormones."
*2. "Cushing's disease is characterized by an oversecretion of glucocorticoid hormones."* *rationale* Cushing's syndrome is characterized by an oversecretion of glucocorticoid hormones. Addison's disease is characterized by the failure of the adrenal cortex to produce and secrete adrenocortical hormones. Options 1 and 4 are inaccurate regarding Cushing's syndrome.
A nurse is reinforcing home care instructions to a client with a diagnosis of Cushing's syndrome. Which statement reflects a need for further client education? 1. "Taking my medications exactly as prescribed is essential." 2. "I need to read the labels on any over-the-counter medications I purchase." 3. "My family needs to be familiar with the signs and symptoms of hypoadrenalism." 4. "I could experience the signs and symptoms of hyperadrenalism because of Cushing's."
*2. "I need to read the labels on any over-the-counter medications I purchase."* *rationale* The client with Cushing's syndrome should be instructed to take the medications exactly as prescribed. The nurse should emphasize the importance of continuing medications, consulting with the health care provider before purchasing any over-the-counter medications, and maintaining regular follow-up care. The nurse should also instruct the client in the signs and symptoms of both hypoadrenalism and hyperadrenalism.
A nurse has just supervised a newly diagnosed diabetes mellitus client self-inject NPH insulin at 7:30 ᴀᴍ. The nurse reviews the time frames for peak insulin action with the client, telling the client to be especially watchful for a hypoglycemic reaction between: 1. 7:30 ᴀᴍ and 9:30 ᴀᴍ 2. 1:30 ᴘᴍ and 7:30 ᴘᴍ 3. 8:30 ᴘᴍ and 12:00 ᴀᴍ 4. 2:30 ᴀᴍ and 4:30 ᴀᴍ
*2. 1:30 ᴘᴍ and 7:30 ᴘᴍ* *rationale* NPH is an intermediate-acting insulin. It begins to work in 1 to 2 hours (onset), peaks in 6 to 12 hours, and lasts for 18 to 24 hours (duration). Hypoglycemic reactions most likely occur during peak time, which in this case is option 2.
Which of the following clients is at risk for developing thyrotoxicosis? 1. A client with hypothyroidism 2. A client with Graves' disease who is having surgery 3. A client with diabetes mellitus scheduled for debridement of a foot ulcer 4. A client with diabetes insipidus scheduled for an invasive diagnostic test
*2. A client with Graves' disease who is having surgery* *rationale* Thyrotoxicosis is usually seen in clients with Graves' disease with the symptoms precipitated by a major stressor. This complication typically occurs during periods of severe physiological or psychological stress such as trauma, sepsis, the birth process, or major surgery. It also must be recognized as a potential complication following a thyroidectomy.
A nurse is caring for a client after thyroidectomy and monitoring for signs of thyroid storm. The nurse understands that which of the following is a manifestation associated with this disorder? 1. Bradycardia 2. Hypotension 3. Constipation 4. Hypothermia
*2. Hypotension* *rationale* Clinical manifestations associated with thyroid storm include a fever as high as 106° F (41.1° C), severe tachycardia, profuse diarrhea, extreme vasodilation, hypotension, atrial fibrillation, hyperreflexia, abdominal pain, diarrhea, and dehydration. With this disorder, the client's condition can rapidly progress to coma and cardiovascular collapse.
A nurse is caring for a client with Addison's disease. The nurse checks the vital signs and determines that the client has orthostatic hypotension. The nurse determines that this finding relates to which of the following? 1. A decrease in cortisol release 2. A decreased secretion of aldosterone 3. An increase in epinephrine secretion 4. Increased levels of androgens
*2. A decreased secretion of aldosterone* *rationale* A decreased secretion of aldosterone results in a limited reabsorption of sodium and water; therefore the client experiences fluid volume deficit. A decrease in cortisol, an increase in epinephrine, and an increase in androgen secretion do not result in orthostatic hypotension.
While collecting data on a client being prepared for an adrenalectomy, the nurse obtains a temperature reading of 100.8° F. The nurse analyzes this temperature reading as: 1. Within normal limits 2. A finding that needs to be reported immediately 3. An expected finding caused by the operative stress response 4. Slightly abnormal but an insignificant finding
*2. A finding that needs to be reported immediately* *rationale* An adrenalectomy is performed because of excess adrenal gland function. Excess cortisol production impairs the immune response, which puts the client at risk for infection. Because of this, the client needs to be protected from infection, and minor variations in normal vital sign values must be reported so that infections are detected early, before they become overwhelming. In addition, the surgeon may elect to postpone surgery in the event of a fever because it can be indicative of infection. Options 1, 3, and 4 are not correct interpretations.
A nurse is reviewing the postoperative prescriptions for a client who had a transsphenoidal hypophysectomy. Which health care provider's prescription, if noted on the record, indicates the need for clarification? 1. Instruct the client about the need for a Medic-Alert bracelet. 2. Apply a loose dressing if any clear drainage is noted. 3. Monitor vital signs and neurological status. 4. Instruct the client to avoid blowing the nose.
*2. Apply a loose dressing if any clear drainage is noted.* *rationale* The nurse should observe for clear nasal drainage, constant swallowing, and a severe, persistent, generalized, or frontal headache. These signs and symptoms indicate cerebrospinal fluid leak into the sinuses. If clear drainage is noted following this procedure, the health care provider needs to be notified immediately. Options 1, 3, and 4 indicate appropriate postoperative interventions.
A client is admitted with a diagnosis of pheochromocytoma. The nurse would monitor which of the following to detect the most common sign of pheochromocytoma? 1. Skin temperature 2. Blood pressure 3. Urine ketones 4. Weight
*2. Blood pressure* *rationale* Hypertension is the major symptom associated with pheochromocytoma and is monitored by taking the client's blood pressure. Glycosuria, weight loss, and diaphoresis are other clinical manifestations of pheochromocytoma; however, hypertension is the most common sign.
A client with a pituitary tumor will undergo transsphenoidal hypophysectomy. The nurse includes which priority item in the preoperative teaching plan for the client? 1. Brushing the teeth vigorously and frequently is important to minimize bacteria in the mouth. 2. Blowing the nose following surgery is prohibited. 3. A small area will be shaved at the base of the neck. 4. It will be necessary to cough and deep breathe following the surgery.
*2. Blowing the nose following surgery is prohibited.* *rationale* The approach used for this surgery is the oronasal route, specifically where the upper lip meets the gum. The surgeon then uses a route through the sphenoid sinus to get to the pituitary gland. The client is not allowed to blow the nose, sneeze, or cough vigorously because these activities could raise intracranial pressure. The client also is not allowed to brush the teeth, to avoid disrupting the surgical site. Alternate methods for performing mouth care are used.
A nurse is caring for a client diagnosed with hyperparathyroidism who is prescribed furosemide (Lasix). The nurse reinforces dietary instructions to the client. Which of the following is an appropriate instruction? 1. Increase dietary intake of calcium. 2. Drink at least 2 to 3 L of fluid daily. 3. Eat sparely when experiencing nausea. 4. Decrease dietary intake of potassium.
*2. Drink at least 2 to 3 L of fluid daily.* *rationale* The aim of treatment in the client with hyperparathyroidism is to increase the renal excretion of calcium and decrease gastrointestinal absorption and bone resorption. This is aided by the sufficient intake of fluids. Dietary restriction of calcium may be used as a component of therapy. The parathyroid is responsible for calcium production, and the term, "hyperparathyroidism" can be indicative of an increase in calcium. The client should eat foods high in potassium, especially if the client is taking furosemide. Limiting nutrients is not advisable.
A client scheduled for a thyroidectomy says to the nurse, "I am so scared to get cut in my neck." Based on the client's statement, the nurse determines that the client is experiencing which problem? 1. Inadequate knowledge about the surgical procedure 2. Fear about impending surgery 3. Embarrassment about the changes in personal appearance 4. Lack of support related to the surgical procedure
*2. Fear about impending surgery* *rationale* The client is having a difficult time coping with the scheduled surgery. The client is able to express fears but is scared. No data in the question support options 1, 3, and 4.
A nurse is monitoring a client with Graves' disease for signs of thyrotoxic crisis (thyroid storm). Which of the following signs and symptoms, if noted in the client, will alert the nurse to the presence of this crisis? *Select all that apply.* 1. Bradycardia 2. Fever 3. Sweating 4. Agitation 5. Pallor
*2. Fever* *3. Sweating* *4. Agitation* *rationale* Thyrotoxic crisis (thyroid storm) is an acute, potentially life-threatening state of extreme thyroid activity that represents a breakdown in the body's tolerance to a chronic excess of thyroid hormones. The clinical manifestations include fever greater than 100° F, severe tachycardia, flushing and sweating, and marked agitation and restlessness. Delirium and coma can occur.
A nurse is caring for a client with pheochromocytoma. The client asks for a snack and something warm to drink. The appropriate choice for this client to meet nutritional needs would be which of the following? 1. Crackers with cheese and tea 2. Graham crackers and warm milk 3. Toast with peanut butter and cocoa 4. Vanilla wafers and coffee with cream and sugar
*2. Graham crackers and warm milk* *rationale* The client with pheochromocytoma needs to be provided with a diet that is high in vitamins, minerals, and calories. Of particular importance is that food or beverages that contain caffeine (e.g., chocolate, coffee, tea, and cola) are prohibited.
A nurse is caring for a client following an adrenalectomy and is monitoring for signs of adrenal insufficiency. Which of the following, if noted in the client, indicates signs and symptoms related to adrenal insufficiency? *Select all that apply.* 1. Double vision 2. Hypotension 3. Mental status changes 4. Weakness 5. Fever
*2. Hypotension* *3. Mental status changes* *4. Weakness* *5. Fever* *rationale* The nurse should be alert to signs and symptoms of adrenal insufficiency in a client following adrenalectomy. These signs and symptoms include weakness, hypotension, fever, and mental status changes. Double vision is generally not associated with this condition.
A client with Cushing's disease is being admitted to the hospital after a stab wound to the abdomen. The nurse plans care and places highest priority on which potential problem? 1. Nervousness 2. Infection 3. Concern about appearance 4. Inability to care for self
*2. Infection* *rationale* The client with a stab wound has a break in the body's first line of defense against infection. The client with Cushing's disease is at great risk for infection because of excess cortisol secretion and subsequent impaired antibody function and decreased proliferation of lymphocytes. The client may also have a potential for the problems listed in the other options but these are not the highest priority at this time.
A nurse is collecting data on a client admitted to the hospital with a diagnosis of myxedema. Which data collection technique will provide data necessary to support the admitting diagnosis? 1. Auscultation of lung sounds 2. Inspection of facial features 3. Percussion of the thyroid gland 4. Palpation of the adrenal glands
*2. Inspection of facial features* *rationale* Inspection of facial features will reveal the characteristic coarse features, presence of edema around the eyes and face, and a blank expression that are characteristic of myxedema. The techniques in the remaining options will not reveal any data that would support the diagnosis of myxedema.
A nurse is providing discharge instructions to a client who had a unilateral adrenalectomy. Which of the following will be a component of the instructions? 1. The reason for maintaining a diabetic diet 2. Instructions about early signs of a wound infection 3. Teaching regarding proper application of an ostomy pouch 4. The need for lifelong replacement of all adrenal hormones
*2. Instructions about early signs of a wound infection* *rationale* A client who is undergoing a unilateral adrenalectomy will be placed on corticosteroids temporarily to avoid a cortisol deficiency. These medications will be gradually weaned in the postoperative period until they are discontinued. Because of the anti-inflammatory properties of corticosteroids, clients who undergo an adrenalectomy are at increased risk for developing wound infections. Because of this increased risk for infection, it is important for the client to know measures to prevent infection, early signs of infection, and what to do if an infection is present. Options 1, 3, and 4 are incorrect instructions.
After several diagnostic tests, a client is diagnosed with diabetes insipidus. The nurse understands that which symptom is indicative of this disorder? 1. Diarrhea 2. Polydipsia 3. Weight gain 4. Blurred vision
*2. Polydipsia* *rationale* Polydipsia and polyuria are classic symptoms of diabetes insipidus. The urine is pale in color, and its specific gravity is low. Anorexia and weight loss occur. Diarrhea, weight loss, and blurred vision are not manifestations of the disorder.
The anticipated intended effect of fludrocortisone acetate (Florinef) for the treatment of Addison's disease is to: 1. Stimulate the immune response. 2. Promote electrolyte balance. 3. Stimulate thyroid production. 4. Stimulate thyrotropin production.
*2. Promote electrolyte balance.* *rationale* Florinef is a long-acting oral medication with mineralocorticoid and moderate glucocorticoid activity used for long-term management of Addison's disease. Mineralocorticoids act on the renal distal tubules to enhance the reabsorption of sodium and chloride ions and the excretion of potassium and hydrogen ions. In small doses, fludrocortisone acetate causes sodium retention and increased urinary potassium excretion. The client rapidly can develop hypotension and fluid and electrolyte imbalance if the medication is discontinued abruptly. Options 1, 3, and 4 are not associated with the effects of this medication.
What would the nurse anticipate being included in the plan of care for a client who has been diagnosed with Graves' disease? 1. Provide a high-fiber diet. 2. Provide a restful environment. 3. Provide three small meals per day. 4. Provide the client with extra blankets.
*2. Provide a restful environment.* *rationale* Because of the hypermetabolic state, the client with Graves' disease needs to be provided with an environment that is restful both physically and mentally. Six full meals a day that are well balanced and high in calories are required, because of the accelerated metabolic rate. Foods that increase peristalsis (e.g., high-fiber foods) need to be avoided. These clients suffer from heat intolerance and require a cool environment.
A nurse is caring for a client with hypothyroidism who is overweight. Which food items would the nurse suggest to include in the plan? 1. Peanut butter, avocado, and red meat 2. Skim milk, apples, whole-grain bread, and cereal 3. Organ meat, carrots, and skim milk 4. Seafood, spinach, and cream cheese
*2. Skim milk, apples, whole-grain bread, and cereal* *rationale* Clients with hypothyroidism may have a problem with being over-weight because of their decreased metabolic need. They should consume foods from all food groups, which will provide them with the necessary nutrients; however, the foods should be low in calories. Option 2 is the only option that identifies food items that are low in calories.
When caring for a client who is having clear drainage from his nares after transsphenoidal hypophysectomy, which action by the nurse is appropriate? 1. Lower the head of the bed. 2. Test the drainage for glucose. 3. Obtain a culture of the drainage. 4. Continue to observe the drainage.
*2. Test the drainage for glucose.* *rationale* After hypophysectomy, the client should be monitored for rhinorrhea, which could indicate a cerebrospinal fluid (CSF) leak. If this occurs, the drainage should be collected and tested for glucose, indicating the presence of CSF. The head of the bed should not be lowered to prevent increased intracranial pressure. Clear nasal drainage would not indicate the need for a culture. Continuing to observe the drainage without taking action could result in a serious complication.
A client who returned to the nursing unit 8 hours ago after hypophysectomy has clear drainage saturating the nasal dressing. The nurse should take which action first? 1. Continue to observe for further drainage. 2. Test the drainage for glucose.* 3. Put the head of the bed flat. 4. Test the drainage for occult blood.
*2. Test the drainage for glucose.* *rationale* Following hypophysectomy the client should be monitored for rhinorrhea (clear nasal drainage), which could indicate a cerebrospinal fluid (CSF) leak. If this occurs, the drainage should be collected and tested for the presence of CSF by testing it for glucose. CSF tests positive for glucose, whereas true nasal secretions would not. It is not necessary to test drainage that is clear for occult blood. The head of the bed should not be lowered, to prevent a rise in intracranial pressure. Continuing to observe the drainage without taking action could put the client at risk for developing a serious complication.
A nurse has reinforced instructions to the client with hyperparathyroidism regarding home care measures related to exercise. Which statement by the client indicates a need for further instruction? *Select all that apply.* 1. "I enjoy exercising but I need to be careful." 2. "I need to pace my activities throughout the day." 3. "I need to limit playing football to only the weekends." 4. "I should gauge my activity level by my energy level." 5. "I should exercise in the evening to encourage a good sleep pattern."
*3. "I need to limit playing football to only the weekends."* *5. "I should exercise in the evening to encourage a good sleep pattern."* *rationale* The client should be instructed to avoid high-impact activity or contact sports such as football. Exercising late in the evening may interfere with restful sleep. The client with hyperparathyroidism should pace activities throughout the day and plan for periods of uninterrupted rest. The client should plan for at least 30 minutes of walking each day to support calcium movement into the bones. The client should be instructed to use energy level as a guide to activity.
A client with Cushing's syndrome verbalizes concern to the nurse regarding the appearance of the buffalo hump that has developed. Which response by the nurse is appropriate? 1. "Don't be concerned, this problem can be covered with clothing." 2. "This is permanent, but looks are deceiving and not that important." 3. "Usually, these physical changes slowly improve following treatment." 4. "Try not to worry about it. There are other things to be concerned about."
*3. "Usually, these physical changes slowly improve following treatment."* *rationale* The client with Cushing's syndrome should be reassured that most physical changes resolve with treatment. Options 1, 2, and 4 are not therapeutic responses.
Following hypophysectomy, a client complains of being very thirsty and having to urinate frequently. The initial nursing action is to: 1. Document the complaints. 2. Increase fluid intake. 3. Check the urine specific gravity. 4. Check for urinary glucose.
*3. Check the urine specific gravity.* *rationale* Following hypophysectomy, diabetes insipidus can occur temporarily because of antidiuretic hormone deficiency. This deficiency is related to surgical manipulation. The nurse should check the urine for specific gravity and report the results if they are less than 1.005. Urinary glucose and diabetes mellitus is not a concern here. In this situation, increasing fluid intake would require a health care provider's prescription. The client's complaint would be documented but not as an initial action.
A nurse is caring for a client with pheochromocytoma. Which data would indicate a potential complication associated with this disorder? 1. A urinary output of 50 mL/hr 2. A coagulation time of 5 minutes 3. Congestion heard on auscultation of the lungs 4. A blood urea nitrogen (BUN) level of 20 mg/dL
*3. Congestion heard on auscultation of the lungs* *rationale* The complications associated with pheochromocytoma include hypertensive retinopathy and nephropathy, myocarditis, congestive heart failure (CHF), increased platelet aggregation, and stroke. Death can occur from shock, stroke, renal failure, dysrhythmias, or dissecting aortic aneurysm. Congestion heard on auscultation of the lungs is indicative of CHF. A urinary output of 50 mL/hr is an appropriate output; the nurse would become concerned if the output were less than 30 mL/hr. A coagulation time of 5 minutes is normal. A BUN level of 20 mg/dL is a normal finding.
A nurse is preparing to provide instructions to a client with Addison's disease regarding diet therapy. The nurse understands that which of the following diets would likely be prescribed for this client? 1. Low-protein diet 2. Low-sodium diet 3. High-sodium diet 4. Low-carbohydrate diet
*3. High-sodium diet* *rationale* A high-sodium, high-complex carbohydrate, and high-protein diet will be prescribed for the client with Addison's disease. To prevent excess fluid and sodium loss, the client is instructed to maintain an adequate salt intake of up to 8 g of sodium daily and to increase salt intake during hot weather, before strenuous exercise, and in response to fever, vomiting, or diarrhea.
A client is diagnosed with hyperparathyroidism. The nurse teaching the client about dietary alterations to manage the disorder tells the client to limit which of the following foods in the diet? 1. Bananas 2. Oatmeal 3. Ice cream 4. Chicken breast
*3. Ice cream* *rationale* The client with hyperparathyroidism is likely to have elevated calcium levels. This client should reduce intake of dairy products such as milk, cheese, ice cream, or yogurt. Apples, bananas, chicken, oatmeal, and pasta are low-calcium foods.
A nurse would expect to note which interventions in the plan of care for a client with hypothyroidism? *Select all that apply.* 1. Provide a cool environment for the client. 2. Instruct the client to consume a high-fat diet. 3. Instruct the client about thyroid replacement therapy. 4. Encourage the client to consume fluids and high-fiber foods in the diet. 5. Instruct the client to contact the health care provider if episodes of chest pain occur. 6. Inform the client that iodine preparations will be prescribed to treat the disorder.
*3. Instruct the client about thyroid replacement therapy.* *4. Encourage the client to consume fluids and high-fiber foods in the diet.* *5. Instruct the client to contact the health care provider if episodes of chest pain occur.* *rationale* The clinical manifestations of hypothyroidism are the result of decreased metabolism from low levels of thyroid hormone. Interventions are aimed at replacement of the hormones and providing measures to support the signs and symptoms related to a decreased metabolism. The nurse encourages the client to consume a well-balanced diet that is low in fat for weight reduction and high in fluids and high-fiber foods to prevent constipation. The client often has cold intolerance and requires a warm environment. The client would notify the health care provider if chest pain occurs since it could be an indication of overreplacement of thyroid hormone. Iodine preparations are used to treat hyperthyroidism. These medications decrease blood flow through the thyroid gland and reduce the production and release of thyroid hormone.
A client with newly diagnosed Cushing's syndrome expresses concern about personal appearance, specifically about the "buffalo hump" that has developed at the base of the neck. When counseling the client about this manifestation, the nurse should incorporate the knowledge that: 1. This is a permanent feature. 2. It can be minimized by wearing tight clothing. 3. It may slowly improve with treatment of the disorder. 4. It will quickly disappear once medication therapy is started.
*3. It may slowly improve with treatment of the disorder.* *rationale* The client with Cushing's syndrome should be reassured that most physical changes resolve over time with treatment. The other options are incorrect.
A client has been diagnosed with hypoparathyroidism. The nurse teaches the client to include foods in the diet that are: 1. High in phosphorus and low in calcium 2. Low in phosphorus and low in calcium 3. Low in phosphorus and high in calcium 4. High in phosphorus and high in calcium
*3. Low in phosphorus and high in calcium* *rationale* Hypoparathyroidism results in hypocalcemia. A therapeutic diet for this disorder is one that is high in calcium but low in phosphorus because these two electrolytes have inverse proportions in the body. All of the other options are unrelated to this disorder and are incorrect.
A nurse reviews a plan of care for a postoperative client following a thyroidectomy and notes that the client is at risk for breathing difficulty. Which of the following nursing interventions will the nurse suggest to include in the plan of care? 1. Maintain a supine position. 2. Encourage coughing and deep breathing exercises. 3. Monitor neck circumference frequently. 4. Maintain a pressure dressing on the operative site.
*3. Monitor neck circumference frequently.* *rationale* Following a thyroidectomy, the client should be placed in an upright position to facilitate air exchange. The nurse should assist the client with deep breathing exercises, but coughing is minimized to prevent tissue damage and stress to the incision. A pressure dressing is not placed on the operative site because it could affect breathing. The nurse should monitor the dressing closely and should loosen the dressing if necessary. Neck circumference is monitored at least every 4 hours to assess for postoperative edema.
Which nursing action would be appropriate to implement when a client has a diagnosis of pheochromocytoma? 1. Weigh the client. 2. Test the client's urine for glucose. 3. Monitor the client's blood pressure. 4. Palpate the client's skin to determine warmth.
*3. Monitor the client's blood pressure.* *rationale* Hypertension is the major symptom that is associated with pheochromocytoma. The blood pressure status is monitored by taking the client's blood pressure. Glycosuria, weight loss, and diaphoresis are also clinical manifestations of pheochromocytoma, but hypertension is the major symptom.
A nurse caring for a client scheduled for a transsphenoidal hypophysectomy to remove a tumor in the pituitary gland assists to develop a plan of care for the client. The nurse suggests including which specific information in the preoperative teaching plan? 1. Hair will need to be shaved. 2. Deep breathing and coughing will be needed after surgery. 3. Toothbrushing will not be permitted for at least 2 weeks following surgery. 4. Spinal anesthesia is used.
*3. Toothbrushing will not be permitted for at least 2 weeks following surgery.* *rationale* Based on the location of the surgical procedure, spinal anesthesia would not be used. In addition, the hair would not be shaved. Although coughing and deep breathing are important, specific to this procedure is avoiding toothbrushing to prevent disruption of the surgical site. Also, coughing may disrupt the surgical site.
A preoperative client is scheduled for adrenalectomy to remove a pheochromocytoma. The nurse would most closely monitor which of the following items in the preoperative period? 1. Intake and output 2. Blood urea nitrogen (BUN) 3. Vital signs 4. Urine glucose and ketones
*3. Vital signs* *rationale* Hypertension is the hallmark of pheochromocytoma. Severe hypertension can precipitate a stroke or sudden blindness. Although all the items are appropriate nursing assessments for the client with pheochromocytoma, the priority is to monitor the vital signs, especially the blood pressure.
A health care provider prescribes a 24-hour urine collection for vanillylmandelic acid (VMA). The nurse instructs the client in the procedure for the collection of the urine. Which statement by the client would indicate a need for further instruction? 1. "I will start the collection in 2 days. I cannot eat or drink any tea, chocolate, vanilla, or fruit until the test is completed." 2. "When I start the collection, I will urinate and discard that specimen." 3. "I will pour the urine into the collection bottle each time I urinate and refrigerate the urine." 4. "I can take any medications if I need to before the collection."
*4. "I can take any medications if I need to before the collection."* *rationale* Because a 24-hour urine collection is a timed quantitative determination, it is essential that the client start the test with an empty bladder. Therefore the client is instructed to void and discard the first urine and note the time and start the test. The 24-hour urine specimen collection bottle must be kept on ice or refrigerated. In a VMA collection, the client is instructed to avoid tea, chocolate, vanilla, and all fruits for 2 days before urine collection begins. Also clients are reminded not to take certain medications for 2 to 3 days before the test.
A client with myxedema has changes in intellectual function such as impaired memory, decreased attention span, and lethargy. The client's husband is upset and shares his concerns with the nurse. Which statement by the nurse is helpful to the client's husband? 1. "Would you like me to ask the health care provider for a prescription for a stimulant?" 2. "Give it time. I've seen dozens of clients with this problem that fully recover." 3. "I don't blame you for being frustrated, because the symptoms will only get worse." 4. "It's obvious that you are concerned about your wife's condition, but the symptoms may improve with continued therapy."
*4. "It's obvious that you are concerned about your wife's condition, but the symptoms may improve with continued therapy."* *rationale* Using therapeutic communication techniques, the nurse acknowledges the husband's concerns and conveys that the client's symptoms are common with myxedema. With thyroid hormone therapy, these symptoms should decrease, and cognitive function often returns to normal. Option 1 is not helpful, and it blocks further communication. Option 3 is pessimistic and untrue. Option 2 is not appropriate and offers false reassurance.
A client with pheochromocytoma is scheduled for surgery and says to the nurse, "I'm not sure that surgery is the best thing to do." What response by the nurse is appropriate? 1. "I think you are making the right decision to have the surgery." 2. "You are very ill. Your health care provider has made the correct decision." 3. "There is no reason to worry. Your health care provider is a wonderful surgeon." 4. "You have concerns about the surgical treatment for your condition."
*4. "You have concerns about the surgical treatment for your condition."* *rationale* Paraphrasing is restating the client's message in the nurse's own words. Option 4 addresses the therapeutic communication technique of paraphrasing. The client is reaching out for understanding. In option 3, the nurse is offering a false reassurance, and this type of response will block communication. Option 2 also represents a communication block because it reflects a lack of the client's right to an opinion. In option 1, the nurse is expressing approval, which can be harmful to a nurse-client relationship.
The nurse caring for a client who has had a subtotal thyroidectomy reviews the plan of care and determines which problem is the priority for this client in the immediate postoperative period? 1. Dehydration 2. Infection 3. Urinary retention 4. Bleeding
*4. Bleeding* *rationale* Hemorrhage is one of the most severe complications that can occur following thyroidectomy. The nurse must frequently check the neck dressing for bleeding and monitor vital signs to detect early signs of hemorrhage, which could lead to shock. T3 and T4 do not regulate fluid volumes in the body. Infection is a concern for any postoperative client but is not the priority in the immediate postoperative period. Urinary retention can occur in postoperative clients as a result of medication and anesthesia but is not the priority from the options provided.
A nurse working on an endocrine nursing unit understands that which correct concept is used in planning care? 1. Clients with Cushing's syndrome are likely to experience episodic hypotension. 2. Clients with hyperthyroidism must be monitored for weight gain. 3. Clients who have diabetes insipidus should be assessed for fluid excess. 4. Clients who have hyperparathyroidism should be protected against falls.
*4. Clients who have hyperparathyroidism should be protected against falls.* *rationale* Hyperparathyroidism is a disease that involves excess secretion of parathyroid hormone (PTH). Elevation of PTH causes excess calcium to be removed from the bones. There is a decline in bone mass, which may cause a fracture if a fall occurs. Cushing's syndrome is likely to cause hypertension. Clients with hypothyroidism must be monitored for weight gain and clients with hyperthyroidism must be monitored for weight loss. Clients who have diabetes insipidus should be assessed for fluid deficit.
A nursing student notes in the medical record that a client with Cushing's syndrome is experiencing body image disturbances. The need for additional education regarding this problem is identified when the nursing student suggests which nursing intervention? 1. Encouraging the client's expression of feelings 2. Evaluating the client's understanding of the disease process 3. Encouraging family members to share their feelings about the disease process 4. Evaluating the client's understanding that the body changes need to be dealt with
*4. Evaluating the client's understanding that the body changes need to be dealt with* *rationale* Evaluating the client's understanding that the body changes that occur in this disorder need to be dealt with is an inappropriate nursing intervention. This option does not address the client's feelings. Options 1, 2, and 3 are appropriate because they address the client and family feelings regarding the disorder.
Which clinical manifestation should the nurse expect to note when assessing a client with Addison's disease? 1. Edema 2. Obesity 3. Hirsutism 4. Hypotension
*4. Hypotension* *rationale* Common manifestations of Addison's disease include postural hypotension from fluid loss, syncope, muscle weakness, anorexia, nausea, vomiting, abdominal cramps, weight loss, depression, and irritability. The manifestations in options 1, 2, and 3 are not associated with Addison's disease.
A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is made. The nurse who is assisting to care for the client obtains which of the following immediately in preparation for the treatment of this syndrome? 1. NPH insulin 2. A nasal cannula 3. Intravenous (IV) infusion of sodium bicarbonate 4. IV infusion of normal saline
*4. IV infusion of normal saline* *rationale* The primary goal of treatment is to rehydrate the client to restore fluid volume and to correct electrolyte deficiency. IV fluid replacement is similar to that administered in diabetic ketoacidosis (DKA) and begins with IV infusion of normal saline. Regular insulin, not NPH insulin would be administered. The use of sodium bicarbonate to correct acidosis is avoided because it can precipitate a further drop in serum potassium levels. A nasal cannula for oxygen administration is not necessarily required to treat HHNS.
A client has an endocrine system dysfunction of the pancreas. The nurse anticipates that the client will exhibit impaired secretion of which of the following substances? 1. Amylase 2. Lipase 3. Trypsin 4. Insulin
*4. Insulin* *rationale* The pancreas produces both endocrine and exocrine secretions as part of its normal function. The organ secretes insulin as a key endocrine hormone to regulate the blood glucose level. Other pancreatic endocrine hormones are glucagon and somatostatin. The exocrine pancreas produces digestive enzymes such as amylase, lipase, and trypsin.
A nurse is caring for a client following a thyroidectomy. The client tells the nurse that she is concerned because of voice hoarseness. The client asks the nurse whether the hoarseness will subside. The nurse appropriately tells the client that the hoarseness: 1. Indicates nerve damage 2. Is harmless but permanent 3. Will worsen before it subsides 4. Is normal and will gradually subside
*4. Is normal and will gradually subside* *rationale* Hoarseness that develops in the postoperative period is usually the result of laryngeal pressure or edema and will resolve within a few days. The client should be reassured that the effects are transitory. Options 1, 2, and 3 are incorrect.
Which nursing measure would be effective in preventing complications in a client with Addison's disease? 1. Restricting fluid intake 2. Offering foods high in potassium 3. Checking family support systems 4. Monitoring the blood glucose
*4. Monitoring the blood glucose* *rationale* The decrease in cortisol secretion that characterizes Addison's disease can result in hypoglycemia. Therefore monitoring the blood glucose would detect the presence of hypoglycemia so that it can be treated early to prevent complications. Fluid intake should be encouraged to compensate for dehydration. Potassium intake should be restricted because of hyperkalemia. Option 3 is not a priority for this client.
A client with Graves' disease has exophthalmos and is experiencing photophobia. Which intervention would best assist the client with this problem? 1. Administering methimazole (Tapazole) every 8 hours 2. Lubricating the eyes with tap water every 2 to 4 hours 3. Instructing the client to avoid straining or heavy lifting 4. Obtaining dark glasses for the client
*4. Obtaining dark glasses for the client* *rationale* Because photophobia (light intolerance) accompanies this disorder, dark glasses are helpful in alleviating the symptom. Medical therapy for Graves' disease does not help alleviate the clinical manifestation of exophthalmos. Other interventions may be used to relieve the drying that occurs from not being able to completely close the eyes; however, the question is asking what the nurse can do for photophobia. Tap water, which is hypotonic, could actually cause more swelling to the eye because it could pull fluid into the interstitial space. In addition, the client is at risk for developing an eye infection because the solution is not sterile. There is no need to prevent straining with exophthalmos.
A nurse is caring for a client experiencing thyroid storm. Which of the following would be a priority concern for this client? 1. Inability to cope with the treatment plan 2. Lack of sexual drive 3. Self-consciousness about body appearance 4. Potential for cardiac disturbances
*4. Potential for cardiac disturbances* *rationale* Clients in thyroid storm are experiencing a life-threatening event, which is associated with uncontrolled hyperthyroidism. It is characterized by high fever, severe tachycardia, delirium, dehydration, and extreme irritability. The signs and symptoms of the disorder develop quickly, and therefore emergency measures must be taken to prevent death. These measures include maintaining hemodynamic status and patency of airway as well as providing adequate ventilation. Options 1, 2, and 3 are not a priority in the care of the client in thyroid storm.
A nurse is collecting data regarding a client after a thyroidectomy and notes that the client has developed hoarseness and a weak voice. Which nursing action is appropriate? 1. Check for signs of bleeding. 2. Administer calcium gluconate. 3. Notify the registered nurse immediately. 4. Reassure the client that this is usually a temporary condition.
*4. Reassure the client that this is usually a temporary condition.* *rationale* Weakness and hoarseness of the voice can occur as a result of trauma of the laryngeal nerve. If this develops, the client should be reassured that the problem will subside in a few days. Unnecessary talking should be discouraged. It is not necessary to notify the registered nurse immediately. These signs do not indicate bleeding or the need to administer calcium gluconate.
A nurse is caring for a postoperative adrenalectomy client. Which of the following does the nurse specifically monitor for in this client? 1. Peripheral edema 2. Bilateral exophthalmos 3. Signs and symptoms of hypocalcemia 4. Signs and symptoms of hypovolemia
*4. Signs and symptoms of hypovolemia* *rationale* Following adrenalectomy, the client is at risk for hypovolemia. Aldosterone, secreted by the adrenal cortex, plays a major role in fluid volume balance by retaining sodium and water. A deficiency of adrenocortical hormones does not cause the clinical manifestations noted in options 1, 2, and 3.
When preparing to admit a patient who has been treated for status epilepticus in the emergency department, which equipment should the nurse have available in the room:
-Siderail pads -Oxygen mask -Suction tubing rational: The patient is at risk for further seizures, and oxygen and suctioning may be needed after any seizures to clear the airway and maximize oxygenation. The bed's side rails should be padded to minimize the risk for patient injury during a seizure. Insertion of a nasogastric (NG) tube is not indicated because the airway problem is not caused by vomiting or abdominal distention. Use of tongue blades during a seizure is contraindicated.
When preparing to admit a patient who has been treated for status epilepticus in the emergency department, which equipment should the nurse have available in the room:
-Siderail pads -Oxygen mask -Suction tubing rational: The patient is at risk for further seizures, and oxygen and suctioning may be needed after any seizures to clear the airway and maximize oxygenation. The bed's side rails should be padded to minimize the risk for patient injury during a seizure. Insertion of a nasogastric (NG) tube is not indicated because the airway problem is not caused by vomiting or abdominal distention. Use of tongue blades during a seizure is contraindicated.
Which is the priority assessment in the client experiencing regurgitation? A. Auscultation for crackles B. Inspection of the oral cavity C. Palpation of the cervical lymph nodes D. Culture of the throat for bacterial infection
...ANS: A The client with regurgitation is at risk of aspiration, pneumonia, and bronchitis. The nurse should auscultate the lungs for crackles, an indication of aspiration.
When caring for a patient who experienced a T1 spinal cord transsection 2 days ago, which collaborative and nursing actions will the nurse include in the plan of care:
-Urinary catheter care -Continuous cardiac monitoring -Avoidance of cool room temperature -Administration of H2 receptor blockers rational: The patient is at risk for bradycardia and poikilothermia caused by sympathetic nervous system dysfunction and should have continuous cardiac monitoring and maintenance of a relatively warm room temperature. Gastrointestinal (GI) motility is decreased initially and NG suctioning is indicated. To avoid bladder distention, a urinary retention catheter is used during this acute phase. Stress ulcers are a common complication but can be avoided through the use of the H2 receptor blockers such as famotidine.
A patient with Parkinson's disease is admitted to the hospital for treatment of an acute infection. Which nursing interventions will be included in the plan of care:
-Use an elevated toilet seat -Cut patient's food into small pieces -Place an arm chair at the patient's bedside rational: Since the patient with Parkinson's has difficulty chewing, food should be cut into small pieces. An armchair should be used when the patient is seated so that the patient can use the arms to assist with getting up from the chair. An elevated toilet seat will facilitate getting on and off the toilet. High protein foods will decrease the effectiveness of L-dopa. Parkinson's is a steadily progressive disease without acute exacerbations.
An indication of Chvostek' sign is: Answers: A. Twitching of the lips after tapping the face B. Elevated blood sugar after glucose infusion C. Inability to hold one's arms straight D. Spasms of the hand after blood circulation is cut off
. A Twitching of the lips after tapping the face in the right place is an indication of Chvostek's sign and a sign of hypocalcaemia. Spasms of the hand are associated with Trousseau's sign.
What is a hormone secreted from the posterior lobe of the pituitary gland? Answers: A. LH B. MSH C. ADH D. GnRH
. C ADH is secreted from the posterior pituitary. LH comes from the anterior pituitary, MSH from the intermediate. GnRH is released from the hypothalamus.
A client with Graves' disease experiences a thyroid storm and has tachycardia and hypertension. What medication is most likely to be used? Answers: A. Levofloxcin B. Chlorothiazide C. Percocet D. Propylthiouracil
. D Propylthiouracil is a commonly used medication for treating hyperthyroidism. Levofloxacin is an antibiotic, chlorothiazide is a diuretic, and Percocet a painkiller.
) 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.
...
The nurse is preparing a client for a CT (computed tomography) scanning of the abdomen with contrast. What question should be asked before the examination? A. "Are you allergic to iodine or seafood?" B. "Have you had anything to eat or drink within the past 12 hours?" C. "Have you finished drinking all the required fluid?" D. "Can you tolerate being tilted from side to side during the procedure?"
...ANS: A Allergies to iodine or seafood can mean a cross-allergic reaction to the contrast dye used for CT scans. Clients reporting such allergies are scheduled for CT without contrast to avoid anaphylactic reactions.
In the client with Crohn's disease experiencing severe diarrhea, what should the nurse monitor for as the priority assessment? A. Cardiac dysrhythmias B. Skin irritation C. Anorexia D. Anemia
...ANS: A Although the client with severe diarrhea may experience skin irritation and anemia, the client is most at risk of cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client should have electrolyte levels monitored, and electrolyte replacement may be necessary.
After receiving lactulose the day before, the client reports having seven loose stools in the past 12 hours. Based on this data, what laboratory findings would the nurse expect? A. Hypokalemia B. Hyponatremia C. Hypercalcemia D. Hyperglycemia
...ANS: A Because lactulose can cause the client to have several loose stools daily, the nurse should monitor serum electrolyte levels, particularly the serum potassium level for hypokalemia.
Which of the following clients is most at risk of developing hepatitis B? A. 24-year-old college student who has had several sexual partners B. 54-year-old woman who takes acetaminophen daily for headaches C. 33-year-old business man who travels frequently D. 72-year-old woman who has eaten raw shellfish
...ANS: A Hepatitis B can be spread through sexual contact, needle sharing, needle sticks, blood transfusions, hemodialysis, acupuncture, and the maternal-fetal route.
Which dietary instructions should be included in a teaching plan for the client newly diagnosed with diverticula? A. "You should eat soft foods and smaller meals because they are better tolerated." B. "You have no dietary restrictions; you may eat anything you wish." C. "You should avoid drinking liquids with your meals." D. "You should avoid dairy products."
...ANS: A Soft foods and smaller meals assist in reducing the symptoms of pressure and reflux that accompany diverticula.
What is the nurse's best action for the client who has undergone a laparoscopic cholecystectomy and complains of "free air pain." A. Ambulate the client. B. Instruct the client to breathe deeply and cough. C. Maintain the client on bedrest with his or her legs elevated. D. Insert a rectal tube to facilitate the passage of flatus.
...ANS: A The client who has undergone a laparoscopic cholecystectomy may complain of free air pain because of the retention of carbon dioxide in the abdomen. The nurse assists the client with early ambulation to promote absorption of the carbon dioxide.
A patient with chronic arterial disease has a brachial SBP of 132 mm Hg and an ankle SBP of 102 mm Hg. The ankle-brachial index is ______ and indicates _______ (mild/moderate/severe) arterial disease.
0.77; mild
A client had a transhepatic biliary catheter placed 3 days ago. Which clinical manifestation would indicate that the procedure was successful? A. The client's sclera remains icteric. B. The client's stools are brown in color. C. The client's urine is a dark amber color. D. The client's catheter has blood return on aspiration.
...ANS: B A transhepatic biliary catheter decompresses extrahepatic ducts to promote the flow of bile. When bile flows normally, it reaches the large intestine where bile is converted to urobilinogen, coloring the stools brown.
Which client is most at risk for the development of gallstones? A. 22-year-old woman who is 1 month postpartum B. 65-year-old woman after a liquid protein diet C. 70-year-old man with peptic ulcer disease D. 33-year-old man with type 2 diabetes
...ANS: B Liquid protein diets increase susceptibility to gallstones by releasing cholesterol from tissues, which is then excreted as crystals in the bile.
In a client admitted with cirrhosis of the liver, which serum levels would the nurse expect to be elevated? A. Serum amylase and lipase B. Serum ammonia C. Serum calcium D. Serum CEA
...ANS: B Serum ammonia levels are elevated in conditions that incur hepatocellular injury, such as cirrhosis of the liver. Increased serum amylase and lipase levels are indicators of pancreatitis. CEA levels are useful in assessing the success of cancer therapy or the recurrence of cancer.
The client with esophageal reflux who experiences regurgitation while lying flat is at risk for which complication? A. Erosion B. Bleeding C. Aspiration D. Odynophagia
...ANS: C Regurgitation of stomach contents while the client is recumbent poses a risk of aspiration for the client.
Twenty-four hours after endoscopic retrograde cholangiopancreatography (ERCP), a client develops left upper quadrant abdominal pain and has a temperature of 101° F (38.3° C). What is the nurse's best action? A. Administer acetaminophen for control of fever and pain. B. Document the finding, because it is a normal postprocedure event. C. Notify the health care provider. D. Increase the IV fluid rate.
...ANS: C The client who has undergone an ERCP may develop complications such as perforation or sepsis manifested by fever and abdominal pain. The nurse should report these symptoms to the health care provider immediately.
What is the role of the liver in response to increased energy requirements? A. Storage of fatty acids and triglycerides B. Activation of Kupffer cells C. Storage and release of glycogen D. Removal of ammonia
...ANS: C The liver's role in carbohydrate metabolism involves the storage and release of glycogen as energy requirements change. An increase in energy requirements results in the release of glycogen.
While auscultating the abdomen of a client, the nurse notes increased, loud, gurgling bowel sounds. What would be the nurse's best action? A. Palpate the abdomen. B. Percuss the abdomen. C. Notify the physician. D. Document the finding as the only action.
...ANS: C The presence of increased, loud, gurgling bowel sounds is associated with hypermotility, which can be associated with diarrhea or gastroenteritis. This sound also is heard above a complete intestinal obstruction, and the physician should be notified because the client requires measures to relieve the obstruction, if present.
A client with an exacerbation of ulcerative colitis has been placed on total parenteral nutrition (TPN). The client asks why nutrition is being supplied in this manner and not by mouth. What is the nurse's best response? A. "TPN contains a high percentage of glucose that is more readily absorbed into the bloodstream than into the ulcerated colon." B. "TPN will be given in addition to your meals to help you gain any weight that you may have lost through diarrhea." C. "TPN is considered an elemental formula and, as such, is easier to digest." D. "TPN will be given during this period to allow your bowel to rest."
...ANS: D Bowel rest during severe exacerbations of ulcerative colitis is part of the nonsurgical management of the disease.
What intervention should the nurse suggest to a client to prevent nighttime reflux? A. "Sleep in the right lateral decubitus position." B. "Have a light evening snack before bedtime." C. "Have alcoholic beverages early in the evening." D. "Elevate the head of the bed 8 to 12 inches for sleep."
...ANS: D Elevation of the head of the bed 8 to 12 inches for sleep is helpful in preventing nighttime reflux episodes related to the recumbent position. Wooden blocks or foam wedges can be used to achieve this level of elevation.
After a colonoscopy, a client reports that he is experiencing abdominal fullness and cramping. What is the nurse's best action? A. Insert a rectal tube to assist in passing of flatus. B. Notify the physician immediately because a bowel perforation is suspected. C. Have the client consume only liquids for 4 to 6 hours after the test. D. Explain to the client that this feeling can be expected for several hours after the test.
...ANS: D Feelings of abdominal fullness, cramping, and the passing of flatus are normally expected after a colonoscopy.
During an initial assessment, a client with gastrointestinal problems reports the use of nonsteroidal anti-inflammatory drugs (NSAIDs) three times a day for arthritis pain. What would be the nurse's best response? A. "NSAIDs are not helpful for arthritis pain." B. "NSAIDs should be taken only twice daily." C. "NSAIDs can interfere with the absorption of nutrients." D. "NSAIDs can result in ulcers or bleeding."
...ANS: D Long-term use of NSAIDs for chronic pain can precipitate peptic ulcer formation through the inhibition of prostaglandins.
38. The nurse is inserting an indwelling catheter into a female client. Which interventions should be implemented? Rank in the order of performance. 1. Explain the procedure to the client. 2. Set up the sterile field. 3. Inflate the catheter bulb. 4. Place absorbent pads under the client. 5. Clean the perineum from clean to dirty with Betadine.
1 is first
A client has an exacerbation of multiple sclerosis accompanied by leg spasticity. The physician prescribes dantrolene sodium (Dantrium), 25 mg by mouth daily. How soon after administration can the nurse expect to see a significant reduction in spasticity?
1 to 2 weeks
. The nurse assessing a female client with Cushing's syndrome would expect to note which of the following? a) hirsutism b) hypotension c) hypoglycemia d) pallor
1) A - An increased production of androgens that accompanies a rise in cortisol levels with Cushing's syndrome produces hirsutism and acne in women. Other clinical findings of Cushing's syndrome include hypertension caused by sodium retention, impaired glucose tolerance or diabetes mellitus caused by cortisol's anti-insulin effect and ability to enhance gluconeogenesis, and skin changes including bruising and purplish red striae caused by protein catabolism.
A 58-year-old patient who began experiencing right-sided arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol?
1) Administer oxygen to keep O2 saturation >95% 2) Use National Institute of Health Stroke Scale to assess patient 3) Obtain CT scan without contrast. 4) Infuse tissue plasminogen activator (tPA). rational: The initial actions should be those that help with airway, breathing, and circulation. Baseline neurologic assessments should be done next. A CT scan will be needed to rule out hemorrhagic stroke before tPA can be administered.
In which order will the nurse perform the following actions when caring for a patient with possible C6 spinal cord trauma who is admitted to the emergency department?
1) Immobilize the patient's head, neck, and spine. 2) Administer O2 using a non-rebreather mask. 3) Monitor cardiac rhythm and blood pressure. 4) Infuse normal saline at 150 mL/hr. 5) Transfer the patient to radiology for spinal computed tomography (CT). rational: The first action should be to prevent further injury by stabilizing the patient's spinal cord. Maintenance of oxygenation by administration of 100% O2 is the second priority. Because neurogenic shock is a possible complication, monitoring of heart rhythm and BP are indicated, followed by infusing normal saline for volume replacement. A CT scan to determine the extent and level of injury is needed once initial assessment and stabilization are accomplished.
How should you assist with lumbar puncture?
1) Obtain informed consent 2) Have patient empty bladder 3) Explain that she will be injected with a local anesthetic and she may feel pressure during the procedure. 4) Place patient in lateral recumbent position with knees flexed toward abdomen. Help patient to remain in that position. 5) When procedure is over, change to dorsal recumbent and monitor 6) Encourage fluids to reduce headache. 7) You should also label the tubes removed from the body. Discard 1st and 2nd tubes, 3rd tube goes to lab because it does not have any contamination.
What nursing interventions should be implemented for someone with aphasia?
1) Stand in front of client 2) Speak clearly, slowly. 3) Do not shout or speak loudly. They can hear. 4) Be patient and give client time to respond 5) Use nonverbal communication, e.g. touche, smile 6) Assist client with motor aphasia to practice simple words, 7) Listen carefully 8) Provide simple directions 9) Involve family in practice 10) Show picture cards to help convey a message
68. Which statement indicates the client diagnosed with calcium phosphate renal calculi understands the discharge teaching for ways to prevent future calculi formation? 1. "I should increase my fluid intake, especially in warm weather." 2. "I should eat foods containing cocoa and chocolate." 3. "I will walk about a mile every week and not exercise often." 4. "I should take one (1) vitamin a day with extra calcium."
1. An increased fluid intake ensuring 2 to 3 L of urine a day prevents the stone-forming salts from becoming concentrated enough to precipitate.
List the processes that occur as venous stasis precipitates varicose veins leading to venous stasis ulcers.
1. Venous pressure increases 2. Vein dilate 3. Venous valves become incompetent 4. Venous blood flow reverses 5. Additional venous distention occurs 6. Capillary pressure increases 7. Edema forms 8. Blood supply to local tissues decreases 9. Ulceration occurs
7. The client who is scheduled to have a breast biopsy with sentinel node dissection states, "I don't understand. What does a sentinel node biopsy do?" Which scientific rationale should the nurse use to base the response? 1. A dye is injected into the tumor and traced to determine spread of cells. 2. The surgeon removes the nodes that drain the diseased portion of the breast. 3. The nodes felt manually will be removed and sent to pathology. 4. A visual inspection of the lymph nodes will be made while the client is sleeping.
1. A sentinel node biopsy is a procedure in which a radioactive dye is injected into the tumor and then traced by instrumentation and color to try to identify the exact lymph nodes the tumor could have shed into.
4. The client is diagnosed with ARF. Which signs/symptoms indicate to the nurse the client is in the recovery period? Select all that apply. 1. Increased alertness and no seizure activity. 2. Increase in hemoglobin and hematocrit. 3. Denial of nausea and vomiting. 4. Decreased urine-specific gravity. 5. Increased serum creatinine level.
1,2,3
65. The client diagnosed with renal calculi is scheduled for a 24-hour urine specimen collection. Which interventions should the nurse implement? Select all that apply. 1. Check for the ordered diet and medication modifications. 2. Instruct the client to urinate, and discard this urine when starting collection. 3. Collect all urine during 24 hours and place in appropriate specimen container. 4. Insert an indwelling catheter in client after having the client empty the bladder. 5. Instruct the UAP to notify the nurse when the client urinates.
1,2,3
10. The client is being discharged after a left wedge resection. Which discharge instructions should the nurse include? Select all that apply. 1. Notify the HCP of a temperature of 100˚F. 2. Carry large purses and bundles with the right hand. 3. Do not go to church or anywhere with crowds. 4. Try to keep the arm as still as possible until seen by the HCP. 5. Have a mammogram of the right and left breast yearly.
1,2,5
28. The client diagnosed with cancer of the uterus is scheduled to have radiation brachytherapy. Which precautions should the nurse implement? Select all that apply. 1. Place the client in a private room. 2. Wear a dosimeter when entering the room. 3. Encourage visitors to come and stay with the client. 4. Plan to spend extended time with the client. 5. Notify the nuclear medicine technician.
1,2,5
33. The client is NPO and is receiving total parenteral nutrition (TPN) via a subclavian line. Which precautions should the nurse implement? Select all that apply. 1. Place the solution on an IV pump at the prescribed rate. 2. Monitor blood glucose every six (6) hours. 3. Weigh the client weekly, first thing in the morning. 4. Change the IV tubing every three (3) days. 5. Monitor intake and output every shift.
1,2,5
59. The client returned from surgery after having a TURP and has a P 110, R 24, BP 90/40, and cool and clammy skin. Which interventions should the nurse implement? Select all that apply. 1. Assess the urine in the continuous irrigation drainage bag. 2. Decrease the irrigation fluid in the continuous irrigation catheter. 3. Lower the head of the bed while raising the foot of the bed. 4. Contact the surgeon to give an update on the client's condition. 5. Check the client's postoperative creatinine and BUN.
1,3,4
48. The nurse is caring for a client who is one (1) day postoperative a hysterectomy for cancer of the ovary. Which nursing interventions should the nurse implement? Select all that apply. 1. Assess for calf enlargement and tenderness. 2. Turn, cough, and deep breathe every six (6) hours. 3. Assess pain on a one (1)-to-ten (10) pain scale. 4. Apply sequential compression devices to legs. 5. Assess bowel sounds every four (4) hours.
1,3,4,5
Acromegaly is most frequently diagnosed in: a. Middle-aged adults b. Newborns c. Children ages 2 to 5 d. Adults age 65 and older
1. A: Acromegaly results from benign tumors on the pituitary gland that produce excessive amounts of growth hormone. Although symptoms may present at any age, the diagnosis generally occurs in middle-aged persons. Untreated, the consequences of acromegaly include type 2 diabetes, hypertension and increased risk of cardiovascular disease, arthritis and colon polyps.
30. The telemetry monitor technician notifies the nurse of the morning telemetry readings. Which client should the nurse assess first? 1. The client in normal sinus rhythm with a peaked T wave. 2. The client diagnosed with atrial fibrillation with a rate of 100. 3. The client diagnosed with a myocardial infarction who has occasional PVCs. 4. The client with a first-degree atrioventricular block and a rate of 92.
1. A client with a peaked T wave could be experiencing hyperkalemia. Changes in potassium levels can initiate cardiac dysrhythmias and instability.
81. The client with a continent urinary diversion is being discharged. Which discharge instructions should the nurse include in the teaching? 1. Have the client demonstrate catheterizing the stoma. 2. Instruct the client on how to pouch the stoma. 3. Explain the use of a bedside drainage bag at night. 4. Tell the client to call the HCP if the temperature is 99˚F or less.
1. A continent urinary diversion is a surgical procedure in which a reservoir is created to hold urine until the client can self-catheterize the stoma. The nurse should observe the client's technique before discharge.
44. The nurse is caring for a pregnant client diagnosed with acute pyelonephritis. Which scientific rationale supports the client being hospitalized for this condition? 1. The client must be treated aggressively to prevent maternal/fetal complications. 2. The nurse can force the client to drink fluids and avoid nausea and vomiting. 3. The client will be dehydrated and there won't be sufficient blood flow to the baby. 4. Pregnant clients historically are afraid to take the antibiotics as ordered.
1. A pregnant client diagnosed with a UTI will be admitted for aggressive IV antibiotic therapy. After symptoms subside, the client will be sent home to complete the course of treatment with oral medications.
58. The client asks, "What does an elevated PSA test mean?" On which scientific rationale should the nurse base the response? 1. An elevated PSA can result from several different causes. 2. An elevated PSA can be only from prostate cancer. 3. An elevated PSA can be diagnostic for testicular cancer. 4. An elevated PSA is the only test used to diagnose BPH.
1. An elevated PSA can be from urinary retention, BPH, prostate cancer, or prostate infarct.
1. For a client in hepatic coma, which outcome would be the most appropriate? A. The client is oriented to time, place, and person. B. The client exhibits no ecchymotic areas. C. The client increases oral intake to 2,000 calories/day. D. The client exhibits increased serum albumin level.
1. Answer: A. The client is oriented to time, place, and person. Hepatic coma is the most advanced stage of hepatic encephalopathy. As hepatic coma resolves, improvement in the client's level of consciousness occurs. The client should be able to express orientation to time, place, and person. Ecchymotic areas are related to decreased synthesis of clotting factors. Although oral intake may be related to level of consciousness, it is more closely related to anorexia. The serum albumin level reflects hepatic synthetic ability, not level of consciousness.
2. The nurse is caring for a client diagnosed with ARF. Which laboratory values are most significant for diagnosing ARF? 1. BUN and creatinine. 2. WBC and hemoglobin. 3. Potassium and sodium. 4. Bilirubin and ammonia level.
1. Blood urea nitrogen (BUN) levels reflect the balance between the production and excretion of urea from the kidneys. Creatinine is a by-product of the metabolism of the muscles and is excreted by the kidneys. Creatinine is the ideal substance for determining renal clearance because it is relatively constant in the body and is the laboratory value most significant in diagnosing renal failure.
18. The client diagnosed with CKD has a new arteriovenous fistula in the left forearm. Which intervention should the nurse implement? 1. Teach the client to carry heavy objects with the right arm. 2. Perform all laboratory blood tests on the left arm. 3. Instruct the client to lie on the left arm during the night. 4. Discuss the importance of not performing any hand exercise
1. Carrying heavy objects in the left arm could cause the fistula to clot by putting undue stress on the site, so the client should carry objects with the right arm.
67. The nurse is caring for a client with epididymitis secondary to a chlamydia infection. Which discharge instruction should the nurse discuss? 1. The sexual partner must be prescribed antibiotics. 2. Delay sexual intercourse for a minimum of three (3) months. 3. Expect the urine to have white clumps for one (1) to two (2) months. 4. Drainage from the scrotum is fine as long as there is no fever.
1. Chlamydia is a sexually transmitted disease usually silent in the male partner, but it can cause epididymitis. If both sexual partners are not treated, then the partner can reinfect the client.
53. The client has undergone a bilateral orchiectomy for cancer of the prostate. Which intervention should the nurse implement? 1. Support the scrotal sac with a towel and apply ice. 2. Administer testosterone replacement hormone orally. 3. Encourage the client to place sperm in a sperm bank. 4. Have the client talk to another man with ejaculation dysfunction.
1. Elevating a surgical site and applying ice will reduce edema to the area.
41. The client is reporting chills, fever, and left costovertebral pain. Which diagnostic test should the nurse expect the HCP to prescribe first? 1. A midstream urine for culture. 2. A sonogram of the kidney. 3. An intravenous pyelogram for renal calculi. 4. A CT scan of the kidneys.
1. Fever, chills, and costovertebral pain are symptoms of a urinary tract infection (acute pyelonephritis), which requires a urine culture first to confirm the diagnosis.
10. The client is admitted to the emergency department after a gunshot wound to the abdomen. Which nursing intervention should the nurse implement first to prevent ARF? 1. Administer normal saline IV. 2. Take vital signs. 3. Place client on telemetry. 4. Assess abdominal dressing.
1. Preventing and treating shock with blood and fluid replacement will prevent acute renal failure from hypoperfusion of the kidneys. Significant blood loss is expected in the client with a gunshot wound.
3. The client has undergone a wedge resection for cancer of the left breast. Which discharge instruction should the nurse teach? 1. Don't lift more than five (5) pounds with the left hand until released by the HCP. 2. The cancer has been totally removed and no follow-up therapy will be required. 3. The client should empty the Hemovac drain about every 12 hours. 4. The client should arrange an appointment with a plastic surgeon for reconstruction.
1. The client has had surgery on this side of the body. Pressure on the incision should be limited until the client is released by the HCP to perform normal daily activities.
52. Which intervention should the nurse include when preparing a teaching plan for the client with chronic prostatitis? 1. Sit in a warm sitz bath for 10 to 20 minutes several times daily. 2. Sit in the chair with the feet elevated for two (2) hours daily. 3. Drink at least 3,000 mL of oral fluids, especially tea and coffee, daily. 4. Stop broad-spectrum antibiotics as soon as the symptoms subside.
1. The client should sit in a warm sitz bath for 10 to 20 minutes several times each day to provide comfort and assist with healing.
76. The client diagnosed with cancer of the bladder is undergoing intravesical chemotherapy. Which instruction should the nurse provide the client about the pretherapy routine? 1. Instruct the client to remain NPO after midnight before the procedure. 2. Explain the use of chemotherapy in bladder cancer. 3. Teach the client to administer Neupogen, a biologic response modifier. 4. Have the client take Tylenol, an analgesic, before coming to the clinic.
1. The client will have medication instilled in the bladder which must remain in the bladder for a prescribed length of time. For this reason, the client must remain NPO before the procedure.
21. The client receiving dialysis is complaining of being dizzy and light-headed. Which action should the nurse implement first? 1. Place the client in the Trendelenburg position. 2. Turn off the dialysis machine immediately. 3. Bolus the client with 500 mL of normal saline. 4. Notify the health-care provider as soon as possible.
1. The nurse should place the client's chair with the head lower than the body, which will shunt blood to the brain; this is the Trendelenburg position.
82. Which information regarding the care of a cutaneous ileal conduit should the nurse discuss with the client? 1. Teach the client to instill a few drops of vinegar into the pouch. 2. Tell the client the stoma should be slightly dusky colored. 3. Inform the client large clumps of mucus are expected. 4. Tell the client it is normal for the urine to be pink or red in color.
1. Vinegar will act as a deodorizing agent in the pouch and help prevent a strong urine smell.
What are the signs and symptoms of MYASTHENIA GRAVIS?
1. bobblehead 2. ptosis 3. diplopia 4. slow speech 5. frowning 6. decreased tongue movement 7. drooling 8. pupils slowly react 9. increased frowning 10. decreased chewing
10. A nurse provides dietary instructions to a client with a diagnosis of hyperparathyroidism. Which statement by the client indicates the need for further instructions? a) I need to drink 3000 ml of fluid per day b) I should drink cranberry juice daily c) I should eat foods high in calcium d) I should eat foods high in fiber
10) C - The client with hyperparathyroidism should consume at least 3000 mL of fluid per day. Measures to prevent dehydration are necessary because dehydration increases serum calcium levels and promotes the formation of renal stones. Cranberry juice and prune juice help make the urine more acidic. A high urinary acidity helps prevent renal stone formation because calcium is more soluble in acidic urine than in alkaline urine. Clients should be on a low-calcium, low-vitamin D diet. High-fiber foods are important to prevent constipation and fecal impaction resulting from the hypercalcemia that occurs with this disorder.
10. A 52-year-old man was referred to the clinic due to increased abdominal girth. He is diagnosed with ascites by the presence of a fluid thrill and shifting dullness on percussion. After administering diuretic therapy, which nursing action would be most effective in ensuring safe care? A. Measuring serum potassium for hyperkalemia B. Assessing the client for hypervolemia C. Measuring the client's weight weekly D. Documenting precise intake and output
10. Answer: D. Documenting precise intake and output For the client with ascites receiving diuretic therapy, careful intake and output measurement is essential for safe diuretic therapy. Diuretics lead to fluid losses, which if not monitored closely and documented, could place the client at risk for serious fluid and electrolyte imbalances. Hypokalemia, not hyperkalemia, commonly occurs with diuretic therapy. Because urine output increases, a client should be assessed for hypovolemia, not hypervolemia. Weights are also an accurate indicator of fluid balance. However, for this client, weights should be obtained daily, not weekly.
10. All of the following statements about Hashimoto's disease are true except: a. Many patients are entirely asymptomatic b. Not all patients become hypothyroid c. Most cases of obesity are attributable to Hashimoto's disease d. Hypothyroidism may be subclinical
10. C: Although weight gain may be a symptom of Hashimoto's disease, the majority of obese people have normal thyroid function; rarely is thyroid disorder the sole cause of obesity. Other symptoms of Hashimoto's disease include fatigue, cold intolerance, joint pain, myalgias, constipation, dry hair, skin and nails, impaired fertility, slow heart rate, and depression.
A patient with a head injury opens the eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to remove a painful stimulus. The nurse records the patient's Glasgow Coma Scale score as _______
11 rational: The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor response.
11. Which assessment finding indicates that lactulose is effective in decreasing the ammonia level in the client with hepatic encephalopathy? A. Passage of two or three soft stools daily B. Evidence of watery diarrhea C. Daily deterioration in the client's handwriting D. Appearance of frothy, foul-smelling stools
11. Answer: A. Passage of two or three soft stools daily Lactulose reduces serum ammonia levels by inducing catharsis, subsequently decreasing colonic pH and inhibiting fecal flora from producing ammonia from urea. Ammonia is removed with the stool. Two or three soft stools daily indicate effectiveness of the drug. Watery diarrhea indicates overdose. Daily deterioration in the client's handwriting indicates an increase in the ammonia level and worsening of hepatic encephalopathy. Frothy, foul-smelling stools indicate steatorrhea, caused by impaired fat digestion.
12. Nurse Farrah is providing care for Kristoff who has jaundice. Which statement indicates that the nurse understands the rationale for instituting skin care measures for the client? A. "Jaundice is associated with pressure ulcer formation." B. "Jaundice impairs urea production, which produces pruritus." C. "Jaundice produces pruritus due to impaired bile acid excretion." D. "Jaundice leads to decreased tissue perfusion and subsequent breakdown."
12. Answer: C. "Jaundice produces pruritus due to impaired bile acid excretion." Jaundice is a symptom characterized by increased bilirubin concentration in the blood. Bile acid excretion is impaired, increasing the bile acids in the skin and causing pruritus. Jaundice is not associated with pressure ulcer formation. However, edema and hypoalbuminemia are. Jaundice itself does not impair urea production or lead to decreased tissue perfusion.
13. Which rationale supports explaining the placement of an esophageal tamponade tube in a client who is hemorrhaging? A. Allowing the client to help insert the tube B. Beginning teaching for home care C. Maintaining the client's level of anxiety and alertness D. Obtaining cooperation and reducing fear
13. Answer: D. Obtaining cooperation and reducing fear An esophageal tamponade tube would be inserted in critical situations. Typically, the client is fearful and highly anxious. The nurse therefore explains about the placement to help obtain the client's cooperation and reduce his fear. This type of tube is used only short term and is not indicated for home use. The tube is large and uncomfortable. The client would not be helping to insert the tube. A client's anxiety should be decreased, not maintained, and depending on the degree of hemorrhage, the client may not be alert.
14. For Rico who has chronic pancreatitis, which nursing intervention would be most helpful? A. Allowing liberalized fluid intake B. Counseling to stop alcohol consumption C. Encouraging daily exercise D. Modifying dietary protein
14. Answer: B. Counseling to stop alcohol consumption Chronic pancreatitis typically results from repeated episodes of acute pancreatitis. More than half of chronic pancreatitis cases are associated with alcoholism. Counseling to stop alcohol consumption would be the most helpful for the client. Dietary protein modification is not necessary for chronic pancreatitis. Daily exercise and liberalizing fluid intake would be helpful but not the most beneficial intervention.
15. Mr. Hasakusa is in end-stage liver failure. Which interventions should the nurse implement when addressing hepatic encephalopathy? (Select all that apply.) A. Assessing the client's neurologic status every 2 hours B. Monitoring the client's hemoglobin and hematocrit levels C. Evaluating the client's serum ammonia level D. Monitoring the client's handwriting daily E. Preparing to insert an esophageal tamponade tube F. Making sure the client's fingernails are short
15. Answer: A, C, D Hepatic encephalopathy results from an increased ammonia level due to the liver's inability to covert ammonia to urea, which leads to neurologic dysfunction and possible brain damage. The nurse should monitor the client's neurologic status, serum ammonia level, and handwriting. Monitoring the client's hemoglobin and hematocrit levels and insertion of an esophageal tamponade tube address esophageal bleeding. Keeping fingernails short address jaundice.
The intensive care department nurse is calculating the total intake for a client diagnosed with hypertensive crisis. The client has received 880 mL of D5W, IVPB of 100 mL of 0.9% NS, 8 ounces of water, 4 ounces of milk, and 6 ounces of chicken broth. The client has had a urinary output of 1480 mL. What is the total intake for this client?
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16. A nurse is caring for a client with hyperthyroidism and is instructing the client about dietary measures. The nurse tells the client that it is important to eat foods that are: a) high in bulk and fiber b) low in calories c) low in carbohydrates and fats d) high in calories
16) D - The client with hyperthyroidism is usually extremely hungry because of increased metabolism. The client should be instructed to consume a high-calorie diet with six full meals a day. The client should be instructed to eat foods that are nutritious and contain ample amounts of protein, carbohydrates, fats, and minerals. Clients should be discouraged from eating foods that increase peristalsis and thus result in diarrhea, such as highly seasoned, bulky, and fibrous foods.
16. For a client with hepatic cirrhosis who has altered clotting mechanisms, which intervention would be most important? A. Allowing complete independence of mobility B. Applying pressure to injection sites C. Administering antibiotics as prescribed D. Increasing nutritional intake
16. Answer: B. Applying pressure to injection sites The client with cirrhosis who has altered clotting is at high risk for hemorrhage. Prolonged application of pressure to injection or bleeding sites is important. Complete independence may increase the client's potential for injury, because an unsupervised client may injure himself and bleed excessively. Antibiotics and good nutrition are important to promote liver regeneration. However, they are not most important for a client at high risk for hemorrhage.
17. A client with advanced cirrhosis has been diagnosed with hepatic encephalopathy. The nurse expects to assess for: A. Malaise B. Stomatitis C. Hand tremors D. Weight loss
17. Answer: C. Hand tremors Hepatic encephalopathy results from the accumulation of neurotoxins in the blood, therefore the nurse wants to assess for signs of neurological involvement. Flapping of the hands (asterixis), changes in mentation, agitation, and confusion are common. These clients typically have ascites and edema so experience weight gain. Malaise and stomatitis are not related to neurological involvement.
17. Untreated hyperthyroidism during pregnancy may result in all of the following except: a. Premature birth and miscarriage b. Low birthweight c. Autism d. Preeclampsia
17. C: In addition to the above-mentioned complications of uncontrolled hyperthyroidism in pregnancy, expectant mothers may suffer congestive heart failure and thyroid storm, which is life-threatening thyrotoxicosis with symptoms that include agitation, confusion, tachycardia, shaking, sweating, diarrhea, fever, and restlessness.
18. A client diagnosed with chronic cirrhosis who has ascites and pitting peripheral edema also has hepatic encephalopathy. Which of the following nursing interventions are appropriate to prevent skin breakdown? (Select all that apply.) A. Range of motion every 4 hours B. Turn and reposition every 2 hours C. Abdominal and foot massages every 2 hours D. Alternating air pressure mattress E. Sit in chair for 30 minutes each shift
18. Answer: B, D Edematous tissue must receive meticulous care to prevent tissue breakdown. Range of motion exercises preserve joint function but do not prevent skin breakdown. Abdominal or foot massage will not prevent skin breakdown but must be cleansed carefully to prevent breaks in skin integrity. The feet should be kept at the level of heart or higher so Fowler's position should be employed. An air pressure mattress, careful repositioning can prevent skin breakdown.
19. Which of the following will the nurse include in the care plan for a client hospitalized with viral hepatitis? A. Increase fluid intake to 3000 ml per day B. Adequate bed rest C. Bland diet D. Administer antibiotics as ordered
19. Answer: B. Adequate bed rest Treatment of hepatitis consists of bed rest during the acute phase to reduce metabolic demands on the liver, thus increasing blood supply and cell regeneration. Forcing fluids, antibiotics, and bland diets are not part of the treatment plan for viral hepatitis.
19. Endocrine disorders may be triggered by all of the following except: a. Stress b. Infection c. Chemicals in the food chain and environment d. Cell phone use
19. D: Endocrine function may be influenced by myriad factors. In addition to the above-mentioned, there is evidence that exposure to naturally occurring and man-made endocrine disruptors such as tributyltin, certain bioaccumulating chlorinated compounds, and phytoestrogens is widespread and in susceptible individuals, may trigger endocrine disorders.
27. The nurse is admitting a client diagnosed with Stage Ia cancer of the cervix to an outpatient surgery center for a conization. Which data would the client most likely report? 1. Diffuse watery discharge. 2. No symptoms. 3. Dyspareunia. 4. Intense itching.
2. At this stage the client is asymptomatic and the cancer has been determined by a Pap smear.
2. A nurse is admitting a client with a diagnosis of Addison's disease to the hospital. On assessment, the nurse would expect to note which finding that is a manifestation of this disorder? a) peripheral edema b) excessive facial hair c) lower than normal blood glucose level d) high blood pressure
2) C - Blood glucose levels are low in Addison's disease as a result of decreased secretion of glucocorticoids (cortisol). Edema is absent, and aldosterone secretion is decreased so the client develops a deficient fluid volume. Facial hair increases with adrenocortical hyperfunction. Clients with Addison's disease develop hypotension as a result of deficient fluid volume. Options A, B and D are unrelated to Addison's disease.
64. Which client has the highest risk for developing cancer of the testicles? 1. The client diagnosed with epididymitis. 2. The client born with cryptorchidism. 3. The client with an enlarged prostate. 4. The client diagnosed with hypospadias.
2. Cryptorchidism is the medical term for undescended testicle. The testicles may be in the abdomen or inguinal canal at birth. This condition places the client at higher risk for testicular cancer.
8. The client diagnosed with ARF is placed on bedrest. The client asks the nurse, "Why do I have to stay in bed? I don't feel bad." Which scientific rationale supports the nurse's response? 1. Bedrest helps increase the blood return to the renal circulation. 2. Bedrest reduces the metabolic rate during the acute stage. 3. Bedrest decreases the workload of the left side of the heart. 4. Bedrest aids in reduction of peripheral and sacral edema.
2. Bedrest reduces exertion and the metabolic rate, thereby reducing catabolism and subsequent release of potassium and accumulation of endogenous waste products (urea and creatinine).
60. The nurse is caring for a client with a TURP. Which expected outcome indicates the client's condition is improving? 1. The client is using the maximum amount allowed by the PCA pump. 2. The client's bladder spasms are relieved by medication. 3. The client's scrotum is swollen and tender with movement. 4. The client has passed a large, hard, brown stool this morning.
2. Bladder spasms are common, but being relieved with medication indicates the condition is improving.
8. The client who is four (4) months pregnant finds a lump in her breast and the biopsy is positive for Stage II cancer of the breast. Which treatment should the nurse anticipate the HCP recommending to the client? 1. A lumpectomy to be performed after the baby is born. 2. A modified radical mastectomy. 3. Radiation therapy to the chest wall only. 4. Chemotherapy only until the baby is born.
2. A modified radical mastectomy is recommended for this client because the client is not able to begin radiation or chemotherapy, which are part of the regimen for a lumpectomy or wedge resection. Many breast cancers developed during pregnancy are hormone sensitive and have the ideal grounds for growth. The tumor should be removed as soon as possible.
45. The female client has a mother who died from ovarian cancer and a sister diagnosed with ovarian cancer. Which recommendations should the nurse make regarding early detection of ovarian cancer? 1. The client should consider having a prophylactic bilateral oophorectomy. 2. The client should have a transvaginal ultrasound and a CA-125 laboratory test every six (6) months. 3. The client should have yearly magnetic resonance imaging (MRI) scans. 4. The client should have a biannual gynecological examination with flexible sigmoidoscopy.
2. A transvaginal ultrasound is a sonogram in which the sonogram probe is inserted into the vagina and sound waves are directed toward the ovaries. The CA-125 tumor marker is elevated in several cancers. It is nonspecific but, coupled with the sonogram, can provide information about ovarian cancer for early diagnosis.
75. The client diagnosed with cancer of the bladder is scheduled to have a cutaneous urinary diversion procedure. Which preoperative teaching intervention specific to the procedure should be included? 1. Demonstrate turn, cough, and deep breathing. 2. Explain a bag will drain the urine from now on. 3. Instruct the client on the use of a PCA pump. 4. Take the client to the ICU so the client can become familiar with it.
2. A urinary diversion procedure involves the removal of the bladder. In a cutaneous procedure, the ureters are implanted in some way to allow for stoma formation on the abdominal wall, and the urine drains into a pouch. There are numerous methods used for creating the stoma.
2. Jordin is a client with jaundice who is experiencing pruritus. Which nursing intervention would be included in the care plan for the client? A. Administering vitamin K subcutaneously B. Applying pressure when giving I.M. injections C. Decreasing the client's dietary protein intake D. Keeping the client's fingernails short and smooth
2. Answer: D. Keeping the client's fingernails short and smooth The client with pruritus experiences itching, which may lead to skin breakdown and possibly infection from scratching. Keeping his fingernails short and smooth helps prevent skin breakdown and infection from scratching. Applying pressure when giving I.M. injections and administering vitamin K subcutaneously are important if the client develops bleeding problems. Decreasing the client's dietary intake is appropriate if the client's ammonia levels are increased.
39. The female client presents to the gynecologist's office for the fifth time with an ovarian cyst and is scheduled for an exploratory laparoscopy. The client asks the nurse, "Why do I need to have another surgery? The other cysts have all been benign." Which statement is the nurse's best response? 1. "Because eventually the cysts will become cancerous." 2. "All abnormal findings in the ovary should be checked out." 3. "The surgery will not be painful and you will have peace of mind." 4. "Are you afraid of having surgery? Would you like to talk about it?"
2. Any abnormal ovary which cannot be diagnosed with a transvaginal ultrasound should be examined laparoscopically.
62. The client diagnosed with renal calculi is admitted to the medical unit. Which intervention should the nurse implement first? 1. Monitor the client's urinary output. 2. Assess the client's pain and rule out complications. 3. Increase the client's oral fluid intake. 4. Use a safety gait belt when ambulating the client.
2. Assessment is the first part of the nursing process and is priority. The renal colic pain can be so intense it can cause a vasovagal response, with resulting hypotension and syncope.
55. The client is one (1) day postoperative TURP. Which task should the nurse delegate to the UAP? 1. Increase the irrigation fluid to clear clots from the tubing. 2. Elevate the scrotum on a towel roll for support. 3. Change the dressing on the first postoperative day. 4. Teach the client how to care for the continuous irrigation catheter.
2. Elevating the scrotum on a towel for support is a task which can be delegated to the UAP.
42. The nurse is caring for a client with chronic pyelonephritis. Which assessment data support the diagnosis of chronic pyelonephritis? 1. The client has fever, chills, flank pain, and dysuria. 2. The client complains of fatigue, headaches, and increased urination. 3. The client had a group B beta-hemolytic strep infection last week. 4. The client has an acute viral pneumonia infection.
2. Fatigue, headache, and polyuria as well as loss of weight, anorexia, and excessive thirst are symptoms of chronic pyelonephritis.
28. The nurse writes the client problem of "fluid volume excess" (FVE). Which intervention should be included in the plan of care? 1. Change the IV fluid from 0.9% NS to D5W. 2. Restrict the sodium in the client's diet. 3. Monitor blood glucose levels. 4. Prepare the client for hemodialysis.
2. Fluid volume excess refers to an isotonic expansion of the extracellular fluid by an abnormal expansion of water and sodium. Therefore, sodium is restricted to allow the body to excrete the extra volume.
3. The nurse is caring for a client diagnosed with rule-out ARF. Which condition predisposes the client to developing prerenal failure? 1. Diabetes mellitus. 2. Hypotension. 3. Aminoglycosides. 4. Benign prostatic hypertrophy.
2. Hypotension, which causes a decreased blood supply to the kidney, is one of the most common causes of prerenal failure (before the kidney).
50. The nurse observes red urine and several large clots in the tubing of the normal saline continuous irrigation catheter for the client who is one (1) day postoperative TURP. Which intervention should the nurse implement? 1. Remove the indwelling catheter. 2. Titrate the NS irrigation to run faster. 3. Administer protamine sulfate IVP. 4. Administer vitamin K slowly.
2. Increasing the irrigation fluid will flush out the clots and blood.
20. The nurse is discussing kidney transplants with clients at a dialysis center. Which population is less likely to participate in organ donation? 1. Caucasian. 2. African American. 3. Asian. 4. Hispanic.
2. Many in the African American culture believe the body must be kept intact after death, and organ donation is rare among African Americans. This is also why a client of African American descent will be on a transplant waiting list longer than people of other races. This is because of tissue-typing compatibility. Remember, this does not apply to all African-Americans; every client is an individual.
33. The client is diagnosed with benign uterine fibroid tumors. Which question should the nurse ask to determine if the client is experiencing a complication? 1. "How many periods have you missed?" 2. "Do you get short of breath easily?" 3. "How many times have you been pregnant?" 4. "Where is the location of the pain you are having?"
2. Many women delay surgery until anemia has occurred from the heavy menstrual flow. A symptom of anemia is shortness of breath.
41. The 50-year-old female client complains of bloating and indigestion and tells the nurse she has gained two (2) inches in her waist recently. Which question should the nurse ask the client? 1. "What do you eat before you feel bloated?" 2. "Have you had your ovaries removed?" 3. "Are your stools darker in color lately?" 4. "Is the indigestion worse when you lie down?"
2. Ovarian cancer has vague symptoms of abdominal discomfort, but increasing abdominal girth is the most common symptom. If the client has had the ovaries removed, then the nurse could assess for another cause.
69. Which intervention is most important for the nurse to implement for the client diagnosed with rule-out renal calculi? 1. Assess the client's neurological status every two (2) hours. 2. Strain all urine and send any sediment to the laboratory. 3. Monitor the client's creatinine and BUN levels. 4. Take a 24-hour dietary recall during the client interview.
2. Passing a renal stone may negate the need for the client to have lithotripsy or a surgical procedure. Therefore, all urine must be strained, and a stone, if found, should be sent to the laboratory to determine what caused the stone.
79. The male client diagnosed with metastatic cancer of the bladder is emaciated and refuses to eat. Which nursing action is an example of the ethical principle of paternalism? 1. The nurse allows the client to talk about not wanting to eat. 2. The nurse tells the client if he does not eat, a feeding tube will be placed. 3. The nurse consults the dietitian about the client's nutritional needs. 4. The nurse asks the family to bring favorite foods for the client to eat.
2. Paternalism is deciding for the client what is best, similar to a parent making decisions for a child. Feeding a client, as with a feeding tube, without the client wishing to eat is paternalism.
30. The client has had a total abdominal hysterectomy for cancer of the uterus. Which discharge instruction should the nurse teach? 1. The client should take HRT every day to prevent bone loss. 2. The client should practice pelvic rest until seen by the HCP. 3. The client can drive a car as soon as she is discharged from the hospital. 4. The client should expect some bleeding after this procedure.
2. Pelvic rest means nothing is placed in the vagina. The client does not need a tampon at this time, but sexual intercourse should be avoided until the vaginal area has healed.
19. The male client diagnosed with CKD secondary to diabetes has been receiving dialysis for 12 years. The client is notified he will not be placed on the kidney transplant list. The client tells the nurse he will not be back for any more dialysis treatments. Which response by the nurse is most therapeutic? 1. "You cannot just quit your dialysis. This is not an option." 2. "Your angry at not being on the list, and you want to quit dialysis?" 3. "I will call your nephrologist right now so you can talk to the HCP." 4. "Make your funeral arrangements because you are going to die."
2. Reflecting the client's feelings and restating them are therapeutic responses the nurse should use when addressing the client's issues.
48. The clinic nurse is caring for a client diagnosed with chronic pyelonephritis who is prescribed trimethoprim-sulfamethoxazole (Bactrim), a sulfa antibiotic, twice a day for 90 days. Which statement is the scientific rationale for prescribing this medication? 1. The antibiotic will treat the bladder spasms that accompany a urinary tract infection. 2. If the urine cannot be made bacteria free, the Bactrim will suppress bacterial growth. 3. In three (3) months, the client should be rid of all bacteria in the urinary tract. 4. The HCP is providing the client with enough medication to treat future infections.
2. Some clients develop a chronic infection and must receive antibiotic therapy as a routine daily medication to suppress the bacterial growth. The prescription will be refilled after the 90 days and continued.
69. The 30-year-old male client diagnosed with germinal cell carcinoma of the testes asks the nurse, "What chance do I have? Should I end it all now?" Which response by the nurse indicates an understanding of the disease process? 1. "God does not want you to give up hope and end it all now." 2. "There is a good chance for survival with standard treatment options." 3. "There may be little hope, but ending it all is not the answer." 4. "You have a 50/50 chance of living for at least 5 years."
2. Testicular cancers have very good prognoses, and even if the tumor returns, there is a good prognosis for extended survival.
5. The client had a mastectomy for cancer of the breast and asks the nurse about a TRAM flap procedure. Which information should the nurse explain to the client? 1. The surgeon will insert a saline-filled sac under the skin to simulate a breast. 2. The surgeon will pull the client's own tissue under the skin to create a breast. 3. The surgeon will use tissue from inside the mouth to make a nipple. 4. The surgeon can make the breast any size the client wants the breast to be.
2. The TRAM flap procedure is one in which the client's own tissue is used to form the new breast. Abdominal tissue and fat are pulled under the skin with one end left attached to the site of origin to provide circulation until the body builds collateral circulation in the area.
34. The client has received IV solutions for three (3) days through a 20-gauge IV catheter placed in the left cephalic vein. On morning rounds, the nurse notes the IV site is tender to palpation and a red streak has formed. Which intervention should the nurse implement first? 1. Start a new IV in the right hand. 2. Discontinue the intravenous line. 3. Complete an incident record. 4. Place a warm washrag over the site.
2. The client has signs of phlebitis and the IV must be removed to prevent further complications.
54. The client diagnosed with cancer of the prostate has been placed on luteinizing hormone-releasing hormone (LHRH) agonist therapy. Which statement indicates the client understands the treatment? 1. "I will be able to function sexually as always." 2. "I may have hot flashes while taking this drug." 3. "This medication will cure the prostate cancer." 4. "There are no side effects with this medication."
2. The client may have hot flashes because these drugs increase hypothalamic activity, which stimulates the thermoregulatory centers of the body.
61. The school nurse is preparing a class on testicular cancer for male high school seniors. Which information regarding testicular self-examination should the nurse include? 1. Perform the examination in a cool room under a fan. 2. Any lump should be examined by an HCP as soon as possible. 3. Discuss having a second person confirm a negative result. 4. The procedure will cause mild discomfort if done correctly.
2. The client may note a cordlike structure; this is the spermatic cord and is normal. Any lump or mass felt is abnormal and should be checked by an HCP as soon as possible.
2. The client is diagnosed with breast cancer and is considering whether to have a lumpectomy or a more invasive procedure, a modified radical mastectomy. Which information should the nurse discuss with the client? 1. Ask if the client is afraid of having general anesthesia. 2. Determine how the client feels about radiation and chemotherapy. 3. Tell the client she will need reconstruction with either procedure. 4. Find out if the client has any history of breast cancer in her family.
2. The client should understand the treatment regimen for follow-up care. A lumpectomy requires follow-up with radiation therapy to the breast and then systemic chemotherapy. If the cancer is in its early stages, this regimen has results equal to those with a modified radical mastectomy.
59. The client diagnosed with cancer of the prostate tells the nurse, "I caused this by being promiscuous when I was young and now I have to pay for my sins." Which statement is the nurse's most therapeutic response? 1. "Why would you think prostate cancer is caused by sex?" 2. "You feel guilty about some of your actions when you were young?" 3. "Well, there is nothing you can do about that behavior now." 4. "Have you told the HCP and been checked for an AIDS infection?"
2. The question asks for a therapeutic response from the nurse. This response is restating and clarifying.
64. Which clinical manifestations should the nurse expect to assess for the client diagnosed with a ureteral renal stone? 1. Dull, aching flank pain and microscopic hematuria. 2. Nausea; vomiting; pallor; and cool, clammy skin. 3. Gross hematuria and dull suprapubic pain with voiding. 4. The client will be asymptomatic.
2. The severe flank pain associated with a stone in the ureter often causes a sympathetic response with associated nausea; vomiting; pallor; and cool, clammy skin.
36. The nurse is caring for a client diagnosed with uterine cancer who has been receiving systemic therapy for six (6) months. Which intervention should the nurse implement first? 1. Determine which antineoplastic medication the client has received. 2. Ask the client if she has had any problems with mouth ulcers at home. 3. Administer the biologic response modifier filgrastim (Neupogen). 4. Encourage the client to discuss feelings about having cancer.
2. The systemic side effects of chemotherapy are not always apparent, and the development of stomatitis can be extremely distressing for the client. The nurse should assess the client's tolerance to treatments.
31. The client who is post-thyroidectomy complains of numbness and tingling around the mouth and the tips of the fingers. Which intervention should the nurse implement first? 1. Notify the health-care provider immediately. 2. Tap the cheek about two (2) cm anterior to the earlobe. 3. Check the serum calcium and magnesium levels. 4. Prepare to administer calcium gluconate IVP.
2. These are signs and symptoms of hypocalcemia, and the nurse can confirm this by tapping the cheek to elicit the Chvostek's sign. If the muscles of the cheek begin to twitch, then the HCP should be notified immediately because hypocalcemia is a medical emergency.
11. The UAP tells the nurse the client with ARF has a white crystal-like layer on top of the skin. Which intervention should the nurse implement? 1. Have the assistant apply a moisture barrier cream to the skin. 2. Instruct the UAP to bathe the client in cool water. 3. Tell the UAP not to turn the client in this condition. 4. Explain this is normal and do not do anything for the client.
2. These crystals are uremic frost resulting from irritating toxins deposited in the client's tissues. Bathing in cool water will remove the crystals, promote client comfort, and decrease the itching resulting from uremic frost.
14. The nurse in the dialysis center is initiating the morning dialysis run. Which client should the nurse assess first? 1. The client who has hemoglobin of 9.8 g/dL and hematocrit of 30%. 2. The client who does not have a palpable thrill or auscultated bruit. 3. The client who is complaining of being exhausted and is sleeping. 4. The client who did not take antihypertensive medication this morning.
2. This client's dialysis access is compromised and he or she should be assessed first.
31. The client diagnosed with uterine cancer is complaining of lower back pain and unilateral leg edema. Which statement best explains the scientific rationale for these signs/symptoms? 1. This is expected pain for this type of cancer. 2. This means the cancer has spread to other areas of the pelvis. 3. The pain is a result of the treatment of uterine cancer. 4. Radiation treatment always causes some type of pain in the region.
2. This pain indicates the cancer is in the retroperitoneal region and the prognosis is poor.
20. A husband of a client with graves' disease expresses concern regarding his wife's health because during the past 3 months she has been experiencing nervousness, inability to concentrate even on trivial tasks, and outbursts of temper. On the basis of this information, which nursing diagnosis would the nurse identify as appropriate for the client? a) ineffective coping b) disturbed sensory perception c) social isolation d) grieving
20) A - Frequently, family and friends may report that the client with Graves' disease has become more irritable or depressed. The signs and symptoms in the question are supporting data for the nursing diagnosis of Ineffective coping and are not related to options B, C, and D. The question does not provide data to support options B, C, and D.
20. Spironolactone (Aldactone) is prescribed for a client with chronic cirrhosis and ascites. The nurse should monitor the client for which of the following medication-related side effects? A. Jaundice B. Hyperkalemia C. Tachycardia D. Constipation
20. Answer: B. Hyperkalemia This is a potassium-sparing diuretic so clients should be monitored closely for hyperkalemia. Diarrhea, dizziness, and headaches are other more common side effects. Tachycardia, jaundice, and constipation are not expected side effects of spironolactone (Aldactone).
21. A nurse is caring for a client with hypoparathyroidism. In planning for discharge from the hospital, the nurse identifies which of the following as a potential psychosocial nursing diagnosis? a) impaired comfort related to cold intolerance secondary to decreased metabolic rate b) constipation related to decreased peristaltic action secondary to decreased metabolic rate c) high risk for impaired skin integrity related to edema d) anxiety related to the need for lifelong dietary interventions to control the disease
21) D - Medical management of hypoparathyroidism is aimed at correcting the hypocalcemia. This is accomplished with prescribed medications as well as lifelong compliance to dietary guidelines, which include consumption of foods high in calcium but low in phosphorus. Knowing that the interventions are lifelong can create some anxiety for the client, and this problem needs to be addressed before hospital discharge. The other options are unrelated to this condition and to a psychosocial concern.
What nursing responsibilities are done to obtain a clean-catch urine specimen from a patient (select all that apply)? a. Use sterile container. b. Must start the test with full bladder. c. Insert catheter immediately after voiding. d. Have the patient void, stop, and void in container. e. Have the patient clean the meatus before voiding.
26. a, d, e. A clean-catch urine specimen is obtained in a sterile container after cleaning the meatus. The patient will void a small amount in the toilet, stop, and then void in the container to catch the urine midstream. The first morning specimen is best for a urinalysis. A full bladder is necessary for a urine flow study. A urinary catheter is inserted immediately after voiding to assess residual urine.
27. A nurse provides instructions to a client who is scheduled for a radioactive iodine uptake test. Which statement by the client indicates a need for further instructions? a) the test measures the rate of iodine uptake by my thyroid gland b) I will need to drink a small dose of radioactive iodine before the test c) a 24 hour urine specimen will need to be collected to measure iodine excretion d) I need to minimize close contact with others in my family for a period of 48 hours after the test because of the radioactivity in my system
27) D - The client undergoing a radioactive iodine uptake test needs to be reassured that the amount of radioactive iodine used is very small, that it is not harmful to the client, and that the client will not be radioactive. The other options are correct regarding this diagnostic test.
29. A nurse is caring for a client with Cushing's syndrome who demonstrates withdrawn behavior. The nurse recognizes that this client's behavior is likely related to which nursing diagnosis? a) deficient diversional activity b) powerlessness c) hopelessness d) disturbed body image
29) D - Physical changes in the client's appearance can occur with Cushing's syndrome. Such changes include hirsutism, moon face, buffalo hump, acne, and striae. These changes cause a body image disturbance. Options A, B, and C are not commonly associated with Cushing's syndrome.
47. The elderly client is diagnosed with chronic glomerulonephritis. Which laboratory value indicates to the nurse the condition has become worse? 1. The blood urea nitrogen is 15 mg/dL. 2. The creatinine level is 1.2 mg/dL. 3. The glomerular filtration rate is 40 mL/min. 4. The 24-hour creatinine clearance is 100 mL/min.
3. Glomerular filtration rate (GFR) is approximately 120 mL/min. If the GFR is decreased to 40 mL/min, the kidneys are functioning at about one-third filtration capacity
3. Marie, a 51-year-old woman, is diagnosed with cholecystitis. Which diet, when selected by the client, indicates that the nurse's teaching has been successful? A. 4-6 small meals of low-carbohydrate foods daily B. High-fat, high-carbohydrate meals C. Low-fat, high-carbohydrate meals D. High-fat, low protein meals
3. Answer: C. Low-fat, high-carbohydrate meals For the client with cholecystitis, fat intake should be reduced. The calories from fat should be substituted with carbohydrates. Reducing carbohydrate intake would be contraindicated. Any diet high in fat may lead to another attack of cholecystitis.
3. A nurse is preparing to perform an assessment on a client being admitted to the hospital with a diagnosis of Cushing's syndrome. When performing the assessment, the nurse checks for which significant manifestation of the disorder? a) fluid retention b) stretch marks c) goiter d) melanosis
3) A - Excessive secretion of adrenocortical hormones results in water and sodium reabsorption, causing fluid retention. Stretch marks (striae) are a common feature and can result in a disturbed body image, but are not significant and do not represent a life-threatening situation. Goiter is not a manifestation of Cushing's syndrome. Melanosis is a common manifestation associated with Addison's disease.
72. The client is diagnosed with a uric acid stone. Which foods should the client eliminate from the diet to help prevent reoccurrence? 1. Beer and colas. 2. Asparagus and cabbage. 3. Venison and sardines. 4. Cheese and eggs.
3. Venison, sardines, goose, organ meats, and herring are high-purine foods, which should be eliminated from the diet to help prevent uric acid stones.
46. The nurse is preparing a plan of care for the client diagnosed with acute glomerulonephritis. Which statement is an appropriate long-term goal? 1. The client will have a blood pressure within normal limits. 2. The client will show no protein in the urine. 3. The client will maintain normal renal function. 4. The client will have clear lung sounds.
3. A long-term complication of glomerulonephritis is it can become chronic if unresponsive to treatment, and this can lead to end-stage renal disease. Maintaining renal function is an appropriate long-term goal.
70. The client with a history of renal calculi calls the clinic and reports having burning on urination, chills, and an elevated temperature. Which instruction should the nurse discuss with the client? 1. Increase water intake for the next 24 hours. 2. Take two (2) Tylenol to help decrease the temperature. 3. Come to the clinic and provide a urinalysis specimen. 4. Use a sterile 4 × 4 gauze to strain the client's urine.
3. A urinalysis can assess for hematuria, the presence of white blood cells, crystal fragments, or all three, which can determine if the client has a urinary tract infection or possibly a renal stone, with accompanying signs/symptoms of UTI.
15. The male client diagnosed with CKD has received the initial dose of erythropoietin, a biologic response modifier, 1 week ago. Which complaint by the client indicates the need to notify the health-care provider? 1. The client complains of flu-like symptoms. 2. The client complains of being tired all the time. 3. The client reports an elevation in his blood pressure. 4. The client reports discomfort in his legs and back.
3. After the initial administration of erythropoietin, a client's antihypertensive medications may need to be adjusted. Therefore, this complaint requires notification of the HCP. Erythropoietin therapy is contraindicated in clients with uncontrolled hypertension.
55. The client is diagnosed with metastatic prostate cancer to the bones. Which nursing intervention should the nurse implement? 1. Prepare for a transurethral resection of the prostate. 2. Keep the foot of the bed elevated at all times. 3. Place the client on a scheduled bowel regimen. 4. Discuss the client's altered sexual functioning.
3. Bone metastasis is very painful, and the client should be placed on a scheduled regimen of pain medication. Pain medication slows peristalsis and causes constipation. The client should be placed on a routine bowel management program to prevent impactions.
7. The client diagnosed with ARF is admitted to the intensive care unit and placed on a therapeutic diet. Which diet is most appropriate for the client? 1. A high-potassium and low-calcium diet. 2. A low-fat and low-cholesterol diet. 3. A high-carbohydrate and restricted-protein diet. 4. A regular diet with six (6) small feedings a day.
3. Carbohydrates are increased to provide for the client's caloric intake and protein is restricted to minimize protein breakdown and to prevent accumulation of toxic waste products.
74. Which modifiable risk factor should the nurse identify for the development of cancer of the bladder in a client? 1. Previous exposure to chemicals. 2. Pelvic radiation therapy. 3. Cigarette smoking. 4. Parasitic infections of the bladder.
3. Cigarette smoke contains more than 400 chemicals, 17 of which are known to cause cancer. The risk is directly proportional to the amount of smoking.
68. The nurse is assessing a client with rule-out testicular cancer. Which assessment data support the client having testicular cancer? 1. The client complains of pain when urinating. 2. There is a chancre sore on the shaft of the penis. 3. The client complains of heaviness in the scrotum. 4. There is a red, raised rash on the testes.
3. Classic signs of cancer of the testes are a mass on the testicle, painless enlargement of the testes, and heaviness of the scrotum or lower abdomen.
36. The client has been vomiting and has had numerous episodes of diarrhea. Which laboratory test should the nurse monitor? 1. Serum calcium. 2. Serum phosphorus. 3. Serum potassium. 4. Serum sodium.
3. Clients lose potassium from the GI tract or through the use of diuretic medications. Potassium imbalances can lead to cardiac arrhythmias.
26. The client who has undergone an exploratory laparotomy and subsequent removal of a large intestinal tumor has a nasogastric tube (NGT) in place and an IV running at 150 mL/hr via an IV pump. Which data should be reported to the HCP? 1. The pump keeps sounding an alarm indicating the high pressure has been reached. 2. Intake is 1,800 mL, NGT output is 550 mL, and Foley output is 950 mL. 3. On auscultation, crackles and rhonchi in all lung fields are noted. 4. Client has negative pedal edema and an increasing level of consciousness.
3. Crackles and rhonchi in all lung fields indicate the body is not able to process the amount of fluid being infused. This should be brought to the HCP's attention.
51. The 80-year-old male client has been diagnosed with cancer of the prostate. Which treatment should the nurse discuss with the client? 1. Radiation therapy every day for four (4) weeks. 2. Radical prostatectomy with lymph node dissection. 3. Diethylstilbestrol (DES), an estrogen, daily. 4. Penile implants to maintain sexual functioning.
3. DES is a hormone preparation that suppresses the male hormones and slows the growth of the tumor. Some men with a life expectancy of less than 10 years choose not to treat the cancer at all and will usually die from causes other than prostate cancer.
25. The client is admitted to a nursing unit from a long-term care facility with a hematocrit of 56% and a serum sodium level of 152 mEq/L. Which condition is a cause for these findings? 1. Overhydration. 2. Anemia. 3. Dehydration. 4. Renal failure.
3. Dehydration results in concentrated serum, causing laboratory values to increase because the blood has normal constituents but not enough volume to dilute the values to within normal range or possibly lower.
61. The laboratory data reveal a calcium phosphate renal stone for a client diagnosed with renal calculi. Which discharge teaching intervention should the nurse implement? 1. Encourage the client to eat a low-purine diet and limit foods such as organ meats. 2. Explain the importance of not drinking water two (2) hours before bedtime. 3. Discuss the importance of limiting vitamin D-enriched foods. 4. Prepare the client for extracorporeal shock wave lithotripsy (ESWL).
3. Dietary changes for preventing renal stones include reducing the intake of the primary substance forming the calculi. In this case, limiting vitamin D will inhibit the absorption of calcium from the gastrointestinal tract.
35. The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a gynecology surgery floor. Which intervention cannot be delegated to the UAP? 1. Empty the indwelling catheter on the three (3)-hour postoperative client. 2. Assist the client who is two (2) days post-hysterectomy to the bathroom. 3. Monitor the peri-pad count on a client diagnosed with fibroid tumors. 4. Encourage the client who is refusing to get out of bed to walk in the hall.
3. Monitoring a peri-pad count is done to determine if the client is bleeding excessively; the nurse should do this as part of the assessment.
12. The client has been diagnosed with cancer of the breast. Which referral is most important for the nurse to make? 1. The hospital social worker. 2. CanSurmount. 3. Reach to Recovery. 4. I CanCope.
3. Reach to Recovery is a specific referral program for clients diagnosed with breast cancer.
12. The client diagnosed with ARF is experiencing hyperkalemia. Which medication should the nurse prepare to administer to help decrease the potassium level? 1. Erythropoietin. 2. Calcium gluconate. 3. Regular insulin. 4. Osmotic diuretic.
3. Regular insulin, along with glucose, will drive potassium into the cells, thereby lowering serum potassium levels temporarily.
6. The nurse is developing a plan of care for a client diagnosed with ARF. Which statement is an appropriate outcome for the client? 1. Monitor intake and output every shift. 2. Decrease of pain by 3 levels on a 1-10 scale. 3. Electrolytes are within normal limits. 4. Administer enemas to decrease hyperkalemia.
3. Renal failure causes an imbalance of electrolytes (potassium, sodium, calcium, phosphorus). Therefore, the desired client outcome is electrolytes within normal limits.
62. The nurse enters the room of a 24-year-old client diagnosed with testicular cancer. The fiancée of the client asks the nurse, "Will we be able to have children?" Which is the nurse's best response? 1. "Your fiancée will be able to father children like always." 2. "You will have to adopt children because he will be sterile." 3. "You and he should consider sperm banking prior to treatment." 4. "Have you discussed this with your fiancée? I can't discuss this with you."
3. Sperm banking will allow the client to father children through artificial insemination with the client's sperm.
4. Which recommendation is the American Cancer Society's (ACS) guideline for the early detection of breast cancer? 1. Beginning at age 18, have a biannual clinical breast examination by an HCP. 2. Beginning at age 30, perform monthly breast self-exams. 3. Beginning at age 40, receive a yearly mammogram. 4. Beginning at age 50, have a breast sonogram every five (5) years.
3. The ACS recommends a yearly mammogram for the early detection of breast cancer. A mammogram can detect disease that will not be large enough to feel.
1. The client frequently finds lumps in her breasts, especially around her menstrual period. Which information should the nurse teach the client regarding breast self-care? 1. This is a benign process which does not require follow-up. 2. The client should eliminate chocolate and caffeine from the diet. 3. The client should practice breast self-examination monthly. 4. This is the way breast cancer begins and the client needs surgery.
3. The American Cancer Society no longer recommends breast self-examination (BSE) for all women, but it is advisable for women with known breast conditions to perform BSE monthly to detect potential cancer.
72. The charge nurse is making rounds on the genitourinary surgery floor. Which action by the primary nurse warrants immediate intervention? 1. The nurse elevates the scrotum of a client who has had an orchiectomy. 2. The nurse encourages the client to cough, although he complains of pain. 3. The nurse empties the client's JP drain and leaves it rounded. 4. The nurse asks the unlicensed UAP to empty a catheter drainage bag.
3. The Jackson Pratt (JP) drain is a drain attached to a bulb, and the bulb should remain compressed to apply gentle suction to the surgical site.
67. The client diagnosed with renal calculi is scheduled for lithotripsy. Which postprocedure nursing task is the most appropriate to delegate to the UAP? 1. Monitor the amount, color, and consistency of urine output. 2. Teach the client about care of the indwelling Foley catheter. 3. Assist the client to the car when being discharged home. 4. Take the client's postprocedural vital signs.
3. The UAP could assist the client to the car once the discharge has been completed.
46. The client has had a total abdominal hysterectomy for cancer of the ovary. Which diet should the nurse discuss when providing discharge instructions? 1. A low-residue diet without seeds. 2. A low-sodium, low-fat diet with skim milk. 3. A regular diet with fruits and vegetables. 4. A full liquid-only diet with milk shake supplements.
3. The client is not placed on a specific diet, but it is always a good recommendation to include fruits and vegetables in the diet.
45. The nurse is discharging a client with a health-care facility acquired urinary tract infection. Which information should the nurse include in the discharge teaching? 1. Limit fluid intake so the urinary tract can heal. 2. Collect a routine urine specimen for culture. 3. Take all the antibiotics as prescribed. 4. Tell the client to void every five (5) to six (6) hours.
3. The client should be taught to take all the prescribed medication anytime a prescription is written for antibiotics.
32. The nurse is caring for a client diagnosed with diabetic ketoacidosis (DKA). Which statement best explains the scientific rationale for the client's Kussmaul's respirations? 1. The kidneys produce excess urine and the lungs try to compensate. 2. The respirations increase the amount of carbon dioxide in the bloodstream. 3. The lungs speed up to release carbon dioxide and increase the pH. 4. The shallow and slow respirations will increase the HCO3 in the serum.
3. The lungs attempt to increase the blood pH level by blowing off the carbon dioxide (carbonic acid).
32. The client diagnosed with endometriosis experiences pain rated a "5" on a 1-to-10 pain scale during her menses. Which intervention should the nurse teach the client? 1. Teach the client to take a stool softener when taking morphine, a narcotic. 2. Instruct the client to soak in a tepid bath for 30 to 45 minutes when the pain occurs. 3. Explain the need to take the nonsteroidal anti-inflammatory drugs with food. 4. Discuss the possibility of a hysterectomy to help relieve the pain.
3. The medication of choice for mild to moderate dysmenorrhea is an NSAID. NSAIDs cause gastrointestinal upset and should be taken with food.
35. The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients. Which nursing intervention should the nurse perform? 1. Measure the client's output from the indwelling catheter. 2. Record the client's intake and output on the I & O sheet. 3. Instruct the client on appropriate fluid restrictions. 4. Provide water for a client diagnosed with diabetes insipidus.
3. The nurse cannot delegate teaching.
42. The nurse writes a problem of "anticipatory grieving" for a client diagnosed with ovarian cancer. Which nursing intervention is priority for this client? 1. Request the HCP to order an antidepressant medication. 2. Refer the client to a CanSurmount volunteer for counseling. 3. Encourage the client to verbalize feelings about having cancer. 4. Give the client an advance directive form to fill out.
3. The nurse should plan to spend time with the client and allow the client to discuss the feelings of having cancer, dying, fear of the treatments, and any other concerns.
9. The client who had a right modified radical mastectomy four (4) years before is being admitted for a cardiac workup for chest pain. Which intervention is most important for the nurse to implement? 1. Determine when the client had chemotherapy last. 2. Ask the client if she received Adriamycin, an antineoplastic agent. 3. Post a message at the head of the bed to not use the right arm. 4. Examine the chest wall for cancer sites.
3. The nurse should post a message at the head of the client's bed to not use the right arm for blood pressures or laboratory draws. This client is at risk for lymphedema, and this is a lymphedema precaution.
66. The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a genitourinary floor. Which nursing task can be delegated to the UAP? 1. Increase the drip rate on the Murphy drip irrigation set. 2. Check the suprapubic catheter insertion site for infection. 3. Encourage the two (2)-hour postoperative client to turn and cough. 4. Document the amount of red drainage in the catheter.
3. The unlicensed assistive personnel can be asked to help a client turn, cough, and deep breathe. This requires the UAP to perform an action only, not to use judgment or to assess.
44. The client diagnosed with ovarian cancer is prescribed radiation therapy for regional control of the disease. Which statement indicates the client requires further teaching? 1. "I will not wash the marks off my abdomen." 2. "I will have a treatment every day for six (6) weeks." 3. "Nausea caused by radiation therapy cannot be controlled." 4. "I need to drink a nutritional shake if I don't feel like eating."
3. There are many medications prescribed for cancer or treatment-induced nausea. The client should notify the HCP if adequate relief is not obtained.
25. The nurse is caring for a 30-year-old nulliparous client who is complaining of severe dysmenorrhea. Which diagnostic test should the nurse prepare the client to undergo to determine a diagnosis? 1. A bimanual vaginal exam. 2. A pregnancy test. 3. An exploratory laparoscopy. 4. An ovarian biopsy.
3. There is a high incidence of endometriosis among women who have never had children (nulliparity) and those who have children later in life. The most common way to diagnose this condition is through an exploratory laparoscopy.
40. The nurse is examining a 15-year-old female who is complaining of pain, frequency, and urgency when urinating. After asking the parent to leave the room, which question should the nurse ask the client? 1. "When was your last menstrual cycle?" 2. "Have you noticed any change in the color of the urine?" 3. "Are you sexually active?" 4. "What have you taken for the pain?"
3. These are symptoms of cystitis, a bladder infection which may be caused by sexual intercourse as a result of the introduction of bacteria into the urethra during the physical act. A teenager may not want to divulge this information in front of the parent.
40. The client has had an exploratory laparotomy to remove an ovarian tumor. The pathology report classifies the tumor as a "low malignancy potential" (LMP) tumor. Which statement explains the scientific rationale for this pathology report? 1. The client does not have cancer but will need adjuvant therapy. 2. The client would have developed cancer if the tumor had not been removed. 3. These borderline tumors resemble ovarian cancer but have better outcomes. 4. The client has a very poor prognosis and has less than six (6) months to live.
3. These tumors are low-grade cancers with fewer propensities for metastasis than most ovarian cancers.
80. The client diagnosed with cancer of the bladder states, "I have young children. I am too young to die." Which statement is the nurse's best response? 1. "This cancer is treatable and you should not give up." 2. "Cancer occurs at any age. It is just one of those things." 3. "You are afraid of dying and what will happen to your children." 4. "Have you talked to your children about your dying?"
3. This is an example of restating, a therapeutic technique used to clarify the client's feelings and encourage a discussion of those feelings.
13. The nurse is caring for the client diagnosed with chronic kidney disease (CKD) who is experiencing metabolic acidosis. Which statement best describes the scientific rationale for metabolic acidosis in this client? 1. There is an increased excretion of phosphates and organic acids, which leads to an increase in arterial blood pH. 2. A shortened life span of red blood cells because of damage secondary to dialysis treatments in turn leads to metabolic acidosis. 3. The kidney cannot excrete increased levels of acid because they cannot excrete ammonia or cannot reabsorb sodium bicarbonate. 4. An increase in nausea and vomiting causes a loss of hydrochloric acid and the respiratory system cannot compensate adequately.
3. This is the correct scientific rationale for metabolic acidosis occurring in the client with CKD.
57. The client who is postoperative TURP asks the nurse, "When will I know if I will be able to have sex after my TURP?" Which response is most appropriate by the nurse? 1. "You seem anxious about your surgery." 2. "Tell me about your fears of impotency." 3. "Potency can return in six (6) to eight (8) weeks." 4. "Did you ask your doctor about your concern?"
3. This is usually the length of time clients need to wait prior to having sexual intercourse; this is the information the client wants to know.
24. The client receiving hemodialysis is being discharged home from the dialysis center. Which instruction should the nurse teach the client? 1. Notify the HCP if oral temperature is 102˚F or greater. 2. Apply ice to the access site if it starts bleeding at home. 3. Keep fingernails short and try not to scratch the skin. 4. Encourage significant other to make decisions for the client.
3. Uremic frost, which results when the skin attempts to take over the function of the kidneys, causes itching, which can lead to scratching possibly resulting in a break in the skin.
30. A client with Addison's disease makes all of the following statements. Which one does the nurse analyze as requiring further discussion? a) I wear a Medic-Alert bracelet at all times b) I need to weigh myself daily and record it c) It is important that I drink enough fluids and increase my salt intake d) my medication doses will not need to be adjusted for any reason
30) D - The client with Addison's disease is experiencing deficits of mineralocorticoids, glucocorticoids, and androgens. Aldosterone deficiency affects the ability of the nephrons to conserve sodium, so the client experiences sodium and fluid volume deficit. The client needs to manage this problem with daily hormone replacement and increased fluid and sodium intake. Clients are instructed to weigh themselves daily as a means of monitoring fluid volume balance. Glucocorticoids and mineralocorticoids are essential components of the stress response. Additional doses of hormone replacement therapy are needed with any type of physical or psychological stressor. This information needs to be conveyed to the client and requires that the client wear a Medic-Alert bracelet so that health care professionals are aware of this problem if the client were to experience a medical emergency.
4. A clinic nurse is performing an assessment on a client who has hypothyroidism. The nurse would expect to note which clinical manifestation? a) complaints of difficulty sleeping b) complaints of diarrhea c) significant weight loss since the last clinic visit d) complaints of intolerance to cold weather
4) D - An insufficient level of thyroid hormone causes a decrease in metabolic rate and heat production. Intolerance to cold would be noted. Options A, B and C are clinical manifestations of hyperthyroidism.
43. The client diagnosed with ovarian cancer has had eight (8) courses of chemotherapy. Which laboratory data warrant immediate intervention by the nurse? 1. Absolute neutrophil count of 3,500. 2. Platelet count of 150 × 103. 3. Red blood cell count of 5.0 × 106. 4. Urinalysis report of 100 WBCs.
4. A normal urinalysis contains one (1) to two (2) WBCs. A report of 100 WBCs indicates the presence of an infection. A clean voided specimen should be obtained and a urine culture should be done. This client should be prescribed antibiotics immediately.
73. The nurse is caring for clients on a renal surgery unit. After the afternoon report, which client should the nurse assess first? 1. The male client who just returned from a CT scan who states he left his glasses in the x-ray department. 2. The client who is one (1) day postoperative and has a moderate amount of serous drainage on the dressing. 3. The client who is scheduled for surgery in the morning and wants an explanation of the operative procedure before signing the permit. 4. The client who had ileal conduit surgery this morning and has not had any drainage in the drainage bag.
4. An ileal conduit is a procedure diverting urine from the bladder and provides an alternate cutaneous pathway for urine to exit the body. Urinary output should always be at least 30 mL/hr. This client should be assessed to make sure the stents placed in the ureters have not become dislodged or blocked.
4. The hospital administrator had undergone percutaneous transhepatic cholangiography. which assessment finding indicates complication after the operation? A. Fever and chills B. Hypertension C. Bradycardia D. Nausea and diarrhea
4. Answer: A. Fever and chills Septicemia is a common complication after a percutaneous transhepatic cholangiography. Evidence of fever and chills, possibly indicative of septicemia, is important. Hypotension, not hypertension, is associated with septicemia. Tachycardia, not bradycardia, is most likely to occur. Nausea and diarrhea may occur but are not classic signs of sepsis.
29. The client is admitted with a serum sodium level of 110 mEq/L. Which nursing intervention should be implemented? 1. Encourage fluids orally. 2. Administer 10% saline solution IVPB. 3. Administer antidiuretic hormone intranasally. 4. Place on seizure precautions.
4. Clients with sodium levels less than 120 mEq/L are at risk for seizures as a complication. The lower the sodium level, the greater the risk of a seizure.
43. The female client in an outpatient clinic is being sent home with a diagnosis of urinary tract infection (UTI). Which instruction should the nurse teach to prevent a recurrence of a UTI? 1. Clean the perineum from back to front after a bowel movement. 2. Take warm tub baths instead of hot showers daily. 3. Void immediately preceding sexual intercourse. 4. Avoid coffee, tea, colas, and alcoholic beverages.
4. Coffee, tea, cola, and alcoholic beverages are urinary tract irritants.
52. The nurse writes a client problem of urinary retention for a client diagnosed with Stage IV cancer of the prostate. Which intervention should the nurse implement first? 1. Catheterize the client to determine the amount of residual. 2. Encourage the client to assume a normal position for urinating. 3. Teach the client to use the Valsalva maneuver to empty the bladder. 4. Determine the client's normal voiding pattern.
4. Determining the client's normal voiding patterns provides a baseline for the nurse and client to use when setting goals.
16. The nurse is developing a nursing care plan for the client diagnosed with CKD. Which nursing problem is priority for the client? 1. Low self-esteem. 2. Knowledge deficit. 3. Activity intolerance. 4. Excess fluid volume.
4. Excess fluid volume is priority because of the stress placed on the heart and vessels, which could lead to heart failure, pulmonary edema, and death.
34. The HCP has prescribed two (2) IV antibiotics for the female client diagnosed with diabetes and pneumonia. Which order should the nurse request from the HCP? 1. Request written information on antibiotic-caused vaginal infections. 2. Request yogurt to be served on the client's meal trays. 3. Request a change of one of the antibiotics to an oral route. 4. Request L. acidophilus, a yeast preparation, three (3) times a day.
4. Female clients on antibiotics are at risk for killing the good bacteria, which keep yeast infections in check. This is especially true in clients diagnosed with diabetes. Lactobacillus acidophilus is a yeast replacement medication.
50. The client is diagnosed with early cancer of the prostate. Which assessment data would the client report? 1. Urinary urgency and frequency. 2. Retrograde ejaculation during intercourse. 3. Low back and hip pain. 4. No problems have been noticed.
4. In early-stage prostate cancer, the man will not be aware of the disease. Early detection is achieved by screening for the cancer.
78. The nurse and a licensed practical nurse (LPN) are caring for a group of clients. Which intervention should be assigned to the LPN? 1. Assessment of the client who has had a Kock pouch procedure. 2. Monitoring of the postop client with a WBC of 22,000/mm3. 3. Administration of the prescribed antineoplastic medications. 4. Care for the client going for an MRI of the kidneys.
4. It is in the scope of practice for the LPN to care for this client.
1. The nurse is admitting a client diagnosed with acute renal failure (ARF). Which question is most important for the nurse to ask during the admission interview? 1. "Have you recently traveled outside the United States?" 2. "Did you recently begin a vigorous exercise program?" 3. "Is there a chance you have been exposed to a virus?" 4. "What over-the-counter medications do you take regularly?"
4. Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) and some herbal remedies are nephrotoxic; therefore, asking about medications is appropriate.
63. The client with possible renal calculi is scheduled for a renal ultrasound. Which intervention should the nurse implement for this procedure? 1. Ask if the client is allergic to shellfish or iodine. 2. Keep the client NPO eight (8) hours prior to the ultrasound. 3. Ensure the client has a signed informed consent form. 4. Explain the test is noninvasive and there is no discomfort.
4. No special preparation is needed for this noninvasive, nonpainful test. A conductive gel is applied to the back or flank and then a transducer is applied which produces sound waves, resulting in a picture.
22. The nurse caring for a client diagnosed with CKD writes a client problem of "noncompliance with dietary restrictions." Which intervention should be included in the plan of care? 1. Teach the client the proper diet to eat while undergoing dialysis. 2. Refer the client and significant other to the dietitian. 3. Explain the importance of eating the proper foods. 4. Determine the reason for the client not adhering to the diet.
4. Noncompliance is a choice the client has a right to make, but the nurse should determine the reason for the noncompliance and then take appropriate actions based on the client's rationale. For example, if the client has financial difficulties, the nurse may suggest how the client can afford the proper foods along with medications, or the nurse may be able to refer the client to a social worker.
5. The client diagnosed with ARF has a serum potassium level of 6.8 mEq/L. Which collaborative treatment should the nurse anticipate for the client? 1. Administer a phosphate binder. 2. Type and crossmatch for whole blood. 3. Assess the client for leg cramps. 4. Prepare the client for dialysis.
4. Normal potassium level is 3.5 to 5.5 mEq/L. A level of 6.8 mEq/L is life threatening and could lead to cardiac dysrhythmias. Therefore, the client may be dialyzed to decrease the potassium level quickly. This requires a health-care provider order, so it is a collaborative intervention.
37. The 24-year-old female client presents to the clinic with lower abdominal pain on the left side she rates as a "9" on a 1-to-10 scale. Which diagnostic procedure should the nurse prepare the client for? 1. A computed tomography scan. 2. A lumbar puncture. 3. An appendectomy. 4. A pelvic sonogram.
4. Ovarian cysts are fluid-filled sacs located on the surface of the ovary. A lower pelvic sonogram is the preferred diagnostic tool. It is not invasive and usually not painful.
66. The client is diagnosed with an acute episode of ureteral calculi. Which client problem is priority when caring for this client? 1. Fluid volume loss. 2. Knowledge deficit. 3. Impaired urinary elimination. 4. Alteration in comfort.
4. Pain is priority. The pain can be so severe a sympathetic response may occur, causing nausea; vomiting; pallor; and cool, clammy skin.
63. The client diagnosed with testicular cancer is scheduled for a unilateral orchiectomy. Which information is important to teach regarding sexual functioning? 1. The client will have ejaculation difficulties after the surgery. 2. The client will be prescribed male hormones following the surgery. 3. The client may need to have a penile implant to be able to have intercourse. 4. Libido and orgasm usually are unimpaired after this surgery.
4. Sex drive (libido) and orgasms usually are unimpaired because the client still has one testicle.
83. The client is two (2) days post-ureterosigmoidostomy for cancer of the bladder. Which assessment data warrant notification of the HCP by the nurse? 1. The client complains of pain at a "3," 30 minutes after being medicated. 2. The client complains it hurts to cough and deep breathe. 3. The client ambulates to the end of the hall and back before lunch. 4. The client is lying in a fetal position and has a rigid abdomen.
4. The client is drawn up in a position which relieves pressure off the abdomen; a rigid abdomen is an indicator of peritonitis, a medical emergency.
29. The postmenopausal client reveals it has been several years since her last gynecological examination and states, "Oh, I don't need exams anymore. I am beyond having children." Which statement should be the nurse's response? 1. "As long as you are not sexually active, you don't have to worry." 2. "You should be taking hormone replacement therapy now." 3. "You are beyond bearing children. How does that make you feel?" 4. "There are situations other than pregnancy that should be checked."
4. The client should have a yearly clinical examination of the breasts and pelvic area for the detection of cancer.
6. The nurse is teaching a class on breast health to a group of ladies at a senior citizen's center. Which risk factor is the most important to emphasize to this group? 1. The clients should find out about their family history of breast cancer. 2. Men at this age can get breast cancer also and should be screened. 3. Monthly breast self-examination is the key to early detection. 4. The older a woman gets, the greater the chance of developing breast cancer.
4. The greatest risk factor for developing breast cancer is being female. The second greatest risk factor is being elderly. By age 80, one (1) in every eight (8) women develops breast cancer.
56. The client with a TURP who has a continuous irrigation catheter complains of the need to urinate. Which intervention should the nurse implement first? 1. Call the surgeon to inform the HCP of the client's complaint. 2. Administer the client a narcotic medication for pain. 3. Explain to the client this sensation happens frequently. 4. Assess the continuous irrigation catheter for patency.
4. The nurse should always assess any complaint before dismissing it as a commonly occurring problem.
71. The client had surgery to remove a kidney stone. Which laboratory assessment data warrant immediate intervention by the nurse? 1. A serum potassium level of 3.8 mEq/L. 2. A urinalysis shows microscopic hematuria. 3. A creatinine level of 0.8 mg/100 mL. 4. A white blood cell count of 14,000/mm3.
4. The white blood cell count is elevated; normal is 5,000 to 10,000/mm3.
53. Which nursing diagnosis is priority for the client who has undergone a TURP? 1. Potential for sexual dysfunction. 2. Potential for an altered body image. 3. Potential for chronic infection. 4. Potential for hemorrhage.
4. This is a potentially life-threatening problem.
70. Which tumor marker information is used to follow the progress of a client diagnosed with testicular cancer? 1. CA-125. 2. Carcinogenic embryonic antigen (CEA). 3. DNA ploidy test. 4. Human chorionic gonadotropin (hCG).
4. Tumor markers are substances synthesized by the tumor and released into the bloodstream. They can be used to follow the progress of the disease. Testicular cancers secrete hCG and alpha-fetoprotein.
37. The client from a long-term care facility is admitted to the medical unit with a fever, hot flushed skin, and clumps of white sediment in the indwelling catheter. Which intervention should the nurse implement first? 1. Start an IV with a 20-gauge catheter. 2. Initiate antibiotic therapy IVPB. 3. Collect a urine specimen for culture. 4. Change the indwelling catheter.
4. Unless the nurse can determine the catheter has been inserted within a few days, the nurse should replace the catheter and then get a specimen. This will provide the most accurate specimen for analysis.
57. The client is eight (8) hours post-transurethral prostatectomy for cancer of the prostate. Which nursing intervention is priority at this time? 1. Control postoperative pain. 2. Assess abdominal dressing. 3. Encourage early ambulation to prevent DVT. 4. Monitor fluid and electrolyte balance.
4. With irrigation of the surgical site through the indwelling three (3)-way catheter to prevent blood clots, fluids may be absorbed through the open surgical site and retained. This can lead to fluid volume overload and electrolyte imbalance (hyponatremia).
5. When planning home care for a client with hepatitis A, which preventive measure should be emphasized to protect the client's family? A. Keeping the client in complete isolation B. Using good sanitation with dishes and shared bathrooms C. Avoiding contact with blood-soiled clothing or dressing D. Forbidding the sharing of needles or syringes
5. Answer: B. Using good sanitation with dishes and shared bathrooms Hepatitis A is transmitted through the fecal oral route or from contaminated water or food. Measures to protect the family include good handwashing, personal hygiene and sanitation, and use of standard precautions. Complete isolation is not required. Avoiding contact with blood-soiled clothing or dressings or avoiding the sharing of needles or syringes are precautions needed to prevent transmission of hepatitis B.
. A client has been diagnosed with goiter. The nurse looks for documentation of which of the following in the client's medical record? a) decreased wound healing b) chronic fatigue c) enlarged thyroid gland d) heart damage
6) C - An enlarged thyroid gland occurs in goiter. Decreased wound healing, chronic fatigue, and heart damage are not specifically associated with this condition.
6. For Jayvin who is taking antacids, which instruction would be included in the teaching plan? A. "Take the antacids with 8 oz of water." B. "Avoid taking other medications within 2 hours of this one." C. "Continue taking antacids even when pain subsides." D. "Weigh yourself daily when taking this medication."
6. Answer: B. "Avoid taking other medications within 2 hours of this one." Antacids neutralize gastric acid and decrease the absorption of other medications. The client should be instructed to avoid taking other medications within 2 hours of the antacid. Water, which dilutes the antacid, should not be taken with antacid. A histamine receptor antagonist should be taken even when pain subsides. Daily weights are indicated if the client is taking a diuretic, not an antacid.
The patient is scheduled for a q12h dose of lactulose 30 grams orally. Available is an oral solution containing 5 g/10 mL. How much solution should be poured into the medication cup to give the required dose? 15 mL 30 mL 45 mL 60 mL
60mL Using the medication-calculation equation of dose desired (30 grams) divided by dose on hand (5 grams) and multipled by the quantity (10 mL), the answer is 60 mL.
7. Which clinical manifestation would the nurse expect a client diagnosed with acute cholecystitis to exhibit? A. Jaundice, dark urine, and steatorrhea B. Acute right lower quadrant (RLQ) pain, diarrhea, and dehydration C. Ecchymosis petechiae, and coffee-ground emesis D. Nausea, vomiting, and anorexia
7. Answer: D. Nausea, vomiting, and anorexia Acute cholecystitis is an acute inflammation of the gallbladder commonly manifested by the following: anorexia, nausea, and vomiting; biliary colic; tenderness and rigidity the right upper quadrant (RUQ) elicited on palpation (e.g., Murphy's sign); fever; fat intolerance; and signs and symptoms of jaundice. Ecchymosis, petechiae, and coffee-ground emesis are clinical manifestations of esophageal bleeding. The coffee-ground appearance indicates old bleeding. Jaundice, dark urine, and steatorrhea are clinical manifestations of the icteric phase of hepatitis.
An unconscious patient with a traumatic head injury has a blood pressure of 126/72 mm Hg, and an intracranial pressure of 18 mm Hg. The nurse will calculate the cerebral perfusion pressure as ____________________.
72 mm Hg (The formula for calculation of cerebral perfusion pressure is [(Systolic pressure + Diastolic blood pressure × 2)/3] = intracranial pressure.)
8. Hashimoto's disease is: a. Chronic inflammation of the thyroid gland b. Diagnosed most frequently in Asian-Americans and Pacific Islanders c. A form of hyperthyroidism d. A rare form of hypothyroidism
8. A: Hashimoto's disease is the most common cause of hypothyroidism. It is an autoimmune disease that produces chronic inflammation of the thyroid gland. More women are affected than men and it is generally diagnosed in persons ages 40 to 60. When treatment is indicated, synthetic T4 is administered.
The nursing management of a patient of a patient is sickle cell crisis includes (select all that apply): A. monitoring CBC B. blood transfusion if required and iron chelation C. optimal pain management and oxygen therapy D. rest as needed and DVT prophylaxis E. administration of IV iron and diet high in iron content
A, B, C, D
8. Pierre who is diagnosed with acute pancreatitis is under the care of Nurse Bryan. Which intervention should the nurse include in the care plan for the client? A. Administration of vasopressin and insertion of a balloon tamponade B. Preparation for a paracentesis and administration of diuretics C. Maintenance of nothing-by-mouth status and insertion of nasogastric (NG) tube with low intermittent suction D. Dietary plan of a low-fat diet and increased fluid intake to 2,000 ml/day
8. Answer: C. Maintenance of nothing-by-mouth status and insertion of nasogastric (NG) tube with low intermittent suction With acute pancreatitis, the client is kept on nothing-by-mouth status to inhibit pancreatic stimulation and secretion of pancreatic enzymes. NG intubation with low intermittent suction is used to relieve nausea and vomiting, decrease painful abdominal distention, and remove hydrochloric acid. Vasopressin would be appropriate for a client diagnosed with bleeding esophageal varices. Paracentesis and diuretics would be appropriate for a client diagnosed with portal hypertension and ascites. A low-fat diet and increased fluid intake would further aggravate the pancreatitis.
9. A nurse is monitoring a client for complications following thyroidectomy. The nurse notes that the client's voice is very hoarse, and the client is concerned about the hoarseness and asks the nurse about it. The nurse makes which response to alleviate the client's concern? a) hoarseness and weak voice indicate permanent damage to the nerves b) this complication is expected c) this problem is temporary and will probably subside in a few days d) it is best that you not talk at all until the problem is further evaluated
9) C Temporary hoarseness and a weak voice may occur if there has been unilateral injury to the laryngeal nerve during surgery. If hoarseness or a weak voice is present, the client is reassured that the problem will probably subside in a few days. Unnecessary talking is discouraged to minimize hoarseness. The statements in options A, B, and D will not alleviate the client's concern.
9. When teaching a client about pancreatic function, the nurse understands that pancreatic lipase performs which function? A. Transports fatty acids into the brush border B. Breaks down fat into fatty acids and glycerol C. Triggers cholecystokinin to contract the gallbladder D. Breaks down protein into dipeptides and amino acids
9. Answer: B. Breaks down fat into fatty acids and glycerol Lipase hydrolyses or breaks down fat into fatty acids and glycerol. Lipase is not involved with the transport of fatty acids into the brush border. Fat itself triggers cholecystokinin release. Protein breakdown into dipeptides and amino acids is the function of trypsin, not lipase.
When providing care for a patient with thrombocyopenia, the nurse instructs the patient to: A. dab his or her nose instead of blowing B. be careful when shaving with a safety razor C. continue with physical activities to stimulate thrombopoiesis D. avoid t aspirin because it may mask the fever that occurs with thrombocytopenia
A
Which finding indicates to the nurse that lactulose (Cephulac) is effective for a 72-year-old man who has advanced cirrhosis? a. The patient is alert and oriented. b. The patient denies nausea or anorexia. c. The patient's bilirubin level decreases. d. The patient has at least one stool daily.
A
While collecting data on a client being prepared for an adrenalectomy, the nurse obtains a temperature reading of 100.8° F. The nurse analyzes this temperature reading as which?
A finding that needs to be reported immediately
Which of the following would be an indication of Androgen Insensitivity Syndrome? Answers: A. A 33 year old woman with a karyotype of XY B. A 16 year old male with reduced kidney function C. Failure to respond to cortisol therapy D. Several pregnancies all of which ended in miscarriages
A Androgen Insensitivity Syndrome is when the body does not respond to androgens such as testosterone. This can result in genetic males being born with the appearance of women.
3. Symptoms of Grave's ophthalmopathy include all of the following except: a. Bulging eyeballs b. Dry, irritated eyes and puffy eyelids c. Cataracts d. Light sensitivity
A Grave's ophthalmopathy is an inflammation of tissue behind the eye causing the eyeballs to bulge. In addition to the above-mentioned symptoms, Grave's ophthalmopathy may cause pressure or pain in the eyes, double vision, and trouble moving the eyes. About one-quarter of persons with Grave's disease develop Grave's ophthalmopathy. The condition is frequently self-limiting, resolving without treatment over the course of a year or two.
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.
The nurse receives the change-of-shift report on four clients. Which client does the nurse decide to assess first?
A 28-year-old with urolithiasis who has been receiving morphine sulfate and has not voided for 8 hours
Which of these patients is most appropriate for the intensive care unit (ICU) charge nurse to assign to an RN who has floated from the medical unit?
A 44-year-old receiving IV antibiotics for meningococcal meningitis rational: An RN who works on a medical unit will be familiar with administration of IV antibiotics and with meningitis. The postcraniotomy patient, patient with an ICP monitor, and the patient on a ventilator should be assigned to an RN familiar with the care of critically ill patients.
Which client would be most at risk for developing varicose veins?
A Caucasian female who is a nurse
Following an ascending aortic aneurysm repair, which of the following findings should the nurse report immediately to the health care provider? a) a change in LOC and ability to speak b) shallow respirations and poor coughing c) decreased drainage from the chest tubes d) lower-extremity pulses that are decreased from preoperative baseline
A change in level of consciousness (LOC) and ability to speak because during a repair of an AAA, the blood supply to the carotid arteries may be interrupted, leading to neurologic complications manifested by a decreased LOC and altered pupil responses to light as well as changes in facial symmetry, speech, and movement of upper extremities. The thorax is opened is opened for ascending aortic surgery, and shallow breathing, poor cough, and decreasing chest drainage are expected. Often, lower limb pulses are normally decreased or absent for a short time following surgery.
What is TRIGEMINAL NEURALGIA? What are the considerations?
A cranial nerve disorder affecting sensory branches of the trigeminal nerve (CN V). Lukewarm food, chew on unaffected side, eye care, tearing, blinking, oral hygiene, increased protein, calories, room temperature and avoid touching client.
The nurse is caring for a client with Addison's disease. The nurse checks the client's vital signs and determines that the client has orthostatic hypotension. The nurse determines that this finding relates to which factor?
A decreased secretion of aldosterone
During an abdominal assessment of a male client, the nurse palpates a a large, round mass in the hypogastric region. What is the nurse palpating?
A distended or full bladder
During care of the patient following femoral bypass graft surgery, the nurse immediately notifies the health care provider if the patient experiences...
A loss of palpable pulses and numbness and tingling of the feet
After receiving change-of-shift report on the following four patients, which patient should the nurse see first?
A patient with right-sided weakness who has an infusion of tPA prescribed rational: tPA needs to be infused within the first few hours after stroke symptoms start in order to be effective in minimizing brain injury. The other medications also should be given as quickly as possible, but timing of the medications is not as critical.
The Doctor has order an indwelling catheter inserted in a hospitalized male "PT". The nurse is aware of which of the following considerations? A)The male urethra is more vulnerable to injury during insertion B)In the hospital, a clean technique is used for catheter insertion C)The catheter is inserted 2" to 3" into the meatus D)Since it uses a closed system, the risk for urinary infection is absent
A)The male urethra is more vulnerable to injury during insertion Because of its length the male urethra is more prone to injury and requires that the catheter be inserted 6" to 8". This procedure requires surgical asepsis to prevent introducing bacterica into the urinary tract. The placement of an indwelling catheter has a risk of UTI
Priority nursing actions when caring for a hospitalized patient with a new onset temperature of 102.2*F and severe neurtopenia include: (check all that apply): A. administering the prescribed antibiotic STAT B. drawing peripheral and ventral line blood cultured C. ongoing monitoring of the patient's vitals for signs of septic shock D. taking a full set of vital signs and notifying the physician immediately E. administering infusions of WBCs treated to decrease immunogenicity
A, B, C, D
The priority treatment option for Miss Jones would most likely involve which of the following? A) Behavioral techniques B) Pharmacological measures C) Surgical intervention D) Use of absorbent products
A) Behavioral techniques The least invasive intervention should be attempted first. Phonological and surgical interventions are not recommended until behavioral techniques have been attempted. Using absorbent products may remove motivation from the patient and caregiver to seek Evaluation and treatment of the incontinence. They should be used only after careful evaluation by a healthcare provider
When a person as a fever or diaphortesis, how would the urine output be described? A)Decreased and highly concentrated B)Decreased and highly dilute C)Increased and concentrated D)Increased and dilute
A)Decreased and highly concentrated Fever and diaphoresis cause the kidneys to conserve body fluids, Thus, the urine is concentrated and decreased in amount
Which of the following symptoms are expected in the patient with pheochromocytoma? Select all that Apply (SATA): A) Hypertension B) HA C) Hypoglycemia D) Hypermetabolism E) Dry skin
A, B, and D. The five H's: HA, Hypertension, Hyperhydrosis (sweating), Hypermetabolism and Hyperglycemia.
Which of the following would the nurse monitor for as signs of thyroid storm? SATA: A) T 101.5 B) HR 59 C) Constipation D) Edema E) Chest pain
A, D, and E. Thyroid storm is a form of severe hyperthyroidism usually of abrupt onset. S/S are typically characterized by exaggeration of hyperthyroidism. An extreme fever over 101.3 degrees often occurs along with extreme tachycardia (>130) During thyroid storm increased cardiac compromise may occur as evidenced by edema (HF), chest pain, dyspnea, or palpitations.
11. Following a unilateral adrenalectomy, nurse Betty would assess for hyperkalemia shown by which of the following? a. Muscle weakness b. Tremors c. Diaphoresis d. Constipation
A. Muscle weakness, bradycardia, nausea, diarrhea, and paresthesia of the hands, feet, tongue, and face are findings associated with hyperkalemia, which is transient and occurs from transient hypoaldosteronism when the adenoma is removed. Tremors, diaphoresis, and constipation aren't seen in hyperkalemia.
One of the most challenging nursing interventions to promote healing in the patient with viral hepatitis is a. providing adequate nutritional intake b. promoting strict bed rest during the icteric phase c. providing pain relief without using liver metabolized drugs. d. providing quiet diversional activities during periods of fatigue
A- Adequate nutrition is especially important in promoting regeneration of liver cells, but the anorexia of viral hepatitis is often severe, requiring creative and innovative nursing interventions. Strict bed rest is not usually required, and the patient usually has only minor discomfort from with hepatitis. Diversional activities may be required to promote psychologic rest but not during periods of fatigue
A patient newly diagnosed with acute hep B asks about drug therapy to treat the disease. The most appropriate response by the nurse is informing the patient that a. there are no specific drugs that are effective for treating acute viral hepatitis b, only chronic hep C is treatable, primarily with antiviral agents and alpha interferon. c. no drugs can be used for treatment of viral hepatitis because of the risk of additional liver damage. d. alpha interferon combined with lamivudine (EPivir) will decrease viral load and liver damage if taken for 1 year
A- No specific drugs are effective in treating acute viral hepatitis, although supportive drugs, such as anti-emetics, sedative, or atipruritics, may be used for symptom control. Antiviral agents, such as lamivudine or ribavirin, and alpha interferon may be used for treating chronic hepatitis B or C.
19. Jemma, who weighs 210 lb (95 kg) and has been diagnosed with hyperglycemia tells the nurse that her husband sleeps in another room because her snoring keeps him awake. The nurse notices that she has large hands and a hoarse voice. Which of the following would the nurse suspect as a possible cause of the client's hyperglycemia? a. Acromegaly b. Type 1 diabetes mellitus c. Hypothyroidism d. Deficient growth hormone
A. Acromegaly, which is caused by a pituitary tumor that releases excessive growth hormone, is associated with hyperglycemia, hypertension, diaphoresis, peripheral neuropathy, and joint pain. Enlarged hands and feet are related to lateral bone growth, which is seen in adults with this disorder. The accompanying soft tissue swelling causes hoarseness and often sleep apnea. Type 1 diabetes is usually seen in children, and newly diagnosed persons are usually very ill and thin. Hypothyroidism isn't associated with hyperglycemia, nor is growth hormone deficiency.
8. When caring for a male client with diabetes insipidus, nurse Juliet expects to administer: a. vasopressin (Pitressin Synthetic). b. furosemide (Lasix). c. regular insulin. d. 10% dextrose.
A. Because diabetes insipidus results from decreased antidiuretic hormone (vasopressin) production, the nurse should expect to administer synthetic vasopressin for hormone replacement therapy. Furosemide, a diuretic, is contraindicated because a client with diabetes insipidus experiences polyuria. Insulin and dextrose are used to treat diabetes mellitus and its complications, not diabetes insipidus.
18. Which outcome indicates that treatment of a male client with diabetes insipidus has been effective? a. Fluid intake is less than 2,500 ml/day. b. Urine output measures more than 200 ml/hour. c. Blood pressure is 90/50 mm Hg. d. The heart rate is 126 beats/minute.
A. Diabetes insipidus is characterized by polyuria (up to 8 L/day), constant thirst, and an unusually high oral intake of fluids. Treatment with the appropriate drug should decrease both oral fluid intake and urine output. A urine output of 200 ml/hour indicates continuing polyuria. A blood pressure of 90/50 mm Hg and a heart rate of 126 beats/minute indicate compensation for the continued fluid deficit, suggesting that treatment hasn't been effective.
A female adult client with a history of chronic hyperparathyroidism admits to being noncompliant. Based on initial assessment findings, nurse Julia formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement for this client, which "related-to" phrase should the nurse add? a. Related to bone demineralization resulting in pathologic fractures b. Related to exhaustion secondary to an accelerated metabolic rate c. Related to edema and dry skin secondary to fluid infiltration into the interstitial spaces d. Related to tetany secondary to a decreased serum calcium level
A. Poorly controlled hyperparathyroidism may cause an elevated serum calcium level. This, in turn, may diminish calcium stores in the bone, causing bone demineralization and setting the stage for pathologic fractures and a risk for injury. Hyperparathyroidism doesn't accelerate the metabolic rate. A decreased thyroid hormone level, not an increased parathyroid hormone level, may cause edema and dry skin secondary to fluid infiltration into the interstitial spaces. Hyperparathyroidism causes hypercalcemia, not hypocalcemia; therefore, it isn't associated with tetany.
17. A female client has a serum calcium level of 7.2 mg/dl. During the physical examination, nurse Noah expects to assess: a. Trousseau's sign. b. Homans' sign. c. Hegar's sign. d. Goodell's sign.
A. This client's serum calcium level indicates hypocalcemia, an electrolyte imbalance that causes Trousseau's sign (carpopedal spasm induced by inflating the blood pressure cuff above systolic pressure). Homans' sign (pain on dorsiflexion of the foot) indicates deep vein thrombosis. Hegar's sign (softening of the uterine isthmus) and Goodell's sign (cervical softening) are probable signs of pregnancy.
The patient with cirrhosis is being taught self-care. Which statement indicates the patient needs more teaching? A. "If I notice a fast heart rate or irregular beats, this is normal for cirrhosis." B. "I need to take good care of my belly and ankle skin where it is swollen." C. "A scrotal support may be more comfortable when I have scrotal edema." D. "I can use pillows to support my head to help me breathe when I am in bed."
A. "If I notice a fast heart rate or irregular beats, this is normal for cirrhosis." If the patient with cirrhosis experiences a fast or irregular heart rate, it may be indicative of hypokalemia and should be reported to the health care provider, as this is not normal for cirrhosis. Edematous tissue is subject to breakdown and needs meticulous skin care. Pillows and a semi-Fowler's or Fowler's position will increase respiratory efficiency. A scrotal support may improve comfort if there is scrotal edema.
A postoperative patient has an order to receive morphine sulfate 4 mg IM every 3 to 4 hours prn for pain. On hand are prefilled syringes labeled morphine sulfate 10 mg/mL. How many milliliters should the nurse administer? A. 0.4 mL B. 0.55 mL C. 0.6 mL D. 0.75 mL
A. 0.4 mL Dose (mg) ÷ availability (mg/mL) = mL to administer. Therefore, 4 mg ÷ 10 mg/mL = 0.4 mL.
The nurse is reviewing the laboratory test results for a 68-year-old patient whose warfarin (Coumadin) therapy was terminated during the preoperative period. The nurse concludes that the patient is in the most stable condition for surgery after noting which INR (international normalized ratio) result? A. 1.0 B. 1.8 C. 2.7 D. 3.4
A. 1.0 The therapeutic range for INR is 2.0 to 3.0 for many clinical diagnoses. The larger the INR number, the greater the amount of anticoagulation. For this reason, the safest value before surgery is 1.0, meaning that the anticoagulation has been reversed.
Which patient is most at risk for respiratory depression related to opioid administration for pain relief? A. 82-year-old patient who had abdominal surgery 4 hours ago B. 24-year-old patient who had a vaginal delivery 12 hours ago C. 32-year-old patient with chronic neuropathic pain for 6 months D. 20-year-old patient with a closed reduction of a fractured right arm
A. 82-year-old patient who had abdominal surgery 4 hours ago Patients most at risk for respiratory depression include those who are older, have underlying lung disease, have a history of sleep apnea, or are receiving other central nervous system depressants. For postoperative patients the greatest risk is in the first 24 hours after surgery. Respiratory depression related to opioid administration is higher in hospitalized patients who are opioid naïve.
Which person should the nurse identify as having the highest risk for abdominal aortic aneurysm? A. A 70-year-old male, with high cholesterol and hypertension B. A 40-year-old female with obesity and metabolic syndrome C. A 60-year-old male with renal insufficiency who is physically inactive D. A 65-year-old female with hyperhomocysteinemia and substance abuse
A. A 70-year-old male, with high cholesterol and hypertension The most common etiology of descending abdominal aortic aneurysm (AAA) is atherosclerosis. Male gender, age 65 years or older, and tobacco use are the major risk factors for AAAs of atherosclerotic origin. Other risk factors include the presence of coronary or peripheral artery disease, high blood pressure, and high cholesterol.
The nurse is caring for a woman recently diagnosed with viral hepatitis A. Which individual should the nurse refer for an immunoglobin (IG) injection? A. A caregiver who lives in the same household with the patient B. A friend who delivers meals to the patient and family each week C. A relative with a history of hepatitis A who visits the patient daily D. A child living in the home who received the hepatitis A vaccine 3 months ago
A. A caregiver who lives in the same household with the patient IG is recommended for persons who do not have anti-HAV antibodies and are exposed as a result of close contact with persons who have HAV or foodborne exposure. Persons who have received a dose of HAV vaccine more than 1 month previously or who have a history of HAV infection do not require IG.
When providing discharge teaching for the patient after a laparoscopic cholecystectomy, what information should the nurse include? A. A lower-fat diet may be better tolerated for several weeks. B. Do not return to work or normal activities for 3 weeks. C. Bile-colored drainage will probably drain from the incision. D. Keep the bandages on and the puncture site dry until it heals.
A. A lower-fat diet may be better tolerated for several weeks. Although the usual diet can be resumed, a low-fat diet is usually better tolerated for several weeks following surgery. Normal activities can be gradually resumed as the patient tolerates. Bile-colored drainage or pus, redness, swelling, severe pain, and fever may all indicate infection. The bandage may be removed the day after surgery, and the patient can shower.
The registered nurse (RN) is caring for patients on a surgical unit. Which tasks may the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? A. Administer oral pain medications to a patient after abdominal surgery. B. Teach the patient how to use patient-controlled analgesia after surgery. C. Determine strategies for pain management as part of a patient's discharge plan. D. Evaluate whether the pain management plan is providing adequate pain control.
A. Administer oral pain medications to a patient after abdominal surgery. An LPN/LVN may administer ordered pain medications, but depending on the state nurse practice act and agency policy, the LPN/LVN may not be able to administer medication by all routes. The tasks of teaching, evaluation, and discharge planning are within the scope of practice of an RN.
When making assignments for nurses working in the OR, which case would the manager assign to the new nurse? 1. The client having open-heart surgery. 2. The client having a biopsy of the breast. 3. The client having laser eye surgery. 4. The client having a laparoscopic knee repair.
ANS: 2 The case of a client having a biopsy of the breast would be a good case for an inexperienced nurse because it is simple.
When teaching a patient about the most important respiratory defense mechanism distal to the respiratory bronchioles, which topic would the nurse discuss? A. Alveolar macrophages B. Impaction of particles C. Reflex bronchoconstriction D. Mucociliary clearance mechanism
A. Alveolar macrophages Respiratory defense mechanisms are efficient in protecting the lungs from inhaled particles, microorganisms, and toxic gases. Because ciliated cells are not found below the level of the respiratory bronchioles, the primary defense mechanism at the alveolar level is alveolar macrophages.
A patient with osteoarthritis has been taking ibuprofen (Advil) 400 mg every 8 hours. The patient states that the drug does not seem to work as well as it used to in controlling the pain. The most appropriate response to the patient is based on what knowledge? A. Another NSAID may be indicated because of individual variations in response to drug therapy. B. It may take several months for NSAIDs to reach therapeutic levels in the blood and thus be effective. C. If NSAIDs are not effective in controlling symptoms, systemic corticosteroids are the next line of therapy. D. The patient is probably not compliant with the drug therapy, and therefore the nurse must initially assess the patient's knowledge base and initiate appropriate teaching.
A. Another NSAID may be indicated because of individual variations in response to drug therapy. Patients vary in their response to medications so when one NSAID does not provide relief, another should be tried. There is no evidence to ascertain any noncompliance to drug therapy.
Before administering celecoxib (Celebrex), the nurse will assess the patient's medical record for which medication that would increase the risk of adverse effects? A. Aspirin B. Scopolamine C. Theophylline D. Acetaminophen
A. Aspirin Celecoxib is a nonsteroidal antiinflammatory drug (NSAID) of the cyclooxygenase-2 (COX-2) inhibitor type. Although celecoxib does not inhibit COX-1 and thus has a decreased risk of bleeding, bleeding is still of concern as an adverse effect. For this reason, the drug should not be taken with other drugs that increase risk of bleeding, such as aspirin.
The nurse should teach a patient to avoid which medication while taking ibuprofen? A. Aspirin B. Furosemide (Lasix) C. Nitroglycerin (Nitro-Bid) D. Morphine sulfate (generic)
A. Aspirin The patient should not take aspirin while taking ibuprofen because the combination could increase the risk of GI bleeding.
The nurse admits a 55-year-old female with multiple sclerosis to a long-term care facility. Which finding is of most immediate concern to the nurse? A. Ataxic gait B. Radicular pain C. Severe fatigue D. Urinary retention
A. Ataxis gait An ataxic gait is a staggering, uncoordinated gait. Fall risk is the highest in individuals with gait instability or visual or cognitive impairments. The other signs and symptoms (e.g., fatigue, urinary retention, radicular pain) may also occur in the patient with multiple sclerosis and need to be managed, but are not the priority.
A 40-year-old man tells the nurse he has a diagnosis for the color and temperature changes of his limbs but can't remember the name of it. He says he must stop smoking and avoid trauma and exposure of his limbs to cold temperatures to get better. This description should allow the nurse to ask the patient if he has which diagnosis? A. Buerger's disease B. Venous thrombosis C. Acute arterial ischemia D. Raynaud's phenomenon
A. Buerger's disease Buerger's disease is a nonatherosclerotic, segmental, recurrent inflammatory disorder of small and medium-sized veins and arteries of upper and lower extremities leading to color and temperature changes of the limbs, intermittent claudication, rest pain, and ischemic ulcerations. It primarily occurs in men younger than 45 years old with a long history of tobacco and/or marijuana use. Buerger's disease treatment includes smoking cessation, trauma and cold temperature avoidance, and a walking program. Venous thrombosis is the formation of a thrombus in association with inflammation of the vein. Acute arterial ischemia is a sudden interruption in arterial blood flow to a tissue caused by embolism, thrombosis, or trauma. Raynaud's phenomenon is characterized by vasospasm-induced color changes of the fingers, toes, ears, and nose.
A 50-year-old patient is reporting a sore shoulder after raking the yard. The nurse should suspect which problem? A. Bursitis B. Fasciitis C. Sprained ligament D. Achilles tendonitis
A. Bursitis Bursitis is common in adults over age 40 and with repetitive motion, such as raking. Plantar fasciitis frequently occurs as a stabbing pain at the heel caused by straining the ligament that supports the arch. Achilles tendonitis is an inflammation of the tendon that attaches the calf muscle to the heel bone, not the shoulder, and causes pain with walking or running. A sprained ligament occurs when a ligament is stretched or torn from a direct injury or sudden twisting of the joint, not repetitive motion.
5. A nurse is teaching a client who has hepatitis B about home care. Which of the following should the nurse include in the teaching? (Select all that apply.) A. Limit physical activity. B. Avoid alcohol. C. Take acetaminophen for comfort. D. Wear a mask when in public places. E. Eat small frequent meals.
A. CORRECT: Limiting physical activity and taking frequent rest breaks conserves energy and assists in the recovery process for a client who has hepatitis B. B. CORRECT: Alcohol is metabolized in the liver and should be avoided by the client who has hepatitis B. E. CORRECT: A client who has hepatitis B should eat small frequent meals to promote improved nutrition due to the presence of anorexia.
The parathyroid glands play a major role in regulating which substances? A. Calcium and Phosphorus B. Cholride and potassium C. Potassium and calcium D. Sodium and potassium
A. Calcium and Phosphorus
Musculoskeletal assessment is an important component of care for patients on what type of long-term therapy? A. Corticosteroids B. β-Adrenergic blockers C. Antiplatelet aggregators D. Calcium-channel blockers
A. Corticosteroids Corticosteroids are associated with avascular necrosis and decreased bone and muscle mass. β-blockers, calcium-channel blockers, and antiplatelet aggregators are not commonly associated with damage to the musculoskeletal system.
The patient is calling the clinic with a cough. What assessment should be made first before the nurse advises the patient? A. Cough sound, sputum production, pattern B. Frequency, a family history, hematemesis C. Smoking, medications, residence location D. Weight loss, activity tolerance, orthopnea
A. Cough sound, sputum production, pattern The sound of the cough, sputum production and description, as well as pattern of the cough's occurrence (including acute or chronic) and what its occurrence is related to are the first assessments to be made to determine the severity. Frequency of the cough will not provide a lot of information. Family history can help to determine a genetic cause of the cough. Hematemesis is vomiting blood and not as important as hemoptysis. Smoking is an important risk factor for COPD and lung cancer and may cause a cough. Medications may or may not contribute to a cough as does residence location. Weight loss, activity intolerance, and orthopnea may be related to respiratory or cardiac problems, but are not as important when dealing with a cough.
A 72-year-old patient with kyphosis is scheduled for dual-energy x-ray absorptiometry (DXA) testing. The nurse will plan to a. explain the procedure. b. start an IV line for contrast medium injection. c. give an oral sedative 60 to 90 minutes before the procedure. d. screen the patient for allergies to shellfish or iodine products.
A. DXA testing is painless and noninvasive. No IV access is necessary. Contrast medium is not used. Because the procedure is painless, no antianxiety medications are required.
When assessing a patient's sleep-rest pattern related to respiratory health, what should the nurse ask the patient about (select all that apply)? A. Have trouble falling asleep? B. Need to urinate during the night? C. Awaken abruptly during the night? D. Sleep more than 8 hours per night? E. Need to sleep with the head elevated?
A. Have trouble falling asleep? C. Awaken abruptly during the night? E. Need to sleep with the head elevated? The patient with sleep apnea may have insomnia and/or abrupt awakenings. Patients with cardiovascular disease (e.g., heart failure that may affect respiratory health) may need to sleep with the head elevated on several pillows (orthopnea). Sleeping more than 8 hours per night or needing to urinate during the night is not indicative of impaired respiratory health.
When working with patients, the nurse knows that patients have the most difficulties with diarthrodial joints. Which joints are included in this group of joints? (Select all that apply.) A. Hinge joint of the knee B. Ligaments joining the vertebrae C. Fibrous connective tissue of the skull D. Ball and socket joint of the shoulder or hip E. Cartilaginous connective tissue of the pubis joint
A. Hinge joint of the knee D. Ball and socket joint of the shoulder or hip The diarthrodial joints include the hinge joint of the knee and elbow, the ball and socket joint of the shoulder and hip, the pivot joint of the radioulnar joint, and the condyloid, saddle, and gliding joints of the wrist and hand. The ligaments and cartilaginous connective tissue joining the vertebrae and pubis joint and the fibrous connective tissue of the skull are synarthrotic joints.
A patient with recurrent shortness of breath has just had a bronchoscopy. What is a priority nursing action immediately following the procedure? A. Monitor the patient for laryngeal edema. B. Assess the patient's level of consciousness. C. Monitor and manage the patient's level of pain. D. Assess the patient's heart rate and blood pressure.
A. Monitor the patient for laryngeal edema. Priorities for assessment are the patient's airway and breathing, both of which may be compromised after bronchoscopy by laryngeal edema. These assessment parameters supersede the importance of loss of consciousness (LOC), pain, heart rate, and blood pressure, although the nurse should also be assessing these.
What medications should the nurse expect to include in the teaching plan to decrease the risk of cardiovascular events and death for PAD patients (select all that apply)? A. Ramipril (Altace) B. Cilostazol (Pletal) C. Simvastatin (Zocor) D. Clopidogrel (Plavix) E. Warfarin (Coumadin) F. Aspirin (acetylsalicylic acid)
A. Ramipril (Altace) C. Simvastatin (Zocor) F. Aspirin (acetylsalicylic acid) Angiotensin-converting enzyme inhibitors (e.g., ramipril [Altace]) are used to control hypertension. Statins (e.g., simvastatin [Zocor]) are used for lipid management. Aspirin is used as an antiplatelet agent. Cilostazol (Pletal) is used for intermittent claudication, but it does not reduce CVD morbidity and mortality risks. Clopidogrel may be used if the patient cannot tolerate aspirin. Anticoagulants (e.g., warfarin [Coumadin]) are not recommended to prevent CVD events in PAD patients.
The nurse is developing a treatment regimen for an active 78-year-old woman who has osteoarthritis with chronic joint pain. Which modality would be the safest for this patient? A. Regular exercise program and acetaminophen as needed B. High-dose opioids titrated to reach an acceptable pain level C. Placebo to reduce the risk of adverse medication side effects D. Regularly scheduled doses of nonsteroidal antiinflammatory drugs
A. Regular exercise program and acetaminophen as needed Treatment regimens for older adults should include nondrug modalities such as exercise. Acetaminophen should be used whenever possible instead of nonsteroidal antiinflammatory drugs that have a high incidence of serious GI bleeding when used in older adults. In older adults, opioids should be initiated at low doses and titrated upward while monitoring carefully for side effects. The use of placebos in clinical practice to assess or treat pain outside of the situation of informed consent in research studies is unethical.
Assessment of a patient's peripheral IV site reveals that phlebitis has developed over the past several hours. Which intervention should the nurse implement first? A. Remove the patient's IV catheter. B. Apply an ice pack to the affected area. C. Decrease the IV rate to 20 to 30 mL/hr. D. Administer prophylactic anticoagulants.
A. Remove the patient's IV catheter.
The patient with cirrhosis has an increased abdominal girth from ascites. The nurse should know that this fluid gathers in the abdomen for which reasons (select all that apply)? A. There is decreased colloid oncotic pressure from the liver's inability to synthesize albumin. B. Hyperaldosteronism related to damaged hepatocytes increases sodium and fluid retention. C. Portal hypertension pushes proteins from the blood vessels, causing leaking into the peritoneal cavity. D. Osmoreceptors in the hypothalamus stimulate thirst, which causes the stimulation to take in fluids orally. E. Overactivity of the enlarged spleen results in increased removal of blood cells from the circulation, which decreases the vascular pressure.
A. There is decreased colloid oncotic pressure from the liver's inability to synthesize albumin. B. Hyperaldosteronism related to damaged hepatocytes increases sodium and fluid retention. C. Portal hypertension pushes proteins from the blood vessels, causing leaking into the peritoneal cavity. The ascites related to cirrhosis are caused by decreased colloid oncotic pressure from the lack of albumin from liver inability to synthesize it and the portal hypertension that shifts the protein from the blood vessels to the peritoneal cavity, and hyperaldosteronism which increases sodium and fluid retention. The intake of fluids orally and the removal of blood cells by the spleen do not directly contribute to ascites
When caring for a patient with liver disease, the nurse recognizes the need to prevent bleeding resulting from altered clotting factors and rupture of varices. Which nursing interventions would be appropriate to achieve this outcome (select all that apply)? A. Use smallest gauge needle possible when giving injections or drawing blood. B. Teach patient to avoid straining at stool, vigorous blowing of nose, and coughing. C. Advise patient to use soft-bristle toothbrush and avoid ingestion of irritating food. D. Apply gentle pressure for the shortest possible time period after performing venipuncture. E. Instruct patient to avoid aspirin and NSAIDs to prevent hemorrhage when varices are present.
A. Use smallest gauge needle possible when giving injections or drawing blood. B. Teach patient to avoid straining at stool, vigorous blowing of nose, and coughing. C. Advise patient to use soft-bristle toothbrush and avoid ingestion of irritating food. E. Instruct patient to avoid aspirin and NSAIDs to prevent hemorrhage when varices are present. Using the smallest gauge needle for injections will minimize the risk of bleeding into the tissues. Avoiding straining, nose blowing, and coughing will reduce the risk of hemorrhage at these sites. The use of a soft-bristle toothbrush and avoidance of irritating food will reduce injury to highly vascular mucous membranes. The nurse should apply gentle but prolonged pressure to venipuncture sites to minimize the risk of bleeding. Aspirin and NSAIDs should not be used in patients with liver disease because they interfere with platelet aggregation, thus increasing the risk for bleeding
The nurse is admitting a 68-year-old preoperative patient with a suspected abdominal aortic aneurysm (AAA). The medication history reveals that the patient has been taking warfarin (Coumadin) on a daily basis. Based on this history and the patient's admission diagnosis, the nurse should prepare to administer which medication? A. Vitamin K B. Cobalamin C. Heparin sodium D. Protamine sulfate
A. Vitamin K Coumadin is a Vitamin K antagonist anticoagulant that could cause excessive bleeding during surgery if clotting times are not corrected before surgery. For this reason, vitamin K is given as the antidote for warfarin (Coumadin).
The nurse is providing preoperative teaching to the patient about to undergo a thyroidectomy. Which statement, if made by the patient, indicates the need for further teaching? A) I need to eat super healthy before the surgery and should limit my calories to a healthy amount B) Before the surgery I should practice raising my elbows and placing both hands behind my neck to provide support C) Well, I will have to quit drinking my coffee and alcohol for now D) I will be sure increase my intake of protein and carbohydrates
A. a high calorie diet should be encouraged preoperatively because of the increased metabolic needs of the body. Practicing supporting the neck before the surgery is a good way to remember what to do after the surgery. The patient should avoid consuming any stimulants including tea, coffee, and cola. The patient should increase intake of protein and carbohydrates preoperatively because of increased metabolic needs.
A student nurse asks the RN what can be measured by arterial blood gases (ABGs). The RN tells the student that the ABGs can measure (select all that apply). A. acid-base balance. B. oxygenation status. C. acidity of the blood. D. glucose bound to hemoglobin. E. bicarbonate (HCO3-) in arterial blood.
A. acid-base balance. B. oxygenation status. C. acidity of the blood. E. bicarbonate (HCO3-) in arterial blood. Arterial blood gases (ABGs) are measured to determine oxygenation status and acid-base balance. ABG analysis includes measurement of the PaO2, the partial pressure of carbon dioxide in arterial blood (PaCO2), acidity (pH), and bicarbonate (HCO3-) in arterial blood.
When assessing activity-exercise patterns related to respiratory health, the nurse inquires about: A. dyspnea during rest or exercise. B. recent weight loss or weight gain. C. ability to sleep through the entire night. D. willingness to wear oxygen equipment in public.
A. dyspnea during rest or exercise. In this functional health pattern, determine whether the patient's activity is limited by dyspnea at rest or during exercise.
Identify the rationales for the following interventions in treating the cirrhotic patient with hepatic encephalopathy a. Lactulose (Cephulac) b. Neomycin c. Eliminating blood from the GI tract
A. reduction of ammonia formation by decreasing absorption of ammonia from bowel B. reduction of ammonia formation by reducing bacterial flora that produce ammonia C. Reduction of ammonia formation by removing red blood cells as a source of protein
To promote the release of surfactant, the nurse encourages the patient to: A. take deep breaths. B. cough five times per hour to prevent alveolar collapse. C. decrease fluid intake to reduce fluid accumulation in the alveoli. D. sit with head of bed elevated to promote air movement through the pores of Kohn.
A. take deep breaths. Surfactant is a lipoprotein that lowers the surface tension in the alveoli. It reduces the amount of pressure needed to inflate the alveoli and decreases the tendency of the alveoli to collapse. Deep breaths stretch the alveoli and promote surfactant secretion.
At the end of the shift, the nurse clears the PCA and discovers that the client has used only a small amount of medication. Which intervention should the nurse implement? 1. Determine why the client is not using the PCA. 2. Document the amount and take no action. 3. Chart that the client is not having pain. 4. Contact the HCP and request oral medication.
ANS: 1 Assessing why the client is not using the medication is a priority and then, based on the client's response, a plan of care can be determined.
When preparing the plan of care for the client in acute pain as a result of surgery, the nurse should include which intervention? 1. Administer pain medication as soon as the time frame allows. 2. Use nonpharmacological methods to replace medications. 3. Use cryotherapy after heat therapy because it works faster. 4. Instruct family members to administer medication with the PCA.
ANS: 1 Pain medications should be administered at the frequency ordered by the HCP, not just when the client requests them, especially for acute pain.
When working on the surgical floor, which task can the nurse delegate to the unli- censed nursing assistant (NA)? 1. Take vital signs every four (4) hours. 2. Check the Jackson-Pratt insertion site. 3. Hang the client's next IV bag. 4. Ensure that the client gets pain relief.
ANS: 1 Taking the vital signs of the stable client may be delegated to the NA.
When receiving the client from the OR, which intervention should the PACU nurse implement first? 1. Assess the client's breath sounds. 2. Apply oxygen via nasal cannula. 3. Take the client's blood pressure. 4. Monitor the pulse oximeter reading.
ANS: 1 The airway should be assessed first. When caring for a client, the nurse should follow the ABCs: airway, breathing, and circulation.
While conducting an interview with a 75-year-old client admitted with acute pain, which question would have priority when assisting with pain management? 1. "Have you ever had difficulty getting your pain controlled?" 2. "What types of surgery have you had in the last 10 years?" 3. "Have you ever been addicted to narcotics?" 4. "Do you have a list of your prescription medications?"
ANS: 1 The answer to this request would indicate if the client has had a negative experience that may influence the client's pain man- agement.
Which activities are the circulating nurse's responsibilities in the operating room? 1. Monitor the position of the client, prepare the surgical site, and ensure the client's safety. 2. Give preoperative medication in the holding area and monitor the client's response to anesthesia. 3. Prepare sutures; set up the sterile field; and count all needles, sponges, and instruments. 4. Prepare the medications to be administered by the anesthesiologist and change the tubing for the anesthesia machine.
ANS: 1 The circulating nurse has many responsibilities in the OR, including coordinating the activities in the OR; keeping the OR clean; ensuring the safety of the client; and maintaining the humidity, lighting, and safety of the equipment.
While working in the operating room, the nurse notices that the client has tachycar- dia and hypotension. Which interventions should the nurse anticipate? 1. Prepare ice packs and mix dantrolene sodium. 2. Request the defibrillator to be brought into the OR. 3. Draw a PTT and prepare a heparin drip. 4. Obtain fingerstick blood glucose immediately.
ANS: 1 Unexplained tachycardia, hypotension, and elevated temperature are signs of malignant hyperthermia, which is treated with ice packs and Dantrolene sodium.
The nurse requests a client to sign the surgical consent form for an emergency appendectomy. Which statement by the client indicates that further teaching is needed? 1. "I will be glad when this is over so that I can go home." 2. "I will not be able to eat or drink anything prior to my surgery." 3. "I need to practice relaxing by listening to my favorite music." 4. "I will need to get up and walk as soon as possible."
ANS: 1 When recuperating from emergency surgery, the client will be in the hospital for a few days. This is not a day-surgery procedure. The client needs more teaching.
Which nursing intervention would be priority for the client experiencing acute pain? 1. Assess verbal and nonverbal behavior. 2. Wait for the client to request pain medication. 3. Bring the pain medication on a scheduled basis. 4. Teach the client to use only imagery every hour for the pain.
ANS: 1 Assessing verbal and nonverbal cues is the priority intervention because pain is subjective.
The nurse is caring for a client scheduled for abdominal surgery. Which interventions should the nurse include in the plan of care? Select all that apply. 1. Perform range-of-motion exercises. 2. Discuss how to cough effectively. 3. Explain how to perform deep-breathing exercises. 4. Teach ways to manage postoperative pain. 5. Discuss events that occur in the post- anesthesia care unit.
ANS: 1,2,3,4,5 1. These exercises help prevent postoperative DVT 2. Coughing effectively aids in the removal of pooled secretions that can cause pneumonia. 3. Deep-breathing exercises keep the alveoli inflated and prevent atelectasis. 4. The client's postoperative pain should be kept within a tolerable range. 5. These interventions help decrease the client's anxiety.
When interviewing the surgical client in the holding area, which information should the nurse report to the health-care provider? Select all that apply. 1. The client has loose, decayed teeth. 2. The client is experiencing anxiety. 3. The client smokes 2 packs of cigarettes a day. 4. The client has had a chest x-ray that does not show infiltrates. 5. The client reports using herbs.
ANS: 1,2,3,5 1.Loose teeth or caries need to be reported to the health-care provider so he or she can make provisions to prevent breaking the teeth and causing the client to possibly aspirate pieces. 2. The nurse should report any client who is extremely anxious. 3. Smokers are at a higher risk for complica- tions from anesthesia. 5. Herbs—for example, St. John's wort, licorice, and ginkgo have serious interactions with anesthesia and with bodily functions such as coagulation.
The nurse receives a report that the postoperative client received Narcan, an opioid antagonist, in PACU. Which client problem should the nurse add to the plan of care? 1. Alteration in comfort. 2. Risk for depressed respiratory pattern. 3. Potential for infection. 4. Fluid and electrolyte imbalance.
ANS: 2 Aclientwithrespiratorydepressiontreated with Narcan can have another episode within 15 minutes after receiving the drug as a result of the short half-life of the medication.
Which statement would be an expected outcome for the postoperative client who had general anesthesia? 1. The client will be able to sit in the chair for 30 minutes. 2. The client will have a pulse oximetry reading of 97% on room air. 3. The client will have a urine output of 30 mL per hour. 4. The client will be able to distinguish sharp from dull sensations.
ANS: 2 The anesthesia machine takes over the function of the lungs during surgery so the expected outcome should directly reflect the client's respiratory status; the alveoli can collapse, causing atelectasis.
Which statement would be an expected outcome for a client experiencing acute pain? 1. The client will have decreased use of medication. 2. The client will participate in self-care activities. 3. The client will use relaxation techniques. 4. The client will repeat instructions about medications.
ANS: 2 Clients experiencing acute pain will not be involved in self-care because of their reluctance to move, which increases the pain; therefore, participation indicates the client's pain is tolerable.
The nurse identifies the nursing diagnosis "risk for injury related to positioning" for the client in the operating room. Which nursing action should the nurse implement? 1. Avoid using the cautery unit that does not have a biomedical tag on it. 2. Carefully pad the client's elbows before covering the client with a blanket. 3. Apply a warming pad on the OR table before placing the client on the table. 4. Check the chart for any prescription or over-the-counter medication use.
ANS: 2 Padding the elbows decreases pressure so that nerve damage and pressure ulcers are prevented. This addresses the etiology of the nursing diagnosis.
When positioning the intraoperative client for surgery, which client should the nurse consider at the highest rank for irreparable nerve damage? 1. The 16-year-old client in the dorsal recumbent position having an appendectomy. 2. The 68-year-old client in the Trendelenburg position having a cholecystectomy. 3. The 45-year-old client in the reverse Trendelenburg position having a biopsy. 4. The 22-year-old client in the lateral position having a nephrectomy.
ANS: 2 The client's age, along with positioning with increased weight and pressure on the shoulders, puts this client at higher risk.
The nurse in the holding area of the surgery department is interviewing a client who requests to keep his religious medal on during surgery. Which intervention should the nurse implement? 1. Notify the surgeon about the client's request to wear the medal. 2. Tape the medal to the client and allow the client to wear the medal. 3. Request that the family member take the medal prior to surgery. 4. Explain that taking the medal to surgery is against the policy.
ANS: 2 The medal should be taped and the client should be allowed to wear the medal because meeting spiritual needs is essential to this client's care.
Which nursing intervention has the highest priority when preparing the client for a surgical procedure? 1. Pad the client's elbows and knees. 2. Apply soft restraint straps to the extremities. 3. Prepare the client's incision site. 4. Document the temperature of the room.
ANS: 2 This action would prevent the client from falling off the table, which is the highest priority.
Which intervention should the nurse delegate to the unlicensed nursing assistant when caring for the client experiencing acute pain? 1. Take the pain medication to the room. 2. Apply an ice pack to the site of pain. 3. Check on the client 30 minutes after he or she takes the pain medication. 4. Observe the patient's ability to use the PCA.
ANS: 2 This task does not require teaching, evaluating, or nursing judgment and therefore could be delegated.
The 26-year-old male client in the PACU has a heart rate of 110, has a rising temper- ature, and complains of muscle stiffness. Which interventions should the nurse imple- ment? Select all apply. 1. Give a back rub to the client to relieve stiffness. 2. Apply ice packs to axillary and groin areas. 3. Prepare a nice slush for the client to drink. 4. Prepare to administer Dantrolene, a smooth-muscle relaxant. 5. Reposition the client on a warming blanket.
ANS: 2,3,4 2. Ice packs should be applied to the axillary and groin areas for a client experiencing malignant hyperthermia. 3. The client would be NPO to prepare for intubation, but an ice slush would be used to irrigate the bladder and stomach per nasogastric tube. 4. Dantrolene is the drug of choice for treatment.
The patient's IV has been infusing at a very high rate and now the patient appears to be in fluid volume overload, as indicated by: 1. hypotension. 2. tachycardia. 3. pulmonary edema. 4. kidney failure.
ANS: 3 An IV infusing at a high rate is used to increase intravascular fluid volume, but there is an equalization level, after which the patient goes into fluid overload; this results in pulmonary edema.
The postoperative client is transferred from the PACU to the surgical floor. Which action should the nurse implement first? 1. Apply anti-embolism hose to the client. 2. Attach the drain to 20 cm suction. 3. Assess the client's vital signs. 4. Listen to the report from the anesthesiologist.
ANS: 3 Assessing the client's status after transfer from the PACU should be the nurse's first intervention.
After transferring the client from the PACU to the surgical unit, the client's vital signs are T 98F, P 106, R 24, and BP 88/40. The client is awake and oriented times three (3). The client's skin is pale and damp. Which intervention should the nurse implement first? 1. Call the surgeon and report the vital signs. 2. Start an IV of D5RL with 20 mEq KCl at 125 mL/hour. 3. Elevate the feet and lower the head. 4. Monitor the vital signs every 15 minutes.
ANS: 3 By lowering the head of the bed and raising the feet, the blood is shunted to the brain until volume-expanding fluids can be administered, which is the first intervention for a client who is hemorrhaging.
The unlicensed nursing assistant reports the vital signs for a first-day postoperative client of T 100.8F, P 80, R 24, and B/P 148/80. Which intervention would be most appropriate for the nurse to implement? 1. Administer the antibiotic earlier than scheduled. 2. Change the dressing over the wound. 3. Help the client turn, cough, and deep breathe q2h 4. Encourage the client to ambulate in the hall.
ANS: 3 Having the client turn, cough, and deep breathe is the best intervention for the nurse to implement because if a client has a fever within the first day, it is usually caused by a respiratory problem.
Which intervention has the highest priority when administering pain medication to a client experiencing acute pain? 1. Monitor the client's vital signs. 2. Verify the time of the last dose. 3. Check for the client's allergies. 4. Discuss the pain with the client.
ANS: 3 The face scale is the best way to assess pain for a four (4)-year-old child.
Which intervention would be the best way for the nurse to assess a four (4)-year-old client for acute pain? 1. Use words that a four (4)-year-old child can remember. 2. Explain the 0-10 pain scale to the child's parent. 3. Have the child point to the face that describes the pain. 4. Administer the medication every four (4) hours.
ANS: 3 The face scale is the best way to assess pain for a four (4)-year-old child.
While completing the preoperative assessment, the male client tells the nurse that he is allergic to codeine. Which intervention should the nurse implement first? 1. Apply an allergy bracelet on the client's wrist. 2. Label the client's allergies on the front of the chart. 3. Ask the client what happens when he takes the drug. 4. Document the allergy on the medication administration record.
ANS: 3 The nurse should first assess the events that occurred when the client took this medication because many clients think that a side effect, such as nausea, is an allergic reaction.
When completing the assessment for the client in the day surgery unit, the client states, "I am really afraid of having this surgery. I'm afraid of what they will find." Which statement would be the best therapeutic response by the nurse? 1. "Don't worry about your surgery. It is safe." 2. "Tell me why you're worried about your surgery." 3. "Tell me about your fears of having this surgery." 4. "I understand how you feel. Surgery is frightening."
ANS: 3 This statement focuses on the emotion that the client identified and is therapeutic.
Which situation demonstrates the circulating nurse acting as the client's advocate? 1. Plays the client's favorite audio book during surgery. 2. Keeps the family informed of the findings of the surgery. 3. Keeps the operating room door closed at all times. 4. Calls the client by the first name when the client is recovering.
ANS: 3 This would keep the client's dignity by maintaining privacy. With this action, the nurse is speaking for the client while they cannot speak as a result of anesthesia and is an example of client advocacy.
Which situation is an example of the nurse fulfilling the role of client advocate? 1. The nurse brings the client pain medication when it is due. 2. The nurse collaborates with other disciplines during the care conference. 3. The nurse contacts the health-care provider when pain relief is not obtained. 4. The nurse teaches the client to ask for medication before the pain gets to a "5."
ANS: 3 When the nurse contacts the HCP about unrelieved pain, the nurse is speaking when the client cannot, which is the definition of a client advocate.
While the circulating nurse compares the final sponge count with that of the scrub nurse, a discrepancy in the count is found. Which action should the circulating nurse take first? 1. Notify the client's surgeon. 2. Complete an Occurrence Report. 3. Contact the surgical manager. 4. Re-count all sponges.
ANS: 4 A recount of sponges may lead to the discovery of the cause of the presumed error. Usually it is just a miscount or a result of a sponge being placed in a location other than the sterile field, such as the floor or a lower shelf.
Which violation of surgical asepsis would require immediate intervention by the circu- lating nurse? 1. Surgical supplies were cleaned and sterilized prior to the case. 2. The circulating nurse is wearing a long-sleeved sterile gown. 3. Masks covering the mouth and nose are being worn by the surgical team. 4. The scrub nurse setting up the sterile field is wearing artificial nails.
ANS: 4 According to the Centers for Disease Control (CDC), the American Operating Room Nurses Association (AORN), and the Association of Professionals in Infection Control, artificial nails harbor microorganisms, which increase the risk for infection.
Which data indicate the nursing care has been effective for the client who is one (1) day postoperative surgery? 1. Urine output was 160 mL in the past eight (8) hours. 2. Bowel sounds occur four (4) times per minute. 3. T 99.0F, P 98, R 20, and BP 100/60. 4. Lungs are clear bilaterally in all lobes.
ANS: 4 Lung sounds that are clear bilaterally in all lobes indicate the client has adequate gas exchange, which prevents postoperative complications and indicates effective nursing care.
Which nursing task can the nurse delegate to the unlicensed nursing assistant (NA)? 1. Complete the preoperative checklist. 2. Assess the client's preoperative vital signs. 3. Teach the client about coughing and deep breathing. 4. Assist the client to remove clothing and jewelry.
ANS: 4 The NA can remove clothing and jewelry.
The client is scheduled for total hip replacement. Which behavior indicates to the nurse the need for further preoperative teaching? 1. The client uses the diaphragm and abdominal muscles to inhale through the nose and exhale through the mouth. 2. The client takes three slow, deep, breaths and coughs forcefully after inhaling for the third time. 3. The client uses the incentive spirometer and inhales slowly and deeply so that the piston rises to the preset volume. 4. The client gets out of bed by lifting straight upright from the waist and then swings both legs along the side of the bed.
ANS: 4 The correct way to get out of bed postoperatively is to roll onto the side, grasp the side rail to maneuver to the side, and then push up with one hand while swinging the legs over the side. The client needs further teaching.
Which description best defines the role of the nurse anesthetist as a member of the surgical team? a. Functions independently in the administration of anesthetics b. Has the same credentials and responsibilities as an anesthesiologist c. Is responsible for intraoperative administration of anesthetics ordered by the anesthesiologist d. Requires supervision by the anesthesiologist or surgeon while administering anesthesia to a patient
ANS: A The certified registered nurse anesthetist (CRNA) is independently responsible for all aspects of the administration of anesthetic agents. Although the responsibilities of a CRNA and an anesthesiologist have some overlap, the credentialing and roles are different. No supervision by a health care provider is necessary during anesthetic administration by a CRNA. The CRNA assesses the patient and makes the choice of anesthetic agent.
The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia. The nurse will plan to check the laboratory results for the a. Schilling test. b. bilirubin level. c. stool occult blood test. d. gastric analysis testing.
ANS: B Jaundice is caused by the elevation of bilirubin level associated with red blood cell (RBC) hemolysis. The other tests would not be helpful in monitoring or treating a hemolytic anemia.
When caring for a patient during the second postoperative day after abdominal surgery, the nurse obtains an oral temperature of 100.8° F. Which action should the nurse take first? a. Have the patient use the incentive spirometer. b. Assess the surgical incision for redness and swelling. c. Administer the ordered PRN acetaminophen (Tylenol). d. Notify the patient's health care provider about the fever.
ANS: A A temperature of 100.8° F in the first 48 hours is usually caused by atelectasis, and the nurse should have the patient cough and deep breathe. This problem may be resolved by nursing intervention, and therefore notifying the health care provider is not necessary. Acetaminophen will reduce the temperature, but it will not resolve the underlying respiratory congestion. Because evidence of wound infection does not usually occur before the third postoperative day, assessment of the incision is not likely to be useful.
On the day of surgery, the nurse is admitting a patient with a history of cigarette smoking. Which action is most important at this time? a. Auscultate for adventitious breath sounds. b. Ask whether the patient has smoked recently. c. Remind the patient about harmful effects of smoking. d. Calculate the cigarette smoking history in pack-years.
ANS: A Abnormal breath sounds may indicate the presence of an acute respiratory infection or chronic lung disease that will affect the choice of anesthesia and/or proceeding with the scheduled surgery. The other nursing actions also are appropriate but will not affect the immediate surgical procedure as much as the presence of abnormal breath sounds.
A patient who is just waking up after having a general anesthetic is agitated and confused. Which action should the nurse take first? a. Check the O2 saturation. b. Administer the ordered opioid. c. Take the blood pressure and pulse. d. Notify the anesthesia care provider.
ANS: A Emergence delirium may be caused by a variety of factors. However, the nurse should first assess for hypoxemia. The other actions also may be appropriate, but are not the best initial action.
A patient's family history reveals that the patient may be at risk for malignant hyperthermia (MH) during anesthesia. The nurse explains to the patient that a. anesthesia can be administered with minimal risks with the use of appropriate precautions and medications. b. as long as succinylcholine (Anectine) is not administered as a muscle relaxant, the reaction should not occur. c. surgery must be performed under local anesthetic to prevent development of a sudden, extreme increase in body temperature. d. surgery will be delayed until the patient is genetically tested to determine whether he or she is susceptible to malignant hyperthermia
ANS: A General anesthesia can be administered to patients with MH as long as precautions to avoid MH are taken and preparations are made to treat MH if it does occur. Other factors besides succinylcholine administration are associated with MH. Predictions about whether MH will occur based on family history are inconsistent, and it may not be possible to delay surgery.
A patient with a dislocated shoulder is prepared for a closed, manual reduction of the dislocation with monitored anesthesia care (MAC). The nurse anticipates the administration of a. IV midazolam (Versed). b. inhaled desflurane (Suprane). c. epidural lidocaine (Xylocaine). d. eutectic mixture of local anesthetics (EMLA).
ANS: A IV sedatives such as the benzodiazipines are administered for MAC. Inhaled, epidural, and topical agents are not included in MAC.
While caring for a patient who had abdominal surgery on the second postoperative day, which information about the patient is most important to communicate to the health care provider? a. The right calf is swollen, warm, and painful. b. The patient's temperature is 100.3° F c. The 24-hour oral intake is 600 ml greater than the total output. d. The patient complains of abdominal pain at level 6 (0-10 scale).
ANS: A The calf pain, swelling, and warmth suggest that the patient has a deep vein thrombosis, which will require health care provider orders for diagnostic tests and anticoagulants. Because the stress response causes fluid retention for the first 2 to 5 days postoperatively, the difference between intake and output is expected. A temperature elevation to 100.3° F on the second postoperative day suggests atelectasis, and the nurse should have the patient deep breathe and cough. Pain with ambulation is normal, and the nurse should administer the ordered analgesic before patient activities.
A preoperative patient in the holding area asks the nurse, "Will the doctor put me to sleep with a mask over my face?" The most appropriate response by the nurse is, a. "A drug will be given to you through your IV line, which will cause you to go to sleep almost immediately." b. "Only your surgeon can tell you for sure what method of anesthesia will be used. Should I ask your surgeon?" c. "General anesthesia is now given by injecting medication into your veins, so you will not need a mask over your face." d. "Masks are not used anymore for anesthesia. A tube will be inserted into your throat to deliver a gas that will put you to sleep."
ANS: A The first step in general anesthesia is the injection of an intravenous (IV) induction agent, which rapidly induces sleep. The anesthesiologist (not the surgeon) determines the method of anesthesia used. Masks may still be used for inhalation, although many patients are intubated. Total IV anesthesia may be used for some patients but inhalation anesthetics also are commonly used.
The clinic nurse reviews the complete blood cell count (CBC) results for a patient who is scheduled for surgery in a few days. The results are white blood cell count (WBC) 10.2 ⋅ 103/µL; hemoglobin 15 g/dL; hematocrit 45%; platelets 150 ⋅ 103/µL. Which action should the nurse take? a. Send the CBC results to the surgery facility. b. Call the surgeon and anesthesiologist immediately. c. Ask the patient about any symptoms of a recent infection. d. Discuss the possibility of blood transfusion with the patient.
ANS: A The nurse should be sure that the CBC results, which are normal, are available at the surgical facility to avoid delay of the procedure. With normal results, there is no need to notify the surgeon or anesthesiologist, discuss blood transfusion, or ask about recent infection.
During the preoperative interview, a patient scheduled for an elective hysterectomy tells the nurse, "I am afraid that I will die in surgery like my mother did!" Which response by the nurse is most appropriate? a. "Tell me more about what happened to your mother." b. "You will receive medications to reduce your anxiety." c. "You should talk to the doctor again about the surgery." d. "Surgical techniques have improved a lot in recent years."
ANS: A The patient's statement may indicate an unusually high anxiety level or a family history of problems such as malignant hyperthermia, which will require precautions during surgery. The other statements also may address the patient's concerns, but further assessment is needed first.
Five minutes after receiving a preoperative sedative medication by IV injection, a patient asks to get up to go to the bathroom to urinate. Which of the following is the most appropriate action for the nurse to take? A. Offer the patient to use the urinal/bedpan after explaining the need to maintain safety. B. Assist the patient to the bathroom and stay next to the door to assist patient back to bed when done. C. Allow the patient to go to the bathroom since the onset of the medication will be more than 5 minutes. D. Ask the patient to hold the urine for a short period since a urinary catheter will be placed in the operating room.
ANS: A The prime issue after administration of either sedative or opioid analgesic medications is safety. Because the medications affect the central nervous system, the patient is at risk for falls and should not be allowed out of bed, even with assistance.
Which nursing action should the operating room (OR) nurse manager delegate to the registered nurse first assistant (RNFA)? a. Make surgical incisions and suture incisions as needed. b. Coordinate transfer of the patient to the operating table. c. Provide postoperative teaching about coughing to the patient. d. Set up instrument tables at the beginning of the surgical procedure.
ANS: A The role of the RNFA includes skills such as making and suturing incisions and maintaining hemostasis. The other actions should be delegated to other staff members such as the circulating nurse, scrub nurse, or surgical technician.
Which action should the postanesthesia care unit (PACU) nurse delegate to nursing assistive personnel (NAP) who help with the transfer of a patient to the surgical unit? a. Help with the transfer of the patient onto a stretcher. b. Give a verbal report to the surgical unit charge nurse. c. Document the appearance of the patient's incision in the chart. d. Ensure that the receiving nurse understands the postoperative orders.
ANS: A The scope of practice for nursing assistants includes repositioning and moving patients under the supervision of an RN. Providing report to another RN, assessing and documenting the wound appearance, and clarifying physician orders with another RN require RN level education and scope of practice.
Any patient guilt about having a therapeutic abortion may be identified when the nurse assesses the functional health pattern of _____________. a. value-belief. b. cognitive-perceptual. c. sexuality-reproductive. d. coping-stress tolerance.
ANS: A The value-belief pattern includes information about conflicts between a patient's values and proposed medical care. In the cognitive-perceptual pattern, the nurse will ask questions about pain and sensory intactness. The sexuality-reproductive pattern includes data about the impact of the surgery on the patient's sexuality. The coping-stress tolerance pattern assessment will elicit information about how the patient feels about the surgery.
Which action will the nurse include in the plan of care for a 72-year-old woman admitted with multiple myeloma? a. Monitor fluid intake and output. b. Administer calcium supplements. c. Assess lymph nodes for enlargement. d. Limit weight bearing and ambulation.
ANS: A A high fluid intake and urine output helps prevent the complications of kidney stones caused by hypercalcemia and renal failure caused by deposition of Bence-Jones protein in the renal tubules. Weight bearing and ambulation are encouraged to help bone retain calcium. Lymph nodes are not enlarged with multiple myeloma. Calcium supplements will further increase the patient's calcium level and are not used
24. Which action will the nurse include in the plan of care for a 72-year-old woman admitted with multiple myeloma? a. Monitor fluid intake and output. b. Administer calcium supplements. c. Assess lymph nodes for enlargement. d. Limit weight bearing and ambulation.
ANS: A A high fluid intake and urine output helps prevent the complications of kidney stones caused by hypercalcemia and renal failure caused by deposition of Bence-Jones protein in the renal tubules. Weight bearing and ambulation are encouraged to help bone retain calcium. Lymph nodes are not enlarged with multiple myeloma. Calcium supplements will further increase the patient's calcium level and are not used.
An appropriate nursing intervention for a patient with non-Hodgkin's lymphoma whose platelet count drops to 18,000/µL during chemotherapy is to a. check all stools for occult blood. b. encourage fluids to 3000 mL/day. c. provide oral hygiene every 2 hours. d. check the temperature every 4 hours.
ANS: A Because the patient is at risk for spontaneous bleeding, the nurse should check stools for occult blood. A low platelet count does not require an increased fluid intake. Oral hygiene is important, but it is not necessary to provide oral care every 2 hours. The low platelet count does not increase risk for infection, so frequent temperature monitoring is not indicated.
The nurse evaluating effectiveness of prescribed calcitonin (Cibacalcin) and ibandronate (Boniva) for a patient with Paget's disease will consider the patient's a. pain level. b. oral intake. c. daily weight. d. grip strength.
ANS: A Bone pain is one of the common early manifestations of Paget's disease, and the nurse should assess the pain level to determine whether the treatment is effective. The other information will also be collected by the nurse, but will not be used in evaluating the effectiveness of the therapy.
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.
The nurse examines the lymph nodes of a patient during a physical assessment. Which assessment finding would be of most concern to the nurse? a. A 2-cm nontender supraclavicular node b. A 1-cm mobile and nontender axillary node c. An inability to palpate any superficial lymph nodes d. Firm inguinal nodes in a patient with an infected foot
ANS: A Enlarged and nontender nodes are suggestive of malignancies such as lymphoma. Firm nodes are an expected finding in an area of infection. The superficial lymph nodes are usually not palpable in adults, but if they are palpable, they are normally 0.5 to 1 cm and nontender.
6. Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate? a. "I will call my health care provider if my stools turn black." b. "I will take a stool softener if I feel constipated occasionally." c. "I should take the iron with orange juice about an hour before eating." d. "I should increase my fluid and fiber intake while I am taking iron tablets."
ANS: A It is normal for the stools to appear black when a patient is taking iron, and the patient should not call the doctor about this. The other patient statements are correct.
An assessment finding for a 55-year-old patient that alerts the nurse to the presence of osteoporosis is a. a measurable loss of height. b. the presence of bowed legs. c. the aversion to dairy products. d. a statement about frequent falls.
ANS: A Osteoporosis occurring in the vertebrae produces a gradual loss of height. Bowed legs are associated with osteomalacia. Low intake of dairy products is a risk factor for osteoporosis, but it does not indicate that osteoporosis is present. Frequent falls increase the risk for fractures but are not an indicator of osteoporosis.
31. The nurse cares for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider? a. Oxygen saturation is 88%. b. Blood pressure is 145/90 mm Hg. c. Respiratory rate is 22 breaths/minute when lying flat. d. Pain level is 5 (on 0 to 10 scale) with a deep breath.
ANS: A Oxygen saturation would be expected to improve after a thoracentesis. A saturation of 88% indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low oxygen saturation is the priority.
22. A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment? a. Paradoxic chest movement b. Complaint of chest wall pain c. Heart rate of 110 beats/minute d. Large bruised area on the chest
ANS: A Paradoxic chest movement indicates that the patient may have flail chest, which can severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange.
31. Which patient should the nurse assign as the roommate for a patient who has aplastic anemia? a. A patient with chronic heart failure b. A patient who has viral pneumonia c. A patient who has right leg cellulitis d. A patient with multiple abdominal drains
ANS: A Patients with aplastic anemia are at risk for infection because of the low white blood cell production associated with this type of anemia, so the nurse should avoid assigning a roommate with any possible infectious process.
Which patient should the nurse assign as the roommate for a patient who has aplastic anemia? a. A patient with chronic heart failure b. A patient who has viral pneumonia c. A patient who has right leg cellulitis d. A patient with multiple abdominal drains
ANS: A Patients with aplastic anemia are at risk for infection because of the low white blood cell production associated with this type of anemia, so the nurse should avoid assigning a roommate with any possible infectious process.
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/L. 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/L 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.
16. The nurse caring for a patient with type A hemophilia being admitted to the hospital with severe pain and swelling in the right knee will a. immobilize the joint. b. apply heat to the knee. c. assist the patient with light weight bearing. d. perform passive range of motion to the knee.
ANS: A The initial action should be total rest of the knee to minimize bleeding. Ice packs are used to decrease bleeding. Range of motion (ROM) and weight-bearing exercise are contraindicated initially, but after the bleeding stops, ROM and physical therapy are started.
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.
1. Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data 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.
48. The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Document the amount of drainage every eight hours. b. Obtain samples of drainage for culture from the system. c. Assess patient pain level associated with the chest tube. d. Check the water-seal chamber for the correct fluid level.
ANS: A UAP education includes documentation of intake and output. The other actions are within the scope of practice and education of licensed nursing personnel.
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.
A patient's blood pressure in the PACU has dropped from an admission blood pressure of 138/84 to 100/58 with a pulse change of 68 to 94. SpO2 is 98% on 3L of oxygen. In which order should the nurse take these actions? a. Raise the IV infusion rate. b. Assess the patient's dressing. c. Increase the oxygen flow rate. d. Check the patient's temperature.
ANS: A, C, B, D The first nursing action should be to increase the IV infusion rate. Since the most common cause of hypotension is volume loss, the IV rate should be increased. The next action should be to increase the oxygen flow rate to maximize oxygenation of hypoperfused organs. Because hemorrhage is a common cause of postoperative volume loss, the nurse should check the dressing. Finally, the patient should be assessed for vasodilation caused by rewarming.
Which actions will the nurse include in the plan of care when caring for a patient with metastatic bone cancer of the left femur (select all that apply)? a. Monitor serum calcium level. b. Teach about the need for strict bed rest. c. Avoid use of sustained-release opioids for pain. d. Support the left leg when repositioning the patient. e. Support family as they discuss the prognosis of patient
ANS: A, D, E The nurse will monitor for hypercalcemia caused by bone decalcification. Support of the leg helps reduce the risk for pathologic fractures. Although the patient may be reluctant to exercise, activity is important to maintain function and avoid the complications associated with immobility. Adequate pain medication, including sustained-release and rapidly acting opioids, is needed for the severe pain that is frequently associated with bone cancer. The prognosis for metastatic bone cancer is poor so the patient and family need to be supported as they deal with the reality of the situation.
Which of the following is the primary reason for accurately recording the patient's current medications during a preoperative assessment? A. Some medications may alter the patient's perceptions about surgery. B. Many anesthetics alter renal and hepatic function, causing toxicity of other drugs. C. Some medications may interact with anesthetics, altering the potency and effect of the drugs. D. Routine medications are withheld the day of surgery, requiring dosage and schedule adjustments after surgery.
ANS: A. Drug interactions may occur between prescribed medications and anesthetic agents used during surgery. For this reason, it is important to take a careful medication history and check that they have been communicated to the anesthesia care provider.
Which medication should the nurse be prepared to administer to a client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion? A. Morphine B. Demeclocycline C. Dextrose 5% in water D. Tricyclic antidepressants
ANS: B Demeclocycline, a tetracycline derivative, antagonizes antidiuretic hormone and corrects the water and sodium imbalance resulting from SIADH.
A 42-year-old patient is recovering from anesthesia in the postanesthesia care unit (PACU). On admission to the PACU, the blood pressure (BP) is 124/70. Thirty minutes after admission, the blood pressure falls to 112/60, with a pulse of 72 and warm, dry skin. The most appropriate action by the nurse at this time is to a. increase the rate of the IV fluid replacement. b. continue to take vital signs every 15 minutes. c. administer oxygen therapy at 100% per mask. d. notify the anesthesia care provider (ACP) immediately.
ANS: B A slight drop in postoperative BP with a normal pulse and warm, dry skin indicates normal response to the residual effects of anesthesia and requires only ongoing monitoring. Hypotension with tachycardia and/or cool, clammy skin would suggest hypovolemic or hemorrhagic shock and the need for notification of the ACP, increased fluids, and high-concentration oxygen administration.
When a patient is transferred from the postanesthesia care unit (PACU) to the clinical surgical unit, the first action by the nurse on the surgical unit should be to a. assess the patient's pain. b. take the patient's vital signs. c. read the postoperative orders. d. check the rate of the IV infusion.
ANS: B Because the priority concerns after surgery are airway, breathing, and circulation, the vital signs are assessed first. The other actions should take place after the vital signs are obtained and compared with the vital signs before transfer.
Which information about medication use in a preoperative patient is most important to communicate to the health care provider? a. The patient uses acetaminophen (Tylenol) occasionally for aches and pains. b. The patient takes garlic capsules daily but did not take any on the surgical day. c. The patient has a history of cocaine use but quit using the drug over 10 years ago. d. The patient took a sedative medication the previous night to assist in falling asleep.
ANS: B Chronic use of garlic may predispose to intraoperative and postoperative bleeding. The use of a sedative the previous night, occasional acetaminophen use, and a distant history of cocaine use will not usually affect the surgical outcome.
While caring for a patient with abdominal surgery the first postoperative day, the nurse notices new bright-red drainage about 6 cm in diameter on the dressing. In response to this finding, the nurse should first a. reinforce the dressing. b. take the patient's vital signs. c. recheck the dressing in 1 hour for increased drainage. d. notify the patient's surgeon of a potential hemorrhage.
ANS: B New bright-red drainage may indicate hemorrhage, and the nurse should initially assess the patient's vital signs for tachycardia and hypotension. The surgeon should then be notified of the drainage and the vital signs. The dressing may be changed or reinforced, based on the surgeon's orders or institutional policy. The nurse should not wait an hour to recheck the dressing.
Which clinical manifestation alerts the nurse to the possibility of Graves' disease as the cause of hyperthyroidism? A. Weight loss B. Exophthalmos C. Menstrual irregularities D. Increased heart rate and blood pressure
ANS: B Graves' disease causes edema in the extraocular muscles and increased retro-orbital fat that pushes the globe of the eye forward. This exophthalmos is not a feature of hyperthyroidism from any other cause.
A 75-year-old is to be discharged from the ambulatory surgical unit following left eye surgery. The patient tells the nurse, "I do not know if I can take care of myself with this patch over my eye." The most appropriate nursing action is to a. refer the patient for home health care services. b. discuss the specific concerns regarding self- care. c. give the patient written instructions regarding care. d. assess the patient's support system for care at home.
ANS: B The nurse's initial action should be to assess exactly the patient's concerns about self-care. Referral to home health care and assessment of the patient's support system may be appropriate actions but will be based on further assessment of the patient's concerns. Written instructions should be given to the patient, but these are unlikely to address the patient's stated concern about self-care.
An 83-year-old who had a surgical repair of a hip fracture 2 days previously has restrictions on ambulation. Based on this information, the nurse identifies the priority collaborative problem for the patient as a. potential complication: hypovolemic shock. b. potential complication: venous thromboembolism. c. potential complication: fluid and electrolyte imbalance. d. potential complication: impaired surgical wound healing.
ANS: B The patient is older and relatively immobile, two risk factors for development of deep vein thrombosis. The other potential complications are possible postoperative problems, but they are not supported by the data about this patient.
Ten minutes after receiving the ordered preoperative opioid by intravenous (IV) injection, the patient asks to get up to go to the bathroom to urinate. The most appropriate action by the nurse is to 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 the onset of the medication takes more than 10 minutes. d. ask the patient to wait because catheterization is performed at the beginning of the surgical procedure.
ANS: B The patient will be at risk for a fall after receiving the opioid, so the best nursing action is to have the patient use a bedpan or urinal. Having the patient get up either with assistance or independently increases the risk for a fall. The patient will be uncomfortable and risk involuntary incontinence if the bladder is full during transport to the operating room.
Data that were obtained during the perioperative nurse's assessment of a patient in the preoperative holding area that would indicate a need for special protection techniques during surgery include a. a stated allergy to cats and dogs. b. a history of spinal and hip arthritis. c. verbalization of anxiety by the patient. d. having a sip of water 2 hours previously.
ANS: B The patient with arthritis may require special positioning to avoid injury and postoperative discomfort. Preoperative anxiety and having a sip of water 2 to 3 hours before surgery are not unusual for the preoperative patient. An allergy to cats and dogs will not impact the care needed during the intraoperative phase.
During recovery from anesthesia in the postanesthesia care unit (PACU), a patient's vital signs are blood pressure 118/72, pulse 76, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take at this time? a. Place the patient in a side-lying position. b. Encourage the patient to take deep breaths. c. Prepare to transfer the patient from the PACU. d. Increase the rate of the postoperative IV fluids.
ANS: B The patient's borderline SpO2 and sleepiness indicate hypoventilation. The nurse should stimulate the patient and remind the patient to take deep breaths. Placing the patient in a lateral position is needed when the patient first arrives in the PACU and is unconscious. The stable BP and pulse indicate that no changes in fluid intake are required. The patient is not fully awake and has a low SpO2, indicating that transfer from the PACU is not appropriate.
As the nurse prepares a patient the morning of surgery, the patient refuses to remove a wedding ring, saying, "I have never taken it off since the day I was married." The nurse should a. have the patient sign a release and leave the ring on. b. tape the wedding ring securely to the patient's finger. c. tell the patient that the hospital is not liable for loss of the ring. d. suggest that the patient give the ring to a family member to keep.
ANS: B The ring can be taped to the patient's finger and noted on the preoperative checklist. There is no need for a release form or to discuss liability with the patient. Wearing the ring is obviously important to the patient, so the nurse should tape the ring in place rather than have a family member keep the ring for the patient.
Before the administration of preoperative medications, the nurse is preparing to witness the patient signing the operative consent form when the patient says, "I do not really understand what the doctor said." Which action is best for the nurse to take? a. Provide an explanation of the planned surgical procedure. b. Notify the surgeon that the informed consent process is not complete. c. Administer the prescribed preoperative antibiotics and withhold any ordered sedative medications. d. Notify the operating room staff that the surgeon needs to give a more complete explanation of the procedure.
ANS: B The surgeon is responsible for explaining the surgery to the patient, and the nurse should wait until the surgeon has clarified the surgery before having the patient sign the consent form. The nurse should communicate directly with the surgeon about the consent form rather than asking other staff to pass on the message. It is not within the nurse's legal scope of practice to explain the surgical procedure. No preoperative medications should be administered until the patient signs the consent form.
A 36-year-old woman is admitted for an outpatient surgery. Which information obtained by the nurse during the preoperative assessment is most important to report to the anesthesiologist before surgery? a. The patient's lack of knowledge about postoperative pain control measures b. The patient's statement that her last menstrual period was 8 weeks previously c. The patient's history of a postoperative infection following a prior cholecystectomy d. The patient's concern that she will be unable to care for her children postoperatively
ANS: B This statement suggests that the patient may be pregnant, and pregnancy testing is needed before administration of anesthetic agents. Although the other data also may be communicated with the surgeon and anesthesiologist, they will affect postoperative care and do not indicate a need for further assessment before surgery.
11. The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia. The nurse will plan to check the laboratory results for the a. Schilling test. b. bilirubin level. c. stool occult blood test. d. gastric analysis testing.
ANS: B Jaundice is caused by the elevation of bilirubin level associated with red blood cell (RBC) hemolysis. The other tests would not be helpful in monitoring or treating a hemolytic anemia.
A patient who is scheduled for surgery in a week tells the nurse doing the preoperative assessment about an allergy to bananas, kiwifruit, and latex products. Which action is most important for the nurse to take? a. Notify the dietitian about the food allergies. b. Alert the surgery center about the latex allergy. c. Reassure the patient that all allergies are noted on the medical record. d. Ask whether the patient uses antihistamines to reduce allergic reactions.
ANS: B When a patient is allergic to latex, special nonlatex materials are used during surgical procedures and the staff will need to know about the allergy in advance to obtain appropriate nonlatex materials and have them available on the surgical date. The other actions also may be appropriate, but prevention of allergic reaction (either contact dermatitis or anaphylaxis) during surgery is the most important action.
A patient with pancytopenia of unknown origin is scheduled for the following diagnostic tests. The nurse will provide a consent form to sign for which test? a. ABO blood typing b. Bone marrow biopsy c. Abdominal ultrasound d. Complete blood count (CBC)
ANS: B A bone marrow biopsy is a minor surgical procedure that requires the patient or guardian to sign a surgical consent form. The other procedures do not require a signed consent by the patient or guardian.
15. 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.
For the client with cirrhosis, what nursing intervention(s) would be most appropriate to control fluid accumulation in the abdominal cavity? A. Monitoring intake and output B. Providing a low-sodium diet C. Increasing PO fluid intake D. Weighing the client daily
ANS: B A low-sodium diet is one means of controlling abdominal fluid collection. Sodium intake may be restricted to 500 mg to 1 g daily. ...
32. Which patient requires the most rapid assessment and care by the emergency department nurse? a. The patient with hemochromatosis who reports abdominal pain b. The patient with neutropenia who has a temperature of 101.8° F c. The patient with sickle cell anemia who has had nausea and diarrhea for 24 hours d. The patient with thrombocytopenia who has oozing after having a tooth extracted
ANS: B A neutropenic patient with a fever is assumed to have an infection and is at risk for rapidly developing sepsis. Rapid assessment, cultures, and initiation of antibiotic therapy are needed. The other patients also require rapid assessment and care but not as urgently as the neutropenic patient.
Which patient requires the most rapid assessment and care by the emergency department nurse? a. The patient with hemochromatosis who reports abdominal pain b. The patient with neutropenia who has a temperature of 101.8° F c. The patient with sickle cell anemia who has had nausea and diarrhea for 24 hours d. The patient with thrombocytopenia who has oozing after having a tooth extracted
ANS: B A neutropenic patient with a fever is assumed to have an infection and is at risk for rapidly developing sepsis. Rapid assessment, cultures, and initiation of antibiotic therapy are needed. The other patients also require rapid assessment and care but not as urgently as the neutropenic patient.
The nurse is reviewing laboratory results and notes an aPTT level of 28 seconds. The nurse should notify the health care provider in anticipation of adjusting which medication? a. Aspirin b. Heparin c. Warfarin d. Erythropoietin
ANS: B Activated partial thromboplastin time (aPTT) assesses intrinsic coagulation by measuring factors I, II, V, VIII, IX, X, XI, XII. aPTT is increased (prolonged) in heparin administration. aPTT is used to monitor whether heparin is at a therapeutic level (needs to be greater than the normal range of 25 to 35 sec). Prothrombin time (PT) and international normalized ratio (INR) are most commonly used to test for therapeutic levels of warfarin (Coumadin). Aspirin affects platelet function. Erythropoietin is used to stimulate red blood cell production.
39. After receiving change-of-shift report for several patients with neutropenia, which patient should the nurse assess first? a. 56-year-old with frequent explosive diarrhea b. 33-year-old with a fever of 100.8° F (38.2° C) c. 66-year-old who has white pharyngeal lesions d. 23-year old who is complaining of severe fatigue
ANS: B Any fever in a neutropenic patient indicates infection and can quickly lead to sepsis and septic shock. Rapid assessment and (if prescribed) initiation of antibiotic therapy within 1 hour are needed. The other patients also need to be assessed but do not exhibit symptoms of potentially life-threatening problems.
After receiving change-of-shift report for several patients with neutropenia, which patient should the nurse assess first? a. 56-year-old with frequent explosive diarrhea b. 33-year-old with a fever of 100.8° F (38.2° C) c. 66-year-old who has white pharyngeal lesions d. 23-year old who is complaining of severe fatigue
ANS: B Any fever in a neutropenic patient indicates infection and can quickly lead to sepsis and septic shock. Rapid assessment and (if prescribed) initiation of antibiotic therapy within 1 hour are needed. The other patients also need to be assessed but do not exhibit symptoms of potentially life-threatening problems.
27. A patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving nifedipine (Procardia). Which assessment would best indicate to the nurse that the patient's condition is improving? a. Blood pressure (BP) is less than 140/90 mm Hg. b. Patient reports decreased exertional dyspnea. c. Heart rate is between 60 and 100 beats/minute. d. Patient's chest x-ray indicates clear lung fields.
ANS: B Because a major symptom of IPAH is exertional dyspnea, an improvement in this symptom would indicate that the medication was effective. Nifedipine will affect BP and heart rate, but these parameters would not be used to monitor the effectiveness of therapy for a patient with IPAH. The chest x-ray will show clear lung fields even if the therapy is not effective.
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.
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.
A 23-year-old patient with a history of muscular dystrophy is hospitalized with pneumonia. Which nursing action will be included in the plan of care? a. Logroll the patient every 2 hours. b. Assist the patient with ambulation. c. Discuss the need for genetic testing with the patient. d. Teach the patient about the muscle biopsy procedure.
ANS: B Because the goal for the patient with muscular dystrophy is to keep the patient active for as long as possible, assisting the patient to ambulate will be part of the care plan. The patient will not require logrolling. Muscle biopsies are necessary to confirm the diagnosis but are not necessary for a patient who already has a diagnosis. There is no need for genetic testing because the patient already knows the diagnosis.
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
7. 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.
18. A routine complete blood count indicates that an active 80-year-old man may have myelodysplastic syndrome. The nurse will plan to teach the patient about a. blood transfusion b. bone marrow biopsy. c. filgrastim (Neupogen) administration. d. erythropoietin (Epogen) administration.
ANS: B Bone marrow biopsy is needed to make the diagnosis and determine the specific type of myelodysplastic syndrome. The other treatments may be necessary if there is progression of the myelodysplastic syndrome, but the initial action for this asymptomatic patient will be a bone marrow biopsy.
A routine complete blood count indicates that an active 80-year-old man may have myelodysplastic syndrome. The nurse will plan to teach the patient about a. blood transfusion b. bone marrow biopsy. c. filgrastim (Neupogen) administration. d. erythropoietin (Epogen) administration.
ANS: B Bone marrow biopsy is needed to make the diagnosis and determine the specific type of myelodysplastic syndrome. The other treatments may be necessary if there is progression of the myelodysplastic syndrome, but the initial action for this asymptomatic patient will be a bone marrow biopsy.
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.
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.
27. 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.
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.
A 39-year-old patient whose work involves frequent lifting has a history of chronic back pain. After the nurse has taught the patient about correct body mechanics, which patient statement indicates that the teaching has been effective? a. "I will keep my back straight to lift anything higher than my waist." b. "I will begin doing exercises to strengthen the muscles of my back." c. "I can try to sleep with my hips and knees extended to prevent back strain." d. "I can tell my boss that I need to change to a job where I can work at a desk."
ANS: B Exercises can help strengthen the muscles that support the back. Flexion of the hips and knees places less strain on the back. Modifications in the way the patient lifts boxes are needed, but sitting for prolonged periods can aggravate back pain. The patient should not lift above the level of the elbows.
45. An experienced nurse instructs a new nurse about how to care for a patient with dyspnea caused by a pulmonary fungal infection. Which action by the new nurse indicates a need for further teaching? a. Listening to the patient's lung sounds several times during the shift b. Placing the patient on droplet precautions and in a private hospital room c. Increasing the oxygen flow rate to keep the oxygen saturation above 90% d. Monitoring patient serology results to identify the specific infecting organism
ANS: B Fungal infections are not transmitted from person to person. Therefore no isolation procedures are necessary. The other actions by the new nurse are appropriate.
Which action should the nurse take before administering gentamicin (Garamycin) to a patient who has acute osteomyelitis? a. Ask the patient about any nausea. b. Review the patient's creatinine level. c. Obtain the patient's oral temperature. d. Change the prescribed wet-to-dry dressing.
ANS: B Gentamicin is nephrotoxic and can cause renal failure. Monitoring the patient's temperature before gentamicin administration is not necessary. Nausea is not a common side effect of IV gentamicin. There is no need to change the dressing before gentamicin administration.
What would be the effect on the client's hormone response to a naturally occurring hormone if the client were taking a drug that "blocked" that hormone's receptor site? A. The client's response would indicate greater hormone metabolism. B. The client's response would resemble decreased hormone activity. C. The client's response would resemble increased hormone activity. D. The client's response would be unchanged.
ANS: B Hormones cause an activity in the target tissues by binding with their specific cellular receptor sites, thereby changing the cell's activity. When the receptor sites are occupied by other substances that block hormone binding, the cell's response is the same as when there is a decreased level of the hormone.
14. 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.
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.
30. 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.
A diabetic patient's 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.
Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a. Listen to a patient's 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 patient's 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.
34. Which problem reported by a patient with hemophilia is most important for the nurse to communicate to the physician? a. Leg bruises b. Tarry stools c. Skin abrasions d. Bleeding gums
ANS: B Melena is a sign of gastrointestinal bleeding and requires collaborative actions such as checking hemoglobin and hematocrit and administration of coagulation factors. The other problems indicate a need for patient teaching about how to avoid injury, but are not indicators of possible serious blood loss
Administration of hepatitis B vaccine to a healthy 18-year-old patient has been effective when a specimen of the patient's blood reveals a. HBsAg. b. anti-HBs. c. anti-HBc IgG. d. anti-HBc IgM.
B
Which problem reported by a patient with hemophilia is most important for the nurse to communicate to the physician? a. Leg bruises b. Tarry stools c. Skin abrasions d. Bleeding gums
ANS: B Melena is a sign of gastrointestinal bleeding and requires collaborative actions such as checking hemoglobin and hematocrit and administration of coagulation factors. The other problems indicate a need for patient teaching about how to avoid injury, but are not indicators of possible serious blood loss.
3. A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of a. iron. b. folic acid. c. cobalamin (vitamin B12). d. ascorbic acid (vitamin C).
ANS: B Methotrexate use can lead to folic acid deficiency. Supplementation with oral folic acid supplements is the usual treatment. The other nutrients would not correct folic acid deficiency, although they would be used to treat other types of anemia.
A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of a. iron. b. folic acid. c. cobalamin (vitamin B12). d. ascorbic acid (vitamin C).
ANS: B Methotrexate use can lead to folic acid deficiency. Supplementation with oral folic acid supplements is the usual treatment. The other nutrients would not correct folic acid deficiency, although they would be used to treat other types of anemia.
Amputation of digits of legs below the knee may be necessary for ulceration and gangrene
B
5. An appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia is to a. provide a diet high in vitamin K. b. alternate periods of rest and activity. c. teach the patient how to avoid injury. d. place the patient on protective isolation.
ANS: B Nursing care for patients with anemia should alternate periods of rest and activity to encourage activity without causing undue fatigue. There is no indication that the patient has a bleeding disorder, so a diet high in vitamin K or teaching about how to avoid injury is not needed. Protective isolation might be used for a patient with aplastic anemia, but it is not indicated for hemolytic anemia.
An appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia is to a. provide a diet high in vitamin K. b. alternate periods of rest and activity. c. teach the patient how to avoid injury. d. place the patient on protective isolation.
ANS: B Nursing care for patients with anemia should alternate periods of rest and activity to encourage activity without causing undue fatigue. There is no indication that the patient has a bleeding disorder, so a diet high in vitamin K or teaching about how to avoid injury is not needed. Protective isolation might be used for a patient with aplastic anemia, but it is not indicated for hemolytic anemia.
instructs a patient who has osteosarcoma of the tibia about a scheduled above-the-knee amputation. Which statement by a patient indicates that additional patient teaching is needed? a. "I will need to participate in physical therapy after surgery." b. "I did not have this bone cancer until my leg broke a week ago." c. "I wish that I did not have to have chemotherapy after this surgery." d. "I can use the patient-controlled analgesia (PCA) to control postoperative pain."
ANS: B Osteogenic sarcoma may be diagnosed following a fracture, but it is not caused by the injury. The other patient statements indicate that patient teaching has been effective.
8. It is important for the nurse providing care for a patient with sickle cell crisis to a. limit the patient's intake of oral and IV fluids. b. evaluate the effectiveness of opioid analgesics. c. encourage the patient to ambulate as much as tolerated. d. teach the patient about high-protein, high-calorie foods.
ANS: B Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control. Fluid intake should be increased to reduce blood viscosity and improve perfusion. Rest is usually ordered to decrease metabolic requirements. Patients are instructed about the need for dietary folic acid, but high-protein, high-calorie diets are not emphasized.
It is important for the nurse providing care for a patient with sickle cell crisis to a. limit the patient's intake of oral and IV fluids. b. evaluate the effectiveness of opioid analgesics. c. encourage the patient to ambulate as much as tolerated. d. teach the patient about high-protein, high-calorie foods.
ANS: B Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control. Fluid intake should be increased to reduce blood viscosity and improve perfusion. Rest is usually ordered to decrease metabolic requirements. Patients are instructed about the need for dietary folic acid, but high-protein, high-calorie diets are not emphasized.
37. 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.
4. 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.
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.
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 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-Fowler's position.
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.
22. 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.
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.
9. 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.
39. A patient is admitted to the emergency department with an open stab wound to the left chest. What is the first action that the nurse should take? a. Position the patient so that the left chest is dependent. b. Tape a nonporous dressing on three sides over the chest wound. c. Cover the sucking chest wound firmly with an occlusive dressing. d. Keep the head of the patient's bed at no more than 30 degrees elevation.
ANS: B The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the patient on the left side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The head of the bed should be elevated to 30 to 45 degrees to facilitate breathing.
19. Which action will the admitting nurse include in the care plan for a 30-year old woman who is neutropenic? a. Avoid any injections. b. Check temperature every 4 hours. c. Omit fruits or vegetables from the diet. d. Place a "No Visitors" sign on the door.
ANS: B The earliest sign of infection in a neutropenic patient is an elevation in temperature. Although unpeeled fresh fruits and vegetables should be avoided, fruits and vegetables that are peeled or cooked are acceptable. Injections may be required for administration of medications such as filgrastim (Neupogen). The number of visitors may be limited and visitors with communicable diseases should be avoided, but a "no visitors" policy is not needed.
Which action will the admitting nurse include in the care plan for a 30-year old woman who is neutropenic? a. Avoid any injections. b. Check temperature every 4 hours. c. Omit fruits or vegetables from the diet. d. Place a "No Visitors" sign on the door.
ANS: B The earliest sign of infection in a neutropenic patient is an elevation in temperature. Although unpeeled fresh fruits and vegetables should be avoided, fruits and vegetables that are peeled or cooked are acceptable. Injections may be required for administration of medications such as filgrastim (Neupogen). The number of visitors may be limited and visitors with communicable diseases should be avoided, but a "no visitors" policy is not needed.
13. 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's complete blood count (CBC) shows a hemoglobin of 19 g/dL and a hematocrit of 54%. Which question should the nurse ask to determine possible causes of this finding? a. "Have you had a recent weight loss?" b. "Do you have any history of lung disease?" c. "Have you noticed any dark or bloody stools?" d. "What is your dietary intake of meats and protein?"
ANS: B The hemoglobin and hematocrit results indicate polycythemia, which can be associated with chronic obstructive pulmonary disease (COPD). The other questions would be appropriate for patients who are anemic.
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.
21. The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed? a. A large air leak in the water-seal chamber b. 400 mL of blood in the collection chamber c. Complaint of pain with each deep inspiration d. Subcutaneous emphysema at the insertion site
ANS: B The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. An air leak would be expected immediately after chest tube placement for a pneumothorax. Initially, brisk bubbling of air occurs in this chamber when a pneumothorax is evacuated. The pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with pneumothorax. A small amount of subcutaneous air is harmless and will be reabsorbed.
Which action will the nurse take first when a patient is seen in the outpatient clinic with neck pain? a. Provide information about therapeutic neck exercises. b. Ask about numbness or tingling of the hands and arms. c. Suggest that the patient alternate the use of heat and cold to the neck to treat the pain. d. Teach about the use of nonsteroidal antiinflammatory drugs such as ibuprofen (Advil).
ANS: B The nurse's initial action should be further assessment of the pain because cervical nerve root compression will require different treatment than musculoskeletal neck pain. The other actions may also be appropriate, depending on the assessment findings.
20. A patient with newly diagnosed lung cancer tells the nurse, "I don't think I'm going to live to see my next birthday." Which response by the nurse is best? a. "Would you like to talk to the hospital chaplain about your feelings?" b. "Can you tell me what it is that makes you think you will die so soon?" c. "Are you afraid that the treatment for your cancer will not be effective?" d. "Do you think that taking an antidepressant medication would be helpful?"
ANS: B The nurse's initial response should be to collect more assessment data about the patient's statement. The answer beginning "Can you tell me what it is" is the most open-ended question and will offer the best opportunity for obtaining more data. The answer beginning, "Are you afraid" implies that the patient thinks that the cancer will be immediately fatal, although the patient's statement may not be related to the cancer diagnosis. The remaining two answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate.
26. A 30-year-old man with acute myelogenous leukemia develops an absolute neutrophil count of 850/µL while receiving outpatient chemotherapy. Which action by the outpatient clinic nurse is most appropriate? a. Discuss the need for hospital admission to treat the neutropenia. b. Teach the patient to administer filgrastim (Neupogen) injections. c. Plan to discontinue the chemotherapy until the neutropenia resolves. d. Order a high-efficiency particulate air (HEPA) filter for the patient's home.
ANS: B The patient may be taught to self-administer filgrastim injections. Although chemotherapy may be stopped with severe neutropenia (neutrophil count less than 500/µL), administration of filgrastim usually allows the chemotherapy to continue. Patients with neutropenia are at higher risk for infection when exposed to other patients in the hospital. HEPA filters are expensive and are used in the hospital, where the number of pathogens is much higher than in the patient's home environment.
A 30-year-old man with acute myelogenous leukemia develops an absolute neutrophil count of 850/µL while receiving outpatient chemotherapy. Which action by the outpatient clinic nurse is most appropriate? a. Discuss the need for hospital admission to treat the neutropenia. b. Teach the patient to administer filgrastim (Neupogen) injections. c. Plan to discontinue the chemotherapy until the neutropenia resolves. d. Order a high-efficiency particulate air (HEPA) filter for the patient's home.
ANS: B The patient may be taught to self-administer filgrastim injections. Although chemotherapy may be stopped with severe neutropenia (neutrophil count less than 500/µL), administration of filgrastim usually allows the chemotherapy to continue. Patients with neutropenia are at higher risk for infection when exposed to other patients in the hospital. HEPA filters are expensive and are used in the hospital, where the number of pathogens is much higher than in the patient's home environment.
A 50-year-old patient is being discharged after a 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 pain b. How to monitor and care for the 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 to 10 days after discharge
ANS: B The patient will be on IV antibiotics for several months, and the patient will need to recognize signs of infection at the IV site and how to care for the catheter during daily activities such as bathing. IV antibiotics rather than oral antibiotics are used for acute osteomyelitis. Patients are instructed to avoid exercise and heat application because these will increase swelling and the risk for spreading infection.
Several patients call the outpatient clinic and ask to make an appointment as soon as possible. Which patient should the nurse schedule to be seen first? a. 44-year-old with sickle cell anemia who says "my eyes always look sort of yellow" b. 23-year-old with no previous health problems who has a nontender lump in the axilla c. 50-year-old with early-stage chronic lymphocytic leukemia who reports chronic fatigue d. 19-year-old with hemophilia who wants to learn to self-administer factor VII replacement
ANS: B The patient's age and presence of a nontender axillary lump suggest possible lymphoma, which needs rapid diagnosis and treatment. The other patients have questions about treatment or symptoms that are consistent with their diagnosis but do not need to be seen urgently
38. Several patients call the outpatient clinic and ask to make an appointment as soon as possible. Which patient should the nurse schedule to be seen first? a. 44-year-old with sickle cell anemia who says "my eyes always look sort of yellow" b. 23-year-old with no previous health problems who has a nontender lump in the axilla c. 50-year-old with early-stage chronic lymphocytic leukemia who reports chronic fatigue d. 19-year-old with hemophilia who wants to learn to self-administer factor VII replacement
ANS: B The patient's age and presence of a nontender axillary lump suggest possible lymphoma, which needs rapid diagnosis and treatment. The other patients have questions about treatment or symptoms that are consistent with their diagnosis but do not need to be seen urgently.
35. A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which action is most important for the nurse to take? a. Avoid venipunctures. b. Notify the patient's physician. c. Apply sterile dressings to the sites. d. Give prescribed proton-pump inhibitors.
ANS: B The patient's new onset of bleeding and diagnosis of sepsis suggest that disseminated intravascular coagulation (DIC) may have developed, which will require collaborative actions such as diagnostic testing, blood product administration, and heparin administration. The other actions also are appropriate, but the most important action should be to notify the physician so that DIC treatment can be initiated rapidly.
A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which action is most important for the nurse to take? a. Avoid venipunctures. b. Notify the patient's physician. c. Apply sterile dressings to the sites. d. Give prescribed proton-pump inhibitors.
ANS: B The patient's new onset of bleeding and diagnosis of sepsis suggest that disseminated intravascular coagulation (DIC) may have developed, which will require collaborative actions such as diagnostic testing, blood product administration, and heparin administration. The other actions also are appropriate, but the most important action should be to notify the physician so that DIC treatment can be initiated rapidly.
Following laminectomy with a spinal fusion to treat a herniated disc, a patient reports numbness and tingling of the right lower leg. The first action that the nurse should take is to a. report the patient's complaint to the surgeon. b. check the chart for preoperative assessment data. c. check the vital signs for indications of hemorrhage. d. turn the patient to the side to relieve pressure on the right leg.
ANS: B The postoperative movement and sensation of the extremities should be unchanged (or improved) from the preoperative assessment. If the numbness and tingling are new, this information should be immediately reported to the surgeon. Numbness and tingling are not symptoms associated with hemorrhage at the site. Turning the patient will not relieve the numbness.
5. 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 68-year-old woman with acute myelogenous leukemia (AML) asks the nurse whether the planned chemotherapy will be worth undergoing. Which response by the nurse is appropriate? a. "If you do not want to have chemotherapy, other treatment options include stem cell transplantation." b. "The side effects of chemotherapy are difficult, but AML frequently goes into remission with chemotherapy." c. "The decision about treatment is one that you and the doctor need to make rather than asking what I would do." d. "You don't need to make a decision about treatment right now because leukemias in adults tend to progress quite slowly."
ANS: B This response uses therapeutic communication by addressing the patient's question and giving accurate information. The other responses either give inaccurate information or fail to address the patient's question, which will discourage the patient from asking the nurse for information
21. A 68-year-old woman with acute myelogenous leukemia (AML) asks the nurse whether the planned chemotherapy will be worth undergoing. Which response by the nurse is appropriate? a. "If you do not want to have chemotherapy, other treatment options include stem cell transplantation." b. "The side effects of chemotherapy are difficult, but AML frequently goes into remission with chemotherapy." c. "The decision about treatment is one that you and the doctor need to make rather than asking what I would do." d. "You don't need to make a decision about treatment right now because leukemias in adults tend to progress quite slowly."
ANS: B This response uses therapeutic communication by addressing the patient's question and giving accurate information. The other responses either give inaccurate information or fail to address the patient's question, which will discourage the patient from asking the nurse for information.
When administering alendronate (Fosamax) to a patient with osteoporosis, the nurse will a. ask about any leg cramps or hot flashes. b. assist the patient to sit up at the bedside. c. be sure that the patient has recently eaten. d. administer the ordered calcium carbonate.
ANS: B To avoid esophageal erosions, the patient taking bisphosphonates should be upright for at least 30 minutes after taking the medication. Fosamax should be taken on an empty stomach, not after taking other medications or eating. Leg cramps and hot flashes are not side effects of bisphosphonates.
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
28. 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.
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.
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.
28. A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure? a. Start a peripheral IV line to administer the necessary sedative drugs. b. Position the patient sitting upright on the edge of the bed and leaning forward. c. Obtain a large collection device to hold 2 to 3 liters of pleural fluid at one time. d. Remove the water pitcher and remind the patient not to eat or drink anything for 6 hours.
ANS: B When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and can more easily be located and removed. The patient does not usually require sedation for the procedure, and there are no restrictions on oral intake because the patient is not sedated or unconscious. Usually only 1000 to 1200 mL of pleural fluid is removed at one time. Rapid removal of a large volume can result in hypotension, hypoxemia, or pulmonary edema.
A patient complains of dizziness when ambulating in the room on the first postoperative day. In what order will the nurse accomplish the following activities? ____________________ a. Take the patient's blood pressure (BP). b. Have the patient sit down in a chair. c. Give the patient something to drink. d. Notify the patient's health care provider.
ANS: B, A, C, D The first priority for the patient with syncope is to prevent a fall, so the patient should be assisted to a chair. Assessment of the BP will determine whether the dizziness is due to orthostatic hypotension, which occurs because of hypovolemia. Increasing the fluid intake will help prevent orthostatic dizziness. Because this is a common postoperative problem that is usually resolved through nursing measures such as increasing fluid intake and making position changes more slowly, there is no urgent need to notify the health care provider.
A patient is scheduled for a computed tomography (CT) of the chest with contrast media. Which assessment findings should the nurse immediately report to the health care provider (select all that apply)? a. Patient is claustrophobic. b. Patient is allergic to shellfish. c. Patient recently used a bronchodilator inhaler. d. Patient is not able to remove a wedding band. e. Blood urea nitrogen (BUN) and serum creatinine levels are elevated.
ANS: B, E Because the contrast media is iodine-based and may cause dehydration and decreased renal blood flow, asking about iodine allergies (such as allergy to shellfish) and monitoring renal function before the CT scan are necessary. The other actions are not contraindications for CT of the chest, although they may be for other diagnostic tests, such as magnetic resonance imaging (MRI) or pulmonary function testing (PFT).
Following gallbladder surgery, a patient's T-tube is draining dark green fluid. Which action should the nurse take? a. Place the patient on bed rest. b. Notify the patient's surgeon. c. Document the color and amount of drainage. d. Irrigate the T-tube with sterile normal saline.
ANS: C A T-tube normally drains dark green to bright yellow drainage, so no action other than to document the amount and color of the drainage is needed. The other actions are not necessary.
After removal of the nasogastric (NG) tube on the second postoperative day, the patient is placed on a clear liquid diet. Four hours later, the patient complains of sharp, cramping gas pains. Which action should the nurse take? a. Reinsert the NG tube. b. Give the PRN IV opioid. c. Assist the patient to ambulate. d. Place the patient on NPO status.
ANS: C Ambulation encourages peristalsis and the passing of flatus, which will relieve the patient's discomfort. If distention persists, the patient may need to be placed on NPO status, but usually this is not necessary. Morphine administration will further decrease intestinal motility. Gas pains are usually caused by trapping of flatus in the colon, and reinsertion of the NG tube will not relieve the pains.
A patient is to receive atropine before surgery. The nurse teaches the patient to expect a. dizziness. b. weakness. c. dry mouth. d. forgetfulness.
ANS: C Anticholinergic medications decrease oral secretions, so the patient is taught that a dry mouth is an expected side effect. Weakness, forgetfulness, and dizziness are side effects associated with other preoperative medications such as opioids and benzodiazepines.
Which action will the nurse include in the plan of care immediately after surgery for a patient who received ketamine (Ketalar) as an anesthetic agent? a. Administer larger doses of analgesic agents. b. Monitor for severe slowing of the heart rate. c. Provide a quiet environment in the postanesthesia care unit. d. Avoid the use of benzodiazepines in the postoperative period.
ANS: C Hallucinations are an adverse effect associated with the dissociative anesthetics such as ketamine, so the postoperative environment should be kept quiet to decrease the risk of hallucinations. Since ketamine causes profound analgesia lasting into the postoperative period, larger doses of analgesics are not needed. Ketamine causes an increase in heart rate. Benzodiazepine use with ketamine may be used to decrease the incidence of hallucinations and nightmares.
The nurse evaluates that the interventions for the nursing diagnosis of ineffective airway clearance in a postoperative patient have been successful when the a. patient drinks 2 to 3 L of fluid in 24 hours. b. patient uses the spirometer 10 qh c. patient's breath sounds are clear to auscultation. d. patient's temperature is less than 100.4° F orally.
ANS: C One characteristic of ineffective airway clearance is the presence of adventitious breath sounds such as rhonchi or wheezes, so clear breath sounds are an indication of resolution of the problem. Spirometer use and increased fluid intake are interventions for ineffective airway clearance but may not improve breath sounds in all patients. Elevated temperature may occur with atelectasis, but a normal or near-normal temperature does not always indicate resolution of respiratory problems.
Which topic is most important for the nurse to discuss preoperatively with a patient who is scheduled for a colon resection? a. Care for the surgical incision b. Medications used during surgery c. Deep breathing and coughing techniques d. Oral antibiotic therapy after discharge home
ANS: C Preoperative teaching, demonstration, and redemonstration of deep breathing and coughing are needed on patients having abdominal surgery to prevent postoperative atelectasis. Incisional care and the importance of completing antibiotics are better discussed after surgery, when the patient will be more likely to retain this information. The patient does not usually need information about medications that are used intraoperatively.
During the preoperative assessment of a patient scheduled for a colon resection, the patient tells the nurse about using St. John's wort to prevent depression. The nurse should alert the staff in the postanesthesia recovery area that the patient may a. experience increased pain. b. have hypertensive episodes. c. take longer to recover from the anesthesia. d. have more postoperative bleeding than expected.
ANS: C St. John's wort may prolong the effects of anesthetic agents and increase the time to waken completely after surgery. It is not associated with increased bleeding risk, hypertension, or increased pain.
Which action by an inexperienced member of the surgical team requires rapid intervention by the charge nurse? a. Wearing street clothes into the nursing station b. Wearing a surgical mask into the holding room c. Walking into the hallway outside an operating room without the hair covered d. Putting on a surgical mask, cap, and scrubs before entering the operating room
ANS: C The corridors outside the OR are part of the semirestricted area where personnel must wear surgical attire and head coverings. Surgical masks may be worn in the holding room, although they are not necessary. Street clothes may be worn at the nursing station, which is part of the unrestricted area. Wearing a mask and scrubs is essential when going into the OR.
In intervening to promote ambulation, coughing, deep breathing, and turning by a postoperative patient on the first postoperative day, which action by the nurse is most helpful? a. Discuss the complications of immobility and poor cough effort. b. Teach the patient the purpose of respiratory care and ambulation. c. Administer ordered analgesic medications before these activities. d. Give the patient positive reinforcement for accomplishing these activities.
ANS: C The most essential nursing action in encouraging these postoperative activities is administration of adequate analgesia to allow the patient to accomplish the activities with minimal pain. Even with motivation provided by proper teaching, positive reinforcement, and concern about complications, patients will have difficulty if there is a great deal of pain involved with these activities.
The nurse from the general surgical unit is asked to bring the patient's hearing aid to the surgical suite. The nurse will take the hearing aid to the a. clean core. b. scrub sink areas. c. nursing station or information desk. d. corridors of the operating room area.
ANS: C The nurse from the general unit would not be wearing surgical scrub attire or a head covering and would be restricted to the nursing station or information desk, which are unrestricted areas. The clean care, scrub sink area, and corridors are semirestricted areas that require staff members wear surgical scrub attire and head coverings.
An alert 82-year-old who has poor hearing and vision is receiving preoperative teaching from the nurse. His wife answers most questions directed to the patient. Which action should the nurse take when doing the teaching? a. Use printed materials for instruction so that the patient will have more time to review the material. b. Direct the teaching toward the wife because she is the obvious support and caregiver for the patient. c. Provide additional time for the patient to understand preoperative instructions and carry out procedures. d. Ask the patient's wife to wait in the hall in order to focus preoperative teaching with the patient himself.
ANS: C The nurse should allow more time when doing preoperative teaching and preparation for older patients with sensory deficits. Because the patient has visual deficits, he will not be able to use written material for learning. The teaching should be directed toward both the patient and the wife because both will need to understand preoperative procedures and teaching.
After a new nurse has been oriented to the postanesthesia care unit (PACU), the charge nurse will evaluate that the orientation has been successful when the new nurse a. places a patient in the Trendelenburg position when the blood pressure (BP) drops. b. assists a patient to the prone position when the patient is nauseated. c. turns an unconscious patient to the side when the patient arrives in the PACU. d. positions a newly admitted unconscious patient supine with the head elevated.
ANS: C The patient should initially be positioned in the lateral "recovery" position to keep the airway open and avoid aspiration. The prone position is not usually used and would make it difficult to assess the patient's respiratory effort and cardiovascular status. The Trendelenburg position is avoided because it increases the work of breathing. The patient is placed supine with the head elevated after regaining consciousness.
After orienting a new staff member to the scrub nurse role, the nurse preceptor will know that the teaching was effective if the new staff member a. documents all patient care accurately. b. labels all specimens to send to the lab. c. keeps both hands above the operating table level. d. takes the patient to the postanesthesia recovery area.
ANS: C The scrub nurse role includes maintaining asepsis in the operating field. The other actions would be appropriate to the circulating nurse role.
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.
The client has a deficiency of all the following pituitary hormones. Which one should be addressed first? A. Growth hormone B. Luteinizing hormone C. Thyroid-stimulating hormone D. Follicle-stimulating hormone
ANS: C A deficiency of thyroid-stimulating hormone (TSH) is the most life-threatening deficiency of the hormones listed in this question. TSH is needed to ensure proper synthesis and secretion of the thyroid hormones, whose functions are essential for life.
40. The nurse notes that a patient has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which action should the nurse take first? a. Assist the patient to sit upright in a chair. b. Splint the patient's chest during coughing. c. Medicate the patient with prescribed morphine. d. Observe the patient use the incentive spirometer.
ANS: C A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain (which increases with deep breathing and coughing). The first action by the nurse should be to medicate the patient to minimize incisional pain. The other actions are all appropriate ways to improve airway clearance but should be done after the morphine is given.
Inflammation of midsized arteries and veins
B
Intermittent claudication of feet, arms, and hands may be present
B
Which action for a patient with neutropenia is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Assessing the patient for signs and symptoms of infection b. Teaching the patient the purpose of neutropenic precautions c. Administering subcutaneous filgrastim (Neupogen) injection d. Developing a discharge teaching plan for the patient and family
ANS: C Administration of subcutaneous medications is included in LPN/LVN education and scope of practice. Patient education, assessment, and developing the plan of care require RN level education and scope of practice
37. Which action for a patient with neutropenia is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Assessing the patient for signs and symptoms of infection b. Teaching the patient the purpose of neutropenic precautions c. Administering subcutaneous filgrastim (Neupogen) injection d. Developing a discharge teaching plan for the patient and family
ANS: C Administration of subcutaneous medications is included in LPN/LVN education and scope of practice. Patient education, assessment, and developing the plan of care require RN level education and scope of practice.
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.
The client just diagnosed with hyperpituitarism and acromegaly is scheduled for a hypophysectomy. Which statement made by the client indicates a need for clarification regarding this treatment? A. "I will drink whenever I feel thirsty after surgery." B. "I'm glad there will be no visible incision from this surgery." C. "I hope I can go back to wearing size 8 shoes instead of size 12." D. "I will wear slip-on shoes after surgery so I don't have to bend over."
ANS: C Although removal of the tissue that is oversecreting hormones can relieve many symptoms of hyperpituitarism, skeletal changes and organ enlargement are not reversible.
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 patient's condition. A head-to-toe assessment and repeat ABGs may be implemented. However, the priority intervention is to give high-flow oxygen.
46. When a patient with splenomegaly is scheduled for splenectomy, which action will the nurse include in the preoperative plan of care? a. Discourage deep breathing to reduce risk for splenic rupture. b. Teach the patient to use ibuprofen (Advil) for left upper quadrant pain. c. Schedule immunization with the pneumococcal vaccine (Pneumovax). d. Avoid the use of acetaminophen (Tylenol) for 2 weeks prior to surgery.
ANS: C Asplenic patients are at high risk for infection with Pneumococcus and immunization reduces this risk. There is no need to avoid acetaminophen use before surgery, but nonsteroidal antiinflammatory drugs (NSAIDs) may increase bleeding risk and should be avoided. The enlarged spleen may decrease respiratory depth and the patient should be encouraged to take deep breaths
When a patient with splenomegaly is scheduled for splenectomy, which action will the nurse include in the preoperative plan of care? a. Discourage deep breathing to reduce risk for splenic rupture. b. Teach the patient to use ibuprofen (Advil) for left upper quadrant pain. c. Schedule immunization with the pneumococcal vaccine (Pneumovax). d. Avoid the use of acetaminophen (Tylenol) for 2 weeks prior to surgery.
ANS: C Asplenic patients are at high risk for infection with Pneumococcus and immunization reduces this risk. There is no need to avoid acetaminophen use before surgery, but nonsteroidal antiinflammatory drugs (NSAIDs) may increase bleeding risk and should be avoided. The enlarged spleen may decrease respiratory depth and the patient should be encouraged to take deep breaths.
4. A 52-year-old patient has a new diagnosis of pernicious anemia. The nurse determines that the patient understands the teaching about the disorder when the patient states, "I a. need to start eating more red meat and liver." b. will stop having a glass of wine with dinner." c. could choose nasal spray rather than injections of vitamin B12." d. will need to take a proton pump inhibitor like omeprazole (Prilosec)."
ANS: C Because pernicious anemia prevents the absorption of vitamin B12, this patient requires injections or intranasal administration of cobalamin. Alcohol use does not cause cobalamin deficiency. Proton pump inhibitors decrease the absorption of vitamin B12. Eating more foods rich in vitamin B12 is not helpful because the lack of intrinsic factor prevents absorption of the vitamin.
A 52-year-old patient has a new diagnosis of pernicious anemia. The nurse determines that the patient understands the teaching about the disorder when the patient states, "I a. need to start eating more red meat and liver." b. will stop having a glass of wine with dinner." c. could choose nasal spray rather than injections of vitamin B12." d. will need to take a proton pump inhibitor like omeprazole (Prilosec)."
ANS: C Because pernicious anemia prevents the absorption of vitamin B12, this patient requires injections or intranasal administration of cobalamin. Alcohol use does not cause cobalamin deficiency. Proton pump inhibitors decrease the absorption of vitamin B12. Eating more foods rich in vitamin B12 is not helpful because the lack of intrinsic factor prevents absorption of the vitamin.
The "mustache" dressing of a client postoperative from a transsphenoidal hypophysectomy is saturated with clear, yellow-tinged fluid. What is the nurse's best first action? A. Document the finding as the only action. B. Obtain a specimen for culture. C. Test the drainage for glucose. D. Notify the physician.
ANS: C Clear, yellow-tinged drainage could be serous or could contain cerebrospinal fluid (CSF). CSF contains a relatively high concentration of glucose; serous drainage does not.
Strongly associated with smoking
B
24. A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is most appropriate? a. Document the presence of a large air leak. b. Notify the surgeon of a possible pneumothorax. c. Take no further action with the collection device. d. Adjust the dial on the wall regulator to decrease suction.
ANS: C Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. Increasing or decreasing the vacuum source will not adjust the suction pressure. The amount of suction applied is regulated by the amount of water in this chamber and not by the amount of suction applied to the system.
The client who is taking corticosteroids daily for severe asthma now has an elevated blood glucose level. He asks the nurse if he is now considered diabetic. What is the nurse's best response? A. "Yes, the corticosteroids have destroyed the ability of the pancreas to synthesize insulin." B. "Yes, whenever blood glucose levels are abnormally high, the condition is called diabetes." C. "No, the blood glucose level is elevated because corticosteroids increase the synthesis of glucose." D. "No, the lack of insulin is temporary and will return to a normal level when the asthma is better."
ANS: C Corticosteroids cause a "pseudodiabetes" with increased blood glucose levels by stimulating liver synthesis of glucose and suppressing glucose use by cells. The ability of the pancreas to synthesize insulin is unaffected.
43. A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan? a. Purpose of antibiotic therapy b. Ways to limit oral fluid intake c. Appropriate use of cough suppressants d. Safety concerns with home oxygen therapy
ANS: C Cough suppressants are frequently prescribed for acute bronchitis. Because most acute bronchitis is viral in origin, antibiotics are not prescribed unless there are systemic symptoms. Fluid intake is encouraged. Home oxygen is not prescribed for acute bronchitis, although it may be used for chronic bronchitis.
Which client responses demonstrate to the nurse that treatment for diabetes insipidus is effective? A. Urine output is increased; specific gravity is increased. B. Urine output is increased; specific gravity is decreased. C. Urine output is decreased; specific gravity is increased. D. Urine output is decreased; specific gravity is decreased.
ANS: C Diabetes insipidus causes urine output to be greatly increased, with a low urine osmolarity, as evidenced by a low specific gravity. Effective treatment results in a decreased urine output that is more concentrated, as evidenced by an increased specific gravity.
A nurse who works on the orthopedic unit has just received the change-of-shift report. Which patient should the nurse assess first? a. Patient who reports foot pain after hammertoe surgery b. Patient with low back pain and a positive straight-leg-raise test c. Patient who has not voided 10 hours after having a laminectomy d. Patient with osteomyelitis who has a temperature of 100.5° F (38.1° C)
ANS: C Difficulty in voiding may indicate damage to the spinal nerves and should be assessed and reported to the surgeon immediately. The information about the other patients is consistent with their diagnoses. The nurse will need to assess them as quickly as possible, but the information about them does not indicate a need for immediate intervention
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 won't 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.
33. 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.
10. Which instruction will the nurse plan to include in discharge teaching for the patient admitted with a sickle cell crisis? a. Take a daily multivitamin with iron. b. Limit fluids to 2 to 3 quarts per day. c. Avoid exposure to crowds when possible. d. Drink only two caffeinated beverages daily.
ANS: C Exposure to crowds increases the patient's risk for infection, the most common cause of sickle cell crisis. There is no restriction on caffeine use. Iron supplementation is generally not recommended. A high-fluid intake is recommended
Which instruction will the nurse plan to include in discharge teaching for the patient admitted with a sickle cell crisis? a. Take a daily multivitamin with iron. b. Limit fluids to 2 to 3 quarts per day. c. Avoid exposure to crowds when possible. d. Drink only two caffeinated beverages daily.
ANS: C Exposure to crowds increases the patient's risk for infection, the most common cause of sickle cell crisis. There is no restriction on caffeine use. Iron supplementation is generally not recommended. A high-fluid intake is recommended.
The nurse assesses a patient with pernicious anemia. Which assessment finding would the nurse expect? a. Yellow-tinged sclerae b. Shiny, smooth tongue c. Numbness of the extremities d. Gum bleeding and tenderness
ANS: C Extremity numbness is associated with cobalamin (vitamin B12) deficiency or pernicious anemia. Loss of the papillae of the tongue occurs with chronic iron deficiency. Yellow-tinged sclera is associated with hemolytic anemia and the resulting jaundice. Gum bleeding and tenderness occur with thrombocytopenia or neutropenia.
The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. When auscultating the patient's lungs, which finding would the nurse most likely hear? a. Continuous rumbling, snoring, or rattling sounds mainly on expiration b. Continuous high-pitched musical sounds on inspiration and expiration c. Discontinuous, high-pitched sounds of short duration 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, high-pitched 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.
A 67-year-old patient is receiving IV antibiotics at home to treat chronic osteomyelitis of the left femur. The nurse chooses a nursing diagnosis of ineffective health maintenance when the nurse finds that the patient a. is frustrated with the length of treatment required. b. takes and records the oral temperature twice a day. c. is unable to plantar flex the foot on the affected side. d. uses crutches to avoid weight bearing on the affected leg.
ANS: C Foot drop is an indication that the foot is not being supported in a neutral position by a splint. Using crutches and monitoring the oral temperature are appropriate self-care activities. Frustration with the length of treatment is not an indicator of ineffective health maintenance of the osteomyelitis
25. The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy for cancer of the lung. Which information should the nurse include about the patient's postoperative care? a. Positioning on the right side b. Bed rest for the first 24 hours c. Frequent use of an incentive spirometer d. Chest tube placement with continuous drainage
ANS: C Frequent deep breathing and coughing are needed after chest surgery to prevent atelectasis. To promote gas exchange, patients after pneumonectomy are positioned on the surgical side. Early mobilization decreases the risk for postoperative complications such as pneumonia and deep vein thrombosis. In a pneumonectomy, chest tubes may or may not be placed in the space from which the lung was removed. If a chest tube is used, it is clamped and only released by the surgeon to adjust the volume of serosanguineous fluid that will fill the space vacated by the lung. If the cavity overfills, it could compress the remaining lung and compromise the cardiovascular and pulmonary function. Daily chest x-rays can be used to assess the volume and space.
A patient who had a total hip replacement had an intraoperative hemorrhage 14 hours ago. Which laboratory result would the nurse expect to find? a. Hematocrit of 46% b. Hemoglobin of 13.8 g/dL c. Elevated reticulocyte count d. Decreased white blood cell (WBC) count
ANS: C Hemorrhage causes the release of reticulocytes (immature red blood cells) from the bone marrow into circulation. The hematocrit and hemoglobin levels are normal. The WBC count is not affected by bleeding.
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.
What safety measure should the nurse use for the adult client who has growth hormone deficiency? A. Avoid intramuscular medications. B. Place the client in protective isolation. C. Use a lift sheet to reposition the client. D. Assist the client to move slowly from a sitting to a standing position.
ANS: C In adults, growth hormone is necessary to maintain bone density and strength. Adults with growth hormone deficiency have thin, fragile bones.
Which clinical manifestation alerts the nurse to the possibility of an endocrine disorder? A. Chronic constipation B. Weight gain of 5 pounds in the past 12 months C. Increased sense of thirst and increased urine output D. Muscle cramps after heavy exercise and during hot weather
ANS: C Increased thirst and increased urine output are associated with at least two endocrine disorders, diabetes mellitus and diabetes insipidus.
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.
The nurse observes a student who is listening to a patient's 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.
23. A 54-year-old woman with acute myelogenous leukemia (AML) is considering treatment with a hematopoietic stem cell transplant (HSCT). The best approach for the nurse to assist the patient with a treatment decision is to a. emphasize the positive outcomes of a bone marrow transplant. b. discuss the need for adequate insurance to cover post-HSCT care. c. ask the patient whether there are any questions or concerns about HSCT. d. explain that a cure is not possible with any other treatment except HSCT.
ANS: C Offering the patient an opportunity to ask questions or discuss concerns about HSCT will encourage the patient to voice concerns about this treatment and also will allow the nurse to assess whether the patient needs more information about the procedure. Treatment of AML using chemotherapy is another option for the patient. It is not appropriate for the nurse to ask the patient to consider insurance needs in making this decision.
A 54-year-old woman with acute myelogenous leukemia (AML) is considering treatment with a hematopoietic stem cell transplant (HSCT). The best approach for the nurse to assist the patient with a treatment decision is to a. emphasize the positive outcomes of a bone marrow transplant. b. discuss the need for adequate insurance to cover post-HSCT care. c. ask the patient whether there are any questions or concerns about HSCT. d. explain that a cure is not possible with any other treatment except HSCT.
ANS: C Offering the patient an opportunity to ask questions or discuss concerns about HSCT will encourage the patient to voice concerns about this treatment and also will allow the nurse to assess whether the patient needs more information about the procedure. Treatment of AML using chemotherapy is another option for the patient. It is not appropriate for the nurse to ask the patient to consider insurance needs in making this decision.
10. 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.
16. An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action, if recommended by the nurse, will be most helpful in reducing the incidence of lung disease? a. Treat workers with pulmonary fibrosis. b. Teach about symptoms of lung disease. c. Require the use of protective equipment. d. Monitor workers for coughing and wheezing.
ANS: C Prevention of lung disease requires the use of appropriate protective equipment such as masks. The other actions will help in recognition or early treatment of lung disease but will not be effective in prevention of lung damage. Repeated exposure eventually results in diffuse pulmonary fibrosis. Fibrosis is the result of tissue repair after inflammation.
Which nursing action included in the care of a patient after laminectomy can the nurse delegate to experienced unlicensed assistive personnel (UAP)? a. Check ability to plantar and dorsiflex the foot. b. Determine the patient's readiness to ambulate. c. Log roll the patient from side to side every 2 hours. d. Ask about pain control with the patient-controlled analgesia (PCA).
ANS: C Repositioning a patient is included in the education and scope of practice of UAP, and experienced UAP will be familiar with how to maintain alignment in the postoperative patient. Evaluation of the effectiveness of pain medications, assessment of neurologic function, and evaluation of a patient's readiness to ambulate after surgery require higher level nursing education and scope of practice.
An appropriate nursing intervention for a patient who has acute low back pain and muscle spasms is to teach the patient to a. keep both feet flat on the floor when prolonged standing is required. b. twist gently from side to side to maintain range of motion in the spine. c. keep the head elevated slightly and flex the knees when resting in bed. d. avoid the use of cold packs because they will exacerbate the muscle spasms.
ANS: C Resting with the head elevated and knees flexed will reduce the strain on the back and decrease muscle spasms. Twisting from side to side will increase tension on the lumbar area. A pillow placed under the upper back will cause strain on the lumbar spine. Alternate application of cold and heat should be used to decrease pain.
7. The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take? a. Teach about the reason for the blood tests. b. Schedule an appointment for a chest x-ray. c. Teach about the need to get sputum specimens for 2 to 3 consecutive days. d. Instruct the patient to expectorate three specimens as soon as possible.
ANS: C Sputum specimens are obtained on 2 to 3 consecutive 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. A chest x-ray is not bacteriologic testing. Although the findings on chest x-ray examination are important, it is not possible to make a diagnosis of TB solely based on chest x-ray findings because other diseases can mimic the appearance of TB.
42. Which finding about a patient with polycythemia vera is most important for the nurse to report to the health care provider? a. Hematocrit 55% b. Presence of plethora c. Calf swelling and pain d. Platelet count 450,000/L
ANS: C The calf swelling and pain suggest that the patient may have developed a deep vein thrombosis, which will require diagnosis and treatment to avoid complications such as pulmonary embolus. The other findings will also be reported to the health care provider but are expected in a patient with this diagnosis.
Which finding about a patient with polycythemia vera is most important for the nurse to report to the health care provider? a. Hematocrit 55% b. Presence of plethora c. Calf swelling and pain d. Platelet count 450,000/L
ANS: C The calf swelling and pain suggest that the patient may have developed a deep vein thrombosis, which will require diagnosis and treatment to avoid complications such as pulmonary embolus. The other findings will also be reported to the health care provider but are expected in a patient with this diagnosis.
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.
While caring for a patient with respiratory disease, the nurse observes that the patient's 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.
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 will the nurse include in the plan of care for a patient who has thalassemia major? a. Teach the patient to use iron supplements. b. Avoid the use of intramuscular injections. c. Administer iron chelation therapy as needed. d. Notify health care provider of hemoglobin 11g/dL.
ANS: C The frequent transfusions used to treat thalassemia major lead to iron toxicity in patients unless iron chelation therapy is consistently used. Iron supplementation is avoided in patients with thalassemia. There is no need to avoid intramuscular injections. The goal for patients with thalassemia major is to maintain a hemoglobin of 10 g/dL or greater
40. Which action will the nurse include in the plan of care for a patient who has thalassemia major? a. Teach the patient to use iron supplements. b. Avoid the use of intramuscular injections. c. Administer iron chelation therapy as needed. d. Notify health care provider of hemoglobin 11g/dL.
ANS: C The frequent transfusions used to treat thalassemia major lead to iron toxicity in patients unless iron chelation therapy is consistently used. Iron supplementation is avoided in patients with thalassemia. There is no need to avoid intramuscular injections. The goal for patients with thalassemia major is to maintain a hemoglobin of 10 g/dL or greater.
41. The nurse is caring for a patient with idiopathic pulmonary arterial hypertension (IPAH) who is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action by the nurse? a. The oxygen saturation is 94%. b. The blood pressure is 98/56 mm Hg. c. The patient's central IV line is disconnected. d. The international normalized ratio (INR) is prolonged.
ANS: C The half-life of this drug is 6 minutes, so the nurse will need to restart the infusion as soon as possible to prevent rapid clinical deterioration. The other data also indicate a need for ongoing monitoring or intervention, but the priority action is to reconnect the infusion.
44. 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.
6. 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.
When preparing the patient for surgery, which actions will the nurse include in the surgical time-out procedure (select all that apply)? a. Check for placement of IV lines. b. Have the surgeon identify the patient. c. Confirm the hospital chart identification (ID) number. d. Have the patient state name and DOB e. Ask the patient to state the surgical procedure. f. Verify the patient ID band number.
ANS: C, D, E, F These actions are included in surgical time out. IV line placement and identification of the patient by the surgeon are not included in the surgical time-out procedure.
14. 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.
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.
36. 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.
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.
29. 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
As the nurse is preparing a patient for surgery, the patient refuses to remove a wedding ring. Which of the following is the most appropriate action by the nurse? A. Insist the patient remove the ring for safety purposes. B. Explain that the hospital will not be responsible for the ring. C. Tape the ring securely to the finger and document this on the preoperative checklist. D. Note the presence of the ring in the nurse's notes of the chart and on the preoperative checklist.
ANS: C. It is customary policy to tape a patient's wedding band to the finger and make a notation on the preoperative checklist that the ring is taped in place.
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.
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.
32. 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.
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.
The nurse should reposition the patient who has just had a laminectomy and diskectomy by a. instructing the patient to move the legs before turning the rest of the body. b. having the patient turn by grasping the side rails and pulling the shoulders over. c. placing a pillow between the patient's legs and turning the entire body as a unit. d. turning the patient's head and shoulders first, followed by the hips, legs, and feet.
ANS: C The spine should be kept in correct alignment after laminectomy. The other positions will create misalignment of the spine
The health care provider's progress note for a patient states that the complete blood count (CBC) shows a "shift to the left." Which assessment finding will the nurse expect? a. Cool extremities b. Pallor and weakness c. Elevated temperature d. Low oxygen saturation
ANS: C The term shift to the left indicates that the number of immature polymorphonuclear neutrophils (bands) is elevated and that finding is a sign of infection. There is no indication that the patient is at risk for hypoxemia, pallor/weakness, or cool extremities.
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.
While performing preoperative teaching, the patient asks when she needs to stop drinking water before the surgery. Based on the most recent practice guidelines established by the American Society of Anesthesiologists, the nurse tells the patient that A She must be NPO after breakfast. B She needs to be NPO after midnight. I C She can drink clear liquids up to 2 hours before surgery. D She can drink clear liquids up until she is moved to the OR.
ANS: C. Practice guidelines for preoperative fasting state the minimum fasting period for clear liquids is 2 hours. Evidence-based practice no longer supports the long-standing practice of requiring patients to be NPO after midnight.
A patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU) is restless and shouting at the nurse. The patient's oxygen saturation is 99%, and recent lab results are all normal. Which action by the nurse is most appropriate? a. Insert an oral or nasal airway. b. Notify the anesthesia care provider. c. Orient the patient to time, place, and person. d. Be sure that the patient's IV lines are secure.
ANS: D Because the patient's assessment indicates physiologic stability, the most likely cause of the patient's agitation is emergence delirium, which will resolve as the patient wakes up more fully. The nurse should ensure patient safety through interventions such as raising the bed rails and securing IV lines. Emergence delirium is common in patients recovering from anesthesia, so there is no need to notify the ACP. Insertion of an airway is not needed because the oxygen saturation is good. Orientation of the patient is needed but is not likely to be effective until the effects of anesthesia have resolved more completely.
The nurse notes that the oxygen saturation is 88% in an unconscious patient who was transferred to the postanesthesia care unit (PACU) 10 minutes previously. Which action should the nurse take first? a. Elevate the patient's head. b. Suction the patient's mouth. c. Increase the oxygen flow rate. d. Perform the jaw-thrust maneuver.
ANS: D In an unconscious postoperative patient, a likely cause of hypoxemia is airway obstruction by the tongue, and the first action is to clear the airway by maneuvers such as the jaw thrust or chin lift. Increasing the oxygen flow rate and suctioning are not helpful when the airway is obstructed by the tongue. Elevating the patient's head will not be effective in correcting the obstruction but may help with oxygenation after the patient is awake.
When the nurse interviews a patient who is to have outpatient surgery using a general anesthetic, which info is most important to communicate to the surgeon and anesthesiologist before surgery? a. The patient drinks 3 or 4 cups of coffee every morning before going to work. b. The patient takes a baby aspirin daily but stopped taking aspirin 10 days ago. c. The patient drank 4 ounces of apple juice 3 hours before coming to the hospital. d. The patient's father died after receiving general anesthesia for abdominal surgery.
ANS: D The information about the patient's father suggests that there may be a family history of malignant hyperthermia and that precautions may need to be taken to prevent this complication. Current research indicates that having clear liquids 3 hours before surgery does not increase the risk for aspiration in most patients. Patients are instructed to discontinue aspirin 1 to 2 weeks before surgery. The patient should be offered caffeinated beverages postoperatively to prevent a caffeine-withdrawal headache, but this does not have preoperative implications.
A 24-year-old who takes a diuretic and a β-blocker to control blood pressure is scheduled for abdominal surgery. Which patient information is most important to communicate to the health care provider before surgery? a. Pulse rate 59 b. Hematocrit 35% c. Blood pressure 142/78 d. Serum potassium 3.3 mEq/L
ANS: D The low potassium level may increase the risk for intraoperative complications such as dysrhythmias. Slightly elevated blood pressure is common before surgery because of patient anxiety. The heart rate would be expected in a patient taking a β-blocker. The hematocrit is in the low normal range but does not require any intervention before surgery.
A patient in surgery receives a neuromuscular blocking agent as an adjunct to general anesthesia. At completion of the surgery, it is most important that the nurse monitor the patient for a. nausea. b. confusion. c. bronchospasm. d. weak chest-wall movement.
ANS: D The most serious adverse effect of the neuromuscular blocking agents is weakness of the respiratory muscles leading to postoperative hypoxemia. Nausea and confusion are possible adverse effects of these drugs, but they are as great a concern as respiratory depression. Because these medications decrease muscle contraction, laryngospasm and bronchospasm are not concerns.
The nurse analyzes the results of a patient's 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 patient's oxygenation.
The perioperative nurse encourages a family member or a friend to remain with a patient in the preoperative holding area until the patient is taken into the operating room primarily to a. ensure the proper identification of the patient before surgery. b. protect the patient from cross-contamination with other patients. c. assist the perioperative nurse to obtain a complete patient history. d. help relieve the stress of separation for the patient and significant others.
ANS: D The presence of a family member or friend reduces the stress associated with the preoperative period. Although the family may give information about the patient's name and history, this information is obtained and confirmed by the nurse in other ways. Nursing staff, rather than family members, are responsible for prevention of cross-contamination.
Which outcome measure will be best for the operating room (OR) nurse manager to use in determining the effectiveness of the physical environment and traffic control measures in the operating room? a. Smooth functioning of the OR team b. Effective protection of patient privacy c. Rapid completion of surgical procedure d. Low incidence of perioperative infection
ANS: D The primary focus when setting up the OR is the prevention of cross-contamination and transmission of infection to the patient. Patient privacy, efficient completion of procedures, and smooth functioning of the OR team also are important, but the priority is protection of the patient from infection.
Which action will the scrub nurse use to maintain aseptic technique during surgery? a. Use waterproof shoe covers. b. Wear personal protective equipment. c. Insist that all operating room (OR) staff perform a surgical scrub. d. Change gloves after touching the upper arm of the surgeon's gown.
ANS: D The sleeves of a sterile surgical gown are considered sterile only to 2 inches above the elbows, so touching the surgeon's upper arm would contaminate the nurse's gloves. Shoe covers are not sterile. Personal protective equipment is designed to protect caregivers, not the patient, and is not part of aseptic technique. Staff members such as the circulating nurse do not have to perform a surgical scrub before entering the OR.
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
12. 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.
34. A patient with pneumonia has a fever of 101.4° F (38.6° C), a nonproductive cough, and an oxygen saturation of 88%. The patient complains of weakness, fatigue, and needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as the highest priority? 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.
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.
Which assessment finding for a patient who has had a surgical reduction of an open fracture of the right radius is most important to report to the health care provider? a. Serous wound drainage b. Right arm muscle spasms c. Right arm pain with movement d. Temperature 101.4° F (38.6° C)
ANS: D An elevated temperature is suggestive of possible osteomyelitis. The other clinical manifestations are typical after a repair of an open fracture
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.
9. Which statement by a patient indicates good understanding of the nurse's teaching about prevention of sickle cell crisis? a. "Home oxygen therapy is frequently used to decrease sickling." b. "There are no effective medications that can help prevent sickling." c. "Routine continuous dosage narcotics are prescribed to prevent a crisis." d. "Risk for a crisis is decreased by having an annual influenza vaccination."
ANS: D Because infection is the most common cause of a sickle cell crisis, influenza, Haemophilus influenzae, pneumococcal pneumonia, and hepatitis immunizations should be administered. Although continuous dose opioids and oxygen may be administered during a crisis, patients do not receive these therapies to prevent crisis. Hydroxyurea (Hydrea) is a medication used to decrease the number of sickle cell crises.
Which statement by a patient indicates good understanding of the nurse's teaching about prevention of sickle cell crisis? a. "Home oxygen therapy is frequently used to decrease sickling." b. "There are no effective medications that can help prevent sickling." c. "Routine continuous dosage narcotics are prescribed to prevent a crisis." d. "Risk for a crisis is decreased by having an annual influenza vaccination."
ANS: D Because infection is the most common cause of a sickle cell crisis, influenza, Haemophilus influenzae, pneumococcal pneumonia, and hepatitis immunizations should be administered. Although continuous dose opioids and oxygen may be administered during a crisis, patients do not receive these therapies to prevent crisis. Hydroxyurea (Hydrea) is a medication used to decrease the number of sickle cell crises.
41. Which patient information is most important for the nurse to monitor when evaluating the effectiveness of deferoxamine (Desferal) for a patient with hemochromatosis? a. Skin color b. Hematocrit c. Liver function d. Serum iron level
ANS: D Because iron chelating agents are used to lower serum iron levels, the most useful information will be the patient's iron level. The other parameters will also be monitored, but are not the most important to monitor when determining the effectiveness of deferoxamine.
Which patient information is most important for the nurse to monitor when evaluating the effectiveness of deferoxamine (Desferal) for a patient with hemochromatosis? a. Skin color b. Hematocrit c. Liver function d. Serum iron level
ANS: D Because iron chelating agents are used to lower serum iron levels, the most useful information will be the patient's iron level. The other parameters will also be monitored, but are not the most important to monitor when determining the effectiveness of deferoxamine.
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.
A nurse reviews the laboratory data for an older patient. The nurse would be most concerned about which finding? a. Hematocrit of 35% b. Hemoglobin of 11.8 g/dL c. Platelet count of 400,000/µL d. White blood cell (WBC) count of 2800/µL
ANS: D Because the total WBC count is not usually affected by aging, the low WBC count in this patient would indicate that the patient's immune function may be compromised and the underlying cause of the problem needs to be investigated. The platelet count is normal. The slight decrease in hemoglobin and hematocrit are not unusual for an older patient.
12. 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.
The health care provider orders a liver/spleen scan for a patient who has been in a motor vehicle accident. Which action should the nurse take before this procedure? a. Check for any iodine allergy. b. Insert a large-bore IV catheter. c. Place the patient on NPO status. d. Assist the patient to a flat position.
ANS: D During a liver/spleen scan, a radioactive isotope is injected IV and images from the radioactive emission are used to evaluate the structure of the spleen and liver. An indwelling IV catheter is not needed. The patient is placed in a flat position before the scan.
20. Which laboratory test will the nurse use to determine whether filgrastim (Neupogen) is effective for a patient with acute lymphocytic leukemia who is receiving chemotherapy? a. Platelet count b. Reticulocyte count c. Total lymphocyte count d. Absolute neutrophil count
ANS: D Filgrastim increases the neutrophil count and function in neutropenic patients. Although total lymphocyte, platelet, and reticulocyte counts also are important to monitor in this patient, the absolute neutrophil count is used to evaluate the effects of filgrastim.
Which laboratory test will the nurse use to determine whether filgrastim (Neupogen) is effective for a patient with acute lymphocytic leukemia who is receiving chemotherapy? a. Platelet count b. Reticulocyte count c. Total lymphocyte count d. Absolute neutrophil count
ANS: D Filgrastim increases the neutrophil count and function in neutropenic patients. Although total lymphocyte, platelet, and reticulocyte counts also are important to monitor in this patient, the absolute neutrophil count is used to evaluate the effects of filgrastim.
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% to 90%). 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 patient's caregiver to be present during the teaching.
ANS: D Hypoxemia interferes with the patient's ability to learn and retain information, so having the patient's 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.
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.
A patient who has non-Hodgkin's lymphoma is receiving combination treatment with rituximab (Rituxan) and chemotherapy. Which patient assessment finding requires the most rapid action by the nurse? a. Anorexia b. Vomiting c. Oral ulcers d. Lip swelling
ANS: D Lip swelling in angioedema may indicate a hypersensitivity reaction to the rituximab. The nurse should stop the infusion and further assess for anaphylaxis. The other findings may occur with chemotherapy, but are not immediately life threatening
29. The nurse completes discharge teaching for a patient who has had a lung transplant. The nurse evaluates that the teaching has been effective if the patient makes which statement? a. "I will make an appointment to see the doctor every year." b. "I will stop taking the prednisone if I experience a dry cough." c. "I will not worry if I feel a little short of breath with exercise." d. "I will call the health care provider right away if I develop a fever."
ANS: D Low-grade fever may indicate infection or acute rejection so the patient should notify the health care provider immediately if the temperature is elevated. Patients require frequent follow-up visits with the transplant team. Annual health care provider visits would not be sufficient. Home oxygen use is not an expectation after lung transplant. Shortness of breath should be reported. Low-grade fever, fatigue, dyspnea, dry cough, and oxygen desaturation are signs of rejection. Immunosuppressive therapy, including prednisone, needs to be continued to prevent rejection.
What would be the expected clinical manifestation for a client who has excessive production of melanocyte-stimulating hormone? A. Hypoglycemia and hyperkalemia B. Irritability and insomnia C. Increased urine output D. Darkening of the skin
ANS: D Melanocyte-stimulating hormone increases the size of melanocytes in the skin and increases the amount of pigment (melanin) they produce.
13. A critical action by the nurse caring for a patient with an acute exacerbation of polycythemia vera is to a. place the patient on bed rest. b. administer iron supplements. c. avoid use of aspirin products. d. monitor fluid intake and output.
ANS: D Monitoring hydration status is important during an acute exacerbation because the patient is at risk for fluid overload or underhydration. Aspirin therapy is used to decrease risk for thrombosis. The patient should be encouraged to ambulate to prevent deep vein thrombosis (DVT). Iron is contraindicated in patients with polycythemia vera.
18. A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The patient tells the nurse, "I would rather have chemotherapy than surgery." Which response by the nurse is most appropriate? a. "Are you afraid that the surgery will be very painful?" b. "Did you have bad experiences with previous surgeries?" c. "Surgery is the treatment of choice for stage I lung cancer." d. "Tell me what you know about the various treatments available."
ANS: D More assessment of the patient's concerns about surgery is indicated. An open-ended response will elicit the most information from the patient. The answer beginning, "Surgery is the treatment of choice" is accurate, but it discourages the patient from sharing concerns about surgery. The remaining two answers indicate that the nurse has jumped to conclusions about the patient's reasons for not wanting surgery. Chemotherapy is the primary treatment for small cell lung cancer. In non-small cell lung cancer, chemotherapy may be used in the treatment of nonresectable tumors or as adjuvant therapy to surgery.
8. 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.
When assessing a newly admitted patient, the nurse notes pallor of the skin and nail beds. The nurse should ensure that which laboratory test has been ordered? a. Platelet count b. Neutrophil count c. White blood cell count d. Hemoglobin (Hgb) level
ANS: D Pallor of the skin or nail beds is indicative of anemia, which would be indicated by a low Hgb level. Platelet counts indicate a person's clotting ability. A neutrophil is a type of white blood cell that helps to fight infection
38. 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.
15. 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.
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.
35. 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.
47. The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective? a. "I am going to buy a rib binder to wear during the day." b. "I can take shallow breaths to prevent my chest from hurting." c. "I should plan on taking the pain pills only at bedtime so I can sleep." d. "I will use the incentive spirometer every hour or two during the day."
ANS: D Prevention of the complications of atelectasis and pneumonia is a priority after rib fracture. This can be ensured by deep breathing and coughing. Use of a rib binder, shallow breathing, and taking pain medications only at night are likely to result in atelectasis.
A 54-year-old woman who recently reached menopause and has a family history of osteoporosis is diagnosed with osteopenia following densitometry testing. In teaching the woman about her osteoporosis, the nurse explains that a. estrogen replacement therapy must be started to prevent rapid progression to osteoporosis. b. continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis. c. with a family history of osteoporosis, there is no way to prevent or slow gradual bone resorption. d. calcium loss from bones can be slowed by increasing calcium intake and weight-bearing exercise.
ANS: D Progression of osteoporosis can be slowed by increasing calcium intake and weight-bearing exercise. Estrogen replacement therapy does help prevent osteoporosis, but it is not the only treatment and is not appropriate for some patients. Corticosteroid therapy increases the risk for osteoporosis.
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.
Which menu choice by a patient with osteoporosis indicates that the nurse's teaching about appropriate diet has been effective? a. Pancakes with syrup and bacon b. Whole wheat toast and fresh fruit c. Egg-white omelet and a half grapefruit d. Oatmeal with skim milk and fruit yogurt
ANS: D Skim milk and yogurt are high in calcium. The other choices do not contain any high-calcium foods.
The nurse is caring for a patient who is being discharged after an emergency splenectomy following an automobile accident. Which instructions should the nurse include in the discharge teaching? a. Watch for excess bruising. b. Check for swollen lymph nodes. c. Take iron supplements to prevent anemia. d. Wash hands and avoid persons who are ill.
ANS: D Splenectomy increases the risk for infection, especially with gram-positive bacteria. The risks for lymphedema, bleeding, and anemia are not increased after a person has a splenectomy
The client has been taking an oral cortisol preparation for 2 years to manage an autoimmune disease. What effects does the nurse expect this therapy to have on this client's circulating levels of ACTH and aldosterone? A. Increased ACTH, increased aldosterone B. Increased ACTH, decreased aldosterone C. Decreased ACTH, increased aldosterone D. Decreased ACTH, decreased aldosterone
ANS: D Taking exogenous cortisol increases the blood levels of cortisol, causing the negative feedback loops to be inhibited. The elevated cortisol levels will suppress hypothalamic secretion of corticotropin-releasing hormone (CRH). Low levels of CRH suppress the anterior pituitary production of adrenocorticotropic hormone (ACTH). Elevated blood levels of cortisol cause increased sodium retention and water reabsorption, inhibiting aldosterone synthesis.
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.
43. Following successful treatment of Hodgkin's lymphoma for a 55-year-old woman, which topic will the nurse include in patient teaching? a. Potential impact of chemotherapy treatment on fertility b. Application of soothing lotions to treat residual pruritus c. Use of maintenance chemotherapy to maintain remission d. Need for follow-up appointments to screen for malignancy
ANS: D The chemotherapy used in treating Hodgkin's lymphoma results in a high incidence of secondary malignancies; follow-up screening is needed. The fertility of a 55-year-old woman will not be impacted by chemotherapy. Maintenance chemotherapy is not used for Hodgkin's lymphoma. Pruritus is a clinical manifestation of lymphoma, but should not be a concern after treatment.
Following successful treatment of Hodgkin's lymphoma for a 55-year-old woman, which topic will the nurse include in patient teaching? a. Potential impact of chemotherapy treatment on fertility b. Application of soothing lotions to treat residual pruritus c. Use of maintenance chemotherapy to maintain remission d. Need for follow-up appointments to screen for malignancy
ANS: D The chemotherapy used in treating Hodgkin's lymphoma results in a high incidence of secondary malignancies; follow-up screening is needed. The fertility of a 55-year-old woman will not be impacted by chemotherapy. Maintenance chemotherapy is not used for Hodgkin's lymphoma. Pruritus is a clinical manifestation of lymphoma, but should not be a concern after treatment.
The nurse reviews the complete blood count (CBC) and white blood cell (WBC) differential of a patient admitted with abdominal pain. Which information will be most important for the nurse to communicate to the health care provider? a. Monocytes 4% b. Hemoglobin 13.6 g/dL c. Platelet count 168,000/µL d. White blood cells (WBCs) 15,500/µL
ANS: D The elevation in WBCs indicates that the patient has an inflammatory or infectious process ongoing, which may be the cause of the patient's pain, and that further diagnostic testing is needed. The monocytes are at a normal level. The hemoglobin and platelet counts are normal.
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. "I've been taking Tylenol 650 mg every 6 hours for chest-wall pain." d. "I've 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.
The nurse recognizes that teaching a 44-year-old woman following a laparoscopic cholecystectomy has been effective when the patient states which of the following? a. "I can expect yellow-green drainage from the incision for a few days." b. "I can remove the bandages on my incisions tomorrow and take a shower." c. "I should plan to limit my activities and not return to work for 4 to 6 weeks." d. "I will always need to maintain a low-fat diet since I no longer have a gallbladder."
B
The nurse will determine that more teaching is needed if a patient with discomfort from a bunion says, "I will a. give away my high-heeled shoes." b. take ibuprofen (Motrin) if I need it." c. use the bunion pad to cushion the area." d. only wear sandals, no closed-toe shoes."
ANS: D The patient can wear shoes that have a wide forefoot. The other patient statements indicate that the teaching has been effective.
36. A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/minute, blood pressure of 100/60 mmHg, and respirations of 42 breaths/minute. Which action should the nurse take first? a. Administer anticoagulant drug therapy. b. Notify the patient's health care provider. c. Prepare patient for a spiral computed tomography (CT). d. Elevate the head of the bed to a semi-Fowler's position.
ANS: D The patient has symptoms consistent with a pulmonary embolism (PE). Elevating the head of the bed will improve ventilation and gas exchange. The other actions can be accomplished after the head is elevated (and oxygen is started). A spiral CT may be ordered by the health care provider to identify PE. Anticoagulants may be ordered after confirmation of the diagnosis of PE.
23. When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient? a. Emergency pericardiocentesis b. Stabilization of the chest wall with tape c. Administration of an inhaled bronchodilator d. Insertion of a chest tube with a chest drainage system
ANS: D The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patient's clinical manifestations are not consistent with these problems.
19. An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action is best for the nurse to take next? a. Milk the chest tube gently to remove any clots. b. Clamp the chest tube momentarily to check for the origin of the air leak. c. Assist the patient to deep breathe, cough, and use the incentive spirometer. d. Set up the patient controlled analgesia (PCA) and administer the loading dose of morphine.
ANS: D The patient is unlikely to take deep breaths or cough until the pain level is lower. A chest tube output of 100 mL is not unusual in the first hour after thoracotomy and would not require milking of the chest tube. An air leak is expected in the initial postoperative period after thoracotomy.
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.
1. A 62-year old man with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patient's laboratory findings to include a. a hematocrit (Hct) of 38%. b. an RBC count of 4,500,000/L. c. normal red blood cell (RBC) indices. d. a hemoglobin (Hgb) of 8.6 g/dL (86 g/L).
ANS: D The patient's clinical manifestations indicate moderate anemia, which is consistent with a Hgb of 6 to 10 g/dL. The other values are all within the range of normal.
A 62-year old man with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patient's laboratory findings to include a. a hematocrit (Hct) of 38%. b. an RBC count of 4,500,000/L. c. normal red blood cell (RBC) indices. d. a hemoglobin (Hgb) of 8.6 g/dL (86 g/L).
ANS: D The patient's clinical manifestations indicate moderate anemia, which is consistent with a Hgb of 6 to 10 g/dL. The other values are all within the range of normal.
49. 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.
30. 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.
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 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-Fowler's 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
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.
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.
When obtaining assessment data from a patient with a microcytic, hypochromic anemia, the nurse would question the patient about: A. folic acid intake B. dietary intake of iron C. a history of gastric surgery D. a history of sickle cell anemia
B
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.
A patient with pancytopenia has a bone marrow aspiration from the left posterior iliac crest. Which action would be important for the nurse to take after the procedure? a. Elevate the head of the bed to 45 degrees. b. Apply a sterile 2-inch gauze dressing to the site. c. Use a half-inch sterile gauze to pack the wound. d. Have the patient lie on the left side for 1 hour.
ANS: D To decrease the risk for bleeding, the patient should lie on the left side for 30 to 60 minutes. After a bone marrow biopsy, the wound is small and will not be packed with gauze. A pressure dressing is used to cover the aspiration site. There is no indication to elevate the patient's head.
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.
When preparing a client for surgery, which intervention should the nurse implement first? 1. Check the permit for the spouse's signature. 2. Take and document intake and output. 3. Administer the "on call" sedative. 4. Complete the preoperative checklist.
ANS:4 Completing the preoperative checklist has the highest priority to ensure that all details are completed without omissions.
A patient with possible cerebral edema has a serum sodium level of 115 mEq/L (115 mmol/L) and a decreasing level of consciousness (LOC) and complains of a headache. Which of these prescribed interventions should the nurse implement first?
Administer 5% hypertonic saline intravenously. rational: The patient's low sodium indicates that hyponatremia may be causing the cerebral edema, and the nurse's first action should be to correct the low sodium level. Acetaminophen (Tylenol) will have minimal effect on the headache because it is caused by cerebral edema and increased intra-cranial pressure (ICP). Drawing ABGs and obtaining a CT scan may add some useful information, but the low sodium level may lead to seizures unless it is addressed quickly.
Which of these prescribed interventions will the nurse implement first for a hospitalized patient who is experiencing continuous tonic-clonic seizures?
Administer lorazepam (Ativan) 4 mg IV. rational: To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure medications such as the benzodiazepines. A CT scan is appropriate, but prevention of any seizure activity during the CT scan is necessary. Phenytoin also will be administered, but it is not rapidly acting. Patients who are experiencing tonic-clonic seizures are nonresponsive, although the nurse should assess LOC after the seizure.
Which of these prescribed interventions will the nurse implement first for a hospitalized patient who is experiencing continuous tonic-clonic seizures?
Administer lorazepam (Ativan) 4 mg IV. rational: To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure medications such as the benzodiazepines. A CT scan is appropriate, but prevention of any seizure activity during the CT scan is necessary. Phenytoin also will be administered, but it is not rapidly acting. Patients who are experiencing tonic-clonic seizures are nonresponsive, although the nurse should assess LOC after the seizure.
Which of these nursing actions included in the care of a patient who has been experiencing stroke symptoms for 60 minutes can the nurse delegate to an LPN/LVN?
Administer the prescribed clopidogrel (Plavix). rational: Administration of oral medications is included in LPN education and scope of practice. The other actions require more education and scope of practice and should be done by the RN.
What should you make sure to discuss with someone who has multiple sclerosis?
Advanced directives because patient will eventually end up on vent and the use of a peak flow meter.
Following a head injury, an unconscious 32-year-old patient is admitted to the emergency department (ED). The patient's spouse and children stay at the patient's side and constantly ask about the treatment being given. What action is best for the nurse to take?
Allow the family to stay with the patient and briefly explain all procedures to them. rational: The need for information about the diagnosis and care is very high in family members of acutely ill patients, and the nurse should allow the family to observe care and explain the procedures. A pastor or counseling service can offer some support, but research supports information as being more effective. Asking the family to stay in the waiting room will increase their anxiety.
What is motor aphasia?
Also known as EXPRESSIVE APHASIA, Broca's area, it is the inability to speak or write. However, patient can comprehend the spoken or written form of communication.
What is AMYOTROPHIC LATERAL SCLEROSIS? What is important to know about it?
Also known as Lou Gehrig's Disease, it is a progressive neurological disease characterized by neuron death resulting in muscle weakness and eventually paralysis. The patient will die when respiratory paralysis reaches diaphragm so discuss advance directives and make sure to check gag reflex before feeding this patient.
What is autonomic dysreflexia? What is the cause? What are the signs and symptoms?
Also known as hyperreflexia, it is a potentially life threatening condition involving exaggeration of the sympathetic response to stimulation. The condition occurs in people with spinal cord injuries at T-6 or higher. It is triggered by a sustained stimuli such as restrictive clothing, pressure areas, FULL BLADDER, UTI or FECAL IMPACTION. Signs and symptoms above the level of injury: 1) flushed face 2) increased blood pressure 200/100 3) headache 4) distended neck veins 5) decreased heart rate 6) increased sweating, vasodilation Signs and symptoms below level of injury: 1. Pale 2. Cool 3. No sweating, vasoconstriction
The client with a suspected pituitary tumor will most likely exhibit symptoms of: A. Alteration in visual acuity B. Frequent diarrhea C. Alterations in blood glucose D. Urticaria
Answer A is correct. The pituitary is located in the middle of the skull adjacent to the optic nerve and brain. Pressure on the optic nerve can cause an increase in intracranial pressure. Clients frequently complain of headache, nausea, vomiting, and decreasing visual acuity as the intracranial pressure increases. B, C, and D are incorrect because they are not associated with a pituitary tumor.
A client with acromegaly will most likely experience which symptom? A. Bone pain B. Frequent infections C. Fatigue D. Weight loss
Answer A is correct. Acromegaly is an increase in secretion of growth hormone. The growth hormones cause expansion and elongation of the bones. Answers B, C, and D are not directly associated with acromegaly, so they are incorrect.
A client with Cushing's syndrome should be instructed to: A. Avoid alcoholic beverages B. Limit the sodium in her diet C. Increase servings of dark green vegetables D. Limit the amount of protein in her diet
Answer B is correct. A client with Cushing's syndrome has adrenocortical hypersecretion, so she retains sodium and water. The client may drink alcohol in moderation, so answer A is incorrect, and there is no need to eat more green vegetables or limit protein, so answers C and D are incorrect.
A client is admitted for removal of a goiter. Which nursing intervention should receive priority during the post-operative period? A. Maintaining fluid and electrolyte balance B. Assessing the client's airway C. Providing needed nutrition and fluids D. Providing pain relief with narcotic analgesics
Answer B is correct. A goiter is hyperplasia of the thyroid gland. Removal of a goiter can result in laryngeal spasms and airway occlusion. The other answers are lesser in priority.
A client with Addison's disease will most likely exhibit which symptom? A. Hypertension B. Bronze pigmentation C. Hirsutism D. Purple striae
Answer B is correct. Answer B is correct because a bronze pigmentation is a sign of Addison's disease. Answers A, C, and D are symptoms of Cushing's syndrome, making them incorrect.
Which vitamin is directly involved in the metabolism of the hormones secreted by the parathyroid? A. Vitamin C B. Vitamin D C. Vitamin K D. Vitamin B9
Answer B is correct. Vitamin D is related to absorption of calcium and phosphorus. A, C, and D are incorrect because they are not related to the absorption of calcium and phosphorus.
A client is admitted for treatment of hypoparathyroidism. Based on the client's diagnosis, the nurse would anticipate an order for: A. Potassium B. Magnesium C. Calcium D. Iron
Answer C is correct. The parathyroid is responsible for calcium and phosphorus absorption. Clients with hypoparathyroidism have hypocalcemia. Answers A, B, and D are not associated with hypoparathyroidism therefore they are incorrect.
Which item should be kept at the bedside of a client who has just returned from having a thyroidectomy? A. A padded tongue B. An endotracheal tube C. An airway D. A tracheostomy set
Answer D is correct. Laryngeal swelling is not uncommon in clients following a thyroidectomy. A tracheostomy tray should be kept available. The ventilator is not necessary, so answer A is incorrect. The endotracheal tube is very difficult, if not impossible, to intubate if swelling has already occurred, so answer B is incorrect. The airway will do no good because the swelling is in the trachea, so answer C is incorrect.
Which information given by a 70-year-old patient during a health history indicates to the nurse that the patient should be screened for hepatitis C? a. The patient had a blood transfusion in 2005. b. The patient used IV drugs about 20 years ago. c. The patient frequently eats in fast-food restaurants. d. The patient traveled to a country with poor sanitation.
B
34. All of these orders are received for a patient who has vomited 1500 ml of bright red blood. Which order will the nurse act on first? a. Infuse 1000 ml of lactated Ringer's solution. b. Administer IV famotidine (Pepcid) 40 mg. c. Insert NG tube and connect to suction. d. Type and cross match for 4 units of packed red blood cells.
Answer: A Rationale: Because the patient has vomited a large amount of blood, correction of hypovolemia and prevention of hypovolemic shock are the priorities. The other actions are also important to implement quickly but are not the highest priorities. Cognitive Level: Application Text Reference: p. 996 Nursing Process: Implementation NCLEX: Physiological Integrity
2. A patient with deep partial-thickness (second-degree) burns over 70% of the body experiences severe pain associated with nausea and occasional vomiting during dressing changes. To promote relief of the patient's nausea and vomiting, the nurse should a. administer the prescribed morphine sulfate before dressing changes. b. avoid performing dressing changes close to the patient's mealtimes. c. keep the patient NPO for 2 hours before and after dressing changes. d. give the ordered prochlorperazine (Compazine) before dressing changes.
Answer: A Rationale: Because the patient's nausea and vomiting are associated with severe pain, it is likely that they are precipitated by stress and pain. The best treatment will be to provide adequate pain medication before dressing changes. The nurse should avoid doing painful procedures close to mealtimes, but nausea/vomiting that occur at other times should also be addressed. Keeping the patient NPO does not address the reason for the nausea and vomiting and will have an adverse effect on the patient's nutrition. Administration of antiemetics is not the best choice for a patient with nausea caused by pain. Cognitive Level: Application Text Reference: p. 991 Nursing Process: Implementation NCLEX: Physiological Integrity
18. A patient has just arrived on the postoperative unit after having a laparoscopic esophagectomy for treatment of esophageal cancer. Which nursing actions should be included in the postoperative plan of care? a. Elevate the head of the bed to at least 30 degrees. b. Reposition NG tube if drainage stops or decreases. c. Notify doctor immediately about bloody NG drainage. d. Start oral fluids when patient has active bowel sounds.
Answer: A Rationale: Elevation of the head of the bed decreases the risk for reflux and aspiration of gastric secretions. The NG tube should not be repositioned without consulting with the health care provider. Bloody NG drainage is expected for the first 8 to 12 hours. A swallowing study is needed before oral fluids are started. Cognitive Level: Application Text Reference: p. 1011 Nursing Process: Planning NCLEX: Physiological Integrity
24. A patient is hospitalized with vomiting of "coffee-ground" emesis. The nurse will anticipate preparing the patient for a. endoscopy. b. angiography. c. gastric analysis testing. d. barium contrast studies.
Answer: A Rationale: Endoscopy is the primary tool for visualization and diagnosis of upper gastrointestinal (GI) bleeding. Angiography is used only when endoscopy can not be done, because it is more invasive and has more possible complications. Gastric analysis testing may help with determining the cause of gastric irritation, but it is not used for acute GI bleeding. Barium studies are helpful in determining the presence of gastric lesions, but not whether the lesions are actively bleeding. Cognitive Level: Application Text Reference: p. 997 Nursing Process: Planning NCLEX: Physiological Integrity
31. Twelve hours after undergoing a gastroduodenostomy (Billroth I) for treatment of a perforated ulcer, a patient complains of increasing abdominal pain. The nursing assessment reveals an absence of bowel sounds and 200 ml of bright red NG drainage in the last hour. The most appropriate action by the nurse at this time is to a. notify the health care provider. b. irrigate the NG tube. c. administer the ordered morphine sulfate. d. continue to monitor the NG drainage.
Answer: A Rationale: Increased pain and 200 ml of bright red NG drainage 12 hours after surgery indicate possible postoperative hemorrhage, and immediate actions such as blood transfusion and/or return to surgery are needed. Because the NG is draining, there is no indication that irrigation is needed. The patient may need morphine, but this is not the highest priority action. Continuing to monitor the NG drainage is not an adequate response. Cognitive Level: Application Text Reference: p. 1027 Nursing Process: Implementation NCLEX: Physiological Integrity
39. A patient who has intermittent epigastric distress, weight loss, and ascites is diagnosed with stomach cancer. The nurse plans care for the patient with the knowledge that these findings indicate that a. the patient has a poor prognosis with any therapy. b. surgical intervention is not indicated for the patient. c. radiation therapy is the treatment of choice for the patient. d. the patient will need a referral to hospice services.
Answer: A Rationale: Survival rate for patients with stomach cancer is low and the presence of ascites indicates metastasis and is a poor prognostic sign. The patient may be a candidate for surgery, which is the only curative treatment for stomach cancer. Radiation may be used, but it is not the treatment of choice because stomach cancers do not respond well to radiation. The patient may need a referral to hospice services, but this will depend on factors such as the patient's desires and how long the patient is projected to live. Cognitive Level: Application Text Reference: p. 1028 Nursing Process: Planning NCLEX: Physiological Integrity
29. A patient with a bleeding duodenal ulcer has an NG tube in place, and the health care provider orders 30 ml of aluminum hydroxide/magnesium hydroxide (Maalox) to be instilled through the tube every hour. To evaluate the effectiveness of this treatment, the nurse a. periodically aspirates and tests gastric pH. b. measures the amount of residual stomach contents hourly. c. monitors arterial blood gas values on a daily basis. d. checks each stool for the presence of occult blood.
Answer: A Rationale: The purpose for antacids is to increase gastric pH; checking gastric pH is the most direct way of evaluating the effectiveness of the medication. Arterial blood gases may change slightly, but this does not directly reflect the effect of antacids on gastric pH. Because the patient has upper GI bleeding, occult blood in the stools will appear even after the acute bleeding has stopped. The amount of residual stomach contents is not a reflection of resolution of bleeding or of gastric pH. Cognitive Level: Application Text Reference: p. 1020 Nursing Process: Evaluation NCLEX: Physiological Integrity
The patients passed his kidney stone! During stone analysis, it is determined that the stone is composed of uric acid. Which of the following dietary restrictions would be recommended for this patient? A) Avoiding all shellfish B) Limiting calcium intake C) Restricting protein intake D) Drinking less than 1000 ml of water
Answer: A. Stones that are composed of uric acid can be prevented by consuming a low-purine diet (similar for gout). Foods high in purine include shellfish, organ meat, asparagus, and mushrooms. Limiting calcium or protein intake may be appropriate for the stone composed of calcium. Patients with previous kidney stones should be encouraged to drink plenty of fluids, more than 2 L a day
11. When admitting a patient with a stroke who is unconscious and unresponsive to stimuli, the nurse learns from the patient's family that the patient has a history of GERD. The nurse will plan to do frequent assessment of the patient's a. bowel sounds. b. breath sounds. c. apical pulse. d. abdominal girth.
Answer: B Rationale: Because GERD may cause aspiration, the unconscious patient is at risk for developing aspiration pneumonia. Bowel sounds, abdominal girth, and apical pulse will not be affected by the patient's stroke or GERD and do not require more frequent monitoring than the routine. Cognitive Level: Application Text Reference: p. 1005 Nursing Process: Assessment NCLEX: Physiological Integrity
6. A patient who is receiving chemotherapy develops a Candida albicans oral infection. The nurse will anticipate the need for a. hydrogen peroxide rinses. b. administration of nystatin (Mycostatin) oral tablets. c. the use of antiviral agents. d. referral to a dentist for professional tooth cleaning.
Answer: B Rationale: Candida albicans is treated with an antifungal such as nystatin. Oral saltwater rinses may be used but will not cure the infection. Antiviral agents are used for viral infections such as herpes simplex. Referral to a dentist is indicated for gingivitis but not for Candida infection. Cognitive Level: Application Text Reference: p. 1000 Nursing Process: Planning NCLEX: Physiological Integrity
17. Which information will the nurse include when teaching a patient with newly diagnosed GERD? a. "Peppermint tea may be helpful in reducing your symptoms." b. "You will need to keep the head of your bed elevated on blocks." c. "You should avoid eating between meals to reduce acid secretion." d. "Vigorous physical activities may increase the incidence of reflux."
Answer: B Rationale: Elevating the head of the bed will reduce the incidence of reflux while the patient is sleeping. Peppermint will lower LES pressure and increase the chance for reflux. Small, frequent meals are recommended to avoid abdominal distension. There is no need to make changes in physical activities because of GERD. Cognitive Level: Application Text Reference: p. 1007 Nursing Process: Implementation NCLEX: Physiological Integrity
23. The health care provider orders insertion of a 20-gauge orogastric tube for a patient experiencing massive hematemesis. As the nurse inserts the tube, resistance is met in advancing the tube. The appropriate action by the nurse is to a. ask the patient to hyperextend the neck. b. stop and notify the health care provider of the resistance. c. inject additional lubricant through the tube. d. withdraw the tube a few inches and then reinsert.
Answer: B Rationale: No tube should be advanced against resistance because of the risk for mucosal damage or perforation of the esophagus. Hyperextension of the neck will increase the likelihood of insertion into the trachea. Because the tube may be in the trachea, injection of lubricant may cause aspiration. Withdrawal and reinsertion of the tube will increase the risk for mucosal damage or perforation. Cognitive Level: Application Text Reference: p. 996 Nursing Process: Implementation NCLEX: Physiological Integrity
Which topic is most important to include in patient teaching for a 41-year-old patient diagnosed with early alcoholic cirrhosis? a. Maintaining good nutrition b. Avoiding alcohol ingestion c. Taking lactulose (Cephulac) d. Using vitamin B supplements
B
27. The health care provider orders IV ranitidine (Zantac) for a patient with an acute exacerbation of chronic peptic ulcer disease. When teaching the patient about the effect of the medication, which information will the nurse include? a. "Ranitidine constricts the blood vessels in the stomach and decreases bleeding." b. "Ranitidine decreases secretion of gastric acid." c. "Ranitidine neutralizes the acid in the stomach." d. "Ranitidine covers the ulcer with a protective material which promotes healing."
Answer: B Rationale: Ranitidine is a histamine-2 (H2) receptor blocker, which decreases the secretion of gastric acid. The response beginning, "Ranitidine constricts the blood vessels" describes the effect of vasopressin. The response beginning "Ranitidine neutralizes the acid" describes the effect of antacids. And the response beginning "Ranitidine covers the ulcer" describes the action of sucralfate (Carafate). Cognitive Level: Application Text Reference: pp. 998, 1019 Nursing Process: Implementation NCLEX: Physiological Integrity
22. A patient with chronic gastritis associated with the presence of Helicobacter pylori is treated with triple-drug therapy. The nurse explains to the patient that the drugs commonly included in this regimen include a. famotidine (Pepcid), magnesium hydroxide (Mylanta), and pantoprazole (Protonix). b. amoxicillin (Amoxil ), clarithromycin (Biaxin), and omeprazole (Prilosec). c. sucralfate (Carafate), nystatin (Mycostatin), and bismuth subsalicylate (Pepto-Bismol). d. metoclopramide (Reglan), bethanechol (Urecholine), and promethazine (Phenergan).
Answer: B Rationale: The drugs used in triple-drug therapy include a proton pump inhibitor such as omeprazole and the antibiotics amoxicillin and clarithromycin. The other combinations listed are not included in the protocol for H. pylori infection. Cognitive Level: Comprehension Text Reference: p. 1014 Nursing Process: Implementation NCLEX: Physiological Integrity
33. A patient recovering from a gastrojejunostomy (Billroth II) for treatment of a duodenal ulcer develops dizziness, weakness, and palpitations, with an urge to defecate about 20 minutes after eating. To avoid recurrence of these symptoms, the nurse teaches the patient to a. increase the amount of fluid intake with meals. b. lie down for about 30 minutes after eating. c. drink sugared fluids or eat candy after each meal. d. choose foods that are high in carbohydrates.
Answer: B Rationale: The patient is experiencing symptoms of dumping syndrome, which may be reduced by lying down after eating. Increasing fluid intake and choosing high carbohydrate foods will increase the risk for dumping syndrome. Having a sweet drink or hard candy will correct the hypoglycemia that is associated with dumping syndrome but will not prevent dumping syndrome. Cognitive Level: Application Text Reference: p. 1027 Nursing Process: Implementation NCLEX: Physiological Integrity
9. A patient with oral squamous cell carcinoma is transferred to the postoperative surgical unit after a hemiglossectomy and radical neck procedure. When planning care the nurse will anticipate the need to a. insert a long-term central venous catheter for parenteral nutrition. b. use an alphabet board to assist the patient with communication. c. administer chemotherapy starting the first postoperative day. d. reinforce pressure dressings at the surgical incision.
Answer: B Rationale: The patient will have a tracheostomy after having a radical neck procedure, and the nurse should plan ways to allow the patient to communicate. IV fluids (but not parenteral nutrition) are given for 24 to 48 hours, followed by enteral feedings. Chemotherapy is not started until after surgical wounds have healed. Pressure dressings are not used because they could obstruct the patient's airway. Cognitive Level: Application Text Reference: p. 1003 Nursing Process: Planning NCLEX: Physiological Integrity
38. A patient with acute GI bleeding is receiving normal saline IV at a rate of 500 ml/hr. Which assessment data obtained by the nurse are most important to communicate immediately to the health care provider? a. The NG suction is returning coffee-ground material. b. The patient's lungs have crackles audible to the midline. c. The patient's BP has increased to 142/94 mm Hg. d. The bowel sounds are very hyperactive in all four quadrants.
Answer: B Rationale: The patient's lung sounds indicate that pulmonary edema may be developing as a result of the rapid infusion of IV fluid and that the fluid infusion rate should be slowed. The return of coffee-ground material in an NG tube is expected for a patient with upper GI bleeding. The BP is slightly elevated but would not be an indication to contact the health care provider immediately. Hyperactive bowel sounds are common when a patient has GI bleeding. Cognitive Level: Application Text Reference: p. 999 Nursing Process: Assessment NCLEX: Physiological Integrity
30. A patient with a peptic ulcer who has an NG tube develops sudden, severe upper abdominal pain, diaphoresis, and a very firm abdomen. Which action should the nurse take next? a. Irrigate the NG tube. b. Obtain the vital signs. c. Give the ordered antacid. d. Listen for bowel sounds.
Answer: B Rationale: The patient's symptoms suggest acute perforation, and the nurse should assess for signs of hypovolemic shock. Irrigation of the NG tube, administration of antacids, or both would be contraindicated because any material in the stomach will increase the spillage into the peritoneal cavity. The nurse should assess the bowel sounds, but this is not the first action that the nurse should take. Cognitive Level: Application Text Reference: pp. 1023-1024 Nursing Process: Implementation NCLEX: Physiological Integrity
16. A 62-year-old patient who has been diagnosed with esophageal cancer tells the nurse, "I know that my chances are not very good, but I do not feel ready to die yet." Which response by the nurse is most appropriate? a. "You may have quite a few years to live still left." b. "Having this new diagnosis must be very hard for you." c. "Thinking about dying will only make you feel worse." d. "It is important that you be realistic about your prognosis."
Answer: B Rationale: This response is open-ended and will encourage the patient to further discuss feelings of anxiety or sadness about the diagnosis. Patients with esophageal cancer have only a 20% 5-year survival rate, so the response "You may have quite a few years to live still yet" is misleading. The response beginning, "Thinking about dying" indicates that the nurse is not open to discussing the patient's fears of dying. And the response beginning, "It is important that you be realistic," discourages the patient from feeling hopeful, which is important to patients with any life-threatening diagnosis. Cognitive Level: Application Text Reference: p. 1011 Nursing Process: Implementation NCLEX: Psychosocial Integrity
The client with urge incontinence asks you "How can I get rid of this process?" Which is the best response to this client? A) "It's important to accept that this is a natural part of aging" B) "You should avoid artificial sweeteners, caffeine, and alcohol" C) "It could help to void after every time you think of it" D) "Make sure you take your diuretic at bedtime. This will help you pea better"
Answer: B. these substances are bladder irritants and should be avoided. A voiding schedule is best for patient with incontinence, and patients may or not remember to void. Urinary incontinence is not a natural part of aging, and diuretics should not be taken after 4 p.m.
32. The nurse implements discharge teaching for a patient following a gastroduodenostomy for treatment of a peptic ulcer. Which patient statement indicates that the teaching has been effective? a. "I will need to choose foods that are low in fat and high in carbohydrate." b. "I will try to drink liquids along with my meals." c. "Vitamin injections may be needed to prevent problems with anemia." d. "The surgery has cured my peptic ulcer disease."
Answer: C Rationale: Cobalamin deficiency may occur after partial gastrectomy, and the patient may need to receive cobalamin injections. Foods that have moderate fat and low carbohydrate should be chosen to prevent dumping syndrome. Ingestion of liquids with meals is avoided to prevent dumping syndrome. Peptic ulcer disease (PUD) is a chronic problem, and the patient will need to continue lifestyle changes and perhaps medications to prevent recurrence. Cognitive Level: Application Text Reference: p. 1027 Nursing Process: Evaluation NCLEX: Physiological Integrity
28. The family member of a patient who has suffered massive abdominal trauma in an automobile accident asks the nurse why the patient is receiving famotidine (Pepcid). The nurse will explain that the medication will a. decrease the risk for nausea and vomiting. b. prevent aspiration of gastric contents. c. inhibit the development of stress ulcers. d. lower the chance for H. pylori infection.
Answer: C Rationale: Famotidine is administered to prevent the development of physiologic stress ulcers, which are associated with a major physiologic insult such as massive trauma. Famotidine does not decrease nausea or vomiting, prevent aspiration, or prevent H. pylori infection. Cognitive Level: Application Text Reference: pp. 996, 998, 1017, 1019 Nursing Process: Implementation NCLEX: Physiological Integrity
40. When counseling a patient with a family history of stomach cancer about ways to decrease risk for developing stomach cancer, the nurse will teach the patient to avoid a. chronic use of H2-blocking medications. b. emotionally or physically stressful situations. c. smoked foods such as bacon and ham. d. foods that cause abdominal distension.
Answer: C Rationale: Smoked foods such as bacon, ham, and smoked sausage increase the risk for stomach cancer. Use of H2 blockers, stressful situations, and abdominal distension are not associated with an increased incidence of stomach cancer. Cognitive Level: Application Text Reference: p. 1028 Nursing Process: Implementation NCLEX: Physiological Integrity
12. A patient with recurring heartburn receives a new prescription for esomeprazole (Nexium). In teaching the patient about this medication, the nurse explains that this drug a. reduces the reflux of gastric acid by increasing the rate of gastric emptying. b. coats and protects the lining of the stomach and esophagus from gastric acid. c. treats gastroesophageal reflux disease by decreasing stomach acid production. d. neutralizes stomach acid and provides relief of symptoms in a few minutes.
Answer: C Rationale: The proton pump inhibitors decrease the rate of gastric acid secretion. Promotility drugs such as metoclopramide (Reglan) increase the rate of gastric emptying. Cryoprotective medications such as sucralfate (Carafate) protect the stomach. Antacids neutralize stomach acid and work rapidly. Cognitive Level: Comprehension Text Reference: pp. 998, 1006 Nursing Process: Implementation NCLEX: Physiological Integrity
44. A 22-year-old patient with Escherichia coli O157:H7 food poisoning is admitted to the hospital with bloody diarrhea and dehydration. All of the following orders are received. Which order will the nurse question? a. Infuse lactated Ringer's solution at 250 ml/hr. b. Monitor blood urea nitrogen and creatinine daily. c. Administer loperamide (Imodium) after each stool. d. Provide a clear liquid diet and progress diet as tolerated.
Answer: C Rationale: Use of antidiarrheal agents is avoided with this type of food poisoning. The other orders are appropriate. Cognitive Level: Application Text Reference: pp. 1031, 1033 Nursing Process: Implementation NCLEX: Physiological Integrity
Which of the following signs and symptoms would the nurse expect to see in the elderly patient with a UTI? A) Back pain B) High Fever C) ALOC D) Anorexia E) Tachypnea
Answer: C, D, and E. In elderly patients, the nurse would expect to see more nonspecific signs of urinary tract infection including changes in level of consciousness, lethargy, anorexia, new incontinences, hyperventilation, and low-grade fever. Back pain may be present with UTI, but is not common in elderly patients. High fever is typically not present.
The nurse is teaching the patient who has just been given a urinary diversion (ileal conduit). Which of the following statements, if made by the patient, indicates the need for further teaching? A) I should not expect to feel pain at the stoma B) The stoma could bleed when I clean it C) I should report any signs of mucous in the urine to my doctor D) The stoma should be pink and moist
Answer: C. Because a segment of the GI system is typically used to create a urinary diversion, mucous would be expected in the urine. The stoma is vascular, and could bleed when cleaned. There are no nerve endings at the stoma, so there should be no pain. The stoma should be pink and moist like the inside of the mouth.
You are teaching a patient with urinary incontinence about the importance of increasing fluid intake. Which statement, if made by the patient, indicates correct understanding? A) "Increasing my fluid intake will help flush toxins out of my kidneys which helps prevent incontinence" B) "I should double my fluid intake over the next several days" C) "Increased fluids can help with my urinary incontinence by preventing constipation" D) "Like you said, if I drink more water my pea will no longer be bothersome to my bladder"
Answer: C. Increased fluids help by preventing constipation, reduce urge by lowering concentration of urine, and help prevent infection. Although drinking fluids can help promote excretion of toxins out of the body, this does not affect incontinence. Doubling fluid intake may be effective, but we are not aware of the patient's previous intake. Patients should be encouraged do drink 2000-3000 mL if they have no other fluid restrictions.
Ms. White, the nursing instructor, is teaching her students how to prevent infection in patients with an indwelling catheter. Which student demonstrates correct understanding? A) "Hanging the urine bag above the bladder will help prevent infection" B) "It's important to avoid using soap to clean the perineum in the patient with a catheter" C) "The urine bag should be emptied at least every 8 hours" D) "The tubing to the urinary catheter should never be unhooked unless a specimen needs to be taken"
Answer: C. The bag should be emptied at least every eight hours (more if there are large amounts of urine) to prevent the risk of bacterial proliferation. The bag should NEVER be hung above the level of the bladder or set on the ground. Soap and water can be used to clean the perineal area and around the catheter, and should be done twice a day. The tubing of the catheter should NEVER be disconnected, even for a specimen.
42. Which nursing diagnosis is appropriate for the home health nurse to use when planning care for a patient who has had a total gastrectomy with an anastomosis of the esophagus to the jejunum for treatment of stomach cancer? a. Chronic pain related to altered GI tract function secondary to the surgery b. Risk for infection related to ongoing need for parenteral nutrition c. Risk for impaired skin integrity related to leakage from jejunostomy tube d. Imbalanced nutrition: less than body requirements related to inability to absorb nutrients
Answer: D Rationale: After this procedure, there will be less surface area for nutrient absorption and vitamins that are normally absorbed in the duodenum will have poor absorption. Chronic pain may occur, but this is due to cancer, not to changes that occur in GI function because of surgery. Parenteral nutrition may be used in the immediate postoperative period but is not needed on an ongoing basis. The patient will not have a jejunostomy tube. Cognitive Level: Application Text Reference: p. 1031 Nursing Process: Diagnosis NCLEX: Physiological Integrity
15. A patient who has recently been experiencing frequent heartburn is seen in the clinic. The nurse will anticipate teaching the patient about a. endoscopy procedures. b. barium swallow. c. radionuclide tests. d. proton pump inhibitors.
Answer: D Rationale: Because diagnostic testing for heartburn that is probably caused by gastroesophageal reflux disease (GERD) is expensive and uncomfortable, proton pump inhibitors are frequently used for a short period as the first step in the diagnosis of GERD. The other tests may be used but are not usually the first step in diagnosis. Cognitive Level: Application Text Reference: p. 1005 Nursing Process: Planning NCLEX: Physiological Integrity
21. Cobalamin injections have been prescribed for a patient with chronic atrophic gastritis. The nurse determines that teaching regarding the injections has been effective when the patient states, a. "These injections will decrease my risk for developing stomach cancer." b. "These injections will increase the hydrochloric acid in my stomach." c. "The cobalamin injections need to be taken until my inflamed stomach heals." d. "The cobalamin injections will prevent me from becoming anemic."
Answer: D Rationale: Cobalamin supplementation prevents the development of pernicious anemia. The incidence of stomach cancer is higher in patients with chronic gastritis, but cobalamin does not reduce the risk for stomach cancer. Chronic gastritis may cause achlorhydria, but cobalamin does not correct this. The loss of intrinsic factor secretion with chronic gastritis is permanent, and the patient will need lifelong supplementation with cobalamin. Cognitive Level: Application Text Reference: p. 1014 Nursing Process: Evaluation NCLEX: Physiological Integrity
19. The nurse will plan to teach the patient with newly diagnosed achalasia that a. drinking fluids with meals should be avoided. b. lying down and resting after meals is recommended. c. a liquid or blenderized diet will be necessary. d. endoscopic procedures may be used for treatment.
Answer: D Rationale: Endoscopic and laparoscopic procedures are the most effective therapy for improving symptoms caused by achalasia. Patients are advised to drink fluid with meals. Keeping the head elevated after eating will improve esophageal emptying. A semisoft diet is recommended to improve esophageal emptying. Cognitive Level: Application Text Reference: p. 1012 Nursing Process: Planning NCLEX: Physiological Integrity
10. The nurse is assessing a patient with gastroesophageal reflux disease (GERD) who is experiencing increasing discomfort. Which patient statement indicates that additional patient education about GERD is needed? a. "I take antacids between meals and at bedtime each night." b. "I quit smoking several years ago, but I still chew a lot of gum." c. "I sleep with the head of the bed elevated on 4-inch blocks." d. "I eat small meals throughout the day and have a bedtime snack."
Answer: D Rationale: GERD is exacerbated by eating late at night, and the nurse should plan to teach the patient to avoid eating at bedtime. The other patient actions are appropriate to control symptoms of GERD. Cognitive Level: Application Text Reference: p. 1005 Nursing Process: Evaluation NCLEX: Physiological Integrity
To prepare a 56-year-old male patient with ascites for paracentesis, the nurse a. places the patient on NPO status. b. assists the patient to lie flat in bed. c. asks the patient to empty the bladder. d. positions the patient on the right side.
C: The patient should empty the bladder to decrease the risk of bladder perforation during the procedure
35. A patient who requires daily use of a nonsteroidal antiinflammatory drug (NSAID) for management of severe rheumatoid arthritis has recently developed melena. The nurse will anticipate teaching the patient about a. the use of ranitidine (Zantac) to decrease the risk for peptic ulcers. b. reasons for using corticosteroids to treat the arthritis. c. substitution of acetaminophen (Tylenol) for the NSAID. d. the benefits of misoprostol (Cytotec) in protecting the GI mucosa.
Answer: D Rationale: Misoprostol, a prostaglandin analog, is the only drug approved in the United States for preventing gastric ulcers induced by NSAIDs. Ranitidine does increase pH but is not approved for prevention of ulcers in patients chronically taking NSAIDs. Corticosteroids increase risk for ulcer development and will not be substituted for NSAIDs for this patient. Acetaminophen will not be effective in treating the patient's rheumatoid arthritis. Cognitive Level: Application Text Reference: p. 1021 Nursing Process: Planning NCLEX: Physiological Integrity
3. Which of these nursing actions should the RN working in the emergency department delegate to a nursing assistant who is helping with the care of a patient who has been admitted with nausea and vomiting? a. Assess for signs of dehydration. b. Ask the patient what precipitated the nausea. c. Auscultate the bowel sounds. d. Assist the patient with oral care after vomiting.
Answer: D Rationale: Oral care is included in nursing assistant education and scope of practice. The other actions are all assessments that require more education and a higher scope of nursing practice. Cognitive Level: Application Text Reference: pp. 992-995 Nursing Process: Implementation NCLEX: Physiological Integrity
36. The health care provider prescribes antacids and sucralfate (Carafate) for treatment of a patient's peptic ulcer. The nurse will teach the patient to take a. sucralfate and antacids together 30 minutes before each meal. b. antacids 30 minutes before the sucralfate. c. sucralfate at bedtime and antacids before meals. d. antacids after eating and sucralfate 30 minutes before eating.
Answer: D Rationale: Sucralfate is most effective when the pH is low and should not be given with or soon after antacid. Antacids are most effective when taken after eating. Administration of sucralfate 30 minutes before eating and antacids just after eating will ensure that both drugs can be most effective. The other regimens will decrease the effectiveness of the medications. Cognitive Level: Comprehension Text Reference: pp. 1020-1021 Nursing Process: Implementation NCLEX: Physiological Integrity
25. A patient who is vomiting bright red blood is admitted to the emergency department. Which assessment should the nurse accomplish first? a. Measuring the quantity of any emesis b. Checking the level of consciousness c. Auscultating the chest for breath sounds d. Taking the blood pressure (BP) and pulse
Answer: D Rationale: The nurse is concerned about blood loss and possible hypovolemic shock in a patient with acute GI bleeding; BP and pulse are the best indicators of these complications. The other information is also important to obtain, but BP and pulse rate are the best indicators for hypoperfusion. Cognitive Level: Application Text Reference: p. 997 Nursing Process: Assessment NCLEX: Physiological Integrity
26. The health care provider orders IV vasopressin (Pitressin) to be administered to a patient with esophageal bleeding. During administration of the drug, the nurse will monitor the patient for a. polyuria. b. metabolic alkalosis. c. intention tremors. d. chest pain.
Answer: D Rationale: Vasopressin decreases coronary artery perfusion and may cause coronary ischemia. The other symptoms are not adverse effects associated with vasopressin. Cognitive Level: Application Text Reference: p. 997 Nursing Process: Evaluation NCLEX: Physiological Integrity
You are helping the patient who has just had a foley catheter removed to retrain their bladder. As the nurse you would do all of the following except: A) Encourage the patient to drink measured amounts of fluids B) Palpate the bladder to assess for distention C) Teach the client to report any sweating, cold hands, or feelings of anxiety D) Straight cath the patient if the residual urine is more than 50 mL
Answer: D. A straight catheter should only be used if the residual urine is more than 100 mL (urinary retention). Immediately after the voiding attmpt the bladder should be scanned to assess for urinary retention. All other strategies can be used.
The nurse knows that all but which of the following are measures to promote urinary continence: A) Stopping smoking B) Pelvic floor exercises C) Avoiding constipation D) Taking showers not baths
Answer: D. Taking showers and not baths would be appropriate for the patient with recurrent UTI's. Smoking can increase cough which can in turn increase incontinence. Pelvic floor exercises help strengthen muscles and will help with incontinence. Constipation should be avoided as this can promote incontinence.
The patient who has just undergone knee surgery has been found to have not peed in six hours. The nurse can do all of the following to encourage the patient to void except? A) Apply a warm compress to perineum B) Offering hot fluids C) Run water in background D) Helping the patient onto the bedpan
Answer: D. The bedpan is evil for people with urinary retention. It is much more comfortable to pee in a sitting or standing position. Warmth in the form of compresses and hot beverages can help stimulate urination. Running water from a faucet may also trigger the patient to pee. IF the patient cannot void, the bladder should be scanned and catheterization may be necessary.
The client you are taking care of has just been diagnosed with nephrolithiasis. Upon assessment, which priority question should the nurse ask the client? A) Have you seen any blood in your urine? B) Are you have any pain? C) What is your typical diet? D) Have you had any burning pea?
Answer: D. This question assesses for the possibility of developing an infection, a complication of nephrolithiasis (kidney stones). Pain and hematuria would be expected in this patient. Diet can be helpful in preventing kidney stone formation, but it is not a priority question.
The client diagnosed with arterial occlusive disease is one (1) day postoperative right femoral popliteal bypass. Which intervention should the nurse implement?
Apply sequential compression devices to lower extremities
A 32-year-old patient has a stroke resulting from a ruptured aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan?
Applying intermittent pneumatic compression stockings rational: The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboemboism (VTE). Activities such as coughing and sitting up that might increase intracranial pressure (ICP) or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.
A client has returned from a captopril renal scan. Which teaching does the nurse provide when the client returns?
Arise slowly and call for assistance when ambulating." Captopril can cause severe hypotension during and after the procedure, so the client should be warned to avoid rapid position changes and about the risk for falling as a result of orthostatic (positional) hypotension.
A patient seen at the health clinic with a severe migraine headache tells the nurse about having four similar headaches in the last 3 months. Which initial action should the nurse take?
Ask the patient to keep a headache diary. rational: The initial nursing action should be further assessment of the precipitating causes of the headaches, quality, and location of pain, etc. Stress reduction, muscle relaxation, and the triptan drugs may be helpful, but more assessment is needed first.
Which action will the nurse include in the plan of care when caring for a patient who is experiencing trigeminal neuralgia?
Assess intake and output and dietary intake. rational: The patient with an acute episode of trigeminal neuralgia may be unwilling to eat or drink, so assessment of nutritional and hydration status is important. Because stimulation by touch is the precipitating factor for pain, relaxation of the facial muscles will not improve symptoms. Application of ice is likely to precipitate pain. The patient will not want to engage in conversation, which may precipitate attacks.
Which action will the nurse include in the plan of care when caring for a patient who is experiencing trigeminal neuralgia?
Assess intake and output and dietary intake. rational: The patient with an acute episode of trigeminal neuralgia may be unwilling to eat or drink, so assessment of nutritional and hydration status is important. Because stimulation by touch is the precipitating factor for pain, relaxation of the facial muscles will not improve symptoms. Application of ice is likely to precipitate pain. The patient will not want to engage in conversation, which may precipitate attacks.
When caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury, which nursing action has the highest priority?
Assessment of respiratory rate and depth rational: Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function. The other actions also are appropriate but are not as important as assessment of respiratory effort.
Several weeks after a stroke, a patient has urinary incontinence resulting from an impaired awareness of bladder fullness. For an effective bladder training program, which nursing intervention will be best to include in the plan of care?
Assist the patient onto the bedside commode every 2 hours. rational: Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder. A 1200 mL fluid restriction may lead to dehydration. Intermittent catheterization and use of a condom catheter are appropriate in the acute phase of stroke but should not be considered solutions for long-term management because of the risks for urinary tract infection (UTI) and skin breakdown.
The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired self-feeding ability for a patient with right-sided hemiplegia. Which intervention should be included in the plan of care?
Assist the patient to eat with the left hand. rational: Because the nursing diagnosis indicates that the patient's imbalanced nutrition is related to the right-sided hemiplegia, the appropriate interventions will focus on teaching the patient to use the left hand for self-feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition.
After suctioning, the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 16 mm Hg. Which action should the nurse take first?
Assure that the patient's neck is not in a flexed position. rational: Since suctioning will cause a transient increase in intracranial pressure, the nurse should initially check for other factors that might be contributing to the increase and observe the patient for a few minutes. Documentation is needed, but this is not the first action. There is no need to notify the health care provider about this expected reaction to suctioning. Propofol is used to control patient anxiety or agitation; there is no indication that anxiety has contributed to the increase in intracranial pressure.
A 55-year-old patient admitted with an abrupt onset of jaundice and nausea has abnormal liver function studies but serologic testing is negative for viral causes of hepatitis. Which question by the nurse is most appropriate? a. "Is there any history of IV drug use?" b. "Do you use any over-the-counter drugs?" c. "Are you taking corticosteroids for any reason?" d. "Have you recently traveled to a foreign country?"
B
A female patient expresses her concern about becoming pregnant while her partner is on ribavirin therapy for chronic hepatitis C. What should the nurse advise the patient? a. She can plan pregnancy now. b. She should avoid getting pregnant now. c. She should not get pregnant with this partner ever. d. She should avoid any sexual intercourse after conception.
B Any woman who is on ribavirin or whose male partner is on is on ribavirin should avoid pregnancy during treatment. The pregnancy can be planned after the treatment is complete. She can get pregnant with this partner, but not while on treatment. Avoiding intercourse after conception is not necessary. Text Reference - p. 1013
Which of the following symptoms is not typical of Cushing's syndrome? Answers: A. Osteoporosis B. Weight loss C. Diabetes D. Mood instability
B Cushing's syndrome tends to produce rapid weight gain, not weight loss.
A 26 year old female client presents with the symptom of unwanted facial hair. What of the following conditions is most likely? Answers: A. Graves' disease B. PCOS C. Hyperthyroidism D. Addison's disease
B PCOS is well known to cause hormonal irregularities in women which can result in hair growth.
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.
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.
Which of the following terms did note a patient's inability to void even though the kidneys are producing urine that enters the bladder? A) Urgency B) Retention C)Oliguria D)Dysuria
B) Retention Urgency is a strong desire to void. Oliguria is scanty or greatly diminished amount of urine voided in a given time. Dysuria is difficulty urinating
A patient has a nursing diagnoses of in paired urinary illumination related to maturational enuresis. You recognize that your patient Is which of the following? A) An older adult that is 65 years of age is incontinent B) a child older than four years of age who has an voluntary urination C) A 12-month-old child who is in voluntary urination D) A patient with Neurological damage resulting in bladder dysfunction
B) a child older than four years of age who has an voluntary urination Maturational Enuresis Is in voluntary urination after an age when content should be present. A 12-month-old child is not expected to be continent, and Incontinence and neurological damage are not maturational problems
During the patient's acute post op period following repair of an aneurysm, the nurse should ensure that a) hypothermia is maintained to decrease oxygen need. b) the BP and all peripheral pulses are evaluated at least every hour. c) IV fluids are administered at a rate to maintain hourly urine output of 100 mL. d) the patient's BP is kept lower than baseline to prevent leaking at the suture line.
B) the BP and all peripheral pulses are evaluated at least every hour
After surgery, Ms.Young is having difficultly voiding. Which nursing action would most likely lead to an increased difficulty with voiding? A)Pouring warm water over Ms.Young's fingers B)Having Ms.Young ignore the urge to void until her bladder is full C)Using a warm bedpan when MS.Young feels the urge to void D)Stroking Ms.Young's leg or thigh
B)Having Ms.Young ignore the urge to void until her bladder is full Ignoring the urge to void makes urination even more difficult and should be avoided. The other actives are all recommend nursing actions to help promotes urination.
When collecting a urine specimen for routine urinalysis from a "PT", the nurse must keep in mind which of the following? A)A sterile specimen is required for collection B)Results may be altered of a sample if left standing at room temperature for a long time C)The external meatus requires cleaning with antiseptic soap and water before voiding D)A clean-catch midstream specimen is necessary
B)Results may be altered of a sample if left standing at room temperature for a long time Urine chemistry it altered after urine stands at room temperature for a long period of time. For a routine urinalysis, a clean specimen is adequate. The external meatus does not need to be cleaned with an antiseptic, as is required for a clean-catch midstream specimen
What are the precautions that nurses and hospital staff should follow while handling patients suffering from hepatitis infections? Select all that apply. a. The patient must be in a private room, and door should be closed. b. Dispose of the needles and syringes used on the patient carefully. c. Wear gloves while handling articles contaminated by urine or feces. d. Always wear a mask, gown, and gloves when entering the patient's room. e. Follow infection control precautions while injecting the patient, and avoid getting pricked by the used needle.
B, C, E Hepatitis A spreads through the fecal-oral route, and hepatitis B spreads through blood. Hence the virus can spread through needles and syringes used by the patient. Also, the virus can spread while the nurse is handling the urine or fecal material of the patient; hence it is necessary to wear gloves. Hepatitis does not spread through air; hence a mask is not required. A private room is required in respiratory diseases, not in hepatitis. Test-Taking Tip: Study wisely, not hard. Use study strategies to save time and be able to get a good night's sleep the night before your exam. Cramming is not smart, and it is hard work that increases stress while reducing learning. When you cram, your mind is more likely to go blank during a test. When you cram, the information is in your short-term memory so you will need to relearn it before a comprehensive exam. Relearning takes more time. The stress caused by cramming may interfere with your sleep. Your brain needs sleep to function at its best. Text Reference - p. 1014
Laboratory test results that the nurse would expect to find in a patient with cirrhosis include a. serum albumin 7.0 g/dL b. bilirubin total 3.2 mg/dL c. serum cholesterok 260 mg/dL d. aspartate aminotransferase (AST) 6.0 U/L
B- Serum bilirubin, both direct and indirect, would be expected to be increased in cirrhosis. Serum albumin and cholesterol are decreased, and liver enzymes, such as AST and ALT, are elevated
A patient with advanced cirrhosis has a nursing diagnosis of imbalanced nutrition: less than body requirements r/t anorexia and inadequate food intake. An appropriate midday snack for the patient would be a. peanut butter and salt free crackers b. a fresh tomato sandwich with salt free butter c. popcorn with salt free butter and herbal seasoning d. canned chicken noodle soup with low protein bread
B- The patient with advanced, complicated cirrhosis requires a high calore, high carbohydrate diet with moderate to low fat. Patients with cirrhosis are at risk for edema and ascites and their sodium intake should be limited. The tomato sandwich with salt free butter best meets these requirements. Rough foods, such as popcorn, may irritate the esophagus and stomach and lead to bleeding. Peanut butter is high in sodium and fat, and canned chicken noodle soup is very high in sodium
The nurse identifies a need for further teaching when the patient with hepatitis B states, a. I should avoid alcohol completely for as long as a year b. I must avoid all physical contact with my family until the jaundice is gone c. I should use a condom to prevent spread of the disease to my sexual partners d. I will need to rest several times a day, gradually increasing my activity as I tolerate it.
B- The patient with hep B is infectious for 4 to 6 months, and precautions to prevent transmission through percutaneous and sexual contact should be maintained until tests for HBsAg are negative. Close contact does not have to be avoided, but close contacts of the patient should be vaccinated. Alcohol should not be used for at least a year, and rest with increasing activity during convalescence is recommended
13. Early this morning, a female client had a subtotal thyroidectomy. During evening rounds, nurse Tina assesses the client, who now has nausea, a temperature of 105° F (40.5° C), tachycardia, and extreme restlessness. What is the most likely cause of these signs? a. Diabetic ketoacidosis b. Thyroid crisis c. Hypoglycemia d. Tetany
B. Thyroid crisis usually occurs in the first 12 hours after thyroidectomy and causes exaggerated signs of hyperthyroidism, such as high fever, tachycardia, and extreme restlessness. Diabetic ketoacidosis is more likely to produce polyuria, polydipsia, and polyphagia; hypoglycemia, to produce weakness, tremors, profuse perspiration, and hunger. Tetany typically causes uncontrollable muscle spasms, stridor, cyanosis, and possibly asphyxia.
The patient with advanced cirrhosis asks why his or her skin is so yellow. The nurse's response is based on the knowledge that: a. Decreased peristalsis in the gastrointestinal tract contributes to a buildup of bile salts. b. Jaundice results from the body's inability to conjugate and excrete bilirubin. c. A lack of clotting factors promotes the collection of blood under the skin surface. d. Decreased colloidal oncotic pressure from hypoalbuminemia causes the yellowish skin discoloration.
B. Jaundice results from the functional derangement of liver cells and compression of bile ducts by connective tissue overgrowth. Jaundice occurs as a result of the decreased ability to conjugate and excrete bilirubin Jaundice is not caused by a build-up of bile salts, a lack of clotting factors, or decreased colloidal oncotic pressure. Test-Taking Tip: The most reliable way to ensure that you select the correct response to a multiple-choice question is to recall it. Depend on your learning and memory to furnish the answer to the question. To do this, read the stem, and then stop! Do not look at the response options yet. Try to recall what you know and, based on this, what you would give as the answer. After you have taken a few seconds to do this, then look at all of the choices and select the one that most nearly matches the answer you recalled. It is important that you consider all the choices and not just choose the first option that seems to fit the answer you recall. Remember the distractors. The second choice may look okay, but the fourth choice may be worded in a way that makes it a slightly better choice. If you do not weigh all the choices, you are not maximizing your chances of correctly answering each question. Text Reference - p. 1009
A patient has an increased ammonia level associated with hepatic encephalopathy. What assessment finding does the nurse expect? a. Aphasia b. Asterixis c. Hyperactivity d. Acute dementia
B. Asterixis is a twitching spasm of the hands and wrists seen in patients with increased ammonia levels in conditions such as hepatic encephalopathy. Aphasia, hyperactivity, and acute dementia are manifestations not associated with hepatic encephalopathy. Besides asterixis, an increased serum ammonia level causes sedation and confusion that progress to a comatose state. Text Reference - p. 1021
The nurse provides discharge instructions to a patient with newly diagnosed cirrhosis. Which statement made by the patient indicates the need for further teaching? a. "I should take frequent rest periods." b. "I can eat anything that appeals to me." c. "I can do without my glass of wine with dinner." d. "I should take only medications that have been prescribed."
B. Even though a low-protein diet has been questioned in the treatment of patients with cirrhosis, it remains in use. In light of this, it is incorrect for the patient to say that he may eat anything. Patients with cirrhosis must also avoid alcohol. Frequent rest and limitation of medications to those that have been prescribed are appropriate resolutions in a newly diagnosed case of cirrhosis and therefore do not indicate the need for further teaching. Text Reference - p. 1022
A patient has been admitted with diabetes mellitus, malnutrition, osteomyelitis, and alcohol abuse. Laboratory results are significant for an alanine aminotransferase (ALT) of 198 IU/L and aspartate transaminase (AST) of 224 IU/L. Which diagnosis does the nurse attribute these findings to? a. Diabetes mellitus b. Alcohol abuse c. Malnutrition d. Osteomyelitis
B. In the patient with alcohol abuse, liver disease could develop as a complication, increasing the liver function tests above the normal levels. The normal ALT range is 7 to 56 IU/L and the normal AST range is 5 to 40 IU/L. Diabetes would result in elevated blood sugar levels. Malnutrition would be evidenced by low protein levels. Osteomyelitis is an infection of the bone, which would result in an elevated white blood cell count. Text Reference - p. 1015
A 68-year-old man has chronic pain because of lung cancer that has metastasized to the bone in his back and hip. The nurse is teaching the patient and his family about tolerance and physical dependence to opioid medications. Which statement, if made by the patient, indicates a need for further teaching? A. "High doses of the medication may cause more side effects than lower doses." B. "If I need higher doses of the drug to relieve pain, I have developed an addiction." C. "Physical dependence is expected when this drug is used for long periods of time." D. "I may eventually need a higher dose of the medication to get the same pain relief."
B. "If I need higher doses of the drug to relieve pain, I have developed an addiction." Tolerance and physical dependence are not indicators of addiction. Tolerance and physical dependence are normal physiologic responses to chronic exposure to opioids. Tolerance is the need for an increased opioid dose to maintain the same degree of analgesia. Physical dependence is manifested by a withdrawal syndrome that occurs when blood levels of the drug are abruptly decreased. Tolerance is a condition characterized by aberrant behaviors arising from a drive to obtain and take substances for reasons other than the prescribed therapeutic value.
A 42-year-old man who is scheduled for an arthrocentesis arrives at the outpatient surgery unit and states, "I do not want this procedure done today." Which response by the nurse is most appropriate? A. "When would you like to reschedule the procedure?" B. "Tell me what your concerns are about this procedure." C. "The procedure is safe, so why should you be worried?" D. "The procedure is not painful because an anesthetic is used."
B. "Tell me what your concerns are about this procedure." The nurse should use therapeutic communication to determine the patient's concern about the procedure. The nurse should not provide false reassurance. It is not appropriate for the nurse to assume the patient is concerned about pain or to assume the patient is asking to reschedule the procedure.
A 57-year-old postmenopausal woman is scheduled for dual-energy x-ray absorptiometry (DXA). Which statement, if made by the patient to the nurse, indicates understanding of the procedure? A. "The bone density in my heel will be measured." B. "This procedure will not cause any pain or discomfort." C. "I will not be exposed to any radiation during the procedure." D. "I will need to remove my hearing aids before the procedure."
B. "This procedure will not cause any pain or discomfort." Dual-energy x-ray absorptiometry (DXA) is painless and measures the bone mass of spine, femur, forearm, and total body with minimal radiation exposure. A quantitative ultrasound (QUS) evaluates density, elasticity, and strength of bone using ultrasound of the calcaneus (heel). Magnetic resonance imaging would require removal of objects such as hearing aids that have metal parts.
The nurse is caring for a patient with chronic obstructive pulmonary disorder (COPD) and pneumonia who has an order for arterial blood gases to be drawn. What is the minimum length of time the nurse should plan to hold pressure on the puncture site? A. 2 minutes B. 5 minutes C. 10 minutes D. 15 minutes
B. 5 minutes After obtaining blood for an arterial blood gas measurement, the nurse should hold pressure on the puncture site for 5 minutes by the clock to be sure that bleeding has stopped. An artery is an elastic vessel under much higher pressure than veins, and significant blood loss or hematoma formation could occur if the time is insufficient.
Which patient is exhibiting an early clinical manifestation of hypoxemia? A. A 48-year-old patient who is intoxicated and acutely disoriented to time and place B. A 72-year-old patient who has four new premature ventricular contractions per minute C. A 67-year-old patient who has dyspnea while resting in the bed or in a reclining chair D. A 94-year-old patient who has renal insufficiency, anemia, and decreased urine output
B. A 72-year-old patient who has four new premature ventricular contractions per minute Early clinical manifestations of hypoxemia include dysrhythmias (e.g., premature ventricular contractions), unexplained decreased level of consciousness (e.g., disorientation), dyspnea on exertion, and unexplained decreased urine output.
Which information in a 67-year-old woman's health history will alert the nurse to the need for a more focused assessment of the musculoskeletal system? a. The patient sprained her ankle at age 13. b. The patient's mother became shorter with aging. c. The patient takes ibuprofen (Advil) for occasional headaches. d. The patient's father died of complications of miliary tuberculosis.
B. A family history of height loss with aging may indicate osteoporosis, and the nurse should perform a more thorough assessment of the patient's current height and other risk factors for osteoporosis. A sprained ankle during adolescence does not place the patient at increased current risk for musculoskeletal problems. A family history of tuberculosis is not a risk factor. Occasional nonsteroidal antiinflammatory drug (NSAID) use does not indicate any increased musculoskeletal risk.
A nurse is caring for a patient with a diagnosis of deep venous thrombosis (DVT). The patient has an order to receive 30 mg enoxaparin (Lovenox). Which injection site should the nurse use to administer this medication safely? A. Buttock, upper outer quadrant B. Abdomen, anterior-lateral aspect C. Back of the arm, 2 inches away from a mole D. Anterolateral thigh, with no scar tissue nearby
B. Abdomen, anterior-lateral aspect Enoxaparin (Lovenox) is a low-molecular-weight (LMW) heparin that is given as a deep subcutaneous injection in the right and left anterolateral abdomen. All subcutaneous injections should be given away from scars, lesions, or moles.
A female patient with a long-standing history of rheumatoid arthritis has sought care because of increasing stiffness in her right knee that has culminated in complete fixation of the joint. The nurse would document the presence of which problem? A. Atrophy B. Ankylosis C. Crepitation D. Contracture
B. Ankylosis Ankylosis is stiffness or fixation of a joint, whereas contracture is reduced movement as a consequence of fibrosis of soft tissue (muscles, ligaments, or tendons). Atrophy is a flabby appearance of muscle leading to decreased function and tone. Crepitation is a grating or crackling sound that accompanies movement.
A female patient with critical limb ischemia has had peripheral artery bypass surgery to improve her circulation. What care should the nurse provide on postoperative day 1? A. Keep the patient on bed rest. B. Assist the patient with walking several times. C. Have the patient sit in the chair several times. D. Place the patient on her side with knees flexed.
B. Assist the patient with walking several times. To avoid blockage of the graft or stent, the patient should walk several times on postoperative day 1 and subsequent days. Having the patient's knees flexed for sitting in a chair or in bed increase the risk of venous thrombosis and may place stress on the suture lines.
What is BELLS PALSY? What are the considerations?
Bell's palsy is a form of facial paralysis resulting from a dysfunction of the cranial nerve VII (the facial nerve) causing an inability to control facial muscles on the affected side. The biggest complications are pain and an eyelid that won't shut. To protect the eyes from corneal abrasions, use drops and eye patches at night or tape shut to protect.
The patient had abdominal surgery yesterday. Today the lung sounds in the lower lobes have decreased. The nurse knows this could be due to what occurring? A. Pain B. Atelectasis C. Pneumonia D. Pleural effusion
B. Atelectasis Postoperatively there is an increased risk for atelectasis from anesthesia as well as restricted breathing from pain. Without deep breathing to stretch the alveoli, surfactant secretion to hold the alveoli open is not promoted. Pneumonia will occur later after surgery. Pleural effusion occurs because of blockage of lymphatic drainage or an imbalance between intravascular and oncotic fluid pressures, which is not expected in this case
You are the nursing student and you are taking care of the patient recently diagnosed with hyperthyroidism. You can visibly see the thryroid gland enlarged. What is the next thing you should assess? A) Assess for a bruit or a thrill B) Listen to respiratory rate and look at SpO2 C) Check for peripheral pulses D) Poke the neck to see if it is soft or hard
B. Because an enlarged thyroid gland can constrict the neck (often caused by a goiter) it is very important to monitor the patient's respiratory status. After that a bruit or thrill may be felt for over the distended thyroid gland. Palpating to see if the neck is soft or hard may also be done, as a hard nodule may be indicative thyroid cancer.
A patient with left knee pain is diagnosed with bursitis. The nurse will explain that bursitis is an inflammation of a. the synovial membrane that lines the joint. b. a small, fluid-filled sac found at some joints. c. the fibrocartilage that acts as a shock absorber in the knee joint. d. any connective tissue that is found supporting the joints of the body.
B. Bursae are fluid-filled sacs that cushion joints and bony prominences. Fibrocartilage is a solid tissue that cushions some joints. Bursae are a specific type of connective tissue. The synovial membrane lines many joints but is not a bursa.
3. A nurse is caring for a client who has advanced cirrhosis with worsening hepatic encephalopahy. Which of the following is an expected assessment finding? (Select all that apply.) A. Anorexia B. Change in orientation C. Asterixis D. Ascites E. Fetor hepaticus
B. CORRECT: A change in orientation indicates worsening hepatic encephalopathy in a client who has advanced cirrhosis. C. CORRECT: Asterixis, a coarse tremor of the wrists and fingers, is observed as a late complication in a client who has cirrhosis and hepatic encephalopathy E. CORRECT: Fetor hepaticus, a fruity breath odor, is a clinical finding of worsening hepatic encephalopathy in the client who has advanced cirrhosis.
3. A nurse is completing preoperative teaching for a client who will undergo a laparoscopic cholecystectomy. Which of the following should be included in the teaching? A. "The scope will be passed through your rectum." B. "You may have shoulder pain after surgery." C. "The T-tube will remain in place for 1 to 2 weeks." D. "You should limit how often you walk for 1 to 2 weeks."
B. CORRECT: Shoulder pain occurs due to free air that is introduced into the abdomen during laparoscopic surgery.
1. A nurse is providing discharge teaching to a client who is postoperative following open cholecystectomy with T-tube placement. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) A. Take baths rather than showers. B. Clamp T-tube for 1 to 2 hr before and after meals. C. Keep the drainage system above the level of the gallbladder. D. Expect to have constipation. E. Empty drainage bag every 8 hr.
B. CORRECT: The T-tube should be clamped 1 to 2 hr before and after meals to assess tolerance to food postcholecystectomy, and prior to removal. E. CORRECT: The drainage bag attached to the T-tube should be emptied every 8 hr.
2. A nurse is preparing to administer pancrelipase (Viokase) to a client who has pancreatitis. Which of the following is an appropriate nursing action? A. Administer medication 30 min after a snack. B. Offer a glass of water following medication administration. C. Administer the medication 30 min before meals. D. Sprinkle the contents on peanut butter.
B. CORRECT: The client should drink a full glass of water following administration of pancrelipase.
2. A nurse is caring for a client who has a new diagnosis of hepatitis C. Which of the following is an expected laboratory finding? A. Presence of immunoglobin G antibodies (IgG) B. Presence of enzyme immunoassay (EIA) C. Aspartate aminotransferase (AST) 35 units/L D. Alanine aminotransferase (ALT) 15 IU/L
B. CORRECT: The presence of enzyme immunoassay is an expected laboratory finding in a client who has a new diagnosis of hepatitis C.
The patient with sudden pain in the left upper quadrant radiating to the back and vomiting was diagnosed with acute pancreatitis. What intervention(s) should the nurse expect to include in the patient's plan of care? A. Immediately start enteral feeding to prevent malnutrition. B. Insert an NG and maintain NPO status to allow pancreas to rest. C. Initiate early prophylactic antibiotic therapy to prevent infection. D. Administer acetaminophen (Tylenol) every 4 hours for pain relief.
B. Insert an NG and maintain NPO status to allow pancreas to rest. Initial treatment with acute pancreatitis will include an NG tube if there is vomiting and being NPO to decrease pancreatic enzyme stimulation and allow the pancreas to rest and heal. Fluid will be administered to treat or prevent shock. The pain will be treated with IV morphine because of the NPO status. Enteral feedings will only be used for the patient with severe acute pancreatitis in whom oral intake is not resumed. Antibiotic therapy is only needed with acute necrotizing pancreatitis and signs of infection.
The nurse is caring for a newly admitted patient with vascular insufficiency. The patient has a new order for enoxaparin (Lovenox) 30 mg subcutaneously. What should the nurse do to correctly administer this medication? A. Spread the skin before inserting the needle. B. Leave the air bubble in the prefilled syringe. C. Use the back of the arm as the preferred site. D. Sit the patient at a 30-degree angle before administration.
B. Leave the air bubble in the prefilled syringe. The nurse should not expel the air bubble from the prefilled syringe because it should be injected to clear the needle of medication and avoid leaving medication in the needle track in the tissue.
The nurse is caring for a 55-year-old man patient with acute pancreatitis resulting from gallstones. Which clinical manifestation would the nurse expect the patient to exhibit? A. Hematochezia B. Left upper abdominal pain C. Ascites and peripheral edema D. Temperature over 102o F (38.9o C)
B. Left upper abdominal pain Abdominal pain (usually in the left upper quadrant) is the predominant manifestation of acute pancreatitis. Other manifestations of acute pancreatitis include nausea and vomiting, low-grade fever, leukocytosis, hypotension, tachycardia, and jaundice. Abdominal tenderness with muscle guarding is common. Bowel sounds may be decreased or absent. Ileus may occur and causes marked abdominal distention. Areas of cyanosis or greenish to yellow-brown discoloration of the abdominal wall may occur. Other areas of ecchymoses are the flanks (Grey Turner's spots or sign, a bluish flank discoloration) and the periumbilical area (Cullen's sign, a bluish periumbilical discoloration).
The home care nurse visits an 84-year-old woman with pneumonia after her discharge from the hospital. Which assessment finding would the nurse expect because of age-related changes in the musculoskeletal system? A. Positive straight-leg-raising test B. Muscle strength is scale grade 3/5 C. Lateral S-shaped curvature of the spine D. Fingers drift to the ulnar side of the forearm
B. Muscle strength is scale grade 3/5 Decreased muscle strength is an age-related change of the musculoskeletal system caused by decreased number and size of the muscle cells. The other assessment findings indicate musculoskeletal abnormalities. A positive straight-leg-raising test indicates nerve root irritation from intervertebral disk prolapse and herniation. An ulnar deviation or drift indicates rheumatoid arthritis due to tendon contracture. Scoliosis is a lateral curvature of the spine.
In reviewing bone remodeling, what should the nurse know about the involvement of bone cells? A. Osteoclasts add canaliculi. B. Osteoblasts deposit new bone. C. Osteocytes are mature bone cells. D. Osteons create a dense bone structure.
B. Osteoblasts deposit new bone. Bone remodeling is achieved when osteoclasts remove old bone and osteoblasts deposit new bone. Osteocytes are mature bone cells, and osteons or Haversian systems create a dense bone structure, but these are not involved with bone remodeling.
The nurse is caring for a patient who is receiving morphine sulfate via PCA. Which patient assessment data demonstrate the most therapeutic effect of this medication? A. Pain rating 3/10, awake and alert, respirations 24 B. Pain rating 2/10, awake and alert, respirations 18 C. Pain rating 2/10, drowsy but arousable, respirations 18 D. Pain rating 1/10, drowsy but arousable, respirations 16
B. Pain rating 2/10, awake and alert, respirations 18 Effective pain management is achieved when there is adequate pain control (rating of 3 or less on a scale of 0 to 10) with normal respirations and an absence of sedation. These data exhibit the best effectiveness of the pain medication in all of these areas.
To detect early signs of symptoms of inadequate oxygenation, the nurse would examine the patient for: A. dyspnea and hypotension. B. apprehension and restlessness. C. cyanosis and cool, clammy skin. D. increased urine output and diaphoresis.
B. apprehension and restlessness. Early symptoms of inadequate oxygenation include unexplained restlessness, apprehension, and irritability.
When auscultating the chest of an older patient in respiratory distress, it is best to: A. begin listening at the apices. B. begin listening at the lung bases. C. begin listening on the anterior chest. D. ask the patient to breathe through the nose with the mouth closed.
B. begin listening at the lung bases. Normally, auscultation should proceed from the lung apices to the bases, so that opposite areas of the chest are compared. If the patient is likely to tire easily or has respiratory distress, start at the bases.
To detect possible complications in a patient with severe cirrhosis who has bleeding esophageal varices, it is most important for the nurse to monitor a. bilirubin levels. b. ammonia levels. c. potassium levels. d. prothrombin time.
B: The protein in the blood in the gastrointestinal (GI) tract will be absorbed and may result in an increase in the ammonia level because the liver cannot metabolize protein very well
The nurse is caring for a 73-year-old man who has cirrhosis. Which data obtained by the nurse during the assessment will be of most concern? a. The patient complains of right upper-quadrant pain with palpation. b. The patient's hands flap back and forth when the arms are extended. c. The patient has ascites and a 2-kg weight gain from the previous day. d. The patient's skin has multiple spider-shaped blood vessels on the abdomen.
B: Asterixis indicates that the patient has hepatic encephalopathy, and hepatic coma may occur.
14. All of the following organs may be affected by multiple endocrine neoplasia type 1 except: a. Parathyroid glands b. Kidneys c. Pancreas and Duodenum d. Pituitary gland
B: Kidneys Multiple endocrine neoplasia type 1, also known as Werner's syndrome, is a heritable disorder that causes tumors in endocrine glands and the duodenum. Although the tumors associated with multiple endocrine neoplasia type 1 are generally benign, they can produce symptoms chemically by releasing excessive amounts of hormones or mechanically by pressing on adjacent tissue.
11. The most common benign tumor of the pituitary gland is a: a. Glioma b Prolactinoma c. Carcinoid tumor d. Islet cell tumor
B: Prolactinomas can cause symptoms by releasing excessive amounts of prolactin into the blood or mechanically by pressing on surrounding tissues. In women, symptoms may include menstrual irregularities and infertility; in men erectile dysfunction and libido may be impaired.
A serum potassium level of 3.2 mEq/L (3.2 mmol/L) is reported for a patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix). due. Which action should the nurse take? a. Administer both drugs. b. Administer the spironolactone. c. Withhold the spironolactone and administer the furosemide. d. Withhold both drugs until discussed with the health care provider.
B: Spironolactone is a potassium-sparing diuretic and will help increase the patient's potassium level
4. An ACTH stimulation test is commonly used to diagnose: a. Grave's disease b. Adrenal insufficiency and Addison's disease c. Cystic fibrosis d. Hashimoto's disease
B: The ACTH stimulation test measures blood and urine cortisol before and after injection of ACTH. Persons with chronic adrenal insufficiency or Addison's disease generally do not respond with the expected increase in cortisol levels. An abnormal ACTH stimulation test may be followed with a CRH stimulation test to pinpoint the cause of adrenal insufficiency.
A 53-year-old patient is being treated for bleeding esophageal varices with balloon tamponade. Which nursing action will be included in the plan of care? a. Instruct the patient to cough every hour. b. Monitor the patient for shortness of breath. c. Verify the position of the balloon every 4 hours. d. Deflate the gastric balloon if the patient reports nausea.
B: The most common complication of balloon tamponade is aspiration pneumonia
Which action should the nurse take to evaluate treatment effectiveness for a patient who has hepatic encephalopathy? a. Request that the patient stand on one foot. b. Ask the patient to extend both arms forward. c. Request that the patient walk with eyes closed. d. Ask the patient to perform the Valsalva maneuver.
B:Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic encephalopathy
Why should the patient with trigeminal neuralgia chew on the unaffected side? What is the outcome?
Because the unaffected side is painful. Patient would lose weight. The outcome should be weight gain as a result of chewing on unaffected side and eating a high calorie, high protein diet like custard, milk and eggs.
How does GBS progress?
Begins in lower extremities and ascends bilaterally starting with weakness, then ataxia, then bilateral paresthesia progressing in paralysis.
A client is admitted with a diagnosis of pheochromocytoma. The nurse should monitor which parameter to detect the most common sign of pheochromocytoma?
Blood pressure elevation
The nurse is caring for a client after a thyroidectomy and monitoring for signs of thyroid storm. The nurse determines that which sign/symptom is indicative that a thyroid storm may be occurring?
Blood pressure of 80/60 mmHg
A client with a pituitary tumor will undergo transsphenoidal hypophysectomy. The nurse reinforces which information in the preoperative teaching plan for the client?
Blowing the nose following surgery is prohibited.
DIC is a disorder in which: A. the coagulation pathway is generally altered, leading to thrombus formation in all major blood vessels B. an underlying disease depletes hemolytic factors in the blood, leading to diffuse thrombotic episodes and infarcts C. a disease process stimulates coagulation process with resultant thrombosis, as well as depletion of clotting factors, leading to diffuse clotting and hemorrhage D. an inherited predisposition causes a deficiency of clotting factors that leads to overstimulation of coagulation processes in the vasculature
C
The nurse is aware that a major difference between Hodgkin's lymphoma and non-Hodgkin's lymphoma is: A. Hodgkin's lymphoma only occurs in young adults B. Hodgkin's lymphoma is considered potentially curable C. non-Hodgkin's lymphoma can manifest in multiple organs D. non-Hodgkin's lymphoma is treated only with radiation therapy
C
When taking the blood pressure (BP) on the right arm of a patient with severe acute pancreatitis, the nurse notices carpal spasms of the patient's right hand. Which action should the nurse take next? a. Ask the patient about any arm pain. b. Retake the patient's blood pressure. c. Check the calcium level in the chart. d. Notify the health care provider immediately.
C
Which finding is most important for the nurse to communicate to the health care provider about a patient who received a liver transplant 1 week ago? a. Dry palpebral and oral mucosa b. Crackles at bilateral lung bases c. Temperature 100.8° F (38.2° C) d. No bowel movement for 4 days
C
Which laboratory test result will the nurse monitor when evaluating the effects of therapy for a 62-year-old female patient who has acute pancreatitis? a. Calcium b. Bilirubin c. Amylase d. Potassium
C
A client presents with hypocalcemia, hyperphosphatemia, muscle cramps, and positive Trosseau's sign. What diagnosis does this support? Answers: A. Diabetes insipidus B. Conn's syndrome C. Hypoparathyroidism D. Acromegaly
C Hypoparathyroidism often leads to the symptoms mentioned. Conn's syndrome is an aldosterone-producing adenoma.
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.
A patient taking Phenazopyridine (pyridium, a urinary track analgesic) Should be cautioned that her year and may change to what color? A) Pale yellow B) Green C) Orange red D) Brown
C) Orange red Pyridium Is noted for turning the year and orange red, and the patient needs to be aware of this
Mr. Bales is 60 years old and alert. He is timid and reluctant to talk about his urinary retention problem. Which part of this plan could create stress for Mr. Bales and possibly increase his inability to urinate? A) Assisting him in assuming his normal voiding position B) Pulling curtains around him to provide privacy during voiding C) Staying with him while voiding D) Offering a urinal or a regular schedule
C) Staying with him while voiding Mr. Bales will probably be embarrassed if the nurse remains with him as he attempts to void and is more likely to have difficulty voiding
A surgical repair is planned for a patient who has a 5-cm abdominal aortic aneurysm (AAA). On physical assessment of the patient, the nurse would expect to find... A) hoarseness and dysphagia B) sever back pain with flank ecchymosis C) the presence of a bruit in the periumbilical area D) weakness in the lower extremities progressing to paraplegia
C) the presence of a bruit in the periumbilical area, although most abdominal aortic aneurysms (AAA) are asymptomatic, on physical exam a pulsatile mass in the periumbilical area slightly to the left of the midline may be detected, and bruits may be audible with a stethoscope placed over the aneurysm. Hoarseness and dysphagia may occur with aneurysms of the ascending aorta and the aortic arch. Severe back pain with flank ecchymosis is usually present on rupture of an AAA, and neurologic loss in the lower extremities may occur from the pressure of a thoracic aneurysm.
Nursing care for a "PT" with an indwelling catheter includes which of the following A)Irrigation of the catheter with a 30mL of normal saline solution every 4hours B)Disconnecting and reconnecting the drainage system quickly to obtain a urine sample C)Encourage a generous fluid intake of not contraindicate by the "PT" conduction. D)Telling the "PT" that burning and irritation are normal, subsiding within a few days
C)Encourage a generous fluid intake of not contraindicate by the "PT" conduction. A generous fluid intake promotes healthy urinary tract function. Irrigation may introduce bacteria into the urinary tract and is not routinely ordered. The drainage system should never be disconnected to obtain a sample, this could allow bacteria to enter into the urinary tract. Burning and irritation may indicate that an infection is present and should never be disregarded.
In discussing long term management with the patient with alcoholic cirrhosis, the nurse advises the patient that a. a daily exercise regimen is important to increase the blood flow through the liver b. cirrhosis can be reversed if the patient follows a regimen of proper rest and nutrition c. abstinence from alcohol is the most important factor in improvement of the patient's condition d. the only over the counter analgesic that should be used for minor aches and pains is acetaminophen
C- Abstinence from alcohol is very important in alcoholic cirrhosis and may result in improvement if started when liver damage is reduced by rest and nutrition, most changes in the liver cannot be reversed. Exercise does not promote portal circulation, and very moderate exercise is recommended. Acetaminophen should not be used by the patient with liver disease because it is potentially hepatotoxic.
During the treatment of the patient with bleeding esophageal varices, it is most important that the nurse a. prepare the patient for immediate portal shunting surgery b. perform guaiac testing on all stools to detect occult blood c. maintain the patient's airway and prevent aspiration of blood d. monitor for the cardiac effects of IV vasopressin and nitroglycerin
C- Bleeding esophageal varices are a medical emergency. During an episode of bleeding, management of the airway and prevention of aspiration of blood are critical factors. Occult blood as well as fresh blood from the GI tract would be expected and is not tested. Vasopressin causes vasoconstriction, decreased HR, and decreased coronary blood flow; nitroglycerin is given with the vasopressin to counter these side effects. Portal shunting surgery is performed for esophageal varices but not during an acute hemorrhage
During the incubation period of viral hepatitis, the nurse would expect the patient to report a. pruritus and malaise b. dark urine and easy fatigability c. anorexia and right upper quadrant discomfort d. constipation or diarrhea with light colored stools
C- Incubation symptoms occur before the onset of jaundice and include a variety of GI symptoms as well as discomfort and heaviness in the upper right quadrant of the abdomen. Pruritus, dark urine, and light colored stools occur with the onset of jaundice in the acute phase.
A patient with cancer that has metastasized to the liver manifests symptoms of fluid retention, including edema and ascites. To determine the effectiveness of the diuretic therapy that has been prescribed, what should the nurse assess? a. Breath sounds b. Bowel sounds c. Abdominal girth d. Recent blood work
C. Daily measurement of the abdominal girth provides a direct indication of ascitic fluid increase or decrease. Breath and bowel sounds are usually not affected by liver metastasis until the late stages, when fluid overload and multisystem organ involvement occur. Reviewing the results of the most recent blood work will not show direct measurement of the effectiveness of diuretic therapy. Text Reference - p. 1019
A patient admitted to the hospital with cirrhosis of the liver suddenly starts vomiting blood. What is the priority action that the nurse should take in this situation? a. Send for endoscopic variceal ligation. b. Give propronalol orally. c. Stabilize the patient and manage the airway. d. Check for signs of cirrhosis
C. Individuals with cirrhosis of the liver are at risk of bleeding from esophageal and gastric varices. Hematemesis in the patient with cirrhosis of the liver is likely to be variceal bleeding. In this case, the nurse should first stabilize the patient and manage the airway. Once the patient is stable, other steps in treatment can be initiated, such as assessing further and administering necessary medications. Text Reference - p. 1025
The nurse evaluates the effectiveness of a paracentesis in a patient who has ascites. Which measurement is most important for the nurse to note? a. Cardiac output b. Blood pressure c. Abdominal girth d. Intake and output
C. Paracentesis involves the removal of fluid from the abdominal cavity. A large-bore needle connected to tubing is inserted by the health care provider into the distended abdomen. The other end of the tubing also has a large-bore needle, which is inserted into a vacuum bottle. The vacuum bottle is then held below the level of the abdomen, facilitating gravity-flowed removal of the ascites. Several bottles of fluid can be removed, with the result measured by reduction in abdominal girth. Cardiac output may improve after paracentesis, but it is unlikely that this measurement needs to be recorded. Paracentesis has no major effect on blood pressure. Likewise, intake and output continue to be monitored to account for the paracentesis fluid but these are not as informative as abdominal girth. Text Reference - p. 1022
The nurse recalls that hepatic coma results primarily from accumulation of which substance in the blood? a. Sodium b. Calcium c. Ammonia d. Potassium
C. A high ammonia level in the blood is a late manifestation of liver failure that results in hepatic coma, causing neurologic dysfunction and brain damage. Sodium, calcium, and potassium are not directly affected by liver dysfunction or hepatic coma. Text Reference - p. 1021
A patient with hepatitis A asks whether other family members are at risk for "catching" the disease. The nurse's response will be based on the knowledge that hepatitis A is transmitted primarily: a. During sexual intercourse b. By contact with infected body secretions c. Through fecal contamination of food or water d. Through kissing that involves contact with mucous membranes
C. Hepatitis A is primarily transmitted through ingestion of organisms on fecally contaminated hands, food, or water. Care should be taken in the handling of food and water, as well as contaminated items such as bed linens, bedpans, and toilets. Hand hygiene and personal protective equipment such as gloves are important in preventing the spread of infection for hospital personnel. In the home, hand hygiene and good personal hygiene are important in decreasing the risk of transmission. Sexual intercourse, contact with infected body secretions, and contact through mucous membranes all present higher risk for hepatitis B and C than for hepatitis A. Text Reference - p. 1007
6. A female client with hypothyroidism (myxedema) is receiving levothyroxine (Synthroid), 25 mcg P.O. daily. Which finding should nurse Hans recognize as an adverse drug effect? a. Dysuria b. Leg cramps c. Tachycardia d. Blurred vision
C. Levothyroxine, a synthetic thyroid hormone, is given to a client with hypothyroidism to simulate the effects of thyroxine. Adverse effects of this agent include tachycardia. The other options aren't associated with levothyroxine.
21. An incoherent female client with a history of hypothyroidism is brought to the emergency department by the rescue squad. Physical and laboratory findings reveal hypothermia, hypoventilation, respiratory acidosis, bradycardia, hypotension, and nonpitting edema of the face and pretibial area. Knowing that these findings suggest severe hypothyroidism, nurse Libby prepares to take emergency action to prevent the potential complication of: a. Thyroid storm. b. Cretinism. c. myxedema coma. d. Hashimoto's thyroiditis.
C. Severe hypothyroidism may result in myxedema coma, in which a drastic drop in the metabolic rate causes decreased vital signs, hypoventilation (possibly leading to respiratory acidosis), and nonpitting edema. Thyroid storm is an acute complication of hyperthyroidism. Cretinism is a form of hypothyroidism that occurs in infants. Hashimoto's thyroiditis is a common chronic inflammatory disease of the thyroid gland in which autoimmune factors play a prominent role.
16. A male client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate? a. Infusing I.V. fluids rapidly as ordered b. Encouraging increased oral intake c. Restricting fluids d. Administering glucose-containing I.V. fluids as ordered
C. To reduce water retention in a client with the SIADH, the nurse should restrict fluids. Administering fluids by any route would further increase the client's already heightened fluid load.
A nursing student is studying for a test on care of the client with endocrine disorders. Which of the following statements demonstrates an understanding of the difference between hyperthyroidism and hypothyroidism? a. "Deficient amounts of TH cause abnormalities in lipid metabolism, with decreased serum cholesterol and triglyceride levels." b. "Graves' disease is the most common cause of hypothyroidism." c. "Decreased renal blood flow and glomerular filtration rate reduces the kidney's ability to excrete water, which may cause hyponatremia." d. "Increased amounts of TH cause a decrease in cardiac output and peripheral blood flow."
C. "Decreased renal blood flow and glomerular filtration rate reduces the kidney's ability to excrete water, which may cause hyponatremia." Rationale: # 1 is incorrect because deficient amounts of TH cause abnormalities in lipid metabolism with elevated serum cholesterol and triglyceride levels. # 2 is incorrect because Graves' disease is the most common cause of hyperthyroidism, not hypothyroidism. # 4 is incorrect because increased amounts of TH cause an increase in cardiac output and peripheral blood flow.
A 67-year-old male patient had a right total knee replacement 2 days ago. Upon auscultation of the patient's posterior chest, the nurse detects discontinuous, high-pitched breath sounds just before the end of inspiration in the lower portion of both lungs. Which statement most appropriately reflects how the nurse should document the breath sounds? A. "Bibasilar rhonchi present on inspiration." B. "Diminished breath sounds in the bases of both lungs." C. "Fine crackles posterior right and left lower lung fields." D. "Expiratory wheezing scattered throughout the lung fields."
C. "Fine crackles posterior right and left lower lung fields." Fine crackles are described as a series of short-duration, discontinuous, high-pitched sounds heard just before the end of inspiration.
The nurse provides discharge instructions for a 64-year-old woman with ascites and peripheral edema related to cirrhosis. Which statement, if made by the patient, indicates teaching was effective? A. "It is safe to take acetaminophen up to four times a day for pain." B. "Lactulose (Cephulac) should be taken every day to prevent constipation." C. "Herbs and other spices should be used to season my foods instead of salt." D. "I will eat foods high in potassium while taking spironolactone (Aldactone)."
C. "Herbs and other spices should be used to season my foods instead of salt." A low-sodium diet is indicated for the patient with ascites and edema related to cirrhosis. Table salt is a well-known source of sodium and should be avoided. Alternatives to salt to season foods include the use of seasonings such as garlic, parsley, onion, lemon juice, and spices. Pain medications such as acetaminophen, aspirin, and ibuprofen should be avoided as these medications may be toxic to the liver. The patient should avoid potentially hepatotoxic over-the-counter drugs (e.g., acetaminophen) because the diseased liver is unable to metabolize these drugs. Spironolactone is a potassium-sparing diuretic. Lactulose results in the acidification of feces in bowel and trapping of ammonia, causing its elimination in feces.
A patient asks the nurse why a dose of hydromorphone (Dilaudid) by IV push is given before starting the medication via PCA. Which response is most appropriate? A. "PCA will never be effective unless a loading dose is given first." B. "The IV push dose will enhance the effects of the PCA for the next 8 hours." C. "The IV push dose will provide for immediate pain relief, which can be maintained by using the PCA." D. "PCA takes at least 2 hours to begin working, so the IV push dose will provide pain relief in the interim."
C. "The IV push dose will provide for immediate pain relief, which can be maintained by using the PCA." An IV push loading dose of an opioid analgesic provides an effective opioid level in the body, which results in immediate pain control. The PCA medication doses may be smaller and can be used more frequently to maintain pain control when the loading dose begins to wear off.
The nurse instructs a 50-year-old woman about cholestyramine to reduce pruritis caused by gallbladder disease. Which statement by the patient to the nurse indicates she understands the instructions? A. "This medication will help me digest fats and fat-soluble vitamins." B. "I will apply the medicated lotion sparingly to the areas where I itch." C. "The medication is a powder and needs to be mixed with milk or juice." D. "I should take this medication on an empty stomach at the same time each day."
C. "The medication is a powder and needs to be mixed with milk or juice." For treatment of pruritus, cholestyramine may provide relief. This is a resin that binds bile salts in the intestine, increasing their excretion in the feces. Cholestyramine is in powder form and should be mixed with milk or juice before oral administration.
A postoperative patient asks the nurse why the physician ordered daily administration of enoxaparin (Lovenox). Which reply by the nurse is most appropriate? A. "This medication will help prevent breathing problems after surgery, such as pneumonia." B. "This medication will help lower your blood pressure to a safer level, which is very important after surgery." C. "This medication will help prevent blood clots from forming in your legs until your level of activity, such as walking, returns to normal." D. "This medication is a narcotic pain medication that will help take away any muscle aches caused by positioning on the operating room table."
C. "This medication will help prevent blood clots from forming in your legs until your level of activity, such as walking, returns to normal." Enoxaparin is an anticoagulant that is used to prevent DVTs postoperatively. All other explanations/options do not describe the action/purpose of enoxaparin.
The nurse is interpreting a tuberculin skin test (TST) for a 58-year-old female patient with end-stage kidney disease secondary to diabetes mellitus. Which finding would indicate a positive reaction? A. Acid-fast bacilli cultured at the injection site B. 15-mm area of redness at the TST injection site C. 11-mm area of induration at the TST injection site D. Wheal formed immediately after intradermal injection
C. 11-mm area of induration at the TST injection site An area of induration ≥ 10 mm would be a positive reaction in a person with end-stage kidney disease. Reddened, flat areas do not indicate a positive reaction. A wheal appears when the TST is administered that indicates correct administration of the intradermal antigen. Presence of acid-fast bacilli in the sputum indicates active tuberculosis.
A 54-year-old patient admitted with cellulitis and probable osteomyelitis received an injection of radioisotope at 9:00 AM before a bone scan. The nurse should plan to send the patient for the bone scan at what time? A. 9:30 PM B. 10:00 AM C. 11:00 AM D. 1:00 PM
C. 11:00 AM A technician usually administers a calculated dose of a radioisotope 2 hours before a bone scan. If the patient was injected at 9:00 AM, the procedure should be done at 11:00 AM. 10:00 AM would be too early; 1:00 PM and 9:30 PM would be too late.
When assessing a patient receiving morphine sulfate 2 mg every 10 minutes via PCA pump, the nurse should take action as soon as the patient's respiratory rate drops down to or below which parameter? A. 16 breaths/min B. 14 breaths/min C. 12 breaths/min D. 10 breaths/min
C. 12 breaths/min To protect the patient from adverse effects of respiratory depression from this medication, the nurse should alert the physician as soon as the respiratory rate drops down to or below 12 breaths/min.
A patient with cholelithiasis needs to have the gallbladder removed. Which patient assessment is a contraindication for a cholecystectomy? A. Low-grade fever of 100° F and dehydration B. Abscess in the right upper quadrant of the abdomen C. Activated partial thromboplastin time (aPTT) of 54 seconds D. Multiple obstructions in the cystic and common bile duct
C. Activated partial thromboplastin time (aPTT) of 54 seconds An aPTT of 54 seconds is above normal and indicates insufficient clotting ability. If the patient had surgery, significant bleeding complications postoperatively are very likely. Fluids can be given to eliminate the dehydration; the abscess can be assessed, and the obstructions in the cystic and common bile duct would be relieved with the cholecystectomy.
A 54-year-old patient admitted with diabetes mellitus, malnutrition, osteomyelitis, and alcohol abuse has a serum amylase level of 280 U/L and a serum lipase level of 310 U/L. To what diagnosis does the nurse attribute these findings? A. Malnutrition B. Osteomyelitis C. Alcohol abuse D. Diabetes mellitus
C. Alcohol Use The patient with alcohol abuse could develop pancreatitis as a complication, which would increase the serum amylase (normal 30-122 U/L) and serum lipase (normal 31-186 U/L) levels as shown.
The patient's neuropathic pain is not well controlled with the opioid analgesic prescribed. What medications may be added for a multimodal approach to treat the patient's pain (select all that apply)? A. NSAIDs B. Fentanyl C. Antiseizure drugs D. β-adrenergic agonists E. Tricyclic antidepressants
C. Antiseizure drugs E. Tricyclic antidepressants Antiseizure drugs, tricyclic antidepressants, SNRIs, transdermal lidocaine, and α2-adrenergic agonists will be used for multimodal treatment when opioid analgesics alone do not control neuropathic pain.
The patient is hospitalized with pneumonia. Which diagnostic test should be used to measure the efficiency of gas transfer in the lung and tissue oxygenation? A. Thoracentesis B. Bronchoscopy C. Arterial blood gases D. Pulmonary function tests
C. Arterial blood gases Arterial blood gases are used to assess the efficiency of gas transfer in the lung and tissue oxygenation as is pulse oximetry. Thoracentesis is used to obtain specimens for diagnostic evaluation, remove pleural fluid, or instill medication into the pleural space. Bronchoscopy is used for diagnostic purposes, to obtain biopsy specimens, and to assess changes resulting from treatment. Pulmonary function tests measure lung volumes and airflow to diagnose pulmonary disease, monitor disease progression, evaluate disability, and evaluate response to bronchodilators
A 63-year-old woman has been taking prednisone (Deltasone) daily for several years after a kidney transplant to prevent organ rejection. What is most important for the nurse to assess? A. Staggering gait B. Ruptured tendon C. Back or neck pain D. Tardive dyskinesia
C. Back or neck pain Osteoporosis with resultant fractures is a frequent and serious complication of systemic corticosteroid therapy. The ribs and vertebrae are affected the most, and patients should be observed for signs of compression fractures (back and neck pain). Phenytoin (Dilantin) is an antiseizure medication. An adverse effect of phenytoin is an ataxic (or staggering) gait. A rare adverse effect of ciprofloxacin (Cipro) and other fluoroquinolones is tendon rupture, usually of the Achilles tendon. The highest risk is in people age 60 and older and in people taking corticosteroids. Antipsychotics and antidepressants may cause tardive dyskinesia, which is characterized by involuntary movements of the tongue and face.
4. A nurse is reviewing the health record of a client who has pancreatitis. The physical exam report by the provider indicates the presence of Cullen's sign. Which of the following is an appropriate action by the nurse to identify this finding? A. Tap lightly at the costovertebral margin on the client's back. B. Palpate the client's right lower quadrant. C. Inspect the skin around the umbilicus. D. Auscultate the area below the client's scapula.
C. CORRECT: Cullen's sign is indicated by a bluish-grey discoloration in the periumbilical area.
A 32-year-old female is prescribed diltiazem (Cardizem) for Raynaud's phenomenon. To evaluate the patient's expected response to this medication, what is most important for the nurse to assess? A. Improved skin turgor B. Decreased cardiac rate C. Improved finger perfusion D. Decreased mean arterial pressure
C. Improved finger perfusion Raynaud's phenomenon is an episodic vasospastic disorder of small cutaneous arteries, most frequently involving the fingers and toes. Diltiazem (Cardizem) is a calcium channel blocker that relaxes smooth muscles of the arterioles by blocking the influx of calcium into the cells, thus reducing the frequency and severity of vasospastic attacks. Perfusion to the fingertips is improved and vasospastic attacks reduced. Diltiazem may decrease heart rate and blood pressure, but that is not the purpose in Raynaud's phenomenon. Skin turgor is most often a reflection of hydration status.
Which response by the nurse best explains the purpose of ranitidine (Zantac) for a patient admitted with bleeding esophageal varices? a. The medication will reduce the risk for aspiration. b. The medication will inhibit development of gastric ulcers. c. The medication will prevent irritation of the enlarged veins. d. The medication will decrease nausea and improve the appetite.
C: Esophageal varices are dilated submucosal veins. The therapeutic action of H2-receptor blockers in patients with esophageal varices is to prevent irritation and bleeding from the varices caused by reflux of acid gastric contents
After completing the health history, the nurse assessing the musculoskeletal system will begin by a. having the patient move the extremities against resistance. b. feeling for the presence of crepitus during joint movement. c. observing the patient's body build and muscle configuration. d. checking active and passive range of motion for the extremities.
C. The usual technique in the physical assessment is to begin with inspection. Abnormalities in muscle mass or configuration will allow the nurse to perform a more focused assessment of abnormal areas. The other assessments are also included in the assessment but are usually done after inspection.
2. Grave's disease is: a. The most common cause of hypothyroidism b. The most common cause of hyperparathyroidism c. The most common cause of hyperthyroidism d. The most common cause of adrenal insufficiency
C: Grave's disease is an autoimmune disorder characterized by an enlarged thyroid gland and overproduction of thyroid hormones producing symptoms of hyperthyroidism such as rapid heartbeat, heat intolerance, agitation or irritability, weight loss, and trouble sleeping. It usually presents in persons age 20 to 40 and it is much more common in women than in men.
The nurse can best determine adequate arterial oxygenation of the blood by assessing: A. heart rate. B. hemoglobin level. C. arterial oxygen tension. D. arterial carbon dioxide tension.
C. arterial oxygen tension. The ability of the lungs to oxygenate arterial blood adequately is determined by examination of the partial pressure of oxygen in arterial blood (PaO2) and arterial oxygen saturation (SaO2).
During the respiratory assessment of the older adult, the nurse would expect to find (select all that apply): A. a vigorous cough. B. increased chest expansion. C. increased residual volume. D. increased breath sounds in the lung apices. E. increased anteroposterior (AP) chest diameter.
C. increased residual volume. E. increased anteroposterior (AP) chest diameter. The anterior-posterior diameter of the thoracic cage and the residual volume increase in older adults. An older adult has a less forceful cough. The costal cartilages calcify with aging and interfere with chest expansion. Small airways in the lung bases close earlier during expiration. As a consequence, more inspired air is distributed to the lung apices, ventilation is less well matched to perfusion, and the PaO2 is lowered.
15. What is the treatment for hyperparathyroidism? a. Synthetic thyroid hormone b. Desiccated thyroid hormone c. Surgical removal of the glands d. Calcium and phosphate
C: When hyperparathyroidism requires treatment, surgery is the treatment of choice and is considered curative for 95% of cases. Because untreated hyperparathyroidism may elevate blood and urine levels of calcium and deplete phosphorus, bones and teeth may lose the minerals needed to remain strong.
A 38-year-old patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care? a. Restrict daily dietary protein intake. b. Reposition the patient every 4 hours. c. Place the patient on a pressure-relieving mattress. d. Perform passive range of motion daily.
C: decrease the risk for skin breakdown for this patient
A 49-year-old female patient with cirrhosis and esophageal varices has a new prescription for propranolol (Inderal). Which finding is the best indicator that the medication has been effective? a. The patient reports no chest pain. b. Blood pressure is 140/90 mm Hg. c. Stools test negative for occult blood. d. The apical pulse rate is 68 beats/minute.
C: the purpose of Beta-blocker therapy for patients with esophageal varices is to decrease the risk for bleeding from esophageal varices,
A patient with a history of a T2 spinal cord injury tells the nurse, "I feel awful today. My head is throbbing, and I feel sick to my stomach." Which action should the nurse take first?
Check the blood pressure (BP). rational: The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine whether autonomic dysreflexia is occurring. Notification of the patient's health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated after autonomic dysreflexia is ruled out as the cause of the nausea. The nurse may assess for a fecal impaction, but this should be done after checking the BP and lidocaine jelly should be used to prevent further increases in the BP.
After noting that a patient with a head injury has clear nasal drainage, which action should the nurse take?
Check the nasal drainage for glucose. rational: Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. Blowing the nose is avoided to prevent CSF leakage.
A patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?
Check the respiratory rate. rational: The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, circulation) are completed.
Chronic kidney disease
Chronic kidney disease is a condition in which the kidneys are unable to excrete wastes, concentrate urine, and conserve electrolytes. A component of treatment is hemodialysis. Hemodialysis requires the use of a dialyzer that is connected to a shunt, fistula, or other device that allows access to the client's bloodstream. The client's blood is transported from the body through the dialyzer, which removes wastes and excess fluids from the blood. The cleaned blood is then returned to the client's body. You will learn about chronic kidney disease and hemodialysis in your medical-surgical nursing course when you study renal disorders.
Which technique does the nurse use to obtain a sterile urine specimen from a client with a Foley catheter?
Clamp the tubing, attach a syringe to the specimen, and withdraw at least 5 mL of urine. Clamping the tubing, attaching a syringe to the specimen, and withdrawing at least 5 mL of urine is the correct technique for obtaining a sterile urine specimen from the client with a Foley catheter.
The nurse has these client assignments. Which client does the nurse encourage to consume 2 to 3 liters of fluid each day?
Client with hyperparathyroidism A major feature of hyperparathyroidism is hypercalcemia, which predisposes a client to kidney stones; this client should remain hydrated.
Clients should take levothyroxine (Synthroid)
Clients should take this medication in the morning with a full glass of water. Levothyroxine should be taken on an empty stomach, at least one hour before any other medications or vitamins.
The nurse working on an endocrine nursing unit understands that which correct concept is used in planning care?
Clients who have hyperparathyroidism should be protected against falls.
Priority Decision: patient who is postoperative following repair of an AAA has been receiving intravenous fluids at 125 mL/hr continuously for the last 12 hours. Urine output for the last 4 hours has been 60 mL, 42 mL, 28 mL, and 20 mL the last hour. The priority action that the nurse should take is to..
Contact the physician and report the decrease in urine output
A patient with a small AAA is not a good surgical candidate. The nurse teaches the patient that one of the best ways to prevent expansion of the lesion is to...
Control hypertension with prescribed therapy, because Increased systolic BP continually puts pressure on the diseased area of the artery, promoting its expansion. Small aneurysms can be treated by decreasing BP, modifying atherosclerosis risk factors, and monitoring the size of the aneurysm.
A patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. The laboratory data that will be of most concern to the nurse is a. K+ 3.4 mEq/L (3.4 mmol/L). b. Ca+2 7.8 mg/dl (1.95 mmol/L). c. Na+ 154 mEq/L (154 mmol/L). d. HPO4- 3 4.8 mg/dl (1.55 mmol/L).
Correct Answer: C Rationale: The elevated serum sodium level is consistent with the patient's neurologic symptoms and indicates a need for immediate action to prevent further serious complications such as seizures. The potassium and calcium levels vary slightly from the normal but do not require any immediate action by the nurse. The phosphate level is within the normal parameters.
The nurse working in the emergency department (ED) admits a patient with renal failure and a serum potassium level of 8.0 mEq/L. All these orders are received from the health care provider. Which order will the nurse implement first? a. Place the patient on a cardiac monitor. b. Insert a retention catheter. c. Administer Kayexalate 15 g orally. d. Give IV furosemide (Lasix) 40 mg.
Correct Answer: A Rationale: Because cardiac dysrhythmias are a common and potentially fatal complication of hyperkalemia, the first action should be to initiate cardiac monitoring. The other orders are also appropriate and should be accomplished as quickly as possible.
When assessing a patient with increased extracellular fluid (ECF) osmolality, the priority assessment for the nurse to obtain is a. mental status. b. skin turgor. c. capillary refill. d. heart sounds.
Correct Answer: A Rationale: Changes in ECF osmolality lead to swelling or shrinking of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds may also be affected by ECF osmolality changes and resultant fluid shifts, these are signs that occur later and do not have as immediate an impact on patient outcomes.
The nurse has administered 3% saline to a patient with hyponatremia. Which one of these assessment data will require the most rapid response by the nurse? a. There are crackles audible throughout both lung fields. b. The patient's radial pulse is 105 beats/minute. c. The blood pressure increases from 120/80 to 142/94. d. There is sediment and blood in the patient's urine.
Correct Answer: A Rationale: Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a life-threatening adverse effect of hypertonic solutions. The increased pulse rate and blood pressure and the appearance of the urine should also be reported, but they are not as dangerous as the presence of fluid in the alveoli.
The long-term-care nurse is evaluating the effectiveness of protein supplements on a patient who has low serum total protein level. Which of these data indicate that the patient's condition has improved? a. Absence of peripheral edema b. Good skin turgor c. Hematocrit 28% d. Blood pressure 110/72 mm Hg
Correct Answer: A Rationale: Edema is caused by low oncotic pressure in individuals with low serum protein levels; the absence of edema indicates an improvement in the patient's protein status. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status.
A patient is taking hydrochlorothiazide, a potassium-wasting diuretic, for treatment of hypertension. The nurse will teach the patient to report symptoms of adverse effects such as a. generalized weakness. b. facial muscle spasms. c. frequent loose stools. d. personality changes.
Correct Answer: A Rationale: Generalized weakness progressing to flaccidity is a manifestation of hypokalemia. Facial muscle spasms might occur with hypocalcemia. Loose stools are associated with hyperkalemia. Personality changes are not associated with electrolyte disturbances, although changes in mental status are common manifestations with sodium excess or deficit.
A patient is receiving 3% NaCl solution for correction of hyponatremia. During administration of the solution, the most important assessment for the nurse to monitor is a. peripheral pulses. b. lung sounds. c. peripheral edema. d. urinary output.
Correct Answer: B Rationale: Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are the most serious of the symptoms of fluid excess listed. Bounding peripheral pulses, peripheral edema, or changes in urine output are also important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation.
When developing a care plan for a patient with syndrome of inappropriate antidiuretic hormone (SIADH), an intervention that will be important for the nurse to include is a. monitor intake and output hourly. b. restrict oral free water intake. c. ambulate patient at least once per shift. d. use incentive spirometer every 2 hours.
Correct Answer: B Rationale: SIADH causes water retention, which leads to hyponatremia, so water intake is restricted. Intake and output are measured, but hourly monitoring is not required. Ambulation and incentive spirometer use may be included in the care plan but are not indicated for the diagnosis of SIADH.
Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient as a diuretic. Which statement by the patient indicates that the teaching about this medication has been effective? a. "I can have low-fat cheese." b. "I will have apple juice instead of orange juice." c. "I will drink at least 8 glasses of water every day." d. "I can use a salt substitute."
Correct Answer: B Rationale: Spironolactone is a potassium-sparing diuretic. Patients should be taught to choose low-potassium foods such as apple juice rather than foods that have higher levels of potassium, such as citrus fruits. Cheese is high in sodium; the fat content of the cheese is not relevant. Because the patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid intake. Patients are taught to avoid salt substitutes, which are high in potassium.
The nurse obtains all of the following assessment data about a patient with fluid-volume deficit caused by a massive burn injury. Which of the following assessment data will be of greatest concern? a. Oral fluid intake is 100 ml for the last 8 hours. b. The blood pressure is 90/40 mm Hg. c. Urine output is 30 ml over the last hour. d. There is prolonged skin tenting over the sternum.
Correct Answer: B Rationale: The blood pressure indicates that the patient may be developing hypovolemic shock as a result of fluid loss. This will require immediate intervention to prevent the complications associated with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all indicate the need for increasing the patient's fluid intake but not as urgently as the hypotension.
The nurse assesses a pregnant patient with eclampsia who is receiving IV magnesium sulfate and obtains all the following information. Which of these assessment data is most important to report to the health care provider immediately? a. The patient reports feeling "sick to my stomach." b. The patellar and triceps reflexes are absent. c. The patient has been sleeping most of the day. d. The bibasilar breath sounds are decreased.
Correct Answer: B Rationale: The loss of the deep tendon reflexes indicates that the patient's magnesium level may be reaching toxic levels. Nausea and lethargy are also side effects associated with magnesium elevation and should be reported, but they are not as significant as the loss of deep tendon reflexes. The decreased breath sounds suggest that the patient needs to cough and deep breathe to prevent atelectasis.
A diabetic patient with poor glucose control develops diabetic ketoacidosis. The nurse notes that a patient with diabetic ketoacidosis has rapid, deep respirations. Which collaborative intervention will the nurse anticipate implementing? a. Oxygen at 2 to 4 L/min b. IV sodium bicarbonate 50 mEq c. IV 50% dextrose 50 ml d. IV lorazepam (Ativan) 1 mg
Correct Answer: B Rationale: The rapid, deep (Kussmaul) respirations are a compensatory mechanism to "blow off" excessive CO2 generated by the high levels of ketoacids. Oxygen therapy is not indicated because there is no indication that the increased respiratory rate is related to hypoxemia. Administration of 50% dextrose will increase serum glucose level. Ativan administration will slow the respiratory rate and increase the level of acidosis.
A patient who has been NPO with gastric suction and IV fluid replacement for 3 days following surgery develops nausea and vomiting, weakness, and confusion and has a serum sodium level of 125 mEq/L (125 mmol/L). The nurse reviews the health care provider's postoperative medication and IV orders. Which health care provider order should the nurse question? a. Administer 3% saline if serum sodium drops to less than 128 mEq/L. b. IV morphine sulfate 4 mg every 2 hours prn. c. Infuse 5% dextrose in water at 125 ml/hr. d. Give IV metoclopramide (Reglan) 10 mg every 6 hours prn nausea.
Correct Answer: C Rationale: Because the patient's gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringer's solution would usually be ordered for this patient. The other orders are appropriate for a postoperative patient with gastric suction.
A patient who has been receiving diuretic therapy is admitted to the ED with a serum potassium level of 3.1 mEq/L. Of the following medications that the patient has been taking at home, the nurse will be most concerned about a. metoprolol (Lopressor) 12.5 mg orally daily. b. lantus insulin 24 U subcutaneously q-evening. c. oral digoxin (Lanoxin) 0.25 mg daily. d. ibuprofen (Motrin) 400 mg every 6 hours.
Correct Answer: C Rationale: Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse will also need to do more assessment regarding the other medications, but there is not as much concern with the potassium level.
The home health nurse notes that an elderly patient has a low serum protein level. The nurse will plan to assess for a. confusion. b. restlessness. c. edema. d. pallor.
Correct Answer: C Rationale: Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels.
A recently admitted patient has a small-cell carcinoma of the lung, which is causing the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse will monitor carefully for a. rapid and unexpected weight loss. b. increased total urinary output. c. decreased serum sodium level. d. elevation of serum hematocrit.
Correct Answer: C Rationale: SIADH causes water retention and a decrease in serum sodium level. Weight loss, increased urine output, and elevated serum hematocrit may be associated with excessive loss of water, but not with SIADH and water retention.
The IV therapy nurse is inserting a peripherally inserted central catheter (PICC) so that a patient can receive an IV solution containing 50% dextrose. When explaining the need for the PICC, the nurse will include the information that a. to give adequate doses of IV insulin, a centrally located IV catheter is needed. b. blood glucose testing is more accurate when samples are obtained from a central line. c. infusion of the IV solution through a PICC line will allow rapid dilution of 50% dextrose. d. the 50% dextrose is less likely to produce infection when given through a PICC line.
Correct Answer: C Rationale: Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered intravenously. Insulin can be administered intravenously through the peripheral catheter. Blood glucose testing is not more accurate when samples are obtained from a central line. The infection risk is higher with a central catheter than with peripheral IV lines.
A patient with renal insufficiency develops lethargy and somnolence with a blood pressure of 100/60, pulse 62, and respirations 10. The nurse notes that the patient has been taking an aluminum hydroxide/magnesium hydroxide suspension (Maalox) for indigestion. The nurse anticipates that management of the patient will include IV administration of a. magnesium sulfate. b. potassium chloride. c. calcium gluconate. d. sodium chloride.
Correct Answer: C Rationale: The patient has a history and symptoms consistent with hypermagnesemia, so calcium gluconate or calcium chloride will be the initial therapy to oppose the effects of excess magnesium on cell function. Magnesium sulfate infusion is contraindicated because it will increase the serum magnesium level. Potassium chloride and sodium chloride will not impact the patient's symptoms and should be avoided in a patient with renal insufficiency.
Following bowel surgery 2 days ago, a patient has been receiving normal saline intravenously at 100 ml/hr, has a nasogastric tube to low, intermittent suction, and is NPO. An assessment finding that indicates a need to contact the health care provider immediately is a a. weight gain of 2 pounds above the preoperative weight. b. an oral temperature of 100.1° F with bibasilar lung crackles. c. gradually decreasing level of consciousness (LOC). d. serum sodium level of 138 mEq/L (138 mmol/L).
Correct Answer: C Rationale: The patient's history and change in LOC could be indicative of several fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information will be ordered by the health care provider to determine the cause of the change in LOC and the appropriate interventions. A weight gain of 2 pounds (<1 kg) since surgery would not be clinically significant unless associated with other symptoms. The oral temperature elevation and crackles would initially be addressed by having the patient cough and deep breathe. The sodium level is within the normal range of 135 to 145 mEq/L.
A patient with hypercalcemia is being cared for on the medical unit. Nursing actions included on the care plan will include a. maintaining the patient on bedrest to prevent pathologic fractures. b. monitoring for Trousseau's and Chvostek's signs. c. encouraging fluid intake up to 4000 ml every day. d. auscultate breath sounds every 4 hours.
Correct Answer: C Rationale: To decrease the risk for renal calculi, the patient should have an intake of 3000 to 4000 ml daily. Ambulation helps to decrease the loss of calcium from bone and is encouraged in patients with hypercalcemia. Trousseau's and Chvostek's signs are monitored when there is a possibility of hypocalcemia. There is no indication that the patient needs frequent assessment of breath sounds, although these would be assessed every shift.
When caring for an alert and oriented elderly patient with a history of dehydration, the home health nurse will teach the patient to increase fluid intake a. when the patient feels thirsty. b. in the late evening hours. c. as soon as changes in LOC occur. d. if the oral mucosa feels dry.
Correct Answer: D Rationale: An alert elderly patient will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age, and is not an accurate indicator of volume depletion. Many prefer to restrict fluids slightly in the evening to improve sleep quality. The patient will not be likely to notice and act appropriately when changes in LOC occur.
When evaluating the response to treatment for a patient with a fluid imbalance, the most important assessment to include is a. skin turgor. b. presence of edema. c. hourly urine output. d. daily weight.
Correct Answer: D Rationale: Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age; considerable fluid-volume excess may be present before fluid moves into the interstitial space and causes edema; and hourly urine outputs do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds.
The nurse in the outpatient clinic who notes that a patient has a decreased magnesium level will ask the patient about a. intake of dietary protein. b. use of OTC laxatives. c. multivitamin/mineral use. d. daily alcohol intake.
Correct Answer: D Rationale: Hypomagnesemia is associated with alcoholism. Protein intake would not have a significant effect on magnesium level. OTC laxatives (such as milk of magnesia) and use of multivitamins mineral supplements would tend to increase magnesium level.
To prevent laryngeal spasms and respiratory arrest in a patient who is at risk for hypocalcemia, an early sign of hypocalcemia the nurse should assess for is a. weak hand grips. b. confusion. c. constipation. d. lip numbness.
Correct Answer: D Rationale: Numbness and tingling around the lips or in the fingers are early signs of hypocalcemia. Muscle weakness, confusion, and constipation may also occur, but these are later signs of low calcium levels.
ntravenous potassium chloride (KCl) 40 mEq is ordered for treatment of a patient with hypokalemia. In administering the potassium solution, the nurse is aware that a. the KCl should be administered as an IV bolus so that the hypokalemia will be corrected before complications occur. b. the amount of KCl added to IV fluids should not exceed 20 mEq/L to prevent hyperkalemia from developing. c. the KCl should be given only through central lines to avoid venospasm and inflammation at the IV insertion site. d. to reduce the risk for cardiac dysrhythmia, the maximum amount of KCl to be administered in 1 hour is 20 mEq.
Correct Answer: D Rationale: Rapid IV administration of KCl can cause cardiac arrest; KCl is administered at a maximal rate of 20 mEq/hr. Bolus administration of KCl is contraindicated. The rate of administration, not the amount of KCl added to IV fluids, is important. KCl can cause inflammation of peripheral veins, but it can be administered by this route.
A postoperative patient with a nasogastric tube connected to low, intermittent suction is complaining of anxiety and severe incisional pain. The patient has a respiratory rate of 32 breaths per minute. The arterial blood gases (ABG) are pH 7.50, PaO2 90 mm Hg, PaCO2 30 mm Hg, and HCO3 23 mm Hg. Which intervention is most appropriate for the nurse to implement? a. Disconnect the nasogastric tube until the pH is within the normal range. b. Administer the prescribed sodium bicarbonate 50 mEq intravenously. c. Teach the patient about the importance of taking slow, deep breaths. d. Give the patient the ordered morphine sulfate 4 mg intravenously.
Correct Answer: D Rationale: The ABGs indicate respiratory alkalosis, which is caused by the increased respiratory rate. Because the increased respirations are most likely caused by the incisional pain, the first action by the nurse should be to medicate the patient for pain. The nasogastric tube is needed for postoperative gastric decompression and should remain connected to suction. Sodium bicarbonate administration will further increase the pH. Teaching the patient to take slow, deep breaths may be helpful, but it is unlikely to be effective until the pain level is decreased.
A patient who has required prolonged mechanical ventilation has the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L. The nurse interprets these results as a. metabolic acidosis. b. metabolic alkalosis. c. respiratory acidosis. d. respiratory alkalosis.
Correct Answer: D Rationale: The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO3.
Following a thyroidectomy, a patient complains of "a tingling feeling around my mouth." The nurse will immediately check for a. elevated serum potassium level. b. decreased thyroid hormone level. c. bleeding on the patient's dressing. d. the presence of Chvostek's sign.
Correct Answer: D Rationale: The patient's symptoms indicate possible hypocalcemia, which can occur secondary to parathyroid injury/removal during thyroidectomy. There is no indication of a need to check the potassium level, the thyroid hormone level, or for bleeding.
A patient with advanced lung cancer is admitted to the ED with urinary retention caused by renal calculi. Which of these laboratory values will require the most immediate action by the nurse? a. Arterial oxygen saturation 91% b. Serum potassium is 5.1 mEq/L c. Arterial blood pH is 7.32 d. Serum calcium is 18 mEq/L
Correct Answer: D Rationale: The serum calcium is well above the normal level (4.5-5.5 mEq/L) and puts the patient at risk for cardiac dysrhythmias. The nurse should initiate cardiac monitoring and notify the health care provider. The potassium, oxygen saturation, and pH are also abnormal, and the nurse should notify the health care provider about these values as well, but they do not indicate the need for immediate intervention.
A patient with hepatitis A is in the acute phase. The nurse plans care for the patient based on the knowledge that a. pruritus is a common problem with jaundice in this phase. b. the patient is most likely to transmit the disease during this phase. c. gastrointestinal symptoms are not as severe in hepatitis A as they are in hepatitis B. d. extrahepatic manifestations of glomerulonephritis and polyarteritis are common in this phase.
Correct answer: a Rationale: The acute phase of jaundice may be icteric or anicteric. Jaundice results when bilirubin diffuses into the tissues. Pruritus sometimes accompanies jaundice. Pruritus is the result of an accumulation of bile salts beneath the skin.
The patient with advanced cirrhosis asks why his abdomen is so swollen. The nurse's response is based on the knowledge that a. a lack of clotting factors promotes the collection of blood in the abdominal cavity. b. portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space. c. decreased peristalsis in the GI tract contributes to gas formation and distention of the bowel. d. bile salts in the blood irritate the peritoneal membranes, causing edema and pocketing of fluid.
Correct answer: b Rationale: Ascites is the accumulation of serous fluid in the peritoneal or abdominal cavity and is a common manifestation of cirrhosis. With portal hypertension, proteins shift from the blood vessels through the larger pores of the sinusoids (capillaries) into the lymph space. When the lymphatic system is unable to carry off the excess proteins and water, those substances leak through the liver capsule into the peritoneal cavity. Osmotic pressure of the proteins pulls additional fluid into the peritoneal cavity. A second mechanism of ascites formation is hypoalbuminemia, which results from the inability of the liver to synthesize albumin. Hypoalbuminemia results in decreased colloidal oncotic pressure. A third mechanism is hyperaldosteronism, which occurs when aldosterone is not metabolized by damaged hepatocytes. The increased level of aldosterone causes increases in sodium reabsorption by the renal tubules. Sodium retention and an increase in antidiuretic hormone levels cause additional water retention.
A patient with acute hepatitis B is being discharged in 2 days. In the discharge teaching plan the nurse should include instructions to a. avoid alcohol for the first 3 weeks. b. use a condom during sexual intercourse. c. have family members get an injection of immunoglobulin. d. follow a low-protein, moderate-carbohydrate, moderate-fat diet.
Correct answer: b Rationale: Hepatitis B virus may be transmitted by mucosal exposure to infected blood, blood products, or other body fluids (e.g., semen, vaginal secretions, saliva). Hepatitis B is a sexually transmitted disease that is acquired through unprotected sex with an infected person. Condom use should be taught to patients to prevent transmission of hepatitis B.
A patient has been told that she has elevated liver enzymes caused by nonalcoholic fatty liver disease (NAFLD). The nursing teaching plan should include a. having genetic testing done. b. recommending a heart-healthy diet. c. the necessity to reduce weight rapidly. d. avoiding alcohol until liver enzymes return to normal.
Correct answer: b Rationale: Nonalcoholic fatty liver disease (NAFLD) can progress to liver cirrhosis. There is no definitive treatment, and therapy is directed at reduction of risk factors, which include treatment of diabetes, reduction in body weight, and elimination of harmful medications. For patients who are overweight, weight reduction is important. Weight loss improves insulin sensitivity and reduces liver enzyme levels. No specific dietary therapy is recommended. However, a heart-healthy diet as recommended by the American Heart Association is appropriate.
cranberry juice effect on UTIs
Cranberry juice is excreted as hippuric acid, which helps acidify the urine (decrease the pH) and inhibit bacterial growth. Although bacterial growth may be inhibited, bacteria are not destroyed. Glomerular filtration is unaffected by cranberry juice. Cranberry juice acidifies the urine and may increase the burning sensation associated with urination when an infection is present.
A 24-year-old female contracts hepatitis from contaminated food. During the acute (icteric) phase of the patient's illness, the nurse would expect serologic testing to reveal a. antibody to hepatitis D (anti-HDV). b. hepatitis B surface antigen (HBsAg). c. anti-hepatitis A virus immunoglobulin G (anti-HAV IgG). d. anti-hepatitis A virus immunoglobulin M (anti-HAV IgM).
D
A 67-year-old male patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. Which information obtained by the nurse indicates that these therapies have been effective? a. Bowel sounds are present. b. Grey Turner sign resolves. c. Electrolyte levels are normal. d. Abdominal pain is decreased.
D
A patient with multiple myeloma becomes confused and lethargic. The nurse would expect that these clinical manifestations may be explained by diagnostic results that indicate: A. hyperkalemia B. hyperuricemia C. hypercalcemia D. CNS myeloma
D
Because myelodysplastic syndrome arises from pluripotent hematopoietic stem cells in the bone marrow, laboratory results the nurse would expect to find include: A. an excess of T cells B. an excess of platelets C. a deficiency of granulocytes D. a deficiency of all cellular blood components
D
Complications of transfusions that can be decreased by the use of leukocyte depletion or reduction of RBC transfusion are A. chills and hemolysis B. leukostasis and neutrophilia C. fluid overload and pulmonary edema D. transmission of cytomegalovirus and fever
D
Multiple drugs are often used in combination to treat leukemia and lymphoma because: A. there are fewer toxic side effects B. the chance that one drug will be effective is increased C. the drugs work more effectively without causing side effects D. the drugs work by different mechanisms to maximize killing of malignant cells
D
The nurse will ask a 64-year-old patient being admitted with acute pancreatitis specifically about a history of a. diabetes mellitus. b. high-protein diet. c. cigarette smoking. d. alcohol consumption.
D
The nurse would anticipate that a patient with Von Willebrand disease undergoing surgery would be treated with administration of vWF and: A. thrombin B. factor VI C. factor VII D. factor VIII
D
When reviewing the patient's hematologic laboratory values after a splenectomy, the nurse would expect to find: A. leukopenia B. RBC abnormalities C. decreased hemoglobin D. increased platelet count
D
Which data will the nurse monitor in relation to the 4+ pitting edema assessed in a patient with cirrhosis? a. Hemoglobin b. Temperature c. Activity level d. Albumin level
D
Which finding indicates to the nurse that a patient's transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective? a. Increased serum albumin level b. Decreased indirect bilirubin level c. Improved alertness and orientation d. Fewer episodes of bleeding varices
D
In explaining the condition to a client, a nurse would say that Cushing's syndrome is caused primarily by: Answers: A. Low levels of glucocorticoids B. Excess secretion of sodium C. Autoimmunity in the pancreas D. Elevated levels of cortisol
D Cushing's syndrome is caused by elevated levels of cortisol. Glucocorticoids tend to cause this.
When teaching the male patient with acute hepatitis C (HCV), the patient demonstrates understanding when the patient makes which statement? a. "I will use care when kissing my wife to prevent giving it to her." b. "I will need to take adofevir to prevent chronic HCV." c. "Now that I have had HCV, I will have immunity and not get it again." d. "I will need to be checked for chronic HCV and other liver problems."
D The majority of patients who acquire HCV usually develop chronic infection, which may lead to cirrhosis or liver cancer. HCV is not transmitted via saliva, but percutaneously and via high-risk sexual activity exposure. The treatment for acute viral hepatitis focuses on resting the body and adequate nutrition for liver regeneration. Adofevir is taken for severe hepatitis B (HBV) with liver failure. Chronic HCV is treated with pegylated interferon with ribavirin. Immunity with HCV does not occur as it does with hepatitis A virus (HAV) and HBV, so the patient may be reinfected with another type of HCV. Text Reference - p. 1015
A patient with hepatitis A infection is being discharged from the hospital. What is the most important instruction that the nurse should include in the discharge teaching? a. Do not share razors or toothbrushes. b. Isolate the patient from other family members. c. Take acetaminophen every four hours if fever persists. d. Wash hands carefully after bowel movements
D The mode of transmission of hepatitis A infection is the fecal-oral route. Therefore, it is very important to maintain personal and environmental hygiene. The nurse should teach the patient and the family members about careful hand washing immediately after bowel movements and before eating to prevent outbreaks of hepatitis A viral infection. Not sharing toothbrushes and razors is a concern for the prevention of hepatitis B and C, because they are transferred through blood contact. There is no need to isolate the patient with hepatitis A unless he or she is incontinent or maintains poor personal hygiene. Acetaminophen may cause liver damage and should be avoided in hepatic viral infection. Test-Taking Tip: After choosing an answer, go back and reread the question stem along with your chosen answer. Does it fit correctly? The choice that grammatically fits the stem and contains the correct information is the best choice. Text Reference - p. 1014
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.
Which of the following would the nurse incorporate into the teaching plan for a "PT" to promote healthy urinary function? A)Drinking more then 2,000mL per day will cause fluid retention B)The healthy adult should drink four to six 8oz glasses of water per day C)Children need fewer reminds to drink because of a greater thirst sensitivity D)Caffeine-containing beverages should be monitored to prevent excess intake
D)Caffeine-containing beverages should be monitored to prevent excess intake Caffeine intake should be limited because it is irritating to the bladder mucosa. It is recommend that the healthy adult drink 8-10 8 oz glasses of water. Unless a disease process is present
Mr.Chang, a hospitalized "PT" with diabetes mellitus, has developed a UTI. He is 80 years old and has an indwelling catheter in place. Which factor is most likely the cause of the UTI? A)The close proximity of the male genitalia to the rectum B)Decreased immunity C)A high urine glucose level D)The indwelling urinary catheter
D)The indwelling urinary catheter Most UTI in hospitalized "PT" are caused by the presence of indwelling catheters. Additional, although less significant, causes of UTI include a decrease in immunity elder people in the presence of glucose in the urine, Essena diabetes.
Fulminant viral hepatitis as a complication of viral hepatitis is highest in those individuals with a. hepatitis A b. Hepatitis C c. hepatitis B accompanied with hepatitis C d. hepatitis B accompanied with hepatitis D
D- Although fulminant hepatitis can occur with hepatitis A and hepatitis C, it is more common in hepatitis B, especially in Hep B infection accompanied by infection with Hep D virus
A patient with cirrhosis that is refractory to other treatments for esophageal varices undergoes a peritoneovenous shunt. As a result of this procedure, the nurse would expect the patient to experience a. an improved survival rate b. decreased serum ammonia levels c. improved metabolism of nutrients d. improved hemodynamic function and renal perfusion
D- By shunting fluid sequestered in the peritoneum into the venous system, pressur eon esophageal veins is decreased, and more volume is returned to the circulation, improving CO and renal perfusion. However, because ammonia is diverted past the liver, hepatic encephalopathy continues. These procedures do not prolong life or promote liver function.
The nurse recognizes early signs of hepatic encephalopathy in the patient who a. manifests asterixis b. becomes unconscious c. has increasing oliguria d. is irritable and lethargic
D- Early signs of this neurologic condition include euphoria, depression, apathy, irritability, confusion, agitation, drowsiness, and lethargy. Loss of consciousness is usually preceded by asterixis, disorientation, hyperventilation, hypothermia, and alterations in reflexes. Increasing oliguria is a sign of hepatorenal syndrome.
The family members of a patient with hepatitis A ask if there is anything that will prevent them from developing the disease. The best response by the nurse is a. "no immunization is available for hepatitis A, nor are you likely to get the disease" b. "only individuals who have had sexual contact with the patient should receive immunization" c. "all family members should receive the hepatitis A vaccine to prevent or modify the infection" d. "those who have had household or close contact with the patient should receive immune globulin"
D- Individuals who have been exposed to hepatitis A through household contact or foodborne outbreaks should be given immune globulin within 1 to 2 weeks of exposure to prevent or modify the illness. Hep A vaccine is used to provide pre-exposure immunity to the virus and is indicated for individuals at high risk for hep A exposure. Although hep A can be spread by sexual contact, the risk is higher for transmission with the oral-fecal route.
The systemic effects of viral hepatitis are caused primarily by a. cholestasis b. impaired portal circulation c. toxins produced by the infected liver d. activation of the complement system by antigen-antibody complexes
D- The systemic manifestations of rash, angioedema, arthritis, fever, and malaise in viral hepatitis are caused by the activation o the complement system by circulating immune complexes. Liver manifestations include jaundice from hepatic cell damage and cholestasis as well as anorexia perhaps caused by toxins produced by the damaged liver. Impaired portal circulation usually does not occur in uncomplicated viral hepatitis but would be a liver manifestation
9. The nurse is aware that the following is the most common cause of hyperaldosteronism? a. Excessive sodium intake b. A pituitary adenoma c. Deficient potassium intake d. An adrenal adenoma
D. An autonomous aldosterone-producing adenoma is the most common cause of hyperaldosteronism. Hyperplasia is the second most frequent cause. Aldosterone secretion is independent of sodium and potassium intake as well as of pituitary stimulation.
15. When assessing a male client with pheochromocytoma, a tumor of the adrenal medulla that secretes excessive catecholamine, nurse April is most likely to detect: a. a blood pressure of 130/70 mm Hg. b. a blood glucose level of 130 mg/dl. c. bradycardia. d. a blood pressure of 176/88 mm Hg.
D. Pheochromocytoma, a tumor of the adrenal medulla that secretes excessive catecholamine, causes hypertension, tachycardia, hyperglycemia, hypermetabolism, and weight loss. It isn't associated with the other options.
The patient with a history of lung cancer and hepatitis C has developed liver failure and is considering liver transplantation. After the comprehensive evaluation, the nurse knows that which factor discovered may be a contraindication for liver transplantation? The patient has completed a college education. The patient has been able to stop smoking cigarettes. The patient has well controlled type 1 diabetes mellitus. The chest x-ray showed another lung cancer lesion
D. Contraindications for liver transplant include severe extrahepatic disease, advanced hepatocellular carcinoma or other cancer, ongoing drug or alcohol abuse, and the inability to comprehend or comply with the rigorous post-transplant course. It does not matter if the patient has a college education. The fact that the patient has quit smoking is not a contraindication for liver transplant. The patient is a well-controlled diabetic, which is not a contraindication.
25. During preoperative teaching for a female client who will undergo subtotal thyroidectomy, the nurse should include which statement? a. "The head of your bed must remain flat for 24 hours after surgery." b. "You should avoid deep breathing and coughing after surgery." c. "You won't be able to swallow for the first day or two." d. "You must avoid hyperextending your neck after surgery."
D. To prevent undue pressure on the surgical incision after subtotal thyroidectomy, the nurse should advise the client to avoid hyperextending the neck. The client may elevate the head of the bed as desired and should perform deep breathing and coughing to help prevent pneumonia. Subtotal thyroidectomy doesn't affect swallowing.
The nurse is admitting a patient with cirrhosis. The nurse checks the patient's history for which most frequent risk factor associated with cirrhosis? a. Polypharmacy b. Intravenous drug abuse c. Hepatitis A d. Alcohol abuse
D. Cirrhosis is highly correlated with alcohol abuse. Polypharmacy, drug abuse, and hepatitis A are not linked to cirrhosis. Text Reference - p. 1017
7. A 67-year-old male client has been complaining of sleeping more, increased urination, anorexia, weakness, irritability, depression, and bone pain that interferes with her going outdoors. Based on these assessment findings, nurse Richard would suspect which of the following disorders? a. Diabetes mellitus b. Diabetes insipidus c. Hypoparathyroidism d. Hyperparathyroidism
D. Hyperparathyroidism is most common in older women and is characterized by bone pain and weakness from excess parathyroid hormone (PTH). Clients also exhibit hypercaliuria-causing polyuria. While clients with diabetes mellitus and diabetes insipidus also have polyuria, they don't have bone pain and increased sleeping. Hypoparathyroidism is characterized by urinary frequency rather than polyuria.
A patient with a 3-year history of liver cirrhosis is hospitalized for treatment of recently diagnosed esophageal varices. What is the most important information for the nurse to include in the teaching plan for this patient? a. Decrease fluid intake to avoid ascites. b. Eat foods quickly so they do not get cold and cause distress. c. Avoid exercise because it may cause bleeding of the varices. d. Avoid straining during defecation to keep venous pressure low
D. Straining during a bowel movement increases venous pressure and could cause rupture of the varices. Fluid restrictions may be a recommendation for ascites but are not directly associated with esophageal varices. If the patient is able to eat, meals should be soft or liquid, and the patient should be instructed to eat slowly and avoid extremes in food temperature to prevent irritation. Excessive exercise and activity should be avoided in a patient with esophageal varices to prevent hypertension, however, avoiding straining and other activities that cause the Valsalva maneuver is still a higher-priority recommendation. Text Reference - p. 1022
The family of a patient newly diagnosed with hepatitis A asks the nurse what they can do to prevent becoming ill themselves. Which response by the nurse is most appropriate? A. "The hepatitis vaccine will provide immunity from this exposure and future exposures." B. "I am afraid there is nothing you can do since the patient was infectious before admission." C. "You will need to be tested first to make sure you don't have the virus before we can treat you." D. "An injection of immunoglobulin will need to be given to prevent or minimize the effects from this exposure."
D. "An injection of immunoglobulin will need to be given to prevent or minimize the effects from this exposure." Immunoglobulin provides temporary (1-2 months) passive immunity and is effective for preventing hepatitis A if given within 2 weeks after exposure. It may not prevent infection in all persons, but it will at least modify the illness to a subclinical infection. The hepatitis vaccine is only used for preexposure prophylaxis.
When teaching the patient with acute hepatitis C (HCV), the patient demonstrates understanding when the patient makes which statement? A. "I will use care when kissing my wife to prevent giving it to her." B. "I will need to take adofevir (Hepsera) to prevent chronic HCV." C. "Now that I have had HCV, I will have immunity and not get it again." D. "I will need to be checked for chronic HCV and other liver problems."
D. "I will need to be checked for chronic HCV and other liver problems." The majority of patients who acquire HCV usually develop chronic infection, which may lead to cirrhosis or liver cancer. HCV is not transmitted via saliva, but percutaneously and via high-risk sexual activity exposure. The treatment for acute viral hepatitis focuses on resting the body and adequate nutrition for liver regeneration. Adofevir (Hepsera) is taken for severe hepatitis B (HBV) with liver failure. Chronic HCV is treated with pegylated interferon with ribavirin. Immunity with HCV does not occur as it does with HAV and HBV, so the patient may be reinfected with another type of HCV.
The nurse is caring for a patient with a recent history of deep vein thrombosis (DVT). The patient now needs to undergo surgery for appendicitis. The nurse is reviewing the laboratory results for this patient before administering an ordered dose of vitamin K. The nurse determines that the medication is both safe to give and is most needed when the international normalized ratio (INR) is which result? A. 1.0 B. 1.2 C. 1.6 D. 2.2
D. 2.2 Vitamin K is the antidote to warfarin (Coumadin), which the patient has most likely been taking before admission for treatment of DVT. Warfarin is an anticoagulant that impairs the ability of the blood to clot. Therefore it is necessary to give vitamin K before surgery to reduce the risk of hemorrhage. The largest value of the INR indicates the greatest impairment of clotting ability, making 2.2 the correct selection.
Which finding is of highest priority when the nurse is planning care for a 77-year-old patient seen in the outpatient clinic? a. Symmetric joint swelling of fingers b. Decreased right knee range of motion c. Report of left hip aching when jogging d. History of recent loss of balance and fall
D. A history of falls requires further assessment and development of fall prevention strategies. The other changes are more typical of bone and joint changes associated with normal aging.
The nurse finds that a patient can flex the arms when no resistance is applied but is unable to flex when the nurse applies light resistance. The nurse should document the patient's muscle strength as level a. 0. b. 1. c. 2. d. 3.
D. A level 3 indicates that the patient is unable to move against resistance but can move against gravity. Level 1 indicates minimal muscle contraction, level 2 indicates that the arm can move when gravity is eliminated, and level 4 indicates active movement with some resistance.
A 39-year-old woman with a history of smoking and oral contraceptive use is admitted with a venous thromboembolism (VTE) and prescribed unfractionated heparin. What laboratory test should the nurse review to evaluate the expected effect of the heparin? A. Platelet count B. Activated clotting time (ACT) C. International normalized ratio (INR) D. Activated partial thromboplastin time (APTT)
D. Activated partial thromboplastin time (APTT) Unfractionated heparin can be given by continuous IV for VTE treatment. When given IV, heparin requires frequent laboratory monitoring of clotting status as measured by activated partial thromboplastin time (aPTT). Platelet counts can decrease as an adverse reaction to heparin, but that is not the expected effect.
3. A nurse is completing an admission assessment of a client who has pancreatitis. Which of the following is an expected finding? A. Pain in right upper quadrant radiating to right shoulder B. Report of pain being worse when sitting upright C. Pain relieved with defecation D. Epigastric pain radiating to left shoulder
D. CORRECT: A client who has pancreatitis will report severe, boring epigastric pain that radiates to the back, left flank, or left shoulder.
1. A nurse on a medical-surgical unit is admitting a client who has hepatitis B with ascites. Which of the following actions should the nurse include in the plan of care? A. Initiate contact precautions. B. Weigh client weekly. C. Measure abdominal girth 7.5 cm (3 in) above the umbilicus. D. Provide a high-calorie, high-carbohydrate diet.
D. CORRECT: A high-calorie, high-carbohydrate diet is recommended for clients who have hepatitis B.
5. A nurse is completing nutrition teaching for a client who has pancreatitis. Which of the following statements by the client requires further teaching? A. "I plan to eat small, frequent meals." B. "I will eat easy-to-digest foods with limited spice." C. "I will use skim milk when cooking." D. "I plan to drink regular cola."
D. CORRECT: Caffeine-free beverages are recommended for the client who has pancreatitis. Regular cola contains caffeine.
1. A nurse is completing the admission assessment of a client who has acute pancreatitis. Which of the following findings is the priority to be reported to the provider? A. History of cholelithiasis B. Serum amylase levels three times greater than the expected value C. Client report of severe pain radiating to the back that is rated at an "8" D. Hand spasms present when blood pressure is checked
D. CORRECT: The greatest risk to the client is hypocalcemia due to the risk of cardiac dysrhythmia. Hand spasms when taking a blood pressure is an indication of hypocalcemia and is the priority finding to report to the provider
4. A nurse is reviewing a new prescription for ursodiol (Ursodeoxycholic Acid) with a client who has cholelithiasis. Which of the following should be included in the teaching? A. This medication reduces biliary spasms. B. This medication reduces inflammation in the biliary tract. C. This medication dilates the bile duct to promote passage of bile. D. This medication dissolves gall stones.
D. CORRECT: Ursodiol is a bile acid that gradually dissolves cholesterol-based gall stones.
The patient with suspected pancreatic cancer is having many diagnostic studies done. Which one can be used to establish the diagnosis of pancreatic adenocarcinoma and for monitoring the response to treatment? A. Spiral CT scan B. A PET/CT scan C. Abdominal ultrasound D. Cancer-associated antigen 19-9
D. Cancer-associated antigen 19-9 The cancer-associated antigen 19-9 (CA 19-9) is the tumor marker used for the diagnosis of pancreatic adenocarcinoma and for monitoring the response to treatment. Although a spiral CT scan may be the initial study done and provides information on metastasis and vascular involvement, this test and the PET/CT scan or abdominal ultrasound do not provide additional information.
The patient diagnosed with SIADH (Syndrome of inappropriate antidiuretic hormone) has a sodium level of 129 mEq/L. He is receiving IV 3% saline at 100 mL/hr. Which of the following is the nurse most concerned about? A) The patient complains of cramps in his hands B) There is trace edema in the lower extremities C) HR 110 D) The patient is suddenly states "Who are you?"
D. Decreased LOC is a sign of CMP (Central Pontine Myelinlysis) An extremely life-threatening condition that can occur with patient receiving high levels of sodium rich IV fluids. It is a medical emergency and the infusion should be stopped immediately. Cramps in the hands and trace edema are being treated with the infusion of 3% saline solution. HR 110 is also important, but not as emergent as sudden confusion.
The health care provider orders lactulose for a patient with hepatic encephalopathy. The nurse will monitor for effectiveness of this medication for this patient by assessing what? A. Relief of constipation B. Relief of abdominal pain C. Decreased liver enzymes D. Decreased ammonia levels
D. Decreased ammonia levels. Hepatic encephalopathy is a complication of liver disease and is associated with elevated serum ammonia levels. Lactulose traps ammonia in the intestinal tract. Its laxative effect then expels the ammonia from the colon, resulting in decreased serum ammonia levels and correction of hepatic encephalopathy
A male patient was admitted for a possible ruptured aortic aneurysm, but had no back pain. Ten minutes later his assessment includes the following: sinus tachycardia at 138, BP palpable at 65 mm Hg, increasing waist circumference, and no urine output. How should the nurse interpret this assessment about the patient's aneurysm? A. Tamponade will soon occur. B. The renal arteries are involved. C. Perfusion to the legs is impaired. D. He is bleeding into the abdomen.
D. He is bleeding into the abdomen. The lack of back pain indicates the patient is most likely exsanguinating into the abdominal space, and the bleeding is likely to continue without surgical repair. A blockade of the blood flow will not occur in the abdominal space as it would in the retroperitoneal space where surrounding anatomic structures may control the bleeding. The lack of urine output does not indicate renal artery involvement, but that the bleeding is occurring above the renal arteries, which decreases the blood flow to the kidneys. There is no assessment data indicating decreased perfusion to the legs.
A patient who has hepatitis B surface antigen (HBsAg) in the serum is being discharged with pain medication after knee surgery. Which medication order should the nurse question because it is most likely to cause hepatic complications? A. Tramadol (Ultram) B. Hydromorphone (Dilaudid) C. Oxycodone with aspirin (Percodan) D. Hydrocodone with acetaminophen (Vicodin)
D. Hydrocodone with acetaminophen (Vicodin) The analgesic with acetaminophen should be questioned because this patient is a chronic carrier of hepatitis B and is likely to have impaired liver function. Acetaminophen is not suitable for this patient because it is converted to a toxic metabolite in the liver after absorption, increasing the risk of hepatocellular damage.
When planning care for a patient with cirrhosis, the nurse will give highest priority to which nursing diagnosis? A. Impaired skin integrity related to edema, ascites, and pruritus B. Imbalanced nutrition: less than body requirements related to anorexia C. Excess fluid volume related to portal hypertension and hyperaldosteronism D. Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume
D. Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume Although all of these nursing diagnoses are appropriate and important in the care of a patient with cirrhosis, airway and breathing are always the highest priorities.
A patient with a recent history of a dry cough has had a chest x-ray that revealed the presence of nodules. In an effort to determine whether the nodules are malignant or benign, what is the primary care provider likely to order? A. Thoracentesis B. Pulmonary angiogram C. CT scan of the patient's chest D. Positron emission tomography (PET)
D. Positron emission tomography (PET) PET is used to distinguish benign and malignant pulmonary nodules. Because malignant lung cells have an increased uptake of glucose, the PET scan (which uses an IV radioactive glucose preparation) can demonstrate increased uptake of glucose in malignant lung cells. This differentiation cannot be made using CT, a pulmonary angiogram, or thoracentesis.
You are providing discharge teaching to the client with primary Addison's disease. Which statement, if made by the patient, indicates the need for further teaching? A) I will have to take my Florinef and prednisone for the rest of my life B) During hot weather I will be sure to eat lots of salty foods C) I should continue to monitor my blood pressure for any drops D) Because I can't tolerate the heat I will cancel my trip to the Bahamas but I can still go skiing
D. Pt. should avoid cold weather in order to prevent precipitation of an Addisonian crisis which can be caused by stress on the body. The patient should be taught that medication will be taken for the rest of the patient's life. Salt intake should be increased during hot weather d/t hyponatremia. A drop in blood pressure could be a sign of an impending Addisonian crisis
When the patient is experiencing metabolic acidosis secondary to type 1 diabetes mellitus, what physiologic response should the nurse expect to assess in the patient? A. Vomiting B. Increased urination C. Decreased heart rate D. Rapid respiratory rate
D. Rapid respiratory rate When a patient with type 1 diabetes has hyperglycemia and ketonemia causing metabolic acidosis, the physiologic response is to increase the respiratory rate and tidal volume to blow off the excess CO2. Vomiting and increased urination may occur with hyperglycemia, but not as physiologic responses to metabolic acidosis. The heart rate will increase.
What is a priority nursing intervention in the care of a patient with a diagnosis of chronic venous insufficiency (CVI)? A. Application of topical antibiotics to venous ulcers B. Maintaining the patient's legs in a dependent position C. Administration of oral and/or subcutaneous anticoagulants D. Teaching the patient the correct use of compression stockings
D. Teaching the patient the correct use of compression stockings CVI requires conscientious and consistent application of compression stockings. Anticoagulants are not necessarily indicated and antibiotics, if required, are typically oral or IV, not topical. The patient should avoid prolonged positioning with the limb in a dependent position.
The patient with a history of lung cancer and hepatitis C has developed liver failure and is considering liver transplantation. After the comprehensive evaluation, the nurse knows that which factor discovered may be a contraindication for liver transplantation? A. Has completed a college education B. Has been able to stop smoking cigarettes C. Has well-controlled type 1 diabetes mellitus D. The chest x-ray showed another lung cancer lesion.
D. The chest x-ray showed another lung cancer lesion. Contraindications for liver transplant include severe extrahepatic disease, advanced hepatocellular carcinoma or other cancer, ongoing drug and/or alcohol abuse, and the inability to comprehend or comply with the rigorous post-transplant course.
The patient is a known abuser of narcotics and just had surgery. The nurse is frustrated by drug addiction and worried about the high dose of narcotic analgesic prescribed for this patient. What is the best action for the nurse to take? A. Remember that pain can be observed in patients. B. Relieve this patient's pain to avoid adverse consequences. C. Be sure the patient is really in pain before giving the analgesic. D. This patient has the right to appropriate assessment and management of pain.
D. This patient has the right to appropriate assessment and management of pain. Patients with addictive disease and pain have the right to be treated with dignity, respect, and the same quality of pain assessment and management as all other patients. For an addict, severe pain should be treated with a single opioid at much higher doses than those used with drug-naïve patients. Observation of pain is not always evident. The stress of unrelieved pain may contribute to increased drug use in the patient actively abusing drugs.
5. All of the following are symptoms of Cushing's syndrome except: a. Severe fatigue and weakness b. Hypertension and elevated blood glucose c. A protruding hump between the shoulders d. Hair loss
D: Cushing's syndrome also may cause fragile, thin skin prone to bruises and stretch marks on the abdomen and thighs as well as excessive thirst and urination and mood changes such as depression and anxiety. Women who suffer from high levels of cortisol often have irregular menstrual cycles or amenorrhea and present with hair on their faces, necks, chests, abdomens, and thighs.
6. Which of the following conditions is caused by long-term exposure to high levels of cortisol? a. Addison's disease b. Crohn's disease c. Adrenal insufficiency d. Cushing's syndrome
D: Cushing's syndrome is a form of hypercortisolism. Risk factors for Cushing's syndrome are obesity, diabetes, and hypertension. Cushing's syndrome is most frequently diagnosed in persons ages 20 to 50 who have characteristic round faces, upper body obesity, large necks, and relatively thin limbs.
continuous ambulatory peritoneal dialysis (CAPD) treatment
Dialysate is introduced into the peritoneal cavity, where fluids, electrolytes, and wastes are exchanged through the peritoneal membrane. The client can dialyze alone in any location without the need for machinery and continuous technical supervision. Hemodialysis is not necessary with this procedure. Each exchange involves 2 to 3 L of dialysate intraperitoneally, not interperitoneally, for a specified time (dwell time) before being drained.
A patient tells the nurse about using acetaminophen (Tylenol) several times every day for recurrent bilateral headaches. Which action will the nurse plan to take first?
Discuss the need to stop taking the acetaminophen. rational: The headache description suggests that the patient is experiencing medication overuse headache. The initial action will be withdrawal of the medication. The other actions may be needed if headaches persist.
The nurse is discussing discharge teaching with the client who is three (3) days postoperative abdominal aortic aneurysm (AAA) repair. Which discharge instructions should the nurse include when teaching the client?
Do not lift anything more than 20 pounds
The nurse performs a catheterization immediately after the patient voids and obtains 30 ml residual urine. The next step would be to:
Document the procedure with outcome data.
The nurse is caring for a client diagnosed with hyperparathyroidism who is prescribed furosemide (Lasix). The nurse reinforces dietary instructions to the client. Which is an appropriate instruction?
Drink at least 2 to 3 L of fluid daily.
A client with a urinary tract infection is prescribed trimethoprim/sulfamethoxazole (Bactrim). What information does the nurse provide to this client about taking this drug? (Select all that apply.)
Drink at least 3 liters of fluids every day." Correct "Take this drug with 8 ounces of water." Correct "You will need to take all of this drug to get the benefits." C
An older adult client diagnosed with stress incontinence is prescribed the medication oxybutynin (Ditropan). Which side effects does the nurse tell the client to expect? (Select all that apply.)
Dry mouth Increased intraocular pressure Correct Constipation Correct Oxybutynin is an anticholinergic/antispasmodic. Side effects include dry mouth, urinary retention, constipation, and risk for increased intraocular pressure with the potential to make glaucoma worse.
The nurse educator is asking the nursing student to recall the signs/symptoms of hypothyroidism. The nurse educator determines that the student understands this disorder if which are included in the student's response? Select all that apply
Dry skin Constipation Cold intolerance
Papaverine
ED
Letrozole
ER Positive Breast Cancer
Anastrozole
ER positive Breast Cancer. Need adequate intake of Ca and Vit D
A client arrives at the emergency department complaining of extreme muscle weakness after minimal effort. The physician suspects myasthenia gravis. Which drug will be used to test for this disease?
Edrophonium (Tensilon)
A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head?
Elevated 30 degrees
A patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care?
Encourage family members to remain at the bedside. rational: Patients with meningitis and disorientation will be calmed by the presence of someone familiar at the bedside. Restraints should be avoided because they increase agitation and anxiety. The patient requires frequent assessment for complications; the use of touch and a soothing voice will decrease anxiety for most patients. The patient will have photophobia, so the light should be dim.
A client diagnosed with stress incontinence is started on propantheline (Pro-Banthine). What interventions does the nurse suggest to alleviate the side effects of this anticholinergic drug?
Encourage increased fluids. Correct Increase fiber intake. Correct Use hard candy for dry mouth. Anticholinergics cause constipation; increasing fluids and fiber intake will help with this problem.
When caring for a client diagnosed with pheochromocytoma, which information should the nurse know when assisting with planning care?
Excessive catecholamines are released.
After several diagnostic tests, a client is diagnosed with diabetes insipidus. The nurse understands that which signs/symptoms are indicative of this disorder?
Excessive thirst and urine output
What makes someone with myasthenia gravis worse?
Exercise and Infection
Which client problem would be priority in a client diagnosed with arterial occlusive disease who is admitted to the hospital with a foot ulcer?
Risk for peripheral neuropathy
A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering the medications, the patient says, "I don't need the aspirin today. I don't have any aches or pains." Which action should the nurse take?
Explain that the aspirin is ordered to decrease stroke risk. rational: Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the patient's refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider. The aspirin is not ordered to prevent aches and pains.
The client tells the nurse that his cholesterol level is 240 mg/dL. Which action should the nurse implement?
Explain that the client needs to lower the cholesterol level
T or F A tender, red, inflamed induration along the course of a subcutaneous vein is chararcteristic of a venous thromboembolism (VTE).
False, venous thromboembolism should be replaced with superficial vein thrombosis
The nurse is monitoring a client with Graves' disease for signs of thyrotoxic crisis (thyroid storm). Which signs and symptoms noted in the client should alert the nurse to the presence of this crisis? Select all that apply.
Fever Sweating Agitation
The nurse is caring for a client following an adrenalectomy and is monitoring for signs of adrenal insufficiency. Which are signs and symptoms related to adrenal insufficiency? Select all that apply.
Fever Weakness Hypotension Mental status changes
hemodialysis
Following hemodialysis the client's vital signs are monitored to determine whether the client is remaining hemodynamically stable and for comparison to predialysis measurements. The client's blood pressure and weight are expected to be reduced as a result of fluid removal. Laboratory studies are done as per protocol but are not necessarily done after the hemodialysis treatment has ended.
The nurse knows the client understands the teaching concerning a low-fat, low cholesterol diet when the client selects which meal?
Fried fish, garlic mashed potatoes, and ice tea
If someone with GBS has voiding problems, what should you be concerned about?
Get a vent in place because diaphragm is going to be affected next.
What are the adverse reactions from medication?
Gingival hyperplasia, GI disturbances, heptoxicity, ataxia, hypocalcemia, and decrease in vitamin D absorption
The nurse is teaching a class on atherosclerosis. Which statement describes the scientific rationale as to why diabetes is a risk factor for developing atherosclerosis?
Glucose combines with carbon monoxide, instead of with oxygen, and this leads to oxygen deprivation of tissues
What should you teach a patient on DILANTIN?
Good oral hygiene and nutrition are important
The nurse is caring for a client with pheochromocytoma. The client asks for a snack and something warm to drink. Which is the appropriate choice for this client to meet nutritional needs?
Graham crackers and warm milk
As the nursse reviews a diet plan with a patient with diabetes mellitus and renal insufficiency, the patient states that with diabetes and renal failure there is nothing that is good to eat. The patient says,"I am going to eat what I want; I'm goingto die anyway!" The best nursing diagnosis for this patient is:
Grieving, related to actual and perceived losses.
A client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term?
Helicopod
A client undergoes cerebral angiography to evaluate for neurologic deficits. Afterward, the nurse checks frequently for signs and symptoms of complications associated with this procedure. Which findings indicate spasm or occlusion of a cerebral vessel by a clot?
Hemiplegia, seizures, and decreased level of consciousness (LOC)
The nurse is preparing to reinforce instructions to a client with Addison's disease regarding diet therapy. The nurse understands that which diet should be prescribed for this client?
High-sodium, high-carbohydrate diet
A patient with Parkinson's disease has decreased tongue mobility and an inability to move the facial muscles. Which nursing diagnosis is of highest priority?
Imbalanced nutrition: less than body requirements rational: The data about the patient indicate that poor nutrition will be a concern because of decreased swallowing. The other diagnoses also may be appropriate for a patient with Parkinson's disease, but the data do not indicate they are current problems for this patient.
A patient with Parkinson's disease has decreased tongue mobility and an inability to move the facial muscles. Which nursing diagnosis is of highest priority?
Imbalanced nutrition: less than body requirements rational: The data about the patient indicate that poor nutrition will be a concern because of decreased swallowing. The other diagnoses also may be appropriate for a patient with Parkinson's disease, but the data do not indicate they are current problems for this patient.
The community health nurse is developing a program to decrease the incidence of meningitis in adolescents and young adults. Which nursing action is most important?
Immunize adolescents and college freshman against Neisseria meningitides. rational: The Neisseria meningitides vaccination is recommended for children ages 11 and 12, unvaccinated teens entering high school, and college freshmen. Hand washing may help decrease the spread of bacteria, but it is not as effective as immunization. Vaccination with Haemophilus influenzae is for infants and toddlers. Because adolescents and young adults are in school or the workplace, avoiding crowds is not realistic.
While admitting a patient with a basal skull fracture, the nurse notes clear drainage from the patient's nose. Which of these admission orders should the nurse question?
Insert nasogastric tube. rational: Rhinorrhea may indicate a dural tear with cerebrospinal fluid (CSF) leakage, and insertion of a nasogastric tube will increase the risk for infections such as meningitis. Turning the patient, elevating the head, and applying cold pack are appropriate orders.
While admitting a patient with a basal skull fracture, the nurse notes clear drainage from the patient's nose. Which of these admission orders should the nurse question?
Insert nasogastric tube. rational: Rhinorrhea may indicate a dural tear with cerebrospinal fluid (CSF) leakage, and insertion of a nasogastric tube will increase the risk for infections such as meningitis. Turning the patient, elevating the head, and applying cold pack are appropriate orders.
The nurse is collecting data on a client admitted to the hospital with a diagnosis of myxedema. Which data collection technique would provide data necessary to support the admitting diagnosis?
Inspection of facial features
The nurse should expect to note which interventions in the plan of care for a client with hypothyroidism? Select all that apply.
Instruct the client about thyroid replacement therapy. Encourage the client to consume fluids and high-fiber foods in the diet. Instruct the client to contact the health care provider if episodes of chest pain occur.
Which instruction should be included when a client diagnosed with peripheral arterial disease is being discharged?
Instruct the client to walk daily for at least 30 minutes
The nurse is reinforcing discharge instructions to a client who had a unilateral adrenalectomy. Which information should be a component of the instructions?
Instructions about early signs of a wound infection
A physician diagnoses a client with myasthenia gravis and prescribes pyridostigmine (Mestinon), 60 mg by mouth every 3 hours. Before administering this anticholinesterase agent, the nurse reviews the client's history. Which preexisting condition would contraindicate the use of pyridostigmine?
Intestinal obstruction
Which parameter is best for the nurse to monitor to determine whether the prescribed IV mannitol (Osmitrol) has been effective for an unconscious patient?
Intracranial pressure rational: Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure. It may initially reduce hematocrit and increase blood pressure, but these are not the best parameters for evaluation of the effectiveness of the drug. Oxygen saturation will not directly improve as a result of mannitol administration.
What is PARKINSON'S DISEASE?
It is a progressive neurological disease with a slow onset that usually occurs after age 50, rarely occurring in the black population, and leading to a respiratory death. The motor symptoms of Parkinson's disease result from the death of dopamine-generating cells in the substantia nigra, a region of the midbrain; the cause of this cell death is unknown.
What is myasthenia gravis?
It is an autoimmune neuromuscular disease that affects the motor cranial nerves. It is the GRAVE MUSCLE WEAKNESS. Exacerbation and remissions are parts of the disease which tend to be progressive over time.
A nurses caring for a postoperative parathyroidectomy client. Which of the following would require the nurses immediate attention
Laryngeal strider
The nurse is caring for a postoperative parathyroidectomy client. Which would require the nurse's immediate attention?
Laryngeal stridor
A client has been diagnosed with hypoparathyroidism. Which food groups should be included in the diet?
Low in phosphorus and high in calcium
To help prevent embolization of the thrombus in a patient with VTE, the nurse teaches the patient to do what?
Maintain bed rest until edema is relieved and anticoagulation is established.
When calculating actual urinary output during continous bladder irrigations, the nurse would:
Measure the total output and deduct the amount of irrigation solution used.
On which area would the nurse place the bell of the stethoscope when assessing the client with an abdominal aortic aneurysm (AAA)?
Medline above the umbilicus
After receiving furosemide (Lasix) 40 mg slow intravenous push for chest pain related to shortness of breath and generalized edema, the client responds poorly. The client has no relief of the chest pain, shortness of breath, or edema and only minimal urine output (less than 40 mL of urine). The health care provider is notified, and after reviewing the chart, suspects the client has syndrome of inappropriate antidiuretic hormone (SIADH). Which findings would lead to this specific diagnosis? Refer to chart.
Minimal responsiveness to furosemide (Lasix) and small cell lung cancer
The nurse reviews a plan of care for a postoperative client following a thyroidectomy and notes that the client is at risk for breathing difficulty. Which nursing intervention should the nurse include in the plan of care?
Monitor neck circumference frequently.
The nurse is reviewing a plan of care for a client with Addison's disease. The nurse notes that the client is at risk for dehydration and suggests nursing interventions that will prevent this occurrence. Which nursing intervention is an appropriate component of the plan of care? Select all that apply.
Monitoring intake and output Monitoring for changes in mental status Encouraging fluid intake of at least 3000 mL/day
The priority short-term goal for disorders of the urinary system is:
Normal patterns of urinary elimation
A client is scheduled for a cystoscopy later this morning. The consent form is not signed, and the client has not had any preoperative medication. The nurse notes that the provider visited the client the day before. What action does the nurse take?
Notifies the department and the provider he client may be asked to sign the consent form in the department; notifying both the provider and the department ensures communication across the continuum of care, with less likelihood of omission of information
Following a thymectomy, a patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient complains of nausea and severe abdominal cramps. Which action should the nurse take first?
Notify the patient's health care provider. rational: The patient's history and symptoms indicate a possible cholinergic crisis. The health care provider should be notified immediately, and it is likely that atropine will be prescribed. The other actions will be appropriate if the patient is not experiencing a cholinergic crisis.
Following a thymectomy, a patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient complains of nausea and severe abdominal cramps. Which action should the nurse take first?
Notify the patient's health care provider. rational: The patient's history and symptoms indicate a possible cholinergic crisis. The health care provider should be notified immediately, and it is likely that atropine will be prescribed. The other actions will be appropriate if the patient is not experiencing a cholinergic crisis.
When the nurse is assessing a patient with myasthenia gravis, which action will be most important to take?
Observe respiratory effort. rational: Because respiratory insufficiency may be life threatening, it will be most important to monitor respiratory function. The other data also will be assessed but are not as critical.
When the nurse is assessing a patient with myasthenia gravis, which action will be most important to take?
Observe respiratory effort. rational: Because respiratory insufficiency may be life threatening, it will be most important to monitor respiratory function. The other data also will be assessed but are not as critical.
A patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by the spouse. Which action will the nurse take first?
Obtain oxygen saturation. rational: Airway patency and breathing are the most vital functions and should be assessed first. The neurologic assessments should be accomplished next and the health and medication history last.
A patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by the spouse. Which action will the nurse take first?
Obtain oxygen saturation. rational: Airway patency and breathing are the most vital functions and should be assessed first. The neurologic assessments should be accomplished next and the health and medication history last.
What drug is used by someone experiencing autonomic dysreflexia symptoms at home?
PROCARDIA to decrease BP. Prick and squeeze under tongue. Works quickly and raise head of bed.
Which of these nursing actions for a patient with Guillain-Barré syndrome is most appropriate for the nurse to delegate to an experienced nursing assistant?
Passive range of motion to extremities q8hr rational: Assisting a patient with movement is included in nursing assistant education and scope of practice. Administration of tube feedings, administration of ordered medications, and assessment are skills requiring more education and scope of practice, and the RN should perform these skills.
What occurs in the post-ictal period?
Patient sleeps for several hours after seizure. Do not call physician because this is expected.
A client is in the emergency department for an inability to void and for bladder distention. What is most important for the nurse to provide to the client?
Privacy The nurse should provide privacy, assistance, and voiding stimulants, such as warm water over the perineum, as needed, for the client with urinary problems. Increased oral fluids and IV fluids would exacerbate the client's problem.
dietary instructions to a client who is being treated with continuous ambulatory peritoneal dialysis (CAPD)
Proteins eaten should be high quality to replace those lost during dialysis. A high-calorie diet is encouraged. Usually there is a modest restriction of fluids when the client is on dialysis. Usually there is a restriction of high-potassium foods when the client is on dialysis.
A patient who has a head injury is diagnosed with a concussion. Which action will the nurse plan to take?
Provide discharge instructions about monitoring neurologic status. rational: A patient with a minor head trauma is usually discharged with instructions about neurologic monitoring and the need to return if neurologic status deteriorates. MRI, hospital admission, or surgery are not indicated in a patient with a concussion.
After renal angiography, the patient assessment priority is the:
Puncture site
The nurse is collecting data regarding a client after a thyroidectomy and notes that the client has developed hoarseness and a weak voice. Which nursing action is appropriate?
Reassure the client that this is usually a temporary condition.
Which goal would have priority in planning care of the aging patient with urinary incontinence?
Recognizes the urge to void
When reading the urinalyis report, the nurse recognizes this result as abnormal:
Red Blood Cells, 15-20
A patient has a systemic BP of 108/51 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first?
Report the BP and ICP to the health care provider. rational: The patient's cerebral perfusion pressure is 56 mm Hg, below the normal of 60 to 100 mm Hg and approaching the level of ischemia and neuronal death. Immediate changes in the patient's therapy such as fluid infusion or vasopressor administration are needed to improve the cerebral perfusion pressure. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation also will be done, but they are not the first actions that the nurse should take.
What kind of death does a person with multiple sclerosis normally die from?
Respiratory. Watch for hypoxia, restlessness, and agitation.
What activity would be harmful for the incontinent patient?
Restricting fluid intake
A patient with a stroke has progressive development of neurologic deficits with increasing weakness and decreased level of consciousness (LOC). Which nursing diagnosis has the highest priority for the patient?
Risk for aspiration related to inability to protect airway rational: Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses also are appropriate, but interventions to prevent aspiration are the priority at this time.
renal colic
Sharp, severe pain (renal colic) radiating toward the genitalia and thigh is caused by ureteral distention and smooth muscle spasm; relief from pain is the priority. Although the client is overweight and weight loss is desirable, it is a long-term goal. Although hematuria needs to be monitored, blood loss usually is not massive with ureteral colic. Mild hypertension is not the priority when a client is in severe pain.
What kind of shoes should you recommend for a patient with Parkinson's Disease?
Shoes with 1 thread so they can slide through lie. No tennis shoes or leather bottom shoes. Slippers are good.
1. An elevated PSA can be from urinary retention, BPH, prostate cancer, or prostate infarct.
The client asks, "What does an elevated PSA test mean?" On which scientific rationale should the nurse base the response? 1.An elevated PSA can result from several different causes. 2.An elevated PSA can be only from prostate cancer. 3.An elevated PSA can be diagnostic for testicular cancer. 4.An elevated PSA is the only test used to diagnose BPH.
4. Normal potassium level is 3.5 to5.5 mEq/L. A level of 6.8 mEq/L is life threatening and could lead to cardiac dysrhythmias. Therefore, the client may be dialyzed to decrease the potassium level quickly. This requires a health-careprovider order, so it is a collaborative intervention.
The client diagnosed with ARF has a serum potassium level of 6.8 mEq/L. Which collaborative treatment should the nurse anticipate for the client? 1.Administer a phosphate binder. 2.Type and crossmatch for whole blood. 3.Assess the client for leg cramps. 4.Prepare the client for dialysis.
3. Carbohydrates are increased to provide for the client's caloric intake and protein is restricted to minimize protein breakdown and to prevent accumulation of toxic waste products.
The client diagnosed with ARF is admitted to the intensive care unit and placed on a therapeutic diet. Which diet is most appropriate for the client? 1.A high-potassium and low-calcium diet. 2.A low-fat and low-cholesterol diet. 3.A high-carbohydrate and restricted-protein diet. 4.A regular diet with six (6) small feedings a day.
1. Carrying heavy objects in the left arm could cause the fistula to clot by putting undue stress on the site, so the client should carry objects with the right arm.
The client diagnosed with CKD has a new arteriovenous fistula in the left forearm. Which intervention should the nurse implement? 1.Teach the client to carry heavy objects with the right arm. 2.Perform all laboratory blood tests on the left arm. 3.Instruct the client to lie on the left arm during the night. 4.Discuss the importance of not performing any hand exercises.
4. Because the client is in ESRD, fluid must be removed from the body, so the output should be more than the amount instilled. These assessment data require intervention by the nurse.
The client diagnosed with CKD is receiving peritoneal dialysis. Which assessment data warrant immediate intervention by the nurse? 1.Inability to auscultate a bruit over the fistula. 2.The client's abdomen is soft, is nontender, and has bowel sounds. 3.The dialysate being removed from the client's abdomen is clear. 4.The dialysate instilled was 1,500 mL and removed was 1,500 mL.
1, 2, 3 The health-care provider may order certain foods and medications when obtaining a 24-hour urine collection to evaluate for calcium oxalate or uric acid. When the collection begins, the client should completely empty the bladder and discard this urine. The test is started after the bladder is empty. All urine for 24 hours should be saved and put in a container with preservative,refrigerated, or placed on ice as indicated. Not following specific instructions will result in an inaccurate test result.
The client diagnosed with renal calculi is scheduled for a 24-hour urine specimen collection. Which interventions should the nurse implement? Select all that apply. 1.Check for the ordered diet and medication modifications. 2.Instruct the client to urinate, and discard this urine when starting collection. 3.Collect all urine during 24 hours and place in appropriate specimen container. 4.Insert an indwelling catheter in client after having the client empty the bladder.5.Instruct the UAP to notify the nurse when the client urinates.
3. The UAP could assist the client to the car once the discharge has been completed.
The client diagnosed with renal calculi is scheduled for lithotripsy. Which post procedure nursing task is the most appropriate to delegate to the UAP? 1.Monitor the amount, color, and consistency of urine output. 2.Teach the client about care of the indwelling Foley catheter. 3.Assist the client to the car when being discharged home. 4.Take the client's postprocedural vital signs.
4 Unless the nurse can determine the catheter has been inserted within a few days, the nurse should replace the catheter and then get a specimen. This will provide the most accurate specimen for analysis.
The client from a long-term care facility is admitted to the medical unit with a fever,hot flushed skin, and clumps of white sediment in the indwelling catheter. Which intervention should the nurse implement first? 1.Start an IV with a 20-gauge catheter. 2.Initiate antibiotic therapy IVPB. 3.Collect a urine specimen for culture. 4.Change the indwelling catheter.
3. Clients lose potassium from the GI tract or through the use of diuretic medications. Potassium imbalances can lead to cardiac arrhythmias.
The client has been vomiting and has had numerous episodes of diarrhea. Which laboratory test should the nurse monitor? 1.Serum calcium. 2.Serum phosphorus. 3.Serum potassium. 4.Serum sodium.
2. The client has signs of phlebitis and the IV must be removed to prevent further complications.
The client has received IV solutions for three (3) days through a 20-gauge IV catheter placed in the left cephalic vein. On morning rounds, the nurse notes the IV site is tender to palpation and a red streak has formed. Which intervention should the nurse implement first? 1.Start a new IV in the right hand. 2.Discontinue the intravenous line. 3.Complete an incident record. 4.Place a warm washrag over the site.
4. The client who has restricted kidney function from surgery should be monitored for damage as a result of the use of aminoglycoside antibiotics, such as vancomycin, which are nephrotoxic. This level is high and warrants notifying the HCP.
The client is 12 hours postoperative renal surgery. Which data warrant immediate intervention by the nurse? 1.The abdomen is soft, non-tender, and rounded. 2.Pain is not felt with dorsal flexion of the foot. 3.The urine output is 60 mL for the past two (2) hours. 4.The client's trough vancomycin level is 24 mcg/mL.
1, 2, 5 TPN is a hypertonic solution with enough calories, proteins, lipids,electrolytes, and trace elements to sustain life. It is administered via a pump to prevent too-rapid infusion. TPN contains 50% dextrose solution;therefore, the client is monitored to ensure the pancreas is adapting to the high glucose levels. Intake and output are monitored toobserve for fluid balance.
The client is NPO and is receiving total parenteral nutrition (TPN) via a subclavianline. Which precautions should the nurse implement? Select all that apply. 1.Place the solution on an IV pump at the prescribed rate. 2.Monitor blood glucose every six (6) hours. 3.Weigh the client weekly, first thing in the morning. 4.Change the IV tubing every three (3) days.5.Monitor intake and output every shift.
4. Clients with sodium levels less than 120 mEq/L are at risk for seizures as a complication. The lower the sodium level, the greater the risk of a seizure.
The client is admitted with a serum sodium level of 110 mEq/L. Which nursing intervention should be implemented? 1.Encourage fluids orally. 2.Administer 10% saline solution IVPB. 3.Administer antidiuretic hormone intranasally. 4.Place on seizure precautions.
1, 2, 3 Renal failure affects almost every system in the body. Neurologically, the client may have drowsiness, headache, muscle twitching, and seizures. In the recovery period, the client is alert and has no seizure activity. In renal failure, levels of erythropoietin are decreased, leading to anemia. An increase in hemoglobin and hematocrit indicates the client is in the recovery period. Nausea, vomiting, and diarrhea are common in the client with ARF; there-fore, an absence of these indicates the client is in the recovery period.
The client is diagnosed with ARF. Which signs/symptoms indicate to the nurse the client is in the recovery period? Select all that apply. 1.Increased alertness and no seizure activity. 2.Increase in hemoglobin and hematocrit. 3.Denial of nausea and vomiting. 4.Decreased urine-specific gravity. 5.Increased serum creatinine level.
2. Clients experiencing incontinence should eat a high-fiber diet to avoid constipation, which increases pressure on the bladder, which may increase incontinence.
The client is experiencing urinary incontinence. Which intervention should the nurse implement? 1.Teach the client to drink prune juice weekly. 2.Encourage the client to eat a high-fiber diet. 3.Discuss the need to urinate every six (6) hours. 4.Explain the importance of wearing cotton underwear.
2. Elevating the scrotum on a towel for support is a task which can be delegated to the UAP.
The client is one (1) day postoperative TURP. Which task should the nurse delegate to the UAP? 1.Increase the irrigation fluid to clear clots from the tubing. 2.Elevate the scrotum on a towel roll for support. 3.Change the dressing on the first postoperative day. 4.Teach the client how to care for the continuous irrigation catheter.
1 Fever, chills, and costovertebral pain are symptoms of a urinary tract infection (acute pyelonephritis), which requires a urine culture first to confirm the diagnosis.
The client is reporting chills, fever, and left costovertebral pain. Which diagnostic test should the nurse expect the HCP to prescribe first? 1.A midstream urine for culture. 2.A sonogram of the kidney. 3.An intravenous pyelogram for renal calculi. 4.A CT scan of the kidneys.
1, 3, 4 The nurse should assess the drain postoperatively. The head of the bed should be lowered and the foot should be elevated to shunt blood to the central circulating system. The surgeon needs to be notified of the change in condition.
The client returned from surgery after having a TURP and has a P 110, R 24, BP90/40, and cool and clammy skin. Which interventions should the nurse implement?Select all that apply. 1.Assess the urine in the continuous irrigation drainage bag. 2.Decrease the irrigation fluid in the continuous irrigation catheter. 3.Lower the head of the bed while raising the foot of the bed. 4.Contact the surgeon to give an update on the client's condition. 5.Check the client's postoperative creatinine and BUN.
3. Crackles and rhonchi in all lung fieldsindicate the body is not able to processthe amount of fluid being infused. This should be brought to the HCP's attention.
The client who has undergone an exploratory laparotomy and subsequent removal of a large intestinal tumor has a nasogastric tube (NGT) in place and an IV running at 150 mL/hr via an IV pump. Which data should be reported to the HCP? 1.The pump keeps sounding an alarm indicating the high pressure has been reached. 2.Intake is 1,800 mL, NGT output is 550 mL, and Foley output is 950 mL. 3.On auscultation, crackles and rhonchi in all lung fields are noted. 4.Client has negative pedal edema and an increasing level of consciousness.
the nurse is caring for the clients on a surgical floor. Which client should be assessed FIRST?
The client who is four (4) day post-operative abdominal surgery and is complaining of left calf pain when ambulating
2. These are signs and symptoms of hypocalcemia, and the nurse can confirm this by tapping the cheek to elicit the Chvostek's sign. If the muscles of the cheek begin to twitch,then the HCP should be notified immediately because hypocalcemia is a medical emergency.
The client who is post-thyroidectomy complains of numbness and tingling around the mouth and the tips of the fingers. Which intervention should the nurse implement first? 1.Notify the health-care provider immediately. 2.Tap the cheek about two (2) cm anterior to the earlobe. 3.Check the serum calcium and magnesium levels. 4.Prepare to administer calcium gluconate IVP.
3. This is usually the length of time clients need to wait prior to having sexual intercourse; this is the information the client wants to know.
The client who is postoperative TURP asks the nurse, "When will I know if I will be able to have sex after my TURP?" Which response is most appropriate by the nurse? 1."You seem anxious about your surgery." 2."Tell me about your fears of impotency." 3."Potency can return in six (6) to eight (8) weeks." 4."Did you ask your doctor about your concern?"
4. The nurse should always assess any complaint before dismissing it as a commonly occurring problem.
The client with a TURP who has a continuous irrigation catheter complains of the need to urinate. Which intervention should the nurse implement first? 1.Call the surgeon to inform the HCP of the client's complaint. 2.Administer the client a narcotic medication for pain. 3.Explain to the client this sensation happens frequently. 4.Assess the continuous irrigation catheter for patency.
1. Clients who have urinary incontinenceare often embarrassed, so it is the responsibility of the nurse to approach this subject with respect and consideration.
The elderly client being seen in the clinic has complaints of urinary frequency,urgency, and "leaking." Which priority intervention should the nurse implement when interviewing the client? 1.Ensure communication is nonjudgmental and respectful. 2.Set the temperature for comfort in the examination room. 3.Speak loudly to ensure the client understands the nurse. 4.Ensure the examining room has adequate lighting.
3 Glomerular filtration rate (GFR) is approximately 120 mL/min. If the GFR is decreased to 40 mL/min, the kidneys are functioning at about one-third filtration capacity.
The elderly client is diagnosed with chronic glomerulonephritis. Which laboratory value indicates to the nurse the condition has become worse? 1.The blood urea nitrogen is 15 mg/dL. 2.The creatinine level is 1.2 mg/dL. 3.The glomerular filtration rate is 40 mL/min. 4.The 24-hour creatinine clearance is 100 mL/min.
4. Use of the bladder training drill is helpful in stress incontinence. The client is instructed to void at scheduled intervals. After consistently being dry, the interval is increased by 15 minutes until the client reaches an acceptable interval.
The elderly client recovering from a prostatectomy has been experiencing stress incontinence. Which independent nursing intervention should the nurse discuss with the client? 1.Establish a set voiding frequency of every two (2) hours while awake. 2.Encourage a family member to assist the client to the bathroom to void. 3.Apply a transurethral electrical stimulator to relieve symptoms of urinary urgency. 4.Discuss the use of a "bladder drill," including a timed voiding schedule.
3. The nurse cannot delegate teaching.
The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients. Which nursing intervention should the nurse perform? 1.Measure the client's output from the indwelling catheter. 2.Record the client's intake and output on the I & O sheet. 3.Instruct the client on appropriate fluid restrictions. 4.Provide water for a client diagnosed with diabetes insipidus.
1. The UAP can collect specimens.Collecting a midstream urine specimen requires the client to clean the perineal area, to urinate a little, and then collect the rest of the urine output in a sterile container.
The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a medical floor. Which nursing task is most appropriate for the nurse to delegate? 1.Collect a clean voided midstream urine specimen. 2.Evaluate the client's 8-hour intake and output. 3.Assist in checking a unit of blood prior to hanging. 4.Administer a cation-exchange resin enema.
4. Noncompliance is a choice the client has a right to make, but the nurse should determine the reason for the noncompliance and then take appropriate actions based on the client's rationale. For example, if the client has financial difficulties, the nurse may suggest how the client can afford the proper foods along with medications, or the nurse may be able to refer the client to a social worker.
The nurse caring for a client diagnosed with CKD writes a client problem of "noncompliance with dietary restrictions." Which intervention should be included in the plan of care? 1.Teach the client the proper diet to eat while undergoing dialysis. 2.Refer the client and significant other to the dietitian. 3.Explain the importance of eating the proper foods. 4.Determine the reason for the client not adhering to the diet.
2. This client's dialysis access is compromised and he or she should be assessed first.
The nurse in the dialysis center is initiating the morning dialysis run. Which client should the nurse assess first? 1.The client who has hemoglobin of 9.8 g/dL and hematocrit of 30%. 2.The client who does not have a palpable thrill or auscultated bruit. 3.The client who is complaining of being exhausted and is sleeping. 4.The client who did not take antihypertensive medication this morning.
1. Blood urea nitrogen (BUN) levels reflect the balance between the production and excretion of urea from the kidneys. Creatinine is a by-product of the metabolism of the muscles and is excreted by the kidneys. Creatinine is the ideal sub-stance for determining renal clearance because it is relatively constant in the body and is the laboratory value most significant in diagnosing renal failure.
The nurse is caring for a client diagnosed with ARF. Which laboratory values are most significant for diagnosing ARF? 1.BUN and creatinine. 2.WBC and hemoglobin. 3.Potassium and sodium. 4.Bilirubin and ammonia level.
2 Fatigue, headache, and polyuria as well as loss of weight, anorexia, and excessive thirst are symptoms of chronic pyelonephritis.
The nurse is caring for a client with chronic pyelonephritis. Which assessment data support the diagnosis of chronic pyelonephritis? 1.The client has fever, chills, flank pain, and dysuria. 2.The client complains of fatigue, headaches, and increased urination. 3.The client had a group B beta-hemolytic strep infection last week. 4.The client has an acute viral pneumonia infection.
2. When an elderly client's mental status changes to confused and irritable, the nurse should seek the etiology, which may be a UTI secondary to an indwelling catheter. Elderly client soften do not present with classic signs and symptoms of infection.
The nurse is caring for an elderly client who has an indwelling catheter. Which data warrant further investigation? 1.The client's temperature is 98.0˚F. 2.The client has become confused and irritable. 3.The client's urine is clear and light yellow. 4.The client feels the need to urinate.
3. This is the correct scientific rationale for metabolic acidosis occurring in the client with CKD.
The nurse is caring for the client diagnosed with chronic kidney disease (CKD) who is experiencing metabolic acidosis. Which statement best describes the scientific rationale for metabolic acidosis in this client? 1.There is an increased excretion of phosphates and organic acids, which leads to anincrease in arterial blood pH. 2.A shortened life span of red blood cells because of damage secondary to dialysistreatments in turn leads to metabolic acidosis. 3.The kidney cannot excrete increased levels of acid because they cannot excreteammonia or cannot reabsorb sodium bicarbonate. 4.An increase in nausea and vomiting causes a loss of hydrochloric acid and therespiratory system cannot compensate adequately.
3. Renal failure causes an imbalance of electrolytes (potassium, sodium, calcium,phosphorus). Therefore, the desired client outcome is electrolytes within normal limits.
The nurse is developing a plan of care for a client diagnosed with ARF. Which statement is an appropriate outcome for the client? 1.Monitor intake and output every shift. 2.Decrease of pain by 3 levels on a 1-10 scale. 3.Electrolytes are within normal limits. 4.Administer enemas to decrease hyperkalemia.
3 The client should be taught to take all the prescribed medication anytime a prescription is written for antibiotics.
The nurse is discharging a client with a health-care facility acquired urinary tract infection. Which information should the nurse include in the discharge teaching? 1.Limit fluid intake so the urinary tract can heal. 2.Collect a routine urine specimen for culture. 3.Take all the antibiotics as prescribed. 4.Tell the client to void every five (5) to six (6) hours.
2. The elderly woman may have age-related changes (decreased bladder capacity, weakened urinary sphincter,and shortened urethra) causing urinary urgency or incontinence. The elderly client is at risk for falling while attempting to get to the bathroom, so this client should be seen first.
The nurse is discussing how to prioritize care with the UAP. Which client should the nurse instruct the UAP to see first? 1.The immobile client who needs sequential compression devices removed. 2.The elderly woman who needs assistance ambulating to the bathroom. 3.The surgical client who needs help changing the gown after bathing. 4.The male client who needs the intravenous catheter discontinued.
2. Many in the African American culture believe the body must be kept intact after death, and organ donation is rare among African Americans. This is also why a client of African American descent will be on a transplant waiting list longer than people of other races. This is because of tissue-typing compatibility. Remember, this does not apply to all African-Americans; every client is an individual.
The nurse is discussing kidney transplants with clients at a dialysis center. Which population is less likely to participate in organ donation? 1.Caucasian. 2.African American. 3.Asian. 4.Hispanic.
3 These are symptoms of cystitis, a bladder infection which may be caused by sexual intercourse as a result of the introduction of bacteria into the urethra during the physical act. A teenager may not want to divulge this information in front of the parent.
The nurse is examining a 15-year-old female who is complaining of pain, frequency,and urgency when urinating. After asking the parent to leave the room, which question should the nurse ask the client? 1."When was your last menstrual cycle?" 2."Have you noticed any change in the color of the urine?" 3."Are you sexually active?" 4."What have you taken for the pain?"
1, 4, 2, 3, 5 The procedure should be explained to the client. Incontinence pads should be placed under the client before beginning the sterile part of the procedure. The sterile field must be set up prior to checking the bulb and cleaning the client's perineum. The bulb of the catheter should be tested to make sure it will inflate and deflate prior to inserting the catheter into the client. During the procedure, the perineum is swiped with Betadine swabs from front to back and also down the middle, then side to side with new swabs (clean to dirty).
The nurse is inserting an indwelling catheter into a female client. Which interventions should be implemented? Rank in the order of performance. 1.Explain the procedure to the client. 2.Set up the sterile field. 3.Inflate the catheter bulb. 4.Place absorbent pads under the client. 5.Clean the perineum from clean to dirty with Betadine.
1, 5 Vital signs should be monitored every two (2) hours until stable and more frequently if the client is unstable. Skin turgor and mucous membranes should be assessed every shift or more often depending on the client's condition.
The nurse is preparing the plan of care for a client with fluid volume deficit. Which interventions should the nurse include in the plan of care? Select all that apply. 1.Monitor vital signs every two (2) hours until stable. 2.Measure the client's oral intake and urinary output daily. 3.Administer mouth care when bathing the client. 4.Weigh the client weekly in the same clothing at the same time. 5.Assess skin turgor and mucous membranes every shift.
2. The treatment goal of the flaccid bladder is to prevent overdistention.
The nurse is preparing the plan of care for the client diagnosed with a neurogenic flaccid bladder. Which expected outcome is appropriate for this client? 1.The client has conscious control over bladder activity. 2.The client's bladder does not become overdistended. 3.The client has bladder sensation and no discomfort. 4.The client demonstrates how to check for bladder distention.
The nurse obtains all of the following information about a 65-year-old patient in the clinic. When developing a plan to decrease stroke risk, which risk factor is most important for the nurse to address?
The patient's blood pressure (BP) is usually about 180/90 mm Hg. rational: Hypertension is the single most important modifiable risk factor and this patient's hypertension is at the stage 2 level. People who drink more than 1 (for women) or 2 (for men) alcoholic beverages a day may increase risk for hypertension. Physical inactivity and obesity contribute to stroke risk but not so much as hypertension.
The health care provider is considering the use of sumatriptan (Imitrex) for a patient with migraine headaches. Which information obtained by the nurse is most important to report to the health care provider?
The patient has a history of a recent acute myocardial infarction. rational: The triptans cause coronary artery vasoconstriction and should be avoided in patients with coronary artery disease. The other information will be reported to the health care provider, but none of it is an indication that sumatriptan would be an inappropriate treatment.
Which information about a patient with MS indicates that the nurse should consult with the health care provider before giving the prescribed dose of fampridine (Ampyra)?
The patient has an increased creatinine level. rational: Fampridine should not be given to patients with impaired renal function. The other information will not impact on whether the fampridine should be administered.
A patient with sudden-onset right-sided weakness has a CT scan and is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider?
The patient has atrial fibrillation and takes warfarin (Coumadin). rational: The use of warfarin will have contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient's care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated.
When caring for a patient who has Guillain-Barré syndrome, which assessment data obtained by the nurse will require the most immediate action?
The patient has continuous drooling of saliva. rational: Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot pain should be treated with appropriate analgesics, and the BP requires ongoing monitoring, but these actions are not as urgently needed as maintenance of respiratory function. Absence of the reflexes should be documented, but this is a common finding in Guillain-Barré syndrome.
When caring for a patient who has Guillain-Barré syndrome, which assessment data obtained by the nurse will require the most immediate action?
The patient has continuous drooling of saliva. rational: Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot pain should be treated with appropriate analgesics, and the BP requires ongoing monitoring, but these actions are not as urgently needed as maintenance of respiratory function. Absence of the reflexes should be documented, but this is a common finding in Guillain-Barré syndrome.
The nurse is caring for a patient with carotid artery narrowing who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse?
The patient has difficulty talking. rational: Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during the procedure. Slightly elevated pulse rate and blood pressure are not unusual because of anxiety associated with the procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility during the procedure; the nurse should have the patient take some deep breaths.
The nurse is assessing a patient who is being evaluated for a possible spinal cord tumor. Which finding by the nurse requires the most immediate action?
The patient has new onset weakness of both legs. rational: The new onset of symptoms indicates cord compression, an emergency that requires rapid treatment to avoid permanent loss of function. The other patient assessments also indicate a need for nursing action but do not require intervention as rapidly as the new onset weakness.
When caring for a patient who has had a head injury, which assessment information requires the most rapid action by the nurse?
The patient is more difficult to arouse. rational: The change in level of consciousness (LOC) is an indicator of increased intracranial pressure (ICP) and suggests that action by the nurse is needed to prevent complications. The change in BP should be monitored but is not an indicator of a need for immediate nursing action. Headache is not unusual in a patient after a head injury. A slightly irregular apical pulse is not unusual.
Aspirin is ordered for a patient who is admitted with a possible stroke. Which information obtained during the admission assessment indicates that the nurse should consult with the health care provider before giving the aspirin?
The patient states, "My symptoms started with a terrible headache." rational: A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin use, so the nurse can administer the aspirin.
Define the etiology of an AAA?
The primary etiology of an AAA is atherosclerotic plaquing that causes degenerative changes in the media lining of the aorta. The changes lead to loss of elasticity, weakening, and eventual dilation of the aorta. Trauma and infections and possible genetic component are responsible for a small number of AAA's.
A patient who has had a subarachnoid hemorrhage is being cared for in the intensive care unit. Which information about the patient is most important to communicate to the health care provider?
The patient's blood pressure is 90/50 mm Hg. rational: To prevent cerebral vasospasm and maintain cerebral perfusion, blood pressure needs to be maintained at a level higher than 90 mm Hg systolic after a subarachnoid hemorrhage. A low BP or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP. An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider.
A patient who has had a subarachnoid hemorrhage is being cared for in the intensive care unit. Which information about the patient is most important to communicate to the health care provider?
The patient's blood pressure is 90/50 mm Hg. rational: To prevent cerebral vasospasm and maintain cerebral perfusion, blood pressure needs to be maintained at a level higher than 90 mm Hg systolic after a subarachnoid hemorrhage. A low BP or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP. An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider.
An older client with a history of hyperparathyroidism and severe osteoporosis is hospitalized. The nurse caring for the client plans to address which problem first?
The possibility of injury
The patient with VTE is receiving therapy with heparin and asks the nurse whether the drug will dissolve the clot in her leg. The best response by the nurse is...
The purpose of the heparin is to prevent growth of the clot or formation of new clots where the circulation is slowed.
1. A client with a peaked T wave could be experiencing hyperkalemia. Changes in potassium levels can initiate cardiac dysrhythmias and instability.
The telemetry monitor technician notifies the nurse of the morning telemetry readings. Which client should the nurse assess first? 1.The client in normal sinus rhythm with a peaked T wave. 2.The client diagnosed with atrial fibrillation with a rate of 100. 3.The client diagnosed with a myocardial infarction who has occasional PVCs. 4.The client with a first-degree atrioventricular block and a rate of 92.
The male client is diagnosed with Guillain Barre syndrome (GB) and is in the intensive care unit a ventilator. Which cardiovascular rationale explains implementing passive range of motion (ROM) exercises?
They help to prevent DVTs by movement of the blood through the veins
A patient has a tonic-clonic seizure while the nurse is in the patient's room. Which action should the nurse take?
Time and observe and record the details of the seizure and postictal state. rational: Because diagnosis and treatment of seizures frequently are based on the description of the seizure, recording the length and details of the seizure is important. Insertion of an oral airway and restraining the patient during the seizure are contraindicated. The nurse may need to move the patient to decrease the risk of injury during the seizure.
The nurse in the urology clinic is providing teaching for a female client with cystitis. Which instructions does the nurse include in the teaching plan? (Select all that apply.)
Try to take in 64 ounces of fluid each day. Correct Be sure to complete the full course of antibiotics. Correct If urine remains cloudy, call the clinic.
Arterial or Venous disease? Brown pigmentation of the legs
V
Arterial or Venous disease? Dull ache in calf or thigh
V
Arterial or Venous disease? Edema around the ankles
V
Arterial or Venous disease? Heavy ulcer drainage
V
Arterial or Venous disease? Pruritis
V
1. This client requires the most skill and knowledge because this client has the greatest potential for an infection;therefore, the client should not be assigned to a UAP.
Which client should the nurse not assign to a UAP working on a surgical floor? 1.The client with a suprapubic catheter inserted yesterday. 2.The client who has had an indwelling catheter for the past week. 3.The client who is on a bladder-training regimen. 4.The client who had a catheter removed this morning and is being discharged.
2. The severe flank pain associated with a stone in the ureter often causes asympathetic response with associated nausea; vomiting; pallor; and cool,clammy skin.
Which clinical manifestations should the nurse expect to assess for the client diagnosed with a ureteral renal stone? 1.Dull, aching flank pain and microscopic hematuria. 2.Nausea; vomiting; pallor; and cool, clammy skin. 3.Gross hematuria and dull suprapubic pain with voiding. 4.The client will be asymptomatic.
4. Clients with acute bacterial prostatitis will frequently experience a sudden onset of fever and chills. Clients with chronic prostatitis have milder symptoms.
Which data support to the nurse the client's diagnosis of acute bacterial prostatitis? 1.Terminal dribbling. 2.Urinary frequency. 3.Stress incontinence. 4.Sudden fever and chills.
1. Scheduled voiding allows the client to void every two (2) to three (3) hours apart, and when the client has remained consistently dry, the interval is increased by about 15 minutes.
Which information indicates to the nurse the client teaching about treatment of urinary incontinence has been effective? 1.The client prepares a scheduled voiding plan. 2.The client verbalizes the need to increase fluid intake. 3.The client explains how to perform pelvic floor exercises. 4.The client attempts to retain the vaginal cone in place the entire day.
2. Passing a renal stone may negate the need for the client to have lithotripsy or a surgical procedure. Therefore, all urine must be strained, and a stone, if found, should be sent to the laboratory to determine what caused the stone.
Which intervention is most important for the nurse to implement for the client diagnosed with rule-out renal calculi? 1.Assess the client's neurological status every two (2) hours. 2.Strain all urine and send any sediment to the laboratory. 3.Monitor the client's creatinine and BUN levels. 4.Take a 24-hour dietary recall during the client interview.
3. The output should be monitored to detect a decreased amount indicating an obstruction from edema or ureteralstenosis. Any decrease should be reported to the health-care provider.
Which intervention should the nurse implement for the client who has had an ileal conduit? 1.Pouch the stoma with a one (1)-inch margin around the stoma. 2.Refer the client to the United Ostomy Association for discharge teaching. 3.Report to the health-care provider any decrease in urinary output. 4.Monitor the stoma for signs and symptoms of infection every shift.
3. The nurse should first assist the client in getting out of the wet clothes prior to any other action. Wet clothes are embarrassing to the client and can lead to skin breakdown.
Which intervention should the nurse implement first for the client who has had an incontinent episode? 1.Palpate the client's bladder to assess for urinary retention. 2.Obtain a bedside commode for the client. 3.Assist the client with changing the wet clothes. 4.Request the UAP to change the client's linens.
1. The client should sit in a warm sitz bath for 10 to 20 minutes several time seach day to provide comfort and assist with healing.
Which intervention should the nurse include when preparing a teaching plan for the client with chronic prostatitis? 1.Sit in a warm sitz bath for 10 to 20 minutes several times daily. 2.Sit in the chair with the feet elevated for two (2) hours daily. 3.Drink at least 3,000 mL of oral fluids, especially tea and coffee, daily. 4.Stop broad-spectrum antibiotics as soon as the symptoms subside.
4. This is a potentially life-threatening problem.
Which nursing diagnosis is priority for the client who has undergone a TURP? 1.Potential for sexual dysfunction. 2.Potential for an altered body image. 3.Potential for chronic infection. 4.Potential for hemorrhage.
3. The nurse should always assess for allergies to latex prior to inserting a latex catheter or using a drainage system because, if the client is allergic to latex,use of it could cause a life-threatening reaction.
Which nursing intervention is most important before attempting to catheterize a client? 1.Determine the client's history of catheter use. 2.Evaluate the level of anxiety of the client. 3.Verify the client is not allergic to latex. 4.Assess the client's sensation level and ability to void.
3. The client with fluid volume excess has too much fluid. Excess fluid is reflected by adventitious breath sounds. Therefore, an expected outcome is to have no excess fluid, as evidenced by normal, clear breath sounds.
Which outcome should the nurse identify for the client diagnosed with fluid volume excess? 1.The client will void a minimum of 30 mL per hour. 2.The client will have elastic skin turgor. 3.The client will have no adventitious breath sounds. 4.The client will have a serum creatinine of 1.4 mg/dL.
Which medication taken at home by a 47-year-old patient with decreased renal function will be of most concern to the nurse? a. ibuprofen (Motrin) b. warfarin (Coumadin) c. folic acid (vitamin B9) d. penicillin (Bicillin LA)
a NSAIDs are nephrotoxic and should be avoided in patients with impaired renal function
A patient has elevated blood urea nitrogen (BUN) and serum creatinine levels. Which bowel preparation order would the nurse question for this patient who is scheduled for a renal arteriogram? a. Fleet enema b. Tap-water enema c. Senna/docusate (Senokot-S) d. Bisacodyl (Dulcolax) tablets
a High-phosphate enemas, such as Fleet enemas, should be avoided in patients with elevated BUN and creatinine because phosphate cannot be excreted by patients with renal failure
The nurse is caring for a 68-year-old hospitalized patient with a decreased glomerular filtration rate who is scheduled for an intravenous pyelogram (IVP). Which action will be included in the plan of care? a. Monitor the urine output after the procedure. b. Assist with monitored anesthesia care (MAC). c. Give oral contrast solution before the procedure. d. Insert a large size urinary catheter before the IVP.
a Patients with impaired renal function are at risk for decreased renal function after IVP because the contrast medium used is nephrotoxic, so the nurse should monitor the patient's urine output.
In planning care for a patient with metastatic liver cancer, the nurse should include interventions that a. focus primarily on symptomatic and comfort measures. b. reassure the patient that chemotherapy offers a good prognosis. c. promote the patient's confidence that surgical excision of the tumor will be successful. d. provide information necessary for the patient to make decisions regarding liver transplantation.
a Rationale: Nursing intervention for a patient with liver cancer focuses on keeping the patient as comfortable as possible. The prognosis for patients with liver cancer is poor. The cancer grows rapidly, and death may occur within 4 to 7 months as a result of hepatic encephalopathy or massive blood loss from gastrointestinal (GI) bleeding.
What glomerular filtration rate (GFR) would the nurse estimate for a 30-year-old patient with a creatinine clearance result of 60 mL/min? a. 60 mL/min b. 90 mL/min c. 120 mL/min d. 180 mL/min
a The creatinine clearance approximates the GFR
Hypopituitarism
a condition in which the pituitary gland does not produce normal amounts of some or all of its hormones (ACTH, ADH, FSH, GH, LH, oxytocin, prolactin, TSH).
Identify at least one observation made by the nurse that would indicate the presence of the following complications of aortic aneurysm repair. a. Graft thrombosis
a decreased or absent pulses in conjunction with cool, painful extremities below the level of repair
Hypoparathyroidism
a disorder in which the parathyroid glands do not produce enough parathyroid hormone (PTH). PTH helps control serum levels of calcium, phosphorus, and vitamin D.
Number the following physiologic occurrences in the order they occur in the formation of urine. Begin with 1 for the fist occurrence and number through 6 for the last occurrence in the formation of urine. ____ a. Blood is filtered in the glomerulus. ____ b. Reabsorption of water in the loop of Henle. ____ c. Reabsorption of electrolytes, glucose, amino acids, and small proteins in the tubules. ____ d. Acid-base regulation with conservation of bicarbonate (HCO3-) and secretion of excess H+ in the distal tubule. ____ e. Active reabsorption of chloride (Cl-) ions and passive reabsorption of sodium (Na+) ions in the ascending loop of Henle. ____ f. Ultrafiltrate flows from Bowman's capsule and passess down the tubules without blood cells, platelets, or large plasma proteins.
a, 1; b, 4; c, 3; d, 6; e, 5; f, 2. Rationale: Blood is filtered in the glomerulus and the ultrafiltrate flows from the Bowman's capsule to the tubules for reabsorption of essential materials and secretion of the nonessential ones. In the proximal convoluted tubule, most electrolytes, glucose, amino acids, and small proteins are reabsorbed. Water is conserved in the loop of Henle with chloride and sodium reabsorbed in the ascending loop. The distal convoluted tubules complete final water balance and acid-base balance.
A patient with PAD has a nursing diagnosis of ineffective peripheral tissue perfusion. Appropriate teaching for the patient includes instructions to (select all that apply). a) keep legs and feet warm b) walk at least 30 min/day to the point of discomfort c) apply cold compresses when the legs become swollen d) use nicotine replacement therapy as a substitute for smoking e) inspect lower extremities for pulses, temperature, and any swelling
a, b, and e
What are common diagnostic studies done for a patient with severe renal colic (select all that apply)? a. CT scan b. Urinalysis c. Cystoscopy d. Ureteroscopy e. Abdominal ultrasound
a, b, e. Testing would include urinalysis to see crystals and look for red blood cells. Abdominal ultrasound and CT scan may also be done.
The right atrium myocytes secrete atrial natriuretic peptide (ANP)when there is increased plasma volume. What actions does ANP take to produce a large volume of dilute urine (select all that apply)? a. Inhibits renin b. Increases ADH c. Inhibits angiotensin II action d. Decreases sodium excretion e. Increases aldosterone secretion
a, c Rationale: Atrial natriuretic peptide (ANP) responds to increased atrial distention by increasing sodium excretion and inhibiting renin, ADH, and angiotensin action. Aldosterone secretion is also suppressed. ANP also causes afferent arteriole relaxation that increases the glomerular filtration rate (GFR).
Nursing management of the patient with acute pancreatitis includes (select all that apply) a. checking for signs of hypocalcemia. b. providing a diet low in carbohydrates. c. giving insulin based on a sliding scale. d. observing stools for signs of steatorrhea. e. monitoring for infection, particularly respiratory tract infection.
a, e Rationale: During the acute phase, it is important to monitor vital signs. Hemodynamic stability may be compromised by hypotension, fever, and tachypnea. Intravenous fluids are ordered, and the response to therapy is monitored. Fluid and electrolyte balances are closely monitored. Frequent vomiting, along with gastric suction, may result in decreased levels of chloride, sodium, and potassium. Because hypocalcemia can occur in acute pancreatitis, the nurse should observe for symptoms of tetany, such as jerking, irritability, and muscular twitching. Numbness or tingling around the lips and in the fingers is an early indicator of hypocalcemia. The patient should be assessed for Chvostek's sign or Trousseau's sign. A patient with acute pancreatitis should be observed for fever and other manifestations of infection. Respiratory infections are common because the retroperitoneal fluid raises the diaphragm, which causes the patient to take shallow, guarded abdominal breaths.
Which important functions of regulation of water balance and acid-base balance occur in the distal convoluted tubules of the nephron (select all that apply)? a. Secretion of H+ into filtrate b. Reabsorption of water without ADH c. Reabsorption of Na+ in exchange for K+ d. Reabsorption of glucose and amino acids e. Reabsorption of water under ADH influence f. Reabsorption of Ca+2 under parathormone influence
a,c,e,f Rationale: The distal tubules regulate water and acid-base balance by reabsorption of water under antidiuretic hormone (ADH) influence, secreting H and reabsorbing bicarbonate, reabsorption of Na+ in exchange for K+, and reabsorption of Ca+2 with the influence of parathormone. The reabsorption of water without ADH occurs in the proximal convoluted tubule and the descending loop of Henle. The reabsorption of glucose and amino acids occurs in the proximal convoluted tubule. Active reabsorption of Cl- and passive reabsorption of Na+ occurs in the ascending loop of Henle.
Which urine specific gravity value would indicate to the nurse that the patient is receiving excessive IV fluid therapy? a. 1.002 b. 1.010 c. 1.025 d. 1.030
a. A urine specific gravity of 1.002 is low, indicating dilute urine and the excretion of excess fluid. Fluid overload, diuretics, or lack of ADH can cause dilute urine. Normal urine specific gravity is 1.003 to 1.030. A high urine specific gravity indicates concentrated urine that would be seen in dehydration.
In which clinical situation would the increased release of erythropoietin be expected? a. Hypoxemia b. Hypotension c. Hyperkalemia d. Fluid overload
a. Erythropoietin is released when the oxygen tension of the renal blood supply is low and stimulates production of red blood cells in the bone marrow. Hypotension causes activation of the renin-angiotensin-aldosterone system, as well as release of ADH. Hyperkalemia stimulates the release of aldosterone from the adrenal cortex and fluid overload does not directly stimulate factors affecting the erythropoietin release by the kidney.
The nurse is caring for a client who is about to undergo an adrenalectomy. Which of the following Preoperative interventions is most appropriate for this client? a. Maintain careful use of medical and surgical asepsis when providing care and treatments. b. Teach the client about a diet high in sodium to correct any potential sodium imbalances preoperatively. c. Explain to the client that electrolytes and glucose levels will be measured postoperatively. d. Teach the client how to effectively cough and deep breathe once surgery is complete.
a. Maintain careful use of medical and surgical asepsis when providing care and treatments. Rationale: Use careful medical and surgical asepsis when providing care and treatments since Cortisol excess increases the risk of infection. # 2 is incorrect. Nutrition should be addressed preoperatively. Request a dietary consultation to discuss with the client about a diet high in vitamins and proteins. If hypokalemia exists, include foods high in potassium. Glucocorticoid excess increases catabolism. Vitamins and proteins are necessary for tissue repair and wound healing following surgery. # 3 is incorrect. Monitor the results of laboratory tests of electrolytes and glucose levels. Electrolyte and glucose imbalances are corrected
A nurse on a general medical-surgical unit is caring for a client with Cushing's syndrome. Which of the following statements is correct about the medication regimen for Cushing's syndrome? a. Mitotane is used to treat metastatic adrenal cancer. b. Aminogluthimide may be administered to clients with ectopic ACTH-secreting tumors before surgery is performed. c. Ketoconazole increases cortisol synthesis by the adrenal cortex. d. Somatostatin analog increases ACTH secretion in some clients.
a. Mitotane is used to treat metastatic adrenal cancer. Rationale: Mitotane directly suppresses activity of the adrenal cortex and decreases peripheral metabolism of corticosteroids. It is used to treat metastatic adrenal cancer. # 2 is incorrect because aminogluthimide may be administered to clients with ectopic ACTH-secreting tumors that cannot be surgically removed. # 3 is incorrect because ketoconazole inhibits, not increases, cortisol synthesis by the adrenal cortex. # 4 is incorrect because somatostatin suppresses, not increases, ACTH secretion.
The nurse is caring for a client with pheochromocytoma. Which of the following must be included in planning the nursing care for this client ? a. Monitor blood pressure frequently, assessing for hypertension. b. Assess only for physical stressors present. c. Collect a random urine sample. d. Prepare the client for chemotherapy to shrink the tumor.
a. Monitor blood pressure frequently, assessing for hypertension. Rationale: Pheochromocytomas are tumors of chromaffin tissues in the adrenal medulla. These tumors which are usually benign produce catecholamines (epinephrine or norepinephrine) that stimulate the sympathetic nervous system. Although many organs are affected, the most dangerous effects are peripheral vasoconstriction and increased cardiac rate and contractility with resultant paroxysmal hypertension. Systolic blood pressure may rise to 200 to 300 mmHg, the diastolic to 150 to 175 mmHg. # 1 is correct because the careful monitoring of blood pressure is essential. Attacks are often precipitated by physical, emotional, or environmental stimuli, so # 2 is incorrect because more than physical stressors are considered. This condition is life threatening and is usually treated with surgery as the preferred treatment. # 3 is incorrect because it is a random sample and not a 24 hour urine collection. Because catecholamine secretion is episodic, a 24-hour urine is a better surveillance method than serum catecholamines. (Pagana & Pagana, 2002). Surgical removal of the tumor(s) by adrenalectomy is the treatment of choice. # 4 is incorrect because surgery would be the treatment usually completed.
A patient with an obstruction of the renal artery causing renal ischemia exhibits hypertension. What is one factor that may contribute to the hypertension? a. Increased renin release b. Increased ADH secretion c. Decreased aldosterone secretion d. Increased synthesis and release of prostaglandins
a. Renin is released in response to decreased arterial blood pressure (BP), renal ischemia, decreased extracellular fluid (ECF), decreased serum Na+ concentration, and increased urinary Na+ concentration. It is the catalyst of the reninangiotensin- aldosterone system, which raises stimulated. ADH is secreted by the posterior pituitary in response to serum hyperosmolality and low blood volume. Aldosterone is secreted only after stimulation by angiotensin II. Kidney prostaglandins lower BP by causing vasodilation.
The physician documented that the patient has urinary retention. How should the nurse explain this when the nursing student asks what it is? a. Inability to void b. No urine formation c. Large amount of urine output d. Increased incidence of urination
a. Retention is the inability to void. Anuria is no urine formation. Polyuria is a large amount of urine output over time. Frequency is increased incidence of urination.
What is the most likely reason that the BUN would be increased in a patient? a. Has impaired renal function b. Has not eaten enough protein c. Has decreased urea in the urine d. May have nonrenal tissue destruction
a. The blood urea nitrogen (BUN) is increased in patients with renal problems. It may also be increased when there is rapid or extensive tissue damage from other causes. Low protein intake may cause a low BUN.
Describe the pathophysiologic changes of cirrhosis that cause the following a. Portal hypertension b. Esophageal varices
a. scarring and nodular changes in liver lead to compression of the veins and sinusoids, causing resistance of blood flow through the liver from the portal vein b. development of collateral channels of circulation in inelastic, fragile esophageal veins as a result of portal hypertension
A patient with tendonitis asks what the tendon does. The nurse's response is based on the knowledge that tendons a.connect bone to muscle. b.provide strength to muscle. c.lubricate joints with synovial fluid. d.relieve friction between moving parts.
a.connect bone to muscle Tendons are composed of dense, fibrous connective tissue that contains bundles of closely packed collagen fibers arranged in the same plane for additional strength. They connect the muscle sheath to adjacent bone.
While performing passive range of motion for a patient, the nurse puts the ankle joint through the movements of (select all that apply) a.flexion and extension. b.inversion and eversion. c.pronation and supination d.flexion, extension, abduction, and adduction. e.pronation, supination, rotation, and circumduction.
a.flexion and extension. b.inversion and eversion. Common movements that occur at the ankle include inversion, eversion, flexion, and extension.
A normal assessment finding of the musculoskeletal system is a.no deformity or crepitation. b.muscle and bone strength of 4. c.ulnar deviation and subluxation. d.angulation of bone toward midline.
a.no deformity or crepitation Normal physical assessment findings of the musculoskeletal system include normal spinal curvatures; no muscle atrophy or asymmetry; no joint swelling, deformity, or crepitation; no tenderness on palpation of muscles and joints; full range of motion of all joints without pain or laxity; and muscle strength score of 5.
in planning care for the newly admitted pt with acute pancreatitis, which pt outcome should receive highest priority? a. pt expresses satisfaction with pain control b. pt verbalizes understanding of medications for home c. pt increases activity intolerance d. pt maintains normal bowl function
a: because pancreatitis is very painful, pt satisfaction with pain control is a priority
A hospitalized patient complains of a moderate bilateral headache that radiates from the base of the skull. Which of these prescribed PRN medications should the nurse administer initially?
acetaminophen (Tylenol) rational: The patient's symptoms are consistent with a tension headache, and initial therapy usually involves a nonopioid analgesic such as acetaminophen, sometimes combined with a sedative or muscle relaxant. Lorazepam may be used in conjunction with acetaminophen but would not be appropriate as the initial monotherapy. Morphine sulfate and butalbital and aspirin would be more appropriate for a headache that did not respond to a nonopioid analgesic.
Aldosterone is produced by the
adrenal glands
a client with pancreatitis has a hx of alcohol abuse. the nurse will observe the client for agitation, nausea, vomiting, delirium tremens, and visual, auditory and tactile hallucinations. these are indications of: 1. possible cirrhosis of the liver 2. alcohol withdrawal 3. depression 4. suicidal thoughts
alcohol withdrawal
Repair of ______ aneurysms requires cross-clamping of the artery proximal and distal to the aneurysm.
all
which client problem has priority for the client dx with acute pancreatitis? 1. risk for fluid volume deficit 2. alteration in comfort 3. imbalanced nutrition: less than body requirements 4. knowledge deficit
alteration in comfort: autodigestion of the pancreas results in severe epigastric pain, accompanied by nausea, vomiting, abdominal tenderness and muscle guarding
the male client dx with chronic pancreatitis calls and reports to the clinic nurse he has been having a lot of gas along with frothy and very foul smelling stools. which intervention should the nurse implement? 1. explain this is common for chronic pancreatitis 2. ask the client to bring in a stool specimen to the clinic 3. arrange an appointment with the hcp for today 4. discuss the need to decrease fat in the diet so this wont happen
arrange an appointment with the hcp for today: steatorrhea (fatty, frothy, foul smelling stool) is caused by a decrease in pancreatic enzyme secretion and indicates impaired digestion and possibly an increase in the severity of the pancreatitis. the client should see the hcp
The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia. An appropriate nursing intervention to help the patient communicate is to _______________
ask simple questions that the patient can answer with "yes" or "no." rational: Communication will be facilitated and less frustrating to the patient when questions that require a "yes" or "no" response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond.
The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia. An appropriate nursing intervention to help the patient communicate is to _______________
ask simple questions that the patient can answer with "yes" or "no." rational: Communication will be facilitated and less frustrating to the patient when questions that require a "yes" or "no" response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond.
the client is immediate postprocedure endoscopic retrograde cholangiopancreatogram (ERCP). which intervention should the nurse implement? 1. assess for rectal bleeding, 2, increase fluid intake 3. assess gag reflex 4. keep in supine position
assess gag reflex: the gag reflex will be suppressed as a result of the local anesthesia applied to the throat to insert the endoscope into the esophagus; therefore, the gag reflex must be assessed prior to allowing the client to resume eating or drinking
patient teaching to prepare for vanillylmandellic acid test
avoid coffee, tea, bananas, chocolate for 2 to 3 days prior to the test
the client in end stage liver failure has vitamin K deficiency. which interventions should the nurse implement? select all that apply 1. avoid rectal temperatures 2. use only a soft toothbrush 3. monitor the platelet count 4. use small gauge needles 5. assess for asterixis
avoid rectal temps, use only a soft toothbrush, monitor platelet count, use small gauge needles: vitamin k deficiency causes impaired coagulation, therefore, rectal thermometers should be avoided to prevent bleeding. Soft bristle toothbrushes will help prevent bleeding of the gums. platelet count, ptt/pt, and INR should be monitored to assess coagulation status. Injections should be avoided, if at all possible, bc the client is unable to clot, but if they are absolutely necessarily, the nurse should use small gauge needles
A female patient with a suspected urinary tract infection (UTI) is to provide a clean-catch urine specimen for culture and sensitivity testing. To obtain the specimen, the nurse will a. have the patient empty the bladder completely, then obtain the next urine specimen that the patient is able to void. b. teach the patient to clean the urethral area, void a small amount into the toilet, and then void into a sterile specimen cup. c. insert a short sterile "mini" catheter attached to a collecting container into the urethra and bladder to obtain the specimen. d. clean the area around the meatus with a povidone-iodine (Betadine) swab, and then have the patient void into a sterile container.
b
A patient gives the nurse health information before a scheduled intravenous pyelogram (IVP). Which item has the most immediate implications for the patient's care? a. The patient has not had food or drink for 8 hours. b. The patient lists allergies to shellfish and penicillin. c. The patient complains of costovertebral angle (CVA) tenderness. d. The patient used a bisacodyl (Dulcolax) tablet the previous night.
b
The nurse caring for a patient after cystoscopy plans that the patient a. learns to request narcotics for pain. b. understands to expect blood-tinged urine. c. restricts activity to bed rest for a 4 to 6 hours. d. remains NPO for 8 hours to prevent vomiting.
b
How will the nurse assess for flank tenderness in a 30-year-old female patient with suspected pyelonephritis? a. Palpate along both sides of the lumbar vertebral column. b. Strike a flat hand covering the costovertebral angle (CVA). c. Push fingers upward into the two lowest intercostal spaces. d. Percuss between the iliac crest and ribs along the midaxillary line.
b Checking for flank pain is best performed by percussion of the CVA and asking about pain.
Teaching in relation to home management after a laparoscopic cholecystectomy should include a. keeping the bandages on the puncture sites for 48 hours. b. reporting any bile-colored drainage or pus from any incision. c. using over-the-counter antiemetics if nausea and vomiting occur. d. emptying and measuring the contents of the bile bag from the T tube every day.
b Rationale: The following discharge instructions are taught to the patient and caregiver after a laparoscopic cholecystectomy: First, remove the bandages on the puncture site the day after surgery and shower. Second, notify the surgeon if any of the following signs and symptoms occur: redness, swelling, bile-colored drainage or pus from any incision; and severe abdominal pain, nausea, vomiting, fever, or chills. Third, gradually resume normal activities. Fourth, return to work within 1 week of surgery. Fifth, resume a usual diet, but a low-fat diet is usually better tolerated for several weeks after surgery.
The nurse completing a physical assessment for a newly admitted male patient is unable to feel either kidney on palpation. Which action should the nurse take next? a. Obtain a urine specimen to check for hematuria. b. Document the information on the assessment form. c. Ask the patient about any history of recent sore throat. d. Ask the health care provider about scheduling a renal ultrasound.
b The kidneys are protected by the abdominal organs, ribs, and muscles of the back, and may not be palpable under normal circumstances, so no action except to document the assessment information is needed
A 79-year-old man has been admitted with benign prostatic hyperplasia. What is most appropriate to include in the nursing plan of care? a. Limit fluid intake to no more than 1000 mL/day. b. Leave a light on in the bathroom during the night. c. Ask the patient to use a urinal so that urine can be measured. d. Pad the patient's bed to accommodate overflow incontinence.
b The patient's age and diagnosis indicate a likelihood of nocturia
The nurse assessing the urinary system of a 45-year-old female would use auscultation to a. determine kidney position. b. identify renal artery bruits. c. check for ureteral peristalsis. d. assess for bladder distention.
b The presence of a bruit may indicate problems such as renal artery tortuosity or abdominal aortic aneurysm
A client newly diagnosed with Addison's disease is giving a return explanation of teaching done by the primary nurse. Which of the following statements indicates that further teaching is necessary? a. "I need to increase how much I drink each day." b. "I need to weigh myself if I think I am losing or gaining weight." c. "I need to maintain a diet high in sodium and low in potassium." d. "I need to take my medications each day."
b. "I need to weigh myself if I think I am losing or gaining weight." The client is at risk for ineffective therapeutic regimen management. Clients with Addison's disease must learn to provide lifelong self-care that involves varied components: medications, diet, and recognizing and responding to stress. Changes in lifestyle are difficult to maintain permanently. The client needs to take the medications on a daily basis. The client needs to perform daily weights to monitor for signs of dehydration. The client needs to maintain a diet high in sodium and low in potassium, as well as maintain an increased fluid intake. # 2 is incorrect because daily weights need to be performed instead of weighing when a problem is suspected.
A 35-year-old female patient with a possible pituitary adenoma is scheduled for a computed tomography (CT) scan with contrast media. Which patient information is most important for the nurse to communicate to the health care provider before the test? a. Bilateral poor peripheral vision b. Allergies to iodine and shellfish c. Recent weight loss of 20 pounds d. Complaint of ongoing headaches
b. Allergies to iodine and shellfish
A 30-year-old patient seen in the emergency department for severe headache and acute confusion is found to have a serum sodium level of 118 mEq/L. The nurse will anticipate the need for which diagnostic test? a. Urinary 17-ketosteroids b. Antidiuretic hormone level c. Growth hormone stimulation test d. Adrenocorticotropic hormone level
b. Antidiuretic hormone level
A urinalysis of a urine specimen that is not processed within 1 hour may result in erroneous measurement of a. glucose. b. bacteria. c. specific gravity. d. white blood cells.
b. Bacteria in warm urine specimens multiply rapidly and false or unreliable bacterial counts may occur with urine that has been sitting for periods of time. Glucose, specific gravity, and WBCs do not change in urine specimens but pH becomes more alkaline, RBCs are hemolyzed, and casts may disentigrate.
Priority Decision: Following a renal biopsy, what is the nurse's priority? a. Offer warm sitz baths to relieve discomfort. b. Test urine for microscopic bleeding with a dipstick. c. Expect the patient to experience burning on urination. d. Monitor the patient for symptoms of a urinary infection.
b. Bleeding from the kidney following a biopsy is the most serious complication of the procedure and urine must be examined for both gross and microscopic blood, in addition to vital signs and hematocrit levels being monitored. Following a cystoscopy the patient may have burning with urination and warm sitz baths may be used. Urinary infections are a complication of any procedure requiring instrumentation of the bladder.
Which urinalysis results most likely indicate a urinary tract infection (UTI)? a. Yellow; protein 6 mg/dL; pH 6.8; 102/mL bacteria b. Cloudy, yellow; WBC >5/hpf; pH 8.2; numerous casts c. Cloudy, brown; ammonia odor; specific gravity 1.030; RBC 3/hpf d. Clear; colorless; glucose: trace; ketones: trace; osmolality 500 mOsm/kg (500 mmol/kg)
b. Cloudiness in a fresh urine specimen, WBC count above 5 per high-power field (hpf), and the presence of casts are all indicative of urinary tract infection (UTI). The pH is usually elevated because bacteria in urine split the urea alkaline ammonia. Cloudy, brown urine usually indicates hematuria or the presence of bile. Colorless urine is usually very dilute. Option a is characteristic of normal urine.
The male patient is admitted with a diagnosis of benign prostatic hyperplasia (BPH). What urination characteristics should the nurse expect to assess in this patient? a. Oliguria b. Hesitancy c. Hematuria d. Pneumaturia
b. Hesitancy is difficulty starting the urine stream and is common with benign prostatic hyperplasia (BPH). Oliguria is scanty urine formation and output. Hematuria is blood in the urine. Pneumaturia is urine containing gas, as is caused by a fistula between the bowel and bladder.
A client presents to the emergency room with a history of Graves' disease. The client reports having symptoms for a few days, but has not previously sought or received any additional treatment. The client also reports having had a cold a few days back. Which of the following interventions would be appropriate to implement for this client, based on the history and current symptoms? Select all that apply. a. Administer aspirin b. Replace intravenous fluids c. Induce shivering d. Relieve respiratory distress e. Administer a cooling blanket
b. Replace intravenous fluids c. Induce shivering d. Relieve respiratory distress e. Administer a cooling blanket Rationale: Thyroid storm (also called thyroid crisis) is an extreme state of hyperthyroidism that is rare today because of improved diagnosis and treatment methods (Porth, 2005). When it does occur, those affected are usually people with untreated hyperthyroidism (most often Graves' disease) and people with hyperthyroidism who have experienced a stressor, such as an infection, trauma. The rapid increase in metabolic rate that results from the excessive TH causes the manifestations of thyroid storm. The manifestations include hyperthermia, with body temperatures ranging from 102°F (39°C) to 106°F (41°C); tachycardia; systolic hypertension; and gastrointestinal symptoms (abdominal pain, vomiting, diarrhea). Agitation, restlessness, and tremors are common, progressing to confusion, psychosis, delirium, and seizures. The mortality rate is high. Rapid treatment of thyroid storm is essential to preserve life. Treatment includes cooling without aspirin (which increases free TH) or inducing shivering, replacing fluids, glucose, and electrolytes, relieving respiratory distress, stabilizing cardiovascular function, and reducing TH synthesis and secretion. #1 is incorrect because cooling happens without the use of aspirin. All of the other choices are correct.
Which action by a new registered nurse (RN) caring for a patient with a goiter and possible hyperthyroidism indicates that the charge nurse needs to do more teaching? a. The RN checks the blood pressure on both arms. b. The RN palpates the neck thoroughly to check thyroid size. c. The RN lowers the thermostat to decrease the temperature in the room. d. The RN orders nonmedicated eye drops to lubricate the patient's bulging eyes.
b. The RN palpates the neck thoroughly to check thyroid size.
The nurse is caring for a 45-year-old male patient during a water deprivation test. Which finding is most important for the nurse to communicate to the health care provider? a. The patient complains of intense thirst. b. The patient has a 5-lb (2.3 kg) weight loss. c. The patient's urine osmolality does not increase. d. The patient feels dizzy when sitting on the edge of the bed.
b. The patient has a 5-lb (2.3 kg) weight loss.
Which volume of urine in the bladder would cause discomfort and require urinary catheterization? a. 250 mL b. 500 mL c. 1200 mL d. 1500 mL
b. When the amount of urine in the bladder has reached 1200 mL, the person would need relief and probably catheterization. The bladder capacity ranges from 600 to1000 mL. When there is 250 mL of urine in the bladder, the person will usually feel the urge to urinate and 400 to 600 mL will be uncomfortable.
During the physical examination of a 36-year-old female, the nurse finds that the patient's thyroid gland cannot be palpated. The most appropriate action by the nurse is to a. palpate the patient's neck more deeply. b. document that the thyroid was nonpalpable. c. notify the health care provider immediately. d. teach the patient about thyroid hormone testing.
b. document that the thyroid was nonpalpable.
A nurse will teach a patient who is scheduled to complete a 24-hour urine collection for 17-ketosteroids to a. insert and maintain a retention catheter. b. keep the specimen refrigerated or on ice. c. drink at least 3 L of fluid during the 24 hours. d. void and save that specimen to start the collection.
b. keep the specimen refrigerated or on ice.
the nurse is caring for a pt who had an open cholecystectomy 24 hrs ago. which of the follwing actions should the nurse take to assist the pt to maintain an effective breathing pattern? select all that apply a. place in a supine position b. provide analgesics for pain c. encourage coughing and deep breathing d. monitor bowel sounds e. assist with splinting during coughing f. maintain bedrest for 48 hrs after
bce: pain relief allows comfortable breathing, preventing shallow respiration's and guarding, splinting makes coughing more comfortable, encouraging coughing and deep breathing to keep lung clear
Which assessment of a 62-year-old patient who has just had an intravenous pyelogram (IVP) requires immediate action by the nurse? a. The heart rate is 58 beats/minute. b. The patient complains of a dry mouth. c. The respiratory rate is 38 breaths/minute. d. The urine output is 400 mL after 2 hours.
c
A patient passing bloody urine is scheduled for a cystoscopy with cystogram. Which description of the procedure by the nurse is accurate? a. "Your doctor will place a catheter into an artery in your groin and inject a dye that will visualize the blood supply to the kidneys." b. "Your doctor will insert a lighted tube into the bladder, and little catheters will be inserted through the tube into your kidney." c. "Your doctor will insert a lighted tube into the bladder through your urethra, inspect the bladder, and instill a dye that will outline your bladder on x-ray." d. "Your doctor will inject a radioactive solution into a vein in your arm and the distribution of the isotope in your kidneys and bladder will be checked."
c In a cystoscope and cystogram procedure, a cystoscope is inserted into the bladder for direct visualization, and then contrast solution is injected through the scope so that x-rays can be taken.
A male patient in the clinic provides a urine sample that is red-orange in color. Which action should the nurse take first? a. Notify the patient's health care provider. b. Teach correct midstream urine collection. c. Ask the patient about current medications. d. Question the patient about urinary tract infection (UTI) risk factors.
c A red-orange color in the urine is normal with some over-the-counter (OTC) medications such as phenazopyridine (Pyridium).
A hospitalized patient with possible renal insufficiency after coronary artery bypass surgery is scheduled for a creatinine clearance test. Which equipment will the nurse need to obtain? a. Urinary catheter b. Cleaning towelettes c. Large container for urine d. Sterile urine specimen cup
c Because creatinine clearance testing involves a 24-hour urine specimen, the nurse should obtain a large container for the urine collection
A patient with pancreatic cancer is admitted to the hospital for evaluation of possible treatment options. The patient asks the nurse to explain the Whipple procedure that the surgeon has described. The explanation includes the information that a Whipple procedure involves a. creating a bypass around the obstruction caused by the tumor by joining the gallbladder to the jejunum. b. resection of the entire pancreas and the distal portion of the stomach, with anastomosis of the common bile duct and the stomach into the duodenum. c. removal of part of the pancreas, part of the stomach, the duodenum, and the gallbladder, with joining of the pancreatic duct, the common bile duct, and the stomach into the jejunum. d. radical removal of the pancreas, the duodenum, and the spleen, and attachment of the stomach to the jejunum, which requires oral supplementation of pancreatic digestive enzymes and insulin replacement therapy.
c Rationale: The classic operation for pancreatic cancer is a radical pancreaticoduodenectomy, or Whipple procedure. This entails resection of the proximal pancreas (i.e., proximal pancreatectomy), the adjoining duodenum (i.e., duodenectomy), the distal portion of the stomach (i.e., partial gastrectomy), and the distal segment of the common bile duct. The pancreatic duct, common bile duct, and stomach are anastomosed to the jejunum.
Which information from a patient's urinalysis requires that the nurse notify the health care provider? a. pH 6.2 b. Trace protein c. WBC 20 to 26/hpf d. Specific gravity 1.021
c The increased number of white blood cells (WBCs) indicates the presence of urinary tract infection or inflammation
Following teaching about medications for PAD, the nurse determines that additional instruction is necessary when the patient says, a) I should take one ASA a day to prevent clotting in my legs b) The lisinipril (Zestril) I use for my BP may help me walk further without pain c) I will need to have frequent blood tests to evaluate the effect of the oral anticoagulant I will be taking. d) Pletal should help me be able to increase my walking distance and keep clots from forming in my legs
c) I will need to have frequent blood tests to evaluate the effect of the oral anticoagulant I will be taking.
When a patient's urine dipstick test indicates a small amount of protein, the nurse's next action should be to a. send a urine specimen to the laboratory to test for ketones. b. obtain a clean-catch urine for culture and sensitivity testing. c. inquire about which medications the patient is currently taking. d. ask the patient about any family history of chronic renal failure.
c- some medications may give false-positive readings.
A 29-year-old patient in the outpatient clinic will be scheduled for blood cortisol testing. Which instruction will the nurse provide? a. "Avoid adding any salt to your foods for 24 hours before the test." b. "You will need to lie down for 30 minutes before the blood is drawn." c. "Come to the laboratory to have the blood drawn early in the morning." d. "Do not have anything to eat or drink before the blood test is obtained."
c. "Come to the laboratory to have the blood drawn early in the morning."
Which question will provide the most useful information to a nurse who is interviewing a patient about a possible thyroid disorder? a. "What methods do you use to help cope with stress?" b. "Have you experienced any blurring or double vision?" c. "Have you had a recent unplanned weight gain or loss?" d. "Do you have to get up at night to empty your bladder?"
c. "Have you had a recent unplanned weight gain or loss?"
Which diagnostic study would include assessing for iodine sensitivity, teaching the patient to take a cathartic the night before the procedure, and telling the patient that a salty taste may occur during the procedure? a. Cystometrogram b. Renal arteriogram c. Intravenous pyelogram (IVP) d. Kidneys, ureters, bladder (KUB)
c. A cathartic the evening before the procedure and sensitivity to iodine are important for both intravenous pyelogram (IVP) and renal arteriogram but the salty taste is only a possibility with IVP. The cystometrogram involves filling the bladder with water or saline to measure tone and stability. The kidneys, ureters, and bladder (KUB) is an x-ray that may have bowel preparation.
The bone cells that function in the resorption of bone tissue are called a.osteoids b.osteocytes c.osteoclasts d.osteoblasts
c.osteoclasts Osteoclasts participate in bone remodeling by assisting in the breakdown of bone tissue.
The mother of an 8-year-old girl has brought her child to the clinic because she is wetting the bed at night. What terminology should the nurse use when documenting this situation? a. Ascites b. Dysuria c. Enuresis d. Urgency
c. Enuresis is involuntary urination at night. Ascites is excess fluid in the intraperitoneal cavity. Dysuria is painful urination. Urgency is the feeling of needing to void immediately.
The nurse is teaching the patient with hyperthyroidism the importance of stress management. She is teaching how to do deep breathing exercises and listens to the patient's thoughts on coping mechanism and spirituality. The nurse knows this is an important part of this patients plan because: a) Knowing how to cope with stress will help this patient be able to work through some of the difficult treatments of this disease b) Every patient needs to know how to cope with stress c) Extra stress with the patient with hyperthyroidism can lead to life threatening complications d) Listening to the patients thoughts instead of imposing one's own thoughts encourages the patient to become self-reliant
c. Extra stress on the patient with hyperthyroidism can precipitate a life-threatening condition known as thyroid storm. It is important for the nurse to explain procedures to lower patient anxiety to prevent this condition.
Which statement accurately describes glomerular filtration rate (GFR)? a. The primary function of GFR is to excrete nitrogenous waste products. b. Decreased permeability in the glomerulus causes loss of proteins into the urine. c. The GFR is primarily dependent on adequate blood flow and adequate hydrostatic pressure. d. The GFR is decreased with prostaglandins cause vasodilation and increased renal blood flow.
c. GFR is primarily dependent on adequate blood flow and hydrostatic pressure. The glomerulus filters the blood. The GFR is the amount of blood filtered each minute by the glomeruli, which determines the concentration of urea in the blood. Increased permeability in the glomerulus causes loss of proteins in the urine. The prostaglandins increase the GFR with increased renal blood flow.
Which of the following nursing implications is most important in a client being medicated for Addison's disease? a. Administer oral forms of the drug with food to minimize its ulcerogenic effect. b. Monitor capillary blood glucose for hypoglycemia in the diabetic client. c. Instruct the client to never abruptly discontinue the medication. d. Teach the client to consume a diet that is high in potassium, low in sodium, and high in protein.
c. Instruct the client to never abruptly discontinue the medication. Rationale: The primary medical treatment of Addison's disease is replacement of corticosteroids and mineralcorticoids, accompanied by increased sodium in the diet. The client needs to know the importance of maintaining a diet high is sodium and low in potassium. Medications should never be discontinued abruptly because crisis can ensue. Oral forms of the drug are given with food in Cushing's disease.
A 44-year-old patient is admitted with tetany. Which laboratory value should the nurse monitor? a. Total protein b. Blood glucose c. Ionized calcium d. Serum phosphate
c. Ionized calcium
What is a factor that contributes to an increased incidence of urinary tract infections in aging women? a. Length of the urethra b. Larger capacity of bladder c. Relaxation of pelvic floor and bladder muscles d. Tight muscular support at the urinary sphincter
c. Relaxation of female urethra, bladder, vagina, and pelvic floor muscles may contribute to stress and urge incontinence and urinary tract infections. The short urethra of women allows easier ascension and colonization of bacteria in the bladder than occurs in men and the urethra does not lengthen with age. The bladder capacity of men and women is the same but decreases with aging.
What accurately describes a normal physical assessment of the urinary system by the nurse? a. Auscultates the lower abdominal quadrants for fluid sounds b. Palpates an empty bladder at the level of the symphysis pubis c. Percusses the kidney with a firm blow at the posterior costovertebral angle d. Positions the patient prone to palpate the kidneys with a posterior approach
c. To assess for kidney tenderness, the nurse strikes the fist of one hand over the dorsum of the other hand at the posterior costovertebral angle. The upper abdominal quadrants and costovertebral angles are auscultated for vascular bruits in the renal vessels and aorta and an empty bladder is not palpable. The kidneys are palpated through the abdomen, with the patient supine.
The nurse will teach a patient to plan to minimize physical and emotional stress while the patient is undergoing a. a water deprivation test. b. testing for serum T3 and T4 levels. c. a 24-hour urine test for free cortisol. d. a radioactive iodine (I-131) uptake test.
c. a 24-hour urine test for free cortisol.
A nurse is caring for a client with Addison's disease. Which of the following nursing considerations should be employed when caring for this client? a. avoid sodium in the clients diet b. monitor and protect skin integrity c. document the specific gravity of urine d. monitor increases in blood pressure
c. document the specific gravity of urine
A 60-year-old patient is taking spironolactone (Aldactone), a drug that blocks the action of aldosterone on the kidney, for hypertension. The nurse will monitor for a. increased serum sodium. b. decreased urinary output. c. elevated serum potassium. d. evidence of fluid overload.
c. elevated serum potassium.
Which of the following would be a nursing priority for a client just DX with Addison's disease? a. avioding unnecessary activity b. encouraging client to wear a med alert tag c. ensuring the client is adequatly hydrated d. explaining that the client will need life long hormone therapy
c. ensuring the client is adequatly hydrated
While obtaining subjective assessment data related to the musculoskeletal system, it is particularly important to ask a patient about other medical problems such as a.hypertension. b.thyroid problems. c.diabetes mellitus. d.chronic bronchitis.
c.diabetes mellitus The nurse should question the patient about past medical problems because certain illnesses are known to affect the musculoskeletal system directly or indirectly. These diseases include tuberculosis, poliomyelitis, diabetes mellitus, parathyroid problems, hemophilia, rickets, soft tissue infection, and neuromuscular disabilities.
the nurse is collecting data for a pt who develops jaundice and dark, amber colored urine. the nurse recognizes that which of the following is most likely the cause? a. encephalopathy b. pancreatitis c. bile duct obstruction d. cholecystitis
c: bile duct obstruction can result in jaundice and dark aber colored urine due to bile blockage
which clinical manifestations of acute hepatitis A would the nurse expect a pt. to report?
c: headache, nausea, and flu like symptoms are symptoms of hepatitis A
the nurse is caring for a pt with cirrhosis. the nurse would cautiously use sedatives for the pt based on which of the following? a. the livers ability to synthesize protein is altered. b. sedatives may increase the risk of jaundice c. sedatives are potentially toxic to the cirrhosis pt d. sedatives promote the conversion of ammonia to ammonium ion
c: sedatives are potentially toxic to the cirrhosis pt. due to impaired hepatic metabolism of these meds
Identify at least one observation made by the nurse that would indicate the presence of the following complications of aortic aneurysm repair. b. Myocardial ischemia
cardiac dysrhythmias, chest pain
A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to:
carefully move him to a flat surface and turn him on his side.
a client is recovering from a gastrectomy. the nurse will have to administer medication through a nasogastric tube. prior to giving the medications, the nurse will: 1. irrigate the tube with saline 2. reposition the tube and reapply the tube 3. check the tube for placement 4. insert the tube 1 inch further
check the tube for placement: most institutions require a radiograph to check for placement
which gastrointestinal assessment data should the nurse expect to find when assessing the client in end stage liver failure? 1. hypoalbuminemia and muscle wasting 2. oligomenorrhea and decreased body hair 3. clay colored stools and hemorrhoids 4. dyspnea and caput medusae
clay colored stools and hemorrhoids: clay colored stools and hemorrhoids are gastrointestinal effects of liver failure
the female nurse sticks herself with a contaminated needle. which action should the nurse implement first. 1. notify the infection control nurse 2. cleanse the area with soap and water 3. request postexposure prophylaxis 4. check the hepatitis status of the client
cleanse the area with soap and water: the nurse should first clean the needle stick with soap and water and attempt stick bleed to help remove any virus injected into the skin
The client asks the nurse, "How does ergotamine (Ergostat) relieve migraine headaches?" The nurse should respond that it:
constricts cerebral blood vessels.
To assess whether there is any improvement in a patient's dysuria, which question will the nurse ask? a. "Do you have to urinate at night?" b. "Do you have blood in your urine?" c. "Do you have to urinate frequently?" d. "Do you have pain when you urinate?"
d
When working in the urology/nephrology clinic, which patient could the nurse delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Patient who is scheduled for a renal biopsy after a recent kidney transplant b. Patient who will need monitoring for several hours after a renal arteriogram c. Patient who requires teaching about possible post-cystoscopy complications d. Patient who will have catheterization to check for residual urine after voiding
d
Which statement by a patient who had a cystoscopy the previous day should be reported immediately to the health care provider? a. "My urine looks pink." b. "My IV site is bruised." c. "My sleep was restless." d. "My temperature is 101."
d
Which nursing action is essential for a patient immediately after a renal biopsy? a. Check blood glucose to assess for hyperglycemia or hypoglycemia. b. Insert a urinary catheter and test urine for gross or microscopic hematuria. c. Monitor the blood urea nitrogen (BUN) and creatinine to assess renal function. d. Apply a pressure dressing and keep the patient on the affected side for 30 minutes.
d A pressure dressing is applied and the patient is kept on the affected side for 30 to 60 minutes to put pressure on the biopsy side and decrease the risk for bleeding.
A 32-year-old patient who is employed as a hairdresser and has a 15 pack-year history of cigarette smoking is scheduled for an annual physical examination. The nurse will plan to teach the patient about the increased risk for a. renal failure. b. kidney stones. c. pyelonephritis. d. bladder cancer.
d Exposure to the chemicals involved with working as a hairdresser and in smoking both increase the risk of bladder cancer
The nursing management of the patient with cholecystitis associated with cholelithiasis is based on the knowledge that a. shock-wave therapy should be tried initially. b. once gallstones are removed, they tend not to recur. c. the disorder can be successfully treated with oral bile salts that dissolve gallstones. d. laparoscopic cholecystectomy is the treatment of choice in most patients who are symptomatic.
d Rationale: Laparoscopic cholecystectomy is the treatment of choice for symptomatic cholelithiasis.
When obtaining a health history from a 72 year old man with peripheral arterial disease (PAD) of the lower extremities, the nurse asks about a history of related conditions such as... a) Venous thrombosis b) Venous stasis ulcers c) Pulmonary embolism d) Carotid artery disease
d) Carotid artery disease, Regardless of the location, atherosclerosis is responsible for peripheral arterial disease and is related to other cardiovascular disease and its risk factors.
Following discharge teaching with a male patient with an AAA repair, the nurse determines that further instruction is needed when the patient says, a) I should avoid heavy lifting b) I may have some permanent sexual dysfunction as a result of the surgery c) I should maintain a low-fat and low-cholesterol diet to help keep the new graft open d) I should take the pulses in my extremities and let the doctor know if they get too fast or too slow.
d) I should take the pulses in my extremities and let the doctor know if they get too fast or too slow.
A Clinical Instructor is questioning a student nurse about disorders of the parathyroid glands. Which statement by the nursing student, would indicate the need for further teaching? a. "Hyperparathyroidism results in an increased release of calcium and phosphorus by bones, with resultant bone decalcification." b. "Hyperparathyroidism results in deposits in soft tissues and the formation of renal calculi." c. "Hypoparathyroidism results in impaired renal tubular regulation of calcium and phosphate." d. "Hypoparathyroidism results in decreased activation of vitamin D which then results in decreased absorption of calcium by the pancreas."
d. "Hypoparathyroidism results in decreased activation of vitamin D which then results in decreased absorption of calcium by the pancreas." Rationale: Choices 1, 2, and 3 are all correct statements. # 4 demonstrates a need for further teaching because hypoparathyroidism results in decreased activation of vitamin D which then results in decreased absorption of calcium by the intestines, not the pancreas.
Which statement by a 50-year-old female patient indicates to the nurse that further assessment of thyroid function may be necessary? a. "I notice my breasts are tender lately." b. "I am so thirsty that I drink all day long." c. "I get up several times at night to urinate." d. "I feel a lump in my throat when I swallow."
d. "I feel a lump in my throat when I swallow."
An 18-year-old male patient with a small stature is scheduled for a growth hormone stimulation test. In preparation for the test, the nurse will obtain a. ice in a basin. b. glargine insulin. c. a cardiac monitor. d. 50% dextrose solution.
d. 50% dextrose solution.
A nurse on a surgical floor is caring for a post-operative client who has just had a subtotal thyroidectomy. Which of the following assessments should be completed first on the client? a. Assess for signs of tetany by checking for Chvostek's and Trousseau's signs b. Assess dressing (if present) and the area under the client's neck and shoulders for drainage. c. Administer analgesic pain medications as ordered, and monitor their effectiveness. d. Assess respiratory rate, rhythm, depth, and effort.
d. Assess respiratory rate, rhythm, depth, and effort. Rationale: All of the above assessments have importance, but airway and breathing in a client should always be addressed first when prioritizing care. Assess for signs of latent tetany due to calcium deficiency, including tingling of toes, fingers, and lips; muscular twitches; positive Chvostek's and Trousseau's signs; and decreased serum calcium levels. However, tetany may occur in 1 to 7 days after thyroidectomy so # 1 is not the highest priority. Assessing for hemorrhage is always important, but the danger of hemorrhage is greatest in the first 12 to 24 hours after surgery, and as this client is immediately post operative it is not the main concern at this time. Pain medication is important but according to Maslow, pain is a psychosocial need to be addressed after a physiologic need.
A 78-year-old man asks the nurse why he has to urinate so much at night. The nurse should explain to the patient that as an older adult, what may contribute to his nocturia? a. Decreased renal mass b. Decreased detrusor muscle tone c. Decreased ability to conserve sodium d. Decreased ability to concentrate urine
d. Decreased renal blood flow and altered hormone levels result in a decreased ability to concentrate urine that results in an increased volume of dilute urine, which does not maintain the usual diurnal elimination pattern. A decrease in bladder capacity also contributes to nocturia but decreased bladder muscle tone results in urinary retention. Decreased renal mass decreases renal reserve but function is generally adequate under normal circumstances.
Priority Decision: After a patient had a renal arteriogram and is back on the clinical unit, what is the most important action by the nurse? a. Observe for gross bleeding in the urine. b. Place the patient in high Fowler's position. c. Monitor the patient for signs of allergy to the contrast medium. d. Assess peripheral pulses in the involved leg every 30 to 60 minutes.
d. During a renal arteriogram, a catheter is inserted, most commonly at the femoral artery. Following the procedure the patient is positioned with the affected leg extended with a pressure dressing applied. Peripheral pulse monitoring is essential to detect the development of thrombi around the insertion site, which may occlude blood supply to the leg. Gross bleeding in the urine is a complication of a renal biopsy. Allergy to the contrast medium should be established before the procedure.
A nurse is caring for a 60 yr old client affected with hypoparathyroidism. When checking the lab report, the nurse finds that the clients calcium level was very low. Which of the following vitamins regulates the calcium level in the body? a. A b. D c. E d. K
d. K
The patient complains of "wetting when she sneezes." How should the nurse document this information? a. Nocturia b. Micturition c. Urge incontinence d. Stress incontinence
d. Stress incontinence is involuntary urination with increased pressure when sneezing or coughing and is seen with weakness of sphincter control. Nocturia is frequent urination at night. Micturition is the evacuation of urine. Urge incontinence is involuntary urination is preceded by urinary urgency.
When grading muscle strength, the nurse records a score of 3, which indicates a.no detection of muscular contraction. b.a barely detectable flicker of contraction. c.active movement against full resistance without fatigue. d.active movement against gravity but not against resistance.
d. active movement against gravity but not against resistance Muscle strength score of 3 indicates active movement only against gravity and not against resistance
A 61-year-old female patient admitted with pneumonia has a total serum calcium level of 13.3 mg/dL (3.3 mmol/L). The nurse will anticipate the need to teach the patient about testing for _____ levels. a. calcitonin b. catecholamine c. thyroid hormone d. parathyroid hormone
d. parathyroid hormone
To prevent muscle atrophy, the nurse teaches the patient with a leg immobilized in traction to perform (select all that apply) a.flexion contractions. b.tetanic contractions. c.isotonic contractions. d.isometric contractions. e.extension contractions.
d.isometric contractions Isometric contractions increase the tension within a muscle but do not produce movement. Repeated isometric contractions make muscles grow larger and stronger. Muscular atrophy (i.e., decrease in size) occurs with the absence of contraction that results from immobility.
a pt with acute pacreatitis is NPO and has been receiving on IV hydration. which laboratory result indicates the need to consult the dietitian for nutritional support? a. potassium 4.2 mEq/L b. sodium 130 mEq/L c. fasting glucose 82 mg/dL d. serum albumin 2.9g/dL
d: low serum albumin level indicates malnutrition (normal albumin levels are 3.5-5.
the nurse is caring for a pt with chronic pancreatitis, the nurse would expect an elevation in which of the following lab tests? a. serum bilirubin b. serum calcium c. serum albumin d. serum amylase
d: the serum amylase level is elevated in chronic pancreatitis
Identify the factor of Virchow's triad present in each of the following conditions associated with venous thromboembolism (VTE). a) IV therapy
damage to the endothelium
The nurse is teaching a client who has facial muscle weakness and has recently been diagnosed with myasthenia gravis. The nurse should teach the client that myasthenia gravis is caused by:
destruction of acetylcholine receptors.
After a 25-year-old patient has returned home following rehabilitation for a spinal cord injury, the home care nurse notes that the spouse is performing many of the activities that the patient had been managing during rehabilitation. The most appropriate action by the nurse at this time is to _____________
develop a plan to increase the patient's independence in consultation with the patient and the spouse. rational: The best action by the nurse will be to involve all the parties in developing an optimal plan of care. Because family members who will be assisting with the patient's ongoing care need to feel that their input is important, telling the spouse that the patient can perform activities independently is not the best choice. Reminding the patient about the importance of independence may not change the behaviors of the spouse. Supporting the activities of the spouse will lead to ongoing dependency by the patient.
A patient who is seen in the outpatient clinic complains of restless legs syndrome. Which of the following over-the-counter medications that the patient is taking routinely should the nurse discuss with the patient?
diphenhydramine (Benadryl) rational: Antihistamines can aggravate restless legs syndrome. The other medications will not contribute to the restless legs syndrome.
the public health nurse is discussing hep B with a group in the community. which health promotion activities should the nurse discuss with the group? Select all that apply 1. do not share needles or equipment 2. use barrier protection during sex 3. get the hep B vaccine 4. obtain immune globulin injections 5. avoid any type of hepatotoxic medication
do not share needles or equipment, use barrier protection during sex, get the hep B vaccine: hep B can be transmitted by sharing any type of needles, especially those used by drug abusers. hep B can be transmitted thru sexual activity, therefore, the nurse should recommend abstinence, mutual monogamy, or barrier protection. three doses of hep B vaccine provide immunity in 90% of healthy adults
A nurse is providing education to a patient with a history of renal caliculi. What should the nurse include?
drink enough fluids in 24 hours to produce 2 quarts of urine
Objectives of Healthy People 2020 is to reduce the rate of new cases of ESRD. What activities are recommended to achieve this?
early identification of people at risk, control of diabetes and hypertension, education related to diet and exercise
what are effective mechanisms to prevent and control the spread of hep A in any setting? select all that apply 1. education 2. hand washing 3. avoidance of illicit drug use 4. immunizations for hep B virus 5. drink the water while visiting other countries 6. do not drink water while visiting other countries
education, hand washing, do not drink water while visiting other countries: education of children and parents is imp. hand washing is an effective method of prevention. refrain from drinking water while visiting other countries
A client is suspected of having amyotrophic lateral sclerosis (ALS). To help confirm this disorder, the nurse prepares the client for various diagnostic tests. The nurse expects the physician to order:
electromyography (EMG).
When caring for a client with the nursing diagnosis Impaired swallowing related to neuromuscular impairment, the nurse should:
elevate the head of the bed 90 degrees during meals.
expected finding for a patient with primary cushing's disease
elevated blood glucose
which instruction should the nurse discuss with the client who is in the icteric phase of hep C? 1. decrease alcohol intake 2. encourage rest periods 3. eat a large evening meal 4. drink diet drinks and juices
encourage rest periods: adequate rest is needed for maintaining optimal immune function
Repair of an aortic aneurysm by placing an aortic graft inside the aneurysm through the femoral artery is called the _______ _______.
endovascular graft
result of excessive secretion of ADH
excessive retention of water and dilutional hyponatremia
Where should the nurse place their stethoscope to assess the renal arteries for the presence of bruits?
extended midclavicular line
hyponatremia, as serum sodium drops
extra water enters body cells and causes them to swell. Convulsions, shock, coma and death may occur with cerebral edema and increased brain cell volume.
Addison's disease (primary insufficiency) of the adrenal gland results from
failure to produce adequate levels of cortisol and aldosterone
A patient with a T1 spinal cord injury is admitted to the intensive care unit. The nurse will teach the patient and family that ______________
full function of the patient's arms will be retained. rational: The patient with a T1 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with cervical spine injury. Loss of respiratory function occurs with cervical spine injuries. Bradycardia is associated with injuries above the T6 level.
In discussion with the patient with ESRD about dietary needs, the nurse recognies that foods highest in potassium include:
grapefruit, tomatoes, oranges, and bananas.
expected finding in new diagnosis of cushing's disease
hirsutism due to increased androgen production
hyperparathyroidism is associated with
hypercalcemia
c) estrogen therapy
hypercoagulability
e) Smoking
hypercoagulability
a client has been given a dx of acute pancreatitis. the nurse will assess this client for: 1. hyperkalemia 2. metabolic acidosis 3. hypocalcemia 4. hyperglycemia
hyperglycemia: or hypoglycemia could occur if damage is done to the islets of langerhans
two days after her cholecystectomy, a client has been experiencing nausea and vomiting. the client has a t tube in place. for what electrolyte imbalance will the nurse monitor? 1. hypernatremia 2. hyperkalemia 3. hypervolemia 4. hypokalemia
hypokalemia: gastric secretions are high in postassium
With SIADH, hypersecretion of ADH causes
hyponatremia
a nurse is doing preop teaching for a client who will have a cholecystectomy. the nurse teaches that special care must be taken to prevent what postop complication? 1. hypostatic pneumonia 2. thrombosis 3. hemorrhage 4. paralytic ileus
hypostatic pneumonia: the incision is located below the ribcage; therefore the coughing and deep breathing necessary to prevent pneumonia are especially difficult post op
A patient with a neck fracture at the C5 level is admitted to the intensive care unit. During initial assessment of the patient, the nurse recognizes the presence of neurogenic shock on finding ________________
hypotension, bradycardia, and warm extremities. rational: Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of spinal cord injury. Lack of movement and sensation indicate spinal cord injury, but not neurogenic shock.
Central diabetes insipidus may be caused by damage to the
hypothalamus (or pituitary gland).
the client is admitted with end stage liver failure and is prescribed the laxative lactulose (chronulac). which statement indicates the client needs more teaching concerning this med? 1. i should have two to three soft stools a day 2. i must check my ammonia level daily 3. if i have diarrhea, i will call my dr 4. i should check my stool for any blood
i must check my ammonia level daily: there is no instrument used at home to test daily ammonia levels. the ammonia level is a serum level requiring venipuncture and laboratory diagnostic equipment
the client dx with acute pancreatitis is being discharged home. which statement by the client indicates the teaching has been effective? 1. i should decrease my intake of coffee, tea, and cola 2. i will eat a low fat diet and avoid spicy foods 3. i will check my amylase and lipase levels daily 4. i will return to work tomorrow but take it easy
i will eat a low fat diet and avoid spicy foods: high fat and spicy foods stimulate gastric and pancreatic secretions and may precipitate an acute pancreatic attack
A synthetic bifurcation graft is used in aneurysm repair when an AAA extends into the ________ arteries.
iliac
A patient with a dissection of the arch of the aorta has a decreased LOC and weak carotid pulses. The nurse anticipates that initial treatment of the patient will include...
immediate surgery to replace the torn area with a graft.
When obtaining a health history and physical assessment for a patient with possible multiple sclerosis (MS), the nurse should _____________
inquire about any urinary tract problems. rational: Urinary tract problems with incontinence or retention are common symptoms of MS. Chest pain and skin rashes are not symptoms of MS. A decrease in libido is common with MS.
The classic ischemic pain of PAD is known as _______ _________.
intermittent claudication
When admitting a patient who has a tumor of the right frontal lobe, the nurse would expect to find __________
judgment changes rational: The frontal lobes control intellectual activities such as judgment. Speech is controlled in the parietal lobe. Weakness and hemiplegia occur on the contralateral side from the tumor. Swallowing is controlled by the brainstem.
a 38 y/o client has chronic cirrhosis and is jaundiced. to decrease pruritus from the jaundice, the nurse would: 1. use wool blankets 2. keep room temp above 75.8 3. keep the room temp below 70.8 4. use lots of soap in the bathwater
keep the room temp below 70.8: a decrease in sweating decreases pruritus
The nurse is working on a surgical floor. The nurse must logroll a client following a:
laminectomy.
for patient using a thermometer to test bathwater due to diabetic neuropathy, the temp should be
less than 43.3 C or 110 F
a 48 y/o client has a dx of dumping syndrome after gastric surgery. it would be most imp for the client to: 1. drink concentrated carbohydrates such as milkshakes between meals 2. lie down after meals 3. eat large well balanced meals 4. drink fluids with meals
lie down after meals: to decrease the effect of gravity
a client has had gallbladder attacks in the past and is considered at risk for gallstone formation. the nurse should check that the clients diet is: 1. high in antacids and calcium 2. low in cholesterol 3. high in protein and carbohydrates 4. free of electrolytes
low in cholesterol: biliary calculi are high in cholesterol, therefore the cholesterol intake of the client should be limited
which of the following conditions most places a pt. with cirrhosis at risk for bleeding? a. encephalopathy b. low vitamin K c. elevated liver enzymes d. hepatorenal syndrome
low vitamin K: vitamin k is needed for blood clotting, so a low level increases the risk of bleeding
A client is admitted to the emergency department and they diagnose of myxedema coma is made. What nursing action with the nurse prepared to carry out initially
maintain a patent airway
When teaching the patient with peripheral artery disease about modifying risk factors associated with the condition, the nurse emphasizes that...
modifications will reduce the risk of other atherosclerotic conditions such as stroke
the client with an acute exacerbation of chronic pancreatitis has a nasogastric tube. which interventions should the nurse implement? select all that apply 1. monitor the clients bowel sounds 2. monitor the clients food intake 3. assess the clients intravenous site 4. provide oral and nasal care 5. monitor the clients blood glucose
monitor the clients bowel sounds, assess the clients intravenous site, provide oral and nasal care, provide oral and nasal care, monitor the clients blood glucose: the return of bowel sounds indicates the return of peristalsis, and the nasogastric suction is usually discontinued within 24 to 48 hrs thereafter. the nurse should assess for signs of infection or infiltration. fasting and the ng tube increase the clients risk for mucous membrane irritation and brk dwn. blood glucose levels are monitored because clients with chronic pancreatitis can develop diabetes mellitus
the nurse is discussing complications of chronic pancreatitis with a client dx with the disease. which complication should the nurse discuss with the client? 1. diabetes insipudus 2. crohns disease 3. narcotic addiction 4. peritonitis
narcotic addiction: its related to the frequent, severe pain episodes often occurring with chronic pancreatitis which require narcotics for relief
The nurse expects that management of the patient who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects will include ______________
oral administration of low dose aspirin therapy. rational: The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA.
the nurse is preparing to administer am medications to clients. which medication should the nurse question before administering? 1. pancreatic enzymes to the client who has finished breakfast 2. the pain medication, morphine, to the client who has a respiratory rate of 20 3. the loop diuretic to the client who has a serum potassium level of 3.9 mEq/L 4. the beta blocker to the client who has an apical pulse of 68
pancreatic enzymes to the client who has finished breakfast: pancreatic enzymes must be administered with meals to enhance the digestion of starches and fats in the gastrointestinal tract
The client has had a liver biopsy. which postprocedure intervention should the nurse implement? 1. instruct the client to void immediatly 2. keep the client NPO for 8 hours 3. place the client on the right side 4. monitor BUN and creatinine level
place the client on the right side: direct pressure is applied to the site, and then the client is placed on the right side to maintain site pressure
When caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak cough effort and loose-sounding secretions, the initial intervention by the nurse should be to ____________
place the hands on the epigastric area and push upward when the patient coughs. rational: Since the cough effort is poor, the initial action should be to use assisted coughing techniques to improve the ability to mobilize secretions. Administration of oxygen will improve oxygenation, but the data do not indicate hypoxemia. The use of the spirometer may improve respiratory status, but the patient's ability to take deep breaths is limited by the loss of intercostal muscle function. Suctioning may be needed if the patient is unable to expel secretions by coughing but should not be the nurse's first action.
the nurse writes the problem "imbalanced nutrition: less than body requirements" for the client dx with hepatitis. which intervention should the nurse include in the plan of care/ 1. provide a high calorie intake diet 2. discuss tpn 3. instruct the client to decrease salt intake 4. encourage the client to increase water intake
provide a high calorie intake diet: sufficient energy is required for healing. adequate carbohydrate intake can spare protein. the client should eat approximately 16 carbohydrate kilocalories for ea kilogram of ideal body weight daily
When evaluating a patient with trigeminal neuralgia who has had a glycerol rhizotomy, the nurse will ______________
question the patient about social activities with family and friends. rational: Because withdrawal from social activities is a common manifestation of trigeminal neuralgia, asking about social activities will help in evaluating whether the patient's symptoms have improved. Glycerol rhizotomy does not damage the corneal reflex or motor functions of the trigeminal nerve, so there is no need to use an eye shield, do facial exercises, or take precautions with chewing.
A nurse is collecting data regarding a client after a thyroidectomy and notes that the client has developed hoarseness and a week voice. What nursing action is appropriate
reassure the client that is usually a temporary condition
the nurse is developing a plan of care for a client who has a dx of acute pancreatitis. the rationale for maintaining the client on bed rest is to: 1. reduce pancreatic and gastric secretions 2. minimize the effects of hypoglycemia 3. reduce the risk of DVT 4. decrease the likelihood of orthostatic hypotension
reduce pancreatic and gastric secretions: bed rest decreases body metabolism and thus reduces pancreatic and gastric secretions in the client with acute pancreatitis
the client dx with end stage liver failure is admitted with hepatic encephalopathy. which dietary restriction should be implemented by the nurse to address this complication? 1. restrict sodium intake to 2g a day 2. limit oral fluids to 1500ml a day 3. decrease the daily fat intake 4. reduce protein intake to 60 to 80g a day
reduced protein intake 60-80 g a day: ammonia is a by product of protein metabolism and contributes to hepatic encephalopathy. reducing protein intake should decrease ammonia levels
A patient with Bell's palsy refuses to eat while others are present because of embarrassment about drooling. The best response by the nurse to the patient's behavior is to _______________
respect the patient's desire and arrange for privacy at mealtimes. rational: The patient's desire for privacy should be respected to encourage adequate nutrition and reduce patient embarrassment. Liquid supplements will reduce the patient's enjoyment of the taste of food. It would be inappropriate for the nurse to discuss the patient's embarrassment with visitors unless the patient wishes to share this information. Chewing on the unaffected side of the mouth will enhance nutrition and enjoyment of food but will not decrease the drooling.
A patient with Bell's palsy refuses to eat while others are present because of embarrassment about drooling. The best response by the nurse to the patient's behavior is to _______________
respect the patient's desire and arrange for privacy at mealtimes. rational: The patient's desire for privacy should be respected to encourage adequate nutrition and reduce patient embarrassment. Liquid supplements will reduce the patient's enjoyment of the taste of food. It would be inappropriate for the nurse to discuss the patient's embarrassment with visitors unless the patient wishes to share this information. Chewing on the unaffected side of the mouth will enhance nutrition and enjoyment of food but will not decrease the drooling.
after a liver biopsy the nurse should place the client in which position? 1. right side 2. left side 3. high fowlers 4. trendelenburg
right side:when the client is placed on the right side, the biopsy site of the liver capsule is compressed against the chest wall, and the escape of blood or bile is impeded
A patient has a stroke affecting the right hemisphere of the brain. Based on knowledge of the effects of right brain damage, the nurse establishes a nursing diagnosis of _______________
risk for injury related to denial of deficits and impulsiveness. rational: Right-sided brain damage typically causes denial of any deficits and poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability.
the client is admitted to the medical dept. with a dx of r/o acute pancreatitis. which laboratory values should the nurse monitor to confirm this dx? 1. creatinine and BUN 2. troponin and CK-MB 3. serum amylase and lipase 4. serum bilirubin and calcium
serum amylase and lipase: serum amylase increases within 2 to 12 hrs of the onset of acute pancreatitis to 2 to 3 times normal and returns to normal in 3 to 4 days; lipase elevates and remains elevated for 7 to 14 days
the school nurse is discussing methods to prevent an outbreak of hepatitis A with a group of high school teachers. which action is the most imp to teach the high school teachers? 1. do not allow atudents to eat or drink after each other 2. drink bottled water as much as possible 3. encourage protected sexual activity 4. sing the happy birthday song while washing hands
sing the happy birthday song while washing hands: hep A is transmitted via the fecal oral route. good hand washing helps to prevent its spread. singing the happy birthday song takes approximately 30 seconds, which is how long an individual should wash his or her hands
The client dx with end stage liver failure is admitted with esophageal bleeding. the hcp inserts and inflates a triple lumen nasogastric tube (sengstaken-blakemore). which nursing intervention should the nurse implement for this treatment? 1. assess the gag relex every shift 2. stay with the client at all times 3. administer the laxative lactulose (chronulac) 4. monitor the clients ammonia level
stay with the client at all times: while the balloons are inflated, the client must not be left unattended in case they become dislodged and occlude the airway. this is a safety issue
During conventional aortic aneurysm repair, a ______ _______ is sutured to the aorta above and below the aneurysm, and the native aorta is replaced around the site.
synthetic graft
Which health-care providers order should the nurse question in a client diagnosed with an expanding abdominal aortic aneurysm who is scheduled for surgery in the morning?
tap water enema until clear fecal return
A patient with a left-sided brain stroke suddenly bursts into tears when family members visit. The nurse should _____________
teach the family that emotional outbursts are common after strokes. rational: Patients who have left-sided brain stroke are prone to emotional outbursts, which are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient's outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the patient's control and asking the patient to stop will lead to embarrassment.
A client who is learning to use a cane is afraid it will slip with ambulations causing a fall. the nurse provides the client with the greatest reassurance by telling the client that:
the cane has a flared tip with concentric rings to provide stability
During preop preparation of the patient scheduled for a AAA, the nurse establishes baseline data for the patient knowing that...
the cause of the aneurysm is a systemic vascular disease. because atherosclerosis is a systemic disease, the patient with an AAA is likely to have cardiac, pulmonary, cerebral, or lower-extremity vascular problems that should be noted and monitored throughout the perioperative period.
What findings might the nurse note when performing an assessment on a client with long standing renal disease?
the client appears fatigued, peripheral edema, indication of pruritis, crackles at the bases of the lungs
A client with right sided weakness needs to learn how to use a cane. The nurse plans to teach the client to position the can by holding it with the
the client is taught to hold the cane on the opposite side of the weakness. This will be the patient's left hand. The cane is placed 6 inches lateral to the fithe toe
the nurse identifies the client problem "excess fluid volume" for the client in liver failure. which short term goal would be most appropriate for this problem? 1. the client will not gain more than 2kg a day 2. the client will have no increase in abdominal girth 3. the clients v/s will remain WNL 4. the client will receive a low sodium diet
the client will have no increase in abdominal girth: excess fluid volume could be secondary to portal hypertension. therefore, no increase in abdominal girth would be an appropriate short term goal, indicating no excess of fluid volume
A client has been diagnosed with a kidney stone lodged within the medulla of the right kidney. What will the stone most likely affect?
the collection of urine
Myxedema coma
the extreme manifestation of hypothyroidism; uncommon but potentially lethal.
the client with hepatitis asks the nurse, i went to an herbalist, who recommended i take milk thistle. what do you think about the herb? which statement is the nurses best response? 1. you are concerned about taking an herb 2. the herb has been used to treat liver disease 3. I would not take anything that is not prescribed 4. why would you want to take any herbs
the herb has been used to treat liver disease: milk thistle has an active ingredient, silymarin, which has been used to treat liver disease for more than 2000 years. it is a powerful oxidant and promotes liver cell growth
the client dx with liver problems asks the nurse, why are my stools clay colored? on which scientific rationale should the nurse base the response? 1. there is an increase in serum ammonia level. 2. the liver is unable to excrete bilirubin 3. the liver is unable to metabolize fatty foods 4. a damaged liver cannot detoxify vitamins
the liver is unable to excrete bilirubin: bilirubin, the by product of red blood cell destruction, is metabolized in the liver and excreted via the feces, which causes the feces to be brown in color, if the liver is damaged, the bilirubin is excreted via the urine and skin
taping an indwelling catheter for a male client to prevent pressure on the urethra at the penoscrotal junction
the lower abdomen or the inner aspect of the thigh are the recommended sites to eliminate the penoscrotal angle and prevent the formation of a urethrocutaneous fistula
A nurse is evaluating the client's use of a cane for left sided weakness. The nurse would interven if the client moves the cane with witch side as the right leg is moved?
the nurse would interven and correct if the patient moves the cane when the righ leg is moved. The cane is held 6 inches lateral to the fifth great tow. The cane is moved forward with the affected leg. The client leans on the cane for added support while the stronger side swings through
A 55 year old female tells the nurse "Since I stopped having my menstrual periods about a year ago I've noticed a leakage of urine". What should the nurse explain to the client?
there is a decrease in estrogen after menopause which affects the strength of the pubic muscles and can lead to urine leakage
A client three weeks postpartum comes into a clinic with complains of urinary frequency and burning with urination. What can the nurse explain to the patient about these symptoms?
these are consistent with a UTI, after having a baby the bladder may not completely empty, increasing risk of UTI
When performing an assessment on an adult client the nurse is unable to palpate both kidneys. What does this finding suggest?
this is a normal, expected finding
A patient with a history of several transient ischemic attacks (TIAs) arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. The nurse anticipates the need to prepare the patient for __________
tissue plasminogen activator (tPA) infusion. rational: The patient's history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is having an acute ischemic stroke.
The health care provider prescribes clopidogrel (Plavix) for a patient with cerebral atherosclerosis. When teaching about the new medication, the nurse will tell the patient ______________
to call the health care provider if stools are tarry. rational: Plavix inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients should be advised to notify the health care provider about any signs of bleeding. The medication does not lower blood pressure, decrease plaque formation, or dissolve clots.
A nurses caring for a client after a thyroidectomy and notes that calcium gluconate is prescribed for the client. The nurse determines that this medicine has been prescribed to
treat hypoglycemic tetany
When a patient is experiencing a cluster headache, the nurse will plan to assess for _______________
unilateral eyelid swelling. rational: Unilateral eye edema, tearing, and ptosis are characteristic of cluster headaches. Nuchal rigidity suggests meningeal irritation, such as occurs with meningitis. Although nausea and vomiting may occur with migraine headaches, projectile vomiting is more consistent with increases in intracranial pressure (ICP). Unilateral sharp, stabbing pain, rather than throbbing pain, is characteristic of cluster headaches.
Extra PTH results in hypercalcemia. There is also increased calcium in the
urine, which may cause kidney stones. If the client's serum calcium levels are only slightly elevated, s/he should drink plenty of fluids to minimize the risk of kidney stones.
sildenafil (Viagra) is prescribed for a client to treat erectile dysfunction. A nurse reviews the clients medical record and would question the prescription if which of the following is noted in the clients history
use of nitroglycerin
The nurse receives a verbal report that a patient has an occlusion of the left posterior cerebral artery. The nurse will anticipate that the patient may have ___________________
visual deficits. rational: Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle cerebral artery involvement. Cognitive deficits and changes in judgment are more typical of anterior cerebral artery occlusion.
which assessment question is priority for the nurse to ask the client dx with end stage liver failure secondary to alcoholic cirrhosis? 1. how many yrs have you been drinking alcohol 2. have you completed an advance directive 3. when did you have your last alcoholic drink 4. what foods did you eat at your last meal
when did you have your last alcoholic drink?: the nurse must know when the client had the last alcoholic drink to be able to determine when and if the client will experience delirium tremens, the physical withdrawal from alcohol
s/s of addison's disease include
•Muscle weakness, fatigue, •Weight loss, decreased appetite, hyperpigmentation (dark), Low BP, fainting, Salt craving, hypoglycemia, NDV, muscle or joint pains, Irritability, depression, Body hair loss or sexual dysfunction in women
When the patient is being examined for venous thromboembolism (VTE) in the calf, what diagnostic test should the nurse expect to teach the patient about first? ■ Duplex ultrasound ■ Contrast venography ■ Magnetic resonance venography ■ Computed tomography venography
■ Duplex ultrasound The duplex ultrasound is the most widely used test to diagnose VTE. Contrast venography is rarely used now. Magnetic resonance venography is less accurate for calf veins than pelvic and proximal veins. Computed tomography venography may be used but is invasive and much more expensive than the duplex ultrasound.
The patient has CVI and a venous ulcer. The unlicensed assistive personnel (UAP) decides to apply compression stockings because that is what these patients always have ordered. What assessment by the nurse would cause the application of compression stockings to harm the patient? ■ Rest pain ■ High blood pressure ■ Elevated blood sugar ■ Dry, itchy, flaky skin
■ Rest pain Rest pain occurs as peripheral artery disease (PAD) progresses and involves multiple arterial segments. Compression stockings should not be used on patients with PAD. Elevated blood glucose, possibly indicating uncontrolled diabetes mellitus, and hypertension may or may not indicate arterial problems. Dry, itchy, flaky skin indicates venous insufficiency. The RN should be the one to obtain the order and instruct the UAP to apply compression stockings if they are ordered.
The patient had aortic aneurysm repair. What priority nursing action will the nurse use to maintain graft patency? ■ Assess output for renal dysfunction. ■ Use IV fluids to maintain adequate BP. ■ Use oral antihypertensives to maintain cardiac output. ■ Maintain a low BP to prevent pressure on surgical site
■ Use IV fluids to maintain adequate BP. The priority is to maintain an adequate BP (determined by the surgeon) to maintain graft patency. A prolonged low BP may result in graft thrombosis, and hypertension may cause undue stress on arterial anastomoses resulting in leakage of blood or rupture at the suture lines, which is when IV antihypertensives may be used. Renal output will be assessed when the aneurysm repair is above the renal arteries to assess graft patency, not maintain it.
The patient reports tenderness when she touches her leg over a vein. The nurse assesses warmth and a palpable cord in the area. The nurse knows the patient needs treatment to prevent which sequelae? ■ Pulmonary embolism ■ Pulmonary hypertension ■ Post-thrombotic syndrome ■ Venous thromboembolism
■ Venous thromboembolism The clinical manifestations are characteristic of a superficial vein thrombosis. If untreated, the clot may extend to deeper veins, and venous thromboembolism may occur. Pulmonary embolism, pulmonary hypertension, and post-thrombotic syndrome are the sequelae of venous thromboembolism.
