EXAM 1

The nurse has assessed a patients family history for three generations. The presence of which respiratory disease would justify this type of assessment? A) Asthma B) Obstructive sleep apnea C) Community-acquired pneumonia D) Pulmonary edema

A

You are admitting a patient to your medical unit after the patient has been transferred from the emergency department. What is your priority nursing action at this time? A) Identifying the immediate needs of the patient B) Checking the admitting physicians orders C) Obtaining a baseline set of vital signs D) Allowing the family to be with the patient

A

You are the nurse caring for a patient who is to receive IV daunorubicin, a chemotherapeutic agent. You start the infusion and check the insertion site as per protocol. During your most recent check, you note that the IV has infiltrated so you stop the infusion. What is your main concern with this infiltration? A) Extravasation of the medication B) Discomfort to the patient C) Blanching at the site D) Hypersensitivity reaction to the medication

A

A critical-care nurse is caring for a patient diagnosed with pneumonia as a surgical complication. The nurses assessment reveals that the patient has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the patient to do? A) Increase oral fluids unless contraindicated. B) Call the nurse for oral suctioning, as needed. C) Lie in a low Fowlers or supine position. D) Increase activity.

A The nurse should encourage hydration because adequate hydration thins and loosens pulmonary secretions

A nurse is caring for a patient who has been hospitalized with an acute asthma exacerbation. What drugs should the nurse expect to be ordered for this patient to gain underlying control of persistent asthma? A) Rescue inhalers B) Anti-inflammatory drugs C) Antibiotics D) Antitussives

B

A nurse on an oncology unit has arranged for an individual to lead meditation exercises for patients who are interested in this nonpharmacological method of pain control. The nurse should recognize the use of what category of nonpharmacological intervention? A) A body-based modality B) A mind-body method C) A biologically based therapy D) An energy therapy

B

The nursing instructor cites a list of skills that support critical thinking in clinical situations. The nurse should describe skills in which of the following domains? Select all that apply. A) Self-esteem B) Self-regulation C) Inference D) Autonomy E) Interpretation

B, C, E Skills needed in critical thinking include interpretation, analysis, evaluation, inference, explanation and self-regulation

Your patient is 12-hours post ORIF right ankle. The patient is asking for a breakthrough dose of analgesia. The pain-medication orders are written as a combination of an opioid analgesic and a nonsteroidal anti-inflammatory drug (NSAID) given together. What is the primary rationale for administering pain medication in this manner? A) To prevent respiratory depression from the opioid B) To eliminate the need for additional medication during the night C) To achieve better pain control than with one medication alone D) To eliminate the potentially adverse effects of the opioid

C

It is cold season and the school nurse been asked to provide an educational event for the parent teacher organization of the local elementary school. What should the nurse include in teaching about the treatment of pharyngitis? A) Pharyngitis is more common in children whose immunizations are not up to date. B) There are no effective, evidence-based treatments for pharyngitis. C) Use of warm saline gargles or throat irrigations can relieve symptoms. D) Heat may increase the spasms in pharyngeal muscles

C Depending on the severity of the pharyngitis and the degree of pain, warm saline gargles or throat irrigations are used. The benefits of this treatment depend on the degree of heat that is applied. The nurse teaches about these procedures and about the recommended temperature of the solution: high enough to be effective and as warm as the patient can tolerate, usually 105F to 110F (40.6C to 43.3C). Irrigating the throat may reduce spasm in the pharyngeal muscles and relieve soreness of the throat

The nurse is reviewing the electronic health record of a patient with an empyema. What health problem in the patients history is most likely to have caused the empyema? A) Smoking B) Asbestosis C) Pneumonia D) Lung cancer

C Most empyemas occur as complications of bacterial pneumonia or lung abscess

The nurse is assessing the patient for the presence of a Chvosteks sign. What electrolyte imbalance would a positive Chvosteks sign indicate? A) Hypermagnesemia B) Hyponatremia C) Hypocalcemia D) Hyperkalemia

C You can induce Chvosteks sign by tapping the patients facial nerve adjacent to the ear. A brief contraction of the upper lip, nose, or side of the face indicates Chvosteks sign

A nurse has been providing ethical care for many years and is aware of the need to maintain the ethical principle of nonmaleficence. Which of the following actions would be considered a contradiction of this principle? A) Discussing a DNR order with a terminally ill patient B) Assisting a semi-independent patient with ADLs C) Refusing to administer pain medication as ordered D) Providing more care for one patient than for another

C The duty not to inflict as well as prevent and remove harm is termed nonmaleficence.

A patients most recent laboratory results show a slight decrease in potassium. The physician has opted to forego drug therapy but has suggested increasing the patients dietary intake of potassium. Which of the following would be a good source of potassium? A) Apples B) Asparagus C) Carrots D) Bananas

D

An 87-year-old patient has been hospitalized with pneumonia. Which nursing action would be a priority in this patients plan of care? A) Nasogastric intubation B) Administration of probiotic supplements C) Bedrest D) Cautious hydration

D Supportive treatment of pneumonia in the elderly includes hydration (with caution and with frequent assessment because of the risk of fluid overload in the elderly); supplemental oxygen therapy; and assistance with deep breathing, coughing, frequent position changes, and early ambulation.

The public health nurse is presenting a health promotion class to a group of new mothers. How should the nurse best define health? A) Health is being disease free. B) Health is having fulfillment in all domains of life. C) Health is having psychological and physiological harmony. D) Health is being connected in body, mind, and spirit.

D The World Health Organization (WHO) defines health in the preamble to its constitution as a state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity.

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

D,E

6. The nurse is caring for a patient at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the patient. What is an example of a first-line measure to minimize atelectasis? A) Incentive spirometry B) Intermittent positive-pressure breathing (IPPB) C) Positive end-expiratory pressure (PEEP) D) Bronchoscopy

A

A critical care nurse is caring for a client with an endotracheal tube who is on a ventilator. The nurse knows that meticulous airway management of this patient is necessary. What is the main rationale for this? A) Maintaining a patent airway B) Preventing the need for suctioning C) Maintaining the sterility of the patients airway D) Increasing the patients lung compliance

A

A patient has been discharged home after thoracic surgery. The home care nurse performs the initial visit and finds the patient discouraged and saddened. The client states, I am recovering so slowly. I really thought I would be better by now. What nursing action should the nurse prioritize? A) Provide emotional support to the patient and family. B) Schedule a visit to the patients primary physician within 24 hours. C) Notify the physician that the patient needs a referral to a psychiatrist. D) Place a referral for a social worker to visit the patient.

A

A patient has questioned the nurses administration of IV normal saline, asking whether sterile water would be a more appropriate choice than saltwater. Under what circumstances would the nurse administer electrolyte-free water intravenously? A) Never, because it rapidly enters red blood cells, causing them to rupture. B) When the patient is severely dehydrated resulting in neurologic signs and symptoms C) When the patient is in excess of calcium and/or magnesium ions D) When a patients fluid volume deficit is due to acute or chronic renal failure

A

An adult patient has tested positive for tuberculosis (TB). While providing patient teaching, what information should the nurse prioritize? A) The importance of adhering closely to the prescribed medication regimen B) The fact that the disease is a lifelong, chronic condition that will affect ADLs C) The fact that TB is self-limiting, but can take up to 2 years to resolve D) The need to work closely with the occupational and physical therapists

A

An emergency department nurse is caring for a 7-year-old child suspected of having meningitis. The patient is to have a lumbar puncture performed, and the nurse is doing preprocedure teaching with the child and the mother. The nurses action is an example of which therapeutic communication technique? A) Informing B) Suggesting C) Expectation-setting D) Enlightening

A

The critical care nurse and the other members of the care team are assessing the patient to see if he is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify? A) Stable vital signs and ABGs B) Pulse oximetry above 80% and stable vital signs C) Stable nutritional status and ABGs D) Normal orientation and level of consciousness

A

The home care nurse is assessing the home environment of a patient who will be discharged from the hospital shortly after his laryngectomy. The nurse should inform the patient that he may need to arrange for the installation of which system in his home? A) A humidification system B) An air conditioning system C) A water purification system D) A radiant heating system

A

The nurse caring for a 79-year-old man who has just returned to the medicalsurgical unit following surgery for a total knee replacement received report from the PACU. Part of the report had been passed on from the preoperative assessment where it was noted that he has been agitated in the past following opioid administration. What principle should guide the nurses management of the patients pain? A) The elderly may require lower doses of medication and are easily confused with new medications. B) The elderly may have altered absorption and metabolism, which prohibits the use of opioids. C) The elderly may be confused following surgery, which is an age-related phenomenon unrelated to the medication. D) The elderly may require a higher initial dose of pain medication followed by a tapered dose.

A

The nurse is caring for a patient who is ready to be weaned from the ventilator. In preparing to assist in the collaborative process of weaning the patient from a ventilator, the nurse is aware that the weaning of the patient will progress in what order? A) Removal from the ventilator, tube, and then oxygen B) Removal from oxygen, ventilator, and then tube C) Removal of the tube, oxygen, and then ventilator D) Removal from oxygen, tube, and then ventilator

A

The nurse is caring for a patient with metastatic bone cancer. The patient asks the nurse why he has had to keep getting larger doses of his pain medication, although they do not seem to affect him. What is the nurses best response? A) Over time you become more tolerant of the drug. B) You may have become immune to the effects of the drug. C) You may be developing a mild addiction to the drug. D) Your body absorbs less of the drug due to the cancer.

A

The nurse who is a member of the palliative care team is assessing a patient. The patient indicates that he has been saving his PRN analgesics until the pain is intense because his pain control has been inadequate. What teaching should the nurse do with this patient? A) Medication should be taken when pain levels are low so the pain is easier to reduce. B) Pain medication can be increased when the pain becomes intense. C) It is difficult to control chronic pain, so this is an inevitable part of the disease process. D) The patient will likely benefit more from distraction than pharmacologic interventions.

A

The perioperative nurse is writing a care plan for a patient who has returned from surgery 2 hours prior. Which measure should the nurse implement to most decrease the patients risk of developing pulmonary emboli (PE)? A) Early ambulation B) Increased dietary intake of protein C) Maintaining the patient in a supine position D) Administering aspirin with warfarin

A

The public health nurse is administering Mantoux tests to children who are being registered for kindergarten in the community. How should the nurse administer this test? A) Administer intradermal injections into the childrens inner forearms. B) Administer intramuscular injections into each childs vastus lateralis. C) Administer a subcutaneous injection into each childs umbilical area. D) Administer a subcutaneous injection at a 45-degree angle into each childs deltoid.

A

Two patients on your unit have recently returned to the postsurgical unit after knee arthroplasty. One patient is reporting pain of 8 to 9 on a 0-to-10 pain scale, whereas the other patient is reporting a pain level of 3 to 4 on the same pain scale. What is the nurses most plausible rationale for understanding the patients different perceptions of pain? A) Endorphin levels may vary between patients, affecting the perception of pain. B) One of the patients is exaggerating his or her sense of pain. C) The patients are likely experiencing a variance in vasoconstriction. D) One of the patients may be experiencing opioid tolerance.

A

While planning a patients care, the nurse identifies nursing actions to minimize the patients pleuritic pain. Which intervention should the nurse include in the plan of care? A) Avoid actions that will cause the patient to breathe deeply. B) Ambulate the patient at least three times daily. C) Arrange for a soft-textured diet and increased fluid intake. D) Encourage the patient to speak as little as possible

A

You are caring for a patient with sickle cell disease in her home. Over the years, there has been joint damage, and the patient is in chronic pain. The patient has developed a tolerance to her usual pain medication. When does the tolerance to pain medication become the most significant problem? A) When it results in inadequate relief from pain B) When dealing with withdrawal symptoms resulting from the tolerance C) When having to report the patients addiction to her physician D) When the family becomes concerned about increasing dosage

A

You are frequently assessing an 84-year-old womans pain after she suffered a humeral fracture in a fall. When applying the nursing process in pain management for a patient of this age, what principle should you best apply? A) Monitor for signs of drug toxicity due to a decrease in metabolism. B) Monitor for an increase in absorption of the drug due to age-related changes. C) Monitor for a paradoxical increase in pain with opioid administration. D) Administer analgesics every 4 to 6 hours as ordered to control pain.

A

You are providing care for a patient who has a diagnosis of pneumonia attributed toStreptococcus pneumonia infection. Which of the following aspects of nursing care would constitute part of the planning phase of the nursing process? A) Achieve SaO2 92% at all times. B) Auscultate chest q4h. C) Administer oral fluids q1h and PRN. D) Avoid overexertion at all times.

A

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

A

You are the nurse performing a health assessment of an adult male patient. The man states, The doctor has already asked me all these questions. Why are you asking them all over again? What is your best response? A) This history helps us determine what your needs may be for nursing care. B) You are right; this may seem redundant and I'm sure that its frustrating for you. C) I want to make sure your doctor has covered everything that's important for your treatment. D) I am a member of your health care team and we want to make sure that nothing falls through the cracks

A

You are the nurse who is caring for a patient with a newly diagnosed allergy to peanuts. Which of the following is an immediate goal that is most relevant to a nursing diagnosis of deficient knowledge related to appropriate use of an EpiPen? A) The patient will demonstrate correct injection technique with todays teaching session. B) The patient will closely observe the nurse demonstrating the injection. C) The nurse will teach the patients family member to administer the injection. D) The patient will return to the clinic within 2 weeks to demonstrate the injection.

A

You are writing a care plan for an 85-year-old patient who has community-acquired pneumonia and you note decreased breath sounds to bilateral lung bases on auscultation. What is the most appropriate nursing diagnosis for this patient? A) Ineffective airway clearance related to tracheobronchial secretions B) Pneumonia related to progression of disease process C) Poor ventilation related to acute lung infection D) Immobility related to fatigue

A

Your older adult patient has a diagnosis of rheumatoid arthritis (RA) and has been achieving only modest relief of her symptoms with the use of nonsteroidal anti-inflammatory drugs (NSAIDs). When creating this patients plan of care, which nursing diagnosis would most likely be appropriate? A) Self-care deficit related to fatigue and joint stiffness B) Ineffective airway clearance related to chronic pain C) Risk for hopelessness related to body image disturbance D) Anxiety related to chronic joint pain

A

You have just taken report for your shift and you are doing your initial assessment of your patients. One of your patients asks you if an error has been made in her medication. You know that an incident report was filed yesterday after a nurse inadvertently missed a scheduled dose of the patients antibiotic. Which of the following principles would apply if you give an accurate response? A) Veracity B) Confidentiality C) Respect D) Justice

A The obligation to tell the truth and not deceive others is termed veracity

An x-ray of a trauma patient reveals rib fractures and the patient is diagnosed with a small flail chest injury. Which intervention should the nurse include in the patients plan of care? A) Suction the patients airway secretions. B) Immobilize the ribs with an abdominal binder. C) Prepare the patient for surgery. D) Immediately sedate and intubate the patient.

A As with rib fracture, treatment of flail chest is usually supportive. Management includes clearing secretions from the lungs, and controlling pain. If only a small segment of the chest is involved, it is important to clear the airway through positioning, coughing, deep breathing, and suctioning. Intubation is required for severe flail chest injuries, and surgery is required only in rare circumstances to stabilize the flail segment.

A patient is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube? A) To remove air from the pleural space B) To drain copious sputum secretions C) To monitor bleeding around the lungs D) To assist with mechanical ventilation

A Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood

A nurse practitioner has provided care for three different patients with chronic pharyngitis over the past several months. Which patients are at greatest risk for developing chronic pharyngitis? A) Patients who are habitual users of alcohol and tobacco B) Patients who are habitual users of caffeine and other stimulants C) Patients who eat a diet high in spicy foods D) Patients who have gastrointestinal reflux disease (GERD)

A Chronic pharyngitis is common in adults who live and work in dusty surroundings, use the voice to excess, suffer from chronic chough, and habitually use alcohol and tobacco

A pediatric nurse practitioner is caring for a child who has just been diagnosed with asthma. The nurse has provided the parents with information that includes potential causative agents for an asthmatic reaction. What potential causative agent should the nurse describe? A) Pets B) Lack of sleep C) Psychosocial stress D) Bacteria

A Common causative agents that may trigger an asthma attack are as follows: dust, dust mites, pets, soap, certain foods, molds, and pollens.

A nurse uses critical thinking every day when going through the nursing process. Which of the following is an outcome of critical thinking in nursing practice? A) A comprehensive plan of care with a high potential for success B) Identification of the nurses preferred goals for the patient C) A collaborative basis for assigning care D) Increased cost efficiency in health care

A Critical thinking in nursing practice results in a comprehensive plan of care with maximized potential for success

A nurse is evaluating the diagnostic study data of a patient with suspected cystic fibrosis (CF). Which of the following test results is associated with a diagnosis of cystic fibrosis? A) Elevated sweat chloride concentration B) Presence of protein in the urine C) Positive phenylketonuria D) Malignancy on lung biopsy

A Gene mutations affect transport of chloride ions, leading to CF, which is characterized by thick, viscous secretions in the lungs, pancreas, liver, intestine, and reproductive tract as well as increased salt content in sweat gland secretions

The medical nurse who works on a pulmonology unit is aware that several respiratory conditions can affect lung tissue compliance. The presence of what condition would lead to an increase in lung compliance? A) Emphysema B) Pulmonary fibrosis C) Pleural effusion D) Acute respiratory distress syndrome (ARDS)

A High or increased compliance occurs if the lungs have lost their elasticity and the thorax is overdistended, in conditions such as emphysema.

The nurse caring for a patient who is two days post hip replacement notifies the physician that the patients incision is red around the edges, warm to the touch, and seeping a white liquid with a foul odor. What type of problem is the nurse dealing with? A) Collaborative problem B) Nursing problem C) Medical problem D) Administrative problem

A In addition to nursing diagnoses and their related nursing interventions, nursing practice involves certain situations and interventions that do not fall within the definition of nursing diagnoses. These activities pertain to potential problems or complications that are medical in origin and require collaborative interventions with the physician and other members of the health care team.

A group of students have been challenged to prioritize ethical practice when working with a marginalized population. How should the students best understand the concept of ethics? A) The formal, systematic study of moral beliefs B) The informal study of patterns of ideal behavior C) The adherence to culturally rooted, behavioral norms D) The adherence to informal personal values

A In essence, ethics is the formal, systematic study of moral beliefs, whereas morality is the adherence to informal personal values

. A nurse is caring for a 6-year-old patient with cystic fibrosis. In order to enhance the childs nutritional status, what intervention should most likely be included in the plan of care? A) Pancreatic enzyme supplementation with meals B) Provision of five to six small meals per day rather than three larger meals C) Total parenteral nutrition (TPN) D) Magnesium, thiamine, and iron supplementation

A Nearly 90% of patients with CF have pancreatic exocrine insufficiency and require oral pancreatic enzyme supplementation with meals

The nurse is performing a respiratory assessment of an adult patient and is attempting to distinguish between vesicular, bronchovesicular, and bronchial (tubular) breath sounds. The nurse should distinguish between these normal breath sounds on what basis? A) Their location over a specific area of the lung B) The volume of the sounds C) Whether they are heard on inspiration or expiration D) Whether or not they are continuous breath sounds

A Normal breath sounds are distinguished by their location over a specific area of the lung; they are identified as vesicular, bronchovesicular, and bronchial (tubular) breath sounds. Normal breath sounds are heard on both inspiration and expiration, and are continuous.

A nurse has been asked to give a workshop on COPD for a local community group. The nurse emphasizes the importance of smoking cessation because smoking has what pathophysiologic effect? A) Increases the amount of mucus production B) Destabilizes hemoglobin C) Shrinks the alveoli in the lungs D) Collapses the alveoli in the lungs

A Smoking irritates the goblet cells and mucous glands, causing an increased accumulation of mucus, which, in turn, produces more irritation, infection, and damage to the lung

The OR nurse is setting up a water-seal chest drainage system for a patient who has just had a thoracotomy. The nurse knows that the amount of suction in the system is determined by the water level. At what suction level should the nurse set the system? A) 20 cm H2O B) 15 cm H2O C) 10 cm H2O D) 5 cm H2O

A The amount of suction is determined by the water level. It is usually set at 20 cm H2O; adding more fluid results in more suction.

A nurse is admitting a new patient who has been admitted with a diagnosis of COPD exacerbation. How can the nurse best help the patient achieve the goal of maintaining effective oxygenation? A) Teach the patient strategies for promoting diaphragmatic breathing. B) Administer supplementary oxygen by simple face mask. C) Teach the patient to perform airway suctioning. D) Assist the patient in developing an appropriate exercise program.

A The breathing pattern of most people with COPD is shallow, rapid, and inefficient; the more severe the disease, the more inefficient the breathing pattern. With practice, this type of upper chest breathing can be changed to diaphragmatic breathing, which reduces the respiratory rate, increases alveolar ventilation, and sometimes helps expel as much air as possible during expiration. Suctioning is not normally necessary in patients with COPD.

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

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

A patient with emphysema is experiencing shortness of breath. To relieve this patients symptoms, the nurse should assist her into what position? A) Sitting upright, leaning forward slightly B) Low Fowlers, with the neck slightly hyperextended C) Prone D) Trendelenburg

A The typical posture of a person with COPD is to lean forward and use the accessory muscles of respiration to breathe

A medical nurse has obtained a new patients health history and completed the admission assessment. The nurse has followed this by documenting the results and creating a care plan for the patient. Which of the following is the most important rationale for documenting the patients care? A) It provides continuity of care. B) It creates a teaching log for the family. C) It verifies appropriate staffing levels. D) It keeps the patient fully informed

A This record provides a means of communication among members of the health care team and facilitates coordinated planning and continuity of care. It serves as the legal and business record for a health care agency and for the professional staff members who are responsible for the patients care

A nurse is speaking to a group of prospective nursing students about what it is like to be a nurse. What is one characteristic the nurse would cite as necessary to possess to be an effective nurse? A) Sensitivity to cultural differences B) Team-focused approach to problem-solving C) Strict adherence to routine D) Ability to face criticism

A To promote an effective nurse-patient relationship and positive outcomes of care, nursing care must be culturally competent, appropriate, and sensitive to cultural differences.

You are the nurse assessing a 28-year-old woman who has presented to the emergency department with vague complaints of malaise. You note bruising to the patients upper arm that correspond to the outline of fingers as well as yellow bruising around her left eye. The patient makes minimal eye contact during the assessment. How might you best inquire about the bruising? A) Is anyone physically hurting you? B) Tell me about your relationships. C) Do you want to see a social worker? D) Is there something you want to tell me?

A Few patients will discuss the topic of abuse unless they are directly asked. Therefore, it is important to ask direct questions, such as, Is anyone physically hurting you?

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

A, C, D, E

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

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

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

A,B,D

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

A,D,E

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

A,D,E Asthma is a chronic inflammatory disease of the airways that causes airway hyperresponsiveness, mucosal edema, and mucus production

A hospital has been the site of an increased incidence of hospital-acquired pneumonia (HAP). What is an important measure for the prevention of HAP? A) Administration of prophylactic antibiotics B) Administration of pneumococcal vaccine to vulnerable individuals C) Obtaining culture and sensitivity swabs from all newly admitted patients D) Administration of antiretroviral medications to patients over age

B

A nurse in the neurologic ICU has orders to infuse a hypertonic solution into a patient with increased intracranial pressure. This solution will increase the number of dissolved particles in the patients blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described as which of the following? A) Hydrostatic pressure B) Osmosis and osmolality C) Diffusion D) Active transport

B

A nurse is conducting a health assessment of an adult patient when the patient asks, Why do you need all this health information and who is going to see it? What is the nurses best response? A) Please do not worry. It is safe and will be used only to help us with your care. Its accessible to a wide variety of people who are invested in your health. B) It is good you asked and you have a right to know; your information helps us to provide you with the best possible care, and your records are in a secure place. C) Your health information is placed on secure Web sites to provide easy access to anyone wishing to see your medical records. This ensures continuity of care. D) Health information becomes the property of the hospital and we will make sure that no one sees it. Then, in 2 years, we destroy all records and the process starts over.

B

A nurse on a medical-surgical unit has asked to represent the unit on the hospitals quality committee. When describing quality improvement programs to nursing colleagues and members of other health disciplines, what characteristic should the nurse cite? A) These programs establish consequences for health care professionals actions. B) These programs focus on the processes used to provide care. C) These programs identify specific incidents related to quality. D) These programs seek to justify health care costs and systems.

B

A patient is being admitted to the preoperative holding area for a thoracotomy. Preoperative teaching includes what? A) Correct use of a ventilator B) Correct use of incentive spirometry C) Correct use of a mini-nebulizer D) Correct technique for rhythmic breathing

B

A perioperative nurse is caring for a postoperative patient. The patient has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the patients increased risk for what complication? A) Acute respiratory distress syndrome (ARDS) B) Atelectasis C) Aspiration D) Pulmonary embolism

B

In response to a patients complaint of pain, the nurse administered a PRN dose of hydromorphone (Dilaudid). In what phase of the nursing process will the nurse determine whether this medication has had the desired effect? A) Analysis B) Evaluation C) Assessment D) Data collection

B

The nurse is assessing a newly admitted medical patient and notes there is a depression in the lower portion of the patients sternum. This patients health record should note the presence of what chest deformity? A) A barrel chest B) A funnel chest C) A pigeon chest D) Kyphoscoliosis

B

The nurse is caring for a client with an endotracheal tube who is on a ventilator. When assessing the client, the nurse knows to maintain what cuff pressure to maintain appropriate pressure on the tracheal wall? A) Between 10 and 15 mm Hg B) Between 15 and 20 mm Hg C) Between 20 and 25 mm Hg D) Between 25 and 30 mm Hg

B

The wife of a patient you are caring for asks to speak with you. She tells you that she is concerned because her husband is requiring increasingly high doses of analgesia. She states, He was in pain long before he got cancer because he broke his back about 20 years ago. For that problem, though, his pain medicine wasnt just raised and raised. What would be the nurses best response? A) I didnt know that. I will speak to the doctor about your husbands pain control. B) Much cancer pain is caused by tumor involvement and needs to be treated in a way that brings the patient relief. C) Cancer is a chronic kind of pain so the more it hurts the patient, the more medicine we give the patient until it no longer hurts. D) Does the increasing medication dosage concern you?

B

While caring for a patient with an endotracheal tube, the nurses recognizes that suctioning is required how often? A) Every 2 hours when the patient is awake B) When adventitious breath sounds are auscultated C) When there is a need to prevent the patient from coughing D) When the nurse needs to stimulate the cough reflex

B

You are the surgical nurse caring for a 65-year-old female patient who is postoperative day 1 following a thyroidectomy. During your shift assessment, the patient complains of tingling in her lips and fingers. She tells you that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should you first suspect? A) Hypophosphatemia B) Hypocalcemia C) Hypermagnesemia D) Hyperkalemia

B

Your patient is receiving postoperative morphine through a patient-controlled analgesic (PCA) pump and the patients orders specify an initial bolus dose. What is your priority assessment? A) Assessment for decreased level of consciousness (LOC) B) Assessment for respiratory depression C) Assessment for fluid overload D) Assessment for paradoxical increase in pain

B

A nurse is caring for a young adult patient whose medical history includes an alpha1 -antitrypsin deficiency. This deficiency predisposes the patient to what health problem? A) Pulmonary edema B) Lobular emphysema C) Cystic fibrosis (CF) D) Empyema

B A host risk factor for COPD is a deficiency of alpha1 -antitrypsin, an enzyme inhibitor that protects the lung parenchyma from injury. This deficiency predisposes young patients to rapid development of lobular emphysema even in the absence of smoking

What would the critical care nurse recognize as a condition that may indicate a patients need to have a tracheostomy? A) A patient has a respiratory rate of 10 breaths per minute. B) A patient requires permanent ventilation. C) A patient exhibits symptoms of dyspnea. D) A patient has respiratory acidosis.

B A tracheostomy permits long-term use of mechanical ventilation to prevent aspiration of oral and gastric secretions in the unconscious or paralyzed patient.

The acute medical nurse is preparing to wean a patient from the ventilator. Which assessment parameter is most important for the nurse to assess? A) Fluid intake for the last 24 hours B) Baseline arterial blood gas (ABG) levels C) Prior outcomes of weaning D) Electrocardiogram (ECG) results

B Before weaning a patient from mechanical ventilation, it is most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the patient is tolerating the procedure

A medical nurse is caring for a patient who is palliative following metastasis. The nurse is aware of the need to uphold the ethical principle of beneficence. How can the nurse best exemplify this principle in the care of this patient? A) The nurse tactfully regulates the number and timing of visitors as per the patients wishes. B) The nurse stays with the patient during his or her death. C) The nurse ensures that all members of the care team are aware of the patients DNR order. D) The nurse liaises with members of the care team to ensure continuity of care.

B Beneficence is the duty to do good and the active promotion of benevolent acts

The view that health and illness are not static states but that they exist on a continuum is central to professional health care systems. When planning care, this view aids the nurse in appreciating which of the following? A) Care should focus primarily on the treatment of disease. B) A persons state of health is ever-changing C) A person can transition from health to illness rapidly. D) Care should focus on the patients compliance with interventions.

B By viewing health and illness on a continuum, it is possible to consider a person as being neither completely healthy nor completely ill. Instead, a persons state of health is ever-changing and has the potential to range from high-level wellness to extremely poor health and imminent death.

A nurse is unsure how best to respond to a patients vague complaint of feeling off. The nurse is attempting to apply the principles of critical thinking, including metacognition. How can the nurse best foster metacognition? A) By eliciting input from a variety of trusted colleagues B) By examining the way that she thinks and applies reason C) By evaluating her responses to similar situations in the past D) By thinking about the way that an ideal nurse would respond in this situation

B Critical thinking includes metacognition, the examination of ones own reasoning or thought processes, to help refine thinking skills

The nurse recognizes that aspiration is a potential complication of a laryngectomy. How should the nurse best manage this risk? A) Facilitate total parenteral nutrition (TPN). B) Keep a complete suction setup at the bedside. C) Feed the patient several small meals daily. D) Refer the patient for occupational therapy.

B Due to the risk for aspiration, the nurse keeps a suction setup available in the hospital and instructs the family to do so at home for use if needed.

A nurse is developing the teaching portion of a care plan for a patient with COPD. What would be the most important component for the nurse to emphasize? A) Smoking up to one-half of a pack of cigarettes weekly is allowable. B) Chronic inhalation of indoor toxins can cause lung damage. C) Minor respiratory infections are considered to be self-limited and are not treated. D) Activities of daily living (ADLs) should be clustered in the early morning hours.

B Environmental risk factors for COPD include prolonged and intense exposure to occupational dusts and chemicals, indoor air pollution, and outdoor air pollution. Smoking cessation should be taught to all patients who are currently smoking

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

B In elderly patients, the clinical manifestations of fluid and electrolyte disturbances may be subtle or atypical. For example, fluid deficit may cause confusion or cognitive impairment in the elderly person

A patient with thoracic trauma is admitted to the ICU. The nurse notes the patients chest and neck are swollen and there is a crackling sensation when palpated. The nurse consequently identifies the presence of subcutaneous emphysema. If this condition becomes severe and threatens airway patency, what intervention is indicated? A) A chest tube B) A tracheostomy C) An endotracheal tube D) A feeding tube

B In severe cases in which there is widespread subcutaneous emphysema, a tracheostomy is indicated if airway patency is threatened by pressure of the trapped air on the trachea

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

B It is mandatory in most settings to have a physicians order before restraining a patient. Before restraints are used, other strategies, such as asking family members to sit with the patient, or utilizing a specially trained sitter, should be tried.

The nurse caring for a patient post colon resection is assessing the patient on the second postoperative day. The nasogastric tube (NG) remains patent and continues at low intermittent wall suction. The IV is patent and infusing at 125 mL/hr. The patient reports pain at the incision site rated at a 3 on a 0-to-10 rating scale. During your initial shift assessment, the patient complains of cramps in her legs and a tingling sensation in her feet. Your assessment indicates decreased deep tendon reflexes (DTRs) and you suspect the patient has hypokalemia. What other sign or symptom would you expect this patient to exhibit? A) Diarrhea B) Dilute urine C) Increased muscle tone D) Joint pain

B Manifestations of hypokalemia include fatigue, anorexia, nausea, vomiting, muscle weakness, leg cramps, decreased bowel motility, paresthesias (numbness and tingling), and dysrhythmias. If prolonged, hypokalemia can lead to an inability of the kidneys to concentrate urine, causing dilute urine (resulting in polyuria, nocturia) and excessive thirst.

A nurse has begun creating a patients plan of care shortly after the patients admission. It is important that the wording of the chosen nursing diagnoses falls within the taxonomy of nursing. Which organization is responsible for developing the taxonomy of a nursing diagnosis? A) American Nurses Association (ANA) B) NANDA C) National League for Nursing (NLN) D) Joint Commission

B NANDA International is the official organization responsible for developing the taxonomy of nursing diagnoses and formulating nursing diagnoses acceptable for study

An asthma educator is teaching a patient newly diagnosed with asthma and her family about the use of a peak flow meter. The educator should teach the patient that a peak flow meter measures what value? A) Highest airflow during a forced inspiration B) Highest airflow during a forced expiration C) Airflow during a normal inspiration D) Airflow during a normal expiration

B Peak flow meters measure the highest airflow during a forced expiration.

A nurse is reviewing the pathophysiology of cystic fibrosis (CF) in anticipation of a new admission. The nurse should identify what characteristic aspects of CF? A) Alveolar mucus plugging, infection, and eventual bronchiectasis B) Bronchial mucus plugging, inflammation, and eventual bronchiectasis C) Atelectasis, infection, and eventual COPD D) Bronchial mucus plugging, infection, and eventual COPD

B The hallmark pathology of CF is bronchial mucus plugging, inflammation, and eventual bronchiectasis. Commonly, the bronchiectasis begins in the upper lobes and progresses to involve all lobes

A medical nurse educator is reviewing a patients recent episode of metabolic acidosis with members of the nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis? A) The kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance. B) The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. C) The kidneys react rapidly to compensate for imbalances in the body. D) The kidneys regulate the bicarbonate level in the intracellular fluid.

B The kidneys regulate the bicarbonate level in the ECF; they can regenerate bicarbonate ions as well as reabsorb them from the renal tubular cells. In respiratory acidosis and most cases of metabolic acidosis, the kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. In respiratory and metabolic alkalosis, the kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance

A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acid base imbalance? A) Respiratory acidosis B) Respiratory alkalosis C) Increased PaCO2 D) CNS disturbances

B The most common cause of acute respiratory alkalosis is hyperventilation. Extreme anxiety can lead to hyperventilation.

A patient is receiving thrombolytic therapy for the treatment of pulmonary emboli. What is the best way for the nurse to assess the patients oxygenation status at the bedside? A) Obtain serial ABG samples. B) Monitor pulse oximetry readings. C) Test pulmonary function. D) Monitor incentive spirometry volumes.

B The nurse assesses the patient with pulmonary emboli frequently for signs of hypoxemia and monitors the pulse oximetry values to evaluate the effectiveness of the oxygen therapy. ABGs are accurate indicators of oxygenation status, but are not analyzed at the bedside.

You are caring for a patient with a diagnosis of pancreatitis. The patient was admitted from a homeless shelter and is a vague historian. The patient appears malnourished and on day 3 of the patients admission total parenteral nutrition (TPN) has been started. Why would you know to start the infusion of TPN slowly? A) Patients receiving TPN are at risk for hypercalcemia if calories are started too rapidly. B) Malnourished patients receiving parenteral nutrition are at risk for hypophosphatemia if calories are started too aggressively. C) Malnourished patients who receive fluids too rapidly are at risk for hypernatremia. D) Patients receiving TPN need a slow initiation of treatment in order to allow digestive enzymes to accumulate

B The nurse identifies patients who are at risk for hypophosphatemia and monitors them. Because malnourished patients receiving parenteral nutrition are at risk when calories are introduced too aggressively, preventive measures involve gradually introducing the solution to avoid rapid shifts of phosphorus into the cells

An adult patient has requested a do not resuscitate (DNR) order in light of his recent diagnosis with late stage pancreatic cancer. The patients son and daughter-in-law are strongly opposed to the patients request. What is the primary responsibility of the nurse in this situation? A) Perform a slow code until a decision is made. B) Honor the request of the patient. C) Contact a social worker or mediator to intervene. D) Temporarily withhold nursing care until the physician talks to the family.

B The nurse must honor the patients wishes and continue to provide required nursing care

The nurse is providing care for a patient who has just been admitted to the postsurgical unit following a laryngectomy. What assessment should the nurse prioritize? A) The patients swallowing ability B) The patients airway patency C) The patients carotid pulses D) Signs and symptoms of infection

B The patient with a laryngectomy is a risk for airway occlusion and respiratory distress. As in all nursing situations, assessment of the airway is a priority over other potential complications and assessment parameters.

You are part of the health care team caring for an 87-year-old woman who has been admitted to your rehabilitation facility after falling and fracturing her left hip. The patient appears to be failing to regain functional ability and may have to be readmitted to an acute-care facility. When planning this patients care, what do you know about the negative effects of the stress associated with pain? A) Stress is less pronounced in older adults because they generally have more sophisticated coping skills than younger adults B) It is particularly harmful in the elderly who have been injured or who are ill. C) It affects only those patients who are already debilitated prior to experiencing pain. D) It has no inherent negative effects; it just alerts the person/health care team of an underlying disease process.

B The widespread endocrine, immunologic, and inflammatory changes that occur with the stress of pain can have significant negative effects. This is particularly harmful in patients whose health is already compromised by age, illness, or injury.

An admitting nurse is assessing a patient with COPD. The nurse auscultates diminished breath sounds, which signify changes in the airway. These changes indicate to the nurse to monitor the patient for what? A) Kyphosis and clubbing of the fingers B) Dyspnea and hypoxemia C) Sepsis and pneumothorax D) Bradypnea and pursed lip breathing

B These changes in the airway require that the nurse monitor the patient for dyspnea and hypoxemia

A nurse has been offered a position on an obstetric unit and has learned that the unit offers therapeutic abortions, a procedure which contradicts the nurses personal beliefs. What is the nurses ethical obligation to these patients? A) The nurse should adhere to professional standards of practice and offer service to these patients. B) The nurse should make the choice to decline this position and pursue a different nursing role. C) The nurse should decline to care for the patients considering abortion. D) The nurse should express alternatives to women considering terminating their pregnancy.

B To avoid facing ethical dilemmas, nurses can follow certain strategies. For example, when applying for a job, a nurse should ask questions regarding the patient population. If a nurse is uncomfortable with a particular situation, then not accepting the position would be the best option

A nurses assessment reveals that a client with COPD may be experiencing bronchospasm. What assessment finding would suggest that the patient is experiencing bronchospasm? A) Fine or coarse crackles on auscultation B) Wheezes or diminished breath sounds on auscultation C) Reduced respiratory rate or lethargy D) Slow, deliberate respirations

B Wheezing and diminished breath sounds are consistent with bronchospasm

A 52-year-old female patient is receiving care on the oncology unit for breast cancer that has metastasized to her lungs and liver. When addressing the patients pain in her plan of nursing care, the nurse should consider what characteristic of cancer pain? A) Cancer pain is often related to the stress of the patient knowing she has cancer and requires relatively low doses of pain medications along with a high dose of anti-anxiety medications. B) Cancer pain is always chronic and challenging to treat, so distraction is often the best intervention. C) Cancer pain can be acute or chronic and it typically requires comparatively high doses of pain medications. D) Cancer pain is often misreported by patients because of confusion related to their disease process.

C

A nurse has performed tracheal suctioning on a patient who experienced increasing dyspnea prior to a procedure. When applying the nursing process, how can the nurse best evaluate the outcomes of this intervention? A) Determine whether the patient can now perform forced expiratory technique (FET). B) Percuss the patients lungs and thorax. C) Measure the patients oxygen saturation. D) Have the patient perform incentive spirometry

C

A patient in the ICU has had an endotracheal tube in place for 3 weeks. The physician has ordered that a tracheostomy tube be placed. The patients family wants to know why the endotracheal tube cannot be left in place. What would be the nurses best response? A) The physician may feel that mechanical ventilation will have to be used long-term. B) Long-term use of an endotracheal tube diminishes the normal breathing reflex. C) When an endotracheal tube is left in too long it can damage the lining of the windpipe. D) It is much harder to breathe through an endotracheal tube than a tracheostomy

C

A patient with a severe exacerbation of COPD requires reliable and precise oxygen delivery. Which mask will the nurse expect the physician to order? A) Non-rebreather air mask B) Tracheostomy collar C) Venturi mask D) Face tent

C

A patient with migraines does not know whether she is receiving a placebo for pain management or the new drug that is undergoing clinical trials. Upon discussing the patients distress, it becomes evident to the nurse that the patient did not fully understand the informed consent document that she signed. Which ethical principle is most likely involved in this situation? A) Sanctity of life B) Confidentiality C) Veracity D) Fidelity

C

An audit of a large, university medical center reveals that four patients in the hospital have current orders for restraints. You know that restraints are an intervention of last resort, and that it is inappropriate to apply restraints to which of the following patients? A) A postlaryngectomy patient who is attempting to pull out his tracheostomy tube B) A patient in hypovolemic shock trying to remove the dressing over his central venous catheter C) A patient with urosepsis who is ringing the call bell incessantly to use the bedside commode D) A patient with depression who has just tried to commit suicide and whose medications are not achieving adequate symptom control

C

An unlicensed nursing assistant (NA) reports to the nurse that a postsurgical patient is complaining of pain that she rates as 8 on a 0-to-10 point scale. The NA tells the nurse that he thinks the patient is exaggerating and does not need pain medication. What is the nurses best response? A) Pain often comes and goes with postsurgical patients. Please ask her about pain again in about 30 minutes. B) We need to provide pain medications because it is the law, and we must always follow the law. C) Unless there is strong evidence to the contrary, we should take the patients report at face value. D) Its not unusual for patients to misreport pain to get our attention when we are busy.

C

In the process of planning a patients care, the nurse has identified a nursing diagnosis of Ineffective Health Maintenance related to alcohol use. What must precede the determination of this nursing diagnosis? A) Establishment of a plan to address the underlying problem B) Assigning a positive value to each consequence of the diagnosis C) Collecting and analyzing data that corroborates the diagnosis D) Evaluating the patients chances of recovery

C

Nurses in acute care settings must work with other health care team members to maintain quality care while facing pressures to care for patients who are hospitalized for shorter periods of time than in the past. To ensure positive health outcomes when patients return to their homes, what action should the nurse prioritize? A) Promotion of health literacy during hospitalization B) Close communication with insurers C) Thorough and evidence-based discharge planning D) Participation in continuing education initiatives

C

The ED nurse is assessing the respiratory function of a teenage girl who presented with acute shortness of breath. Auscultation reveals continuous wheezes during inspiration and expiration. This finding is most suggestive what? A) Pleurisy B) Emphysema C) Asthma D) Pneumonia

C

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

C

The critical care nurse is precepting a new nurse on the unit. Together they are caring for a patient who has a tracheostomy tube and is receiving mechanical ventilation. What action should the critical care nurse recommend when caring for the cuff? A) Deflate the cuff overnight to prevent tracheal tissue trauma. B) Inflate the cuff to the highest possible pressure in order to prevent aspiration. C) Monitor the pressure in the cuff at least every 8 hours D) Keep the tracheostomy tube plugged at all times.

C

The nurse has noted the emergence of a significant amount of fresh blood at the drain site of a patient who is postoperative day 1 following total laryngectomy. How should the nurse respond to this development? A) Remove the patients drain and apply pressure with a sterile gauze. B) Assess the patient, reposition the patient supine, and apply wall suction to the drain. C) Rapidly assess the patient and notify the surgeon about the patients bleeding. D) Administer a STAT dose of vitamin K to aid coagulation

C

The nurse is creating a care plan for a patient who is status post-total laryngectomy. Much of the plan consists of a long-term postoperative communication plan for laryngeal communication. What form of laryngeal communication will likely be chosen? A) Esophageal speech B) Electric larynx C) Tracheoesophageal puncture D) American sign language (ASL)

C

The nurse is planning the care of a patient who is scheduled for a laryngectomy. The nurse should assign the highest priority to which postoperative nursing diagnosis? A) Anxiety related to diagnosis of cancer B) Altered nutrition related to swallowing difficulties C) Ineffective airway clearance related to airway alterations D) Impaired verbal communication related to removal of the larynx

C

The nurse, in collaboration with the patients family, is determining priorities related to the care of the patient. The nurse explains that it is important to consider the urgency of specific problems when setting priorities. What provides the best framework for prioritizing patient problems? A) Availability of hospital resources B) Family member statements C) Maslows hierarchy of needs D) The nurses skill set

C

You are the home health nurse caring for a homebound client who is terminally ill. You are delivering a patient-controlled analgesia (PCA) pump to the patient at your visit today. The family members will be taking care of the patient. What would your priority nursing interventions be for this visit? A) Teach the family the theory of pain management and the use of alternative therapies. B) Provide psychosocial family support during this emotional experience. C) Provide patient and family teaching regarding the operation of the pump, monitoring the IV site, and knowing the side effects of the medication. D) Provide family teaching regarding use of morphine, recognizing morphine overdose, and offering spiritual guidance.

C

You have just received report on a 27-year-old woman who is coming to your unit from the emergency department with a torn meniscus. You review her PRN medications and see that she has an NSAID (ibuprofen) ordered every 6 hours. If you wanted to implement preventive pain measures when the patient arrives to your unit, what would you do? A) Use a pain scale to assess the patients pain, and let the patient know ibuprofen is available every 6 hours if she needs it. B) Do a complete assessment, and give pain medication based on the patients report of pain. C) Check for allergies, use a pain scale to assess the patients pain, and offer the ibuprofen every 6 hours until the patient is discharged. D) Provide medication as per patient request and offer relaxation techniques to promote comfort.

C

Your patient has just returned from the postanesthetic care unit (PACU) following left tibia open reduction internal fixation (ORIF). The patient is complaining of pain, and you are preparing to administer the patients first scheduled dose of hydromorphone (Dilaudid). Prior to administering the drug, you would prioritize which of the following assessments? A) The patients electrolyte levels B) The patients blood pressure C) The patients allergy status D) The patients hydration status

C

A patient is being treated for bacterial pharyngitis. Which of the following should the nurse recommend when promoting the patients nutrition during treatment? A) A 1.5 L/day fluid restriction B) A high-potassium, low-sodium diet C) A liquid or soft diet D) A high-protein diet

C A liquid or soft diet is provided during the acute stage of the disease, depending on the patients appetite and the degree of discomfort that occurs with swallowing. The patient is encouraged to drink as much fluid as possible (at least 2 to 3 L/day).

The nurse is providing discharge teaching for a patient who developed a pulmonary embolism after total knee surgery. The patient has been converted from heparin to sodium warfarin (Coumadin) anticoagulant therapy. What should the nurse teach the client? A) Coumadin will continue to break up the clot over a period of weeks B) Coumadin must be taken concurrent with ASA to achieve anticoagulation. C) Anticoagulant therapy usually lasts between 3 and 6 months. D) He should take a vitamin supplement containing vitamin K

C Anticoagulant therapy prevents further clot formation, but cannot be used to dissolve a clot. The therapy continues for approximately 3 to 6 months and is not combined with ASA. Vitamin K reverses the effect of anticoagulant therapy and normally should not be taken.

The nurse is preparing to suction a patient with an endotracheal tube. What should be the nurses first step in the suctioning process? A) Explain the suctioning procedure to the patient and reposition the patient. B) Turn on suction source at a pressure not exceeding 120 mm Hg. C) Assess the patients lung sounds and SAO2 via pulse oximeter. D) Perform hand hygiene and don nonsterile gloves, goggles, gown, and mask.

C Assessment data indicate the need for suctioning and allow the nurse to monitor the effect of suction on the patients level of oxygenation. Explaining the procedure would be the second step; performing hand hygiene is the third step, and turning on the suction source is the fourth step.

A patient is undergoing testing to see if he has a pleural effusion. Which of the nurses respiratory assessment findings would be most consistent with this diagnosis? A) Increased tactile fremitus, egophony, and a dull sound upon percussion of the chest wall B) Decreased tactile fremitus, wheezing, and a hyperresonant sound upon percussion of the chest wall C) Lung fields dull to percussion, absent breath sounds, and a pleural friction rub D) Normal tactile fremitus, decreased breath sounds, and a resonant sound upon percussion of the chest wall

C Assessment findings consistent with a pleural effusion include affected lung fields being dull to percussion and absence of breath sounds. A pleural friction rub may also be present

A school nurse is caring for a 10-year-old girl who is having an asthma attack. What is the preferred intervention to alleviate this clients airflow obstruction? A) Administer corticosteroids by metered dose inhaler B) Administer inhaled anticholinergics C) Administer an inhaled beta-adrenergic agonist D) Utilize a peak flow monitoring device

C Asthma exacerbations are best managed by early treatment and education of the patient. Quick-acting beta-adrenergic medications are the first used for prompt relief of airflow obstruction. Systemic corticosteroids may be necessary to decrease airway inflammation in patients who fail to respond to inhaled beta-adrenergic medication

A nurse is teaching a patient with asthma about Azmacort, an inhaled corticosteroid. Which adverse effects should the nurse be sure to address in patient teaching? A) Dyspnea and increased respiratory secretions B) Nausea and vomiting C) Cough and oral thrush D) Fatigue and decreased level of consciousness

C Azmacort has possible adverse effects of cough, dysphonia, oral thrush (candidiasis), and headache. In high doses, systemic effects may occur (e.g., adrenal suppression, osteoporosis, skin thinning, and easy bruising).

A nurse is creating a health promotion intervention focused on chronic obstructive pulmonary disease (COPD). What should the nurse identify as a complication of COPD? A) Lung cancer B) Cystic fibrosis C) Respiratory failure D) Hemothorax

C Complications of COPD include respiratory failure, pneumothorax, atelectasis, pneumonia, and pulmonary hypertension (cor-pulmonale)

While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of the patients closed chest-drainage system. What should the nurse conclude? A) The system is functioning normally. B) The patient has a pneumothorax. C) The system has an air leak. D) The chest tube is obstructed.

C Constant bubbling in the chamber often indicates an air leak and requires immediate assessment and intervention. The patient with a pneumothorax will have intermittent bubbling in the water-seal chamber

A terminally ill patient you are caring for is complaining of pain. The physician has ordered a large dose of intravenous opioids by continuous infusion. You know that one of the adverse effects of this medicine is respiratory depression. When you assess your patients respiratory status, you find that the rate has decreased from 16 breaths per minute to 10 breaths per minute. What action should you take? A) Decrease the rate of IV infusion. B) Stimulate the patient in order to increase respiratory rate. C) Report the decreased respiratory rate to the physician. D) Allow the patient to rest comfortably.

C End-of life issues that often involve ethical dilemmas include pain control, do not resuscitate orders, life support measures, and administration of food and fluids. The risk of respiratory depression is not the intent of the action of pain control. Respiratory depression should not be used as an excuse to withhold pain medication for a terminally ill patient. The patients respiratory status should be carefully monitored and any changes should be reported to the physician.

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

C If additional suctioning is needed, the nurse should withdraw the catheter to the back of the pharynx, reassure the patient, and oxygenate for several minutes before resuming suctioning

The nurse is assessing a patient whose respiratory disease in characterized by chronic hyperinflation of the lungs. What would the nurse most likely assess in this patient? A) Signs of oxygen toxicity B) Chronic chest pain C) A barrel chest D) Long, thin fingers

C In COPD patients with a primary emphysematous component, chronic hyperinflation leads to the barrel chest thorax configuration

You are making initial shift assessments on your patients. While assessing one patients peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy? A) Air emboli B) Phlebitis C) Infiltration D) Fluid overload

C Infiltration is the administration of nonvesicant solution or medication into the surrounding tissue. This can occur when the IV cannula dislodges or perforates the wall of the vein. Infiltration is characterized by edema around the insertion site, leakage of IV fluid from the insertion site, discomfort and coolness in the area of infiltration, and a significant decrease in the flow rate

A nurse is providing discharge teaching for a client with COPD. When teaching the client about breathing exercises, what should the nurse include in the teaching? A) Lie supine to facilitate air entry B) Avoid pursed lip breathing C) Use diaphragmatic breathing D) Use chest breathing

C Inspiratory muscle training and breathing retraining may help improve breathing patterns in patients with COPD. Training in diaphragmatic breathing reduces the respiratory rate, increases alveolar ventilation, and, sometimes, helps expel as much air as possible during expiration. Pursed-lip breathing helps slow expiration, prevents collapse of small airways, and controls the rate and depth of respiration

A patients severe asthma has necessitated the use of a long-acting beta2 -agonist (LABA). Which of the patients statements suggests a need for further education? A) I know that these drugs can sometimes make my heart beat faster. B) I've heard that this drug is particularly good at preventing asthma attacks during exercise. C) Ill make sure to use this each time I feel an asthma attack coming on. D) I've heard that this drug sometimes gets less effective over time.

C LABAs are not used for management of acute asthma symptoms

The nurse is creating a plan of car for a patient diagnosed with acute laryngitis. What intervention should be included in the patients plan of care? A) Place warm cloths on the patients throat, as needed. B) Have the patient inhale warm steam three times daily. C) Encourage the patient to limit speech whenever possible. D) Limit the patients fluid intake to 1.5 L/day.

C Management of acute laryngitis includes resting the voice, avoiding irritants (including smoking), resting, and inhaling cool steam or an aerosol. Fluid intake should be increased

A hospice nurse is caring for a patient who is dying of lymphoma. According to Maslows hierarchy of needs, what dimension of care should the nurse consider primary in importance when caring for a dying patient? A) Spiritual B) Social C) Physiologic D) Emotional

C Maslow ranked human needs as follows: physiologic needs; safety and security; sense of belonging and affection; esteem and self-respect; and self-actualization, which includes self-fulfillment, desire to know and understand, and aesthetic needs.

A nursing student is discussing a patient with viral pharyngitis with the preceptor at the walk-in clinic. What should the preceptor tell the student about nursing care for patients with viral pharyngitis? A) Teaching focuses on safe and effective use of antibiotics. B) The patient should be preliminarily screened for surgery. C) Symptom management is the main focus of medical and nursing care. D) The focus of care is resting the voice to prevent chronic hoarseness

C Nursing care for patients with viral pharyngitis focuses on symptomatic management.

You are caring for a 65-year-old male patient admitted to your medical unit 72 hours ago with pyloric stenosis. A nasogastric tube placed upon admission has been on low intermittent suction ever since. Upon review of the mornings blood work, you notice that the patients potassium is below reference range. You should recognize that the patient may be at risk for what imbalance? A) Hypercalcemia B) Metabolic acidosis C) Metabolic alkalosis D) Respiratory acidosis

C Probably the most common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis in which only gastric fluid is lost. Vomiting, gastric suction, and pyloric stenosis all remove potassium and can cause hypokalemia.

A nurse is aware that an increasing emphasis is being placed on health, health promotion, wellness, and self-care. Which of the following activities would best demonstrate the principles of health promotion? A) A discharge planning initiative between acute care and community care nurses B) Collaboration between several schools of nursing in an urban area C) Creation of a smoking prevention program undertaken in a middle school D) Establishment of a website where patients can check emergency department wait-times

C Smoking prevention is a clear example of health promotion.

The nurse is assessing the respiratory status of a patient who is experiencing an exacerbation of her emphysema symptoms. When preparing to auscultate, what breath sounds should the nurse anticipate? A) Absence of breath sounds B) Wheezing with discontinuous breath sounds C) Faint breath sounds with prolonged expiration D) Faint breath sounds with fine crackles

C The breath sounds of the patient with emphysema are faint or often completely inaudible. When they are heard, the expiratory phase is prolonged.

A gerontologic nurse is teaching a group of medical nurses about the high incidence and mortality of pneumonia in older adults. What is a contributing factor to this that the nurse should describe? A) Older adults have less compliant lung tissue than younger adults. B) Older adults are not normally candidates for pneumococcal vaccination. C) Older adults often lack the classic signs and symptoms of pneumonia. D) Older adults often cannot tolerate the most common antibiotics used to treat pneumonia

C The diagnosis of pneumonia may be missed because the classic symptoms of cough, chest pain, sputum production, and fever may be absent or masked in older adult patients.

The nurse is caring for a patient who is receiving oxygen therapy for pneumonia. How should the nurse best assess whether the patient is hypoxemic? A) Assess the patients level of consciousness (LOC). B) Assess the patients extremities for signs of cyanosis. C) Assess the patients oxygen saturation level. D) Review the patients hemoglobin, hematocrit, and red blood cell levels.

C The effectiveness of the patients oxygen therapy is assessed by the ABG analysis or pulse oximetry

A nurse is planning care for a nephrology patient with a new nursing graduate. The nurse states, A patient in renal failure partially loses the ability to regulate changes in pH. What is the cause of this partial inability? A) The kidneys regulate and reabsorb carbonic acid to change and maintain pH. B) The kidneys buffer acids through electrolyte changes. C) The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH. D) The kidneys combine carbonic acid and bicarbonate to maintain a stable pH.

C The kidneys regulate the bicarbonate level in the ECF; they can regenerate bicarbonate ions as well as reabsorb them from the renal tubular cells. In respiratory acidosis and most cases of metabolic acidosis, the kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. The lungs regulate and reabsorb carbonic acid to change and maintain pH

While assessing an acutely ill patients respiratory rate, the nurse assesses four normal breaths followed by an episode of apnea lasting 20 seconds. How should the nurse document this finding? A) Eupnea B) Apnea C) Biots respiration D) Cheyne-Stokes

C The nurse will document that the patient is demonstrating a Biots respiration pattern. Biots respiration is characterized by periods of normal breathing (three to four breaths) followed by varying periods of apnea (usually 10 seconds to 1 minute). Cheyne-Stokes is a similar respiratory pattern, but it involves a regular cycle where the rate and depth of breathing increase and then decrease until apnea occurs

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

C The three most common symptoms of asthma are cough, dyspnea, and wheezing

A patient with chronic lung disease is undergoing lung function testing. What test result denotes the volume of air inspired and expired with a normal breath? A) Total lung capacity B) Forced vital capacity C) Tidal volume D) Residual volume

C Tidal volume refers to the volume of air inspired and expired with a normal breath 500 ML. Total lung capacity is the maximal amount of air the lungs and respiratory passages can hold after a forced inspiration. Forced vital capacity is vital capacity performed with a maximally forced expiration. Residual volume is the maximal amount of air left in the lung after a maximal expiration.

. You are the case manager for a 35-year-old man being seen at a primary care clinic for chronic low back pain. When you meet with the patient, he says that he is having problems at work; in the past year he has been absent from work about once every 2 weeks, is short-tempered with other workers, feels tired all the time, and is worried about losing his job. You are developing this patients plan of care. On what should the goals for the plan of care focus? A) Increase the patients pain tolerance in order to achieve psychosocial benefits. B) Decrease the patients need to work and increase his sleep to 8 hours per night. C) Evaluate other work options to decrease the risk of depression and ineffective coping. D) Decrease the time lost from work to increase the quality of interpersonal relationships and decrease anxiety

D

A group of nursing students are participating in a community health clinic. When providing care in this context, what should the students teach participants about disease prevention? A) It is best achieved through attending self-help groups. B) It is best achieved by reducing psychological stress. C) It is best achieved by being an active participant in the community. D) It is best achieved by exhibiting behaviors that promote health.

D

A nurse has been using the nursing process as a framework for planning and providing patient care. What action would the nurse do during the evaluation phase of the nursing process? A) Have a patient provide input on the quality of care received. B) Remove a patients surgical staples on the scheduled postoperative day. C) Provide information on a follow-up appointment for a postoperative patient. D) Document a patients improved air entry with incentive spirometric use.

D

A nurse is teaching a patient how to perform flow type incentive spirometry prior to his scheduled thoracic surgery. What instruction should the nurse provide to the patient? A) Hold the spirometer at your lips and breathe in and out like you normally would. B) When youre ready, blow hard into the spirometer for as long as you can. C) Take a deep breath and then blow short, forceful breaths into the spirometer. D) Breathe in deeply through the spirometer, hold your breath briefly, and then exhale.

D

A patient admitted with right leg thrombophlebitis is to be discharged from an acute-care facility. Following treatment with a heparin infusion, the nurse notes that the patients leg is pain-free, without redness or edema. Which step of the nursing process does this reflect? A) Diagnosis B) Analysis C) Implementation D) Evaluation

D

A patient in the ICU is status post embolectomy after a pulmonary embolus. What assessment parameter does the nurse monitor most closely on a patient who is postoperative following an embolectomy? A) Pupillary response B) Pressure in the vena cava C) White blood cell differential D) Pulmonary arterial pressure

D

A registered nurse is performing the admission assessment of a 37-year-old man who will be treated for pancreatitis on the medical unit. During the nursing assessment, the nurse asks the patient questions related to his spirituality. What is the primary rationale for this aspect of the nurses assessment? A) The patients spiritual environment can affect his physical activity. B) The patients spiritual environment can affect his ability to communicate. C) The patients spiritual environment can affect his quality of sexual relationships. D) The patients spiritual environment can affect his response to illness.

D

The ICU nurse is caring for a patient who experienced trauma in a workplace accident. The patient is complaining of having trouble breathing with abdominal pain. An ABG reveals the following results: pH 7.28, PaCO2 50 mm Hg, HCO3 23 mEq/L. The nurse should recognize the likelihood of what acidbase disorder? A) Respiratory acidosis B) Metabolic alkalosis C) Respiratory alkalosis D) Mixed acidbase disorde

D

The home health nurse is assisting a patient and his family in planning the patients return to work after surgery and the development of postsurgical complications. The nurse is preparing a plan of care that addresses the patients multifaceted needs. To which level of Maslows hierarchy of basic needs does the patients need for self-fulfillment relate? A) Physiologic B) Transcendence C) Love and belonging D) Self-actualization

D

The mother of a cancer patient comes to the nurse concerned with her daughters safety. She states that her daughters morphine dose that she needs to control her pain is getting higher and higher. As a result, the mother is afraid that her daughter will overdose. The nurse educates the mother about what aspect of her pain management? A) The dose range is higher with cancer patients, and the medical team will be very careful to prevent addiction. B) Frequently, female patients and younger patients need higher doses of opioids to be comfortable. C) The increased risk of overdose is an inevitable risk of maintaining adequate pain control during cancer treatment. D) There is no absolute maximum opioid dose and her daughter is becoming more tolerant to the drug

D

The nurse caring for a patient recently diagnosed with lung disease encourages the patient not to smoke. What is the primary rationale behind this nursing action? A) Smoking decreases the amount of mucus production. B) Smoke particles compete for binding sites on hemoglobin. C) Smoking causes atrophy of the alveoli. D) Smoking damages the ciliary cleansing mechanism.

D

The nurse is assessing a patient who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the patients respirations. How should the nurse best respond to this assessment finding? A) Gently reinsert the chest tube 1 to 2 cm and observe if the water level stabilizes. B) Inform the physician promptly that there is in imminent leak in the drainage system. C) Encourage the patient to do deep breathing and coughing exercises. D) Document that the chest drainage system is operating as it is intended

D

The nurse is caring for a male patient whose diagnosis of bone cancer is causing severe and increasing pain. Before introducing nonpharmacological pain control interventions into the patients plan of care, the nurse should teach the patient which of the following? A) Nonpharmacological interventions must be provided by individuals other than members of the healthcare team. B) These interventions will not directly reduce pain, but will refocus him on positive stimuli. C) These interventions carry similar risks of adverse effects as analgesics. D) Reducing his use of analgesics is not the purpose of these interventions.

D

The nurse is caring for a patient who is postoperative day 2 following a total laryngectomy for supraglottic cancer. The nurse should prioritize what assessment? A) Assessment of body image B) Assessment of jugular venous pressure C) Assessment of carotid pulse D) Assessment of swallowing ability

D

The nurse is performing an admission assessment of a 72-year-old female patient who understands minimal English. An interpreter who speaks the patients language is unavailable and no members of the care team speak the language. How should the nurse best perform data collection? A) Have a family member provide the data. B) Obtain the data from the old chart and physicians assessment. C) Obtain the data only from the patient, prioritizing aspects that the patient understands. D) Collect all possible data from the patient and have the family supplement missing details.

D

The physician has recommended an amniocentesis for an 18-year-old primiparous woman. The patient is 34 weeks gestation and does not want this procedure. The physician is insistent the patient have the procedure. The physician arranges for the amniocentesis to be performed. The nurse should recognize that the physician is in violation of what ethical principle? A) Veracity B) Beneficence C) Nonmaleficence D) Autonomy

D

With increases in longevity, people have had to become more knowledgeable about their health and the professional health care that they receive. One outcome of this phenomenon is the development of organized self-care education programs. Which of the following do these programs prioritize? A) Adequate prenatal care B) Government advocacy and lobbying C) Judicious use of online communities D) Management of illness

D

You are creating a nursing care plan for a patient with a primary diagnosis of cellulitis and a secondary diagnosis of chronic pain. What common trait of patients who live with chronic pain should inform your care planning? A) They are typically more comfortable with underlying pain than patients without chronic pain. B) They often have a lower pain threshold than patients without chronic pain. C) They often have an increased tolerance of pain. D) They can experience acute pain in addition to chronic pain.

D

You are following the care plan that was created for a patient newly admitted to your unit. Which of the following aspects of the care plan would be considered a nursing implementation? A) The patient will express an understanding of her diagnosis. B) The patient appears diaphoretic. C) The patient is at risk for aspiration. D) Ambulate the patient twice per day with partial assistance.

D

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

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

A nursing is planning the care of a patient with emphysema who will soon be discharged. What teaching should the nurse prioritize in the plan of care? A) Taking prophylactic antibiotics as ordered B) Adhering to the treatment regimen in order to cure the disease C) Avoiding airplanes, buses, and other crowded public places D) Setting realistic short-term and long-range goals

D A major area of teaching involves setting and accepting realistic short-term and long-range goals.

A nurse is educating a patient in anticipation of a procedure that will require a water-sealed chest drainage system. What should the nurse tell the patient and the family that this drainage system is used for? A) Maintaining positive chest-wall pressure B) Monitoring pleural fluid osmolarity C) Providing positive intrathoracic pressure D) Removing excess air and fluid

D Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood

A patient has been diagnosed with heart failure that has not yet responded to treatment. What breath sound should the nurse expect to assess on auscultation? A) Expiratory wheezes B) Inspiratory wheezes C) Rhonchi D) Crackles

D Crackles reflect underlying inflammation or congestion and are often present in such conditions as pneumonia, bronchitis, and congestive heart failure. Rhonchi and wheezes are associated with airway obstruction, which is not a part of the pathophysiology of heart failure.

A nurse is admitting a new patient to the medical unit. During the initial nursing assessment, the nurse has asked many supplementary open-ended questions while gathering information about the new patient. What is the nurse achieving through this approach? A) Interpreting what the patient has said B) Evaluating what the patient has said C) Assessing what the patient has said D) Validating what the patient has said

D Critical thinkers validate the information presented to make sure that it is accurate (not just supposition or opinion), that it makes sense, and that it is based on fact and evidence.

The nursing instructor is explaining critical thinking to a class of first-semester nursing students. When promoting critical thinking skills in these students, the instructor should encourage them to do which of the following actions? A) Disregard input from people who do not have to make the particular decision. B) Set aside all prejudices and personal experiences when making decisions. C) Weigh each of the potential negative outcomes in a situation. D) Examine and analyze all available information.

D Critical thinking involves reasoning and purposeful, systematic, reflective, rational, outcome-directed thinking based on a body of knowledge, as well as examination and analysis of all available information and ideas

A nurse is preparing to perform an admission assessment on a patient with COPD. It is most important for the nurse to review which of the following? A) Social work assessment B) Insurance coverage C) Chloride levels D) Available diagnostic tests

D In addition to the patients history, the nurse reviews the results of available diagnostic tests. Social work assessment is not a priority for the majority of patients

A patients total laryngectomy has created a need for alaryngeal speech which will be achieved through the use of tracheoesophageal puncture. What action should the nurse describe to the patient when teaching him about this process? A) Training on how to perform controlled belching B) Use of an electronically enhanced artificial pharynx C) Insertion of a specialized nasogastric tube D) Fitting for a voice prosthesis

D In patients receiving transesophageal puncture, a valve is placed in the tracheal stoma to divert air into the esophagus and out the mouth. Once the puncture is surgically created and has healed, a voice prosthesis (Blom-Singer) is fitted over the puncture site

A student nurse has been assigned to provide basic care for a 58-year-old man with a diagnosis of AIDS related pneumonia. The student tells the instructor that she is unwilling to care for this patient. What key component of critical thinking is most likely missing from this students practice? A) Compliance with direction B) Respect for authority C) Analyzing information and situations D) Withholding judgment

D Key components of critical thinking behavior are withholding judgment and being open to options and explanations from one patient to another in similar circumstances.

The nurse is providing care for a patient with chronic obstructive pulmonary disease (COPD). The nurses most recent assessment reveals an SaO2 of 89%. The nurse is aware that part of critical thinking is determining the significance of data that have been gathered. What characteristic of critical thinking is used in determining the best response to this assessment finding? A) Extrapolation B) Inference C) Characterization D) Interpretation

D Nurses use interpretation to determine the significance of data that are gathered. This specific process is not described as extrapolation, inference, or characterization.

A nurse is explaining to a patient with asthma what her new prescription for prednisone is used for. What would be the most accurate explanation that the nurse could give? A) To ensure long-term prevention of asthma exacerbations B) To cure any systemic infection underlying asthma attacks C) To prevent recurrent pulmonary infections D) To gain prompt control of inadequately controlled, persistent asthma

D Prednisone is used for a short-term (310 days) burst to gain prompt control of inadequately controlled, persistent asthma

A patient is having pulmonary-function studies performed. The patient performs a spirometry test, revealing an FEV1 /FVC ratio of 60%. How should the nurse interpret this assessment finding? A) Strong exercise tolerance B) Exhalation volume is normal C) Respiratory infection D) Obstructive lung disease

D Spirometry is used to evaluate airflow obstruction, which is determined by the ratio of forced expiration volume in 1 second to forced vital capacity. Obstructive lung disease is apparent when an FEV1 /FVC ratio is less than 70%.

During report, a nurse finds that she has been assigned to care for a patient admitted with an opportunistic infection secondary to AIDS. The nurse informs the clinical nurse leader that she is refusing to care for him because he has AIDS. The nurse has an obligation to this patient under which legal premise? A) Good Samaritan Act B) Nursing Interventions Classification (NIC) C) Patient Self-Determination Act D) ANA Code of Ethics

D The ethical obligation to care for all patients is clearly identified in the first statement of the ANA Code of Ethics for Nurses

The home care nurse is monitoring a patient discharged home after resolution of a pulmonary embolus. For what potential complication would the home care nurse be most closely monitoring this patient? A) Signs and symptoms of pulmonary infection B) Swallowing ability and signs of aspiration C) Activity level and role performance D) Residual effects of compromised oxygenation

D The home care nurse should monitor the patient for residual effects of the PE, which involved a severe disruption in respiration and oxygenation. PE has a noninfectious etiology; pneumonia is not impossible, but it is a less likely sequela. Swallowing ability is unlikely to be affected; activity level is important, but secondary to the effects of deoxygenation.

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

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

You are caring for a patient who is being treated on the oncology unit with a diagnosis of lung cancer with bone metastases. During your assessment, you note the patient complains of a new onset of weakness with abdominal pain. Further assessment suggests that the patient likely has a fluid volume deficit. You should recognize that this patient may be experiencing what electrolyte imbalance? A) Hypernatremia B) Hypomagnesemia C) Hypophosphatemia D) Hypercalcemia

D The most common causes of hypercalcemia are malignancies and hyperparathyroidism. Anorexia, nausea, vomiting, and constipation are common symptoms of hypercalcemia. Dehydration occurs with nausea, vomiting, anorexia, and calcium reabsorption at the proximal renal tubule. Abdominal and bone pain may also be present.

You are the nurse caring for the 25-year-old victim of a motor vehicle accident with a fractured pelvis and a ruptured bladder. The nurses aide (NA) tells you that she is concerned because the patients resting heart rate is 110 beats per minute, her respirations are 24 breaths per minute, temperature is 99.1F axillary, and the blood pressure is 125/85 mm Hg. What other information is most important as you assess this patients physiologic status? A) The patients understanding of pain physiology B) The patients serum glucose level C) The patients white blood cell count D) The patients rating of her pain

D The nurses assessment of the patients pain is a priority.

The nurse caring for a patient with an endotracheal tube recognizes several disadvantages of an endotracheal tube. What would the nurse recognize as a disadvantage of endotracheal tubes? A) Cognition is decreased. B) Daily arterial blood gases (ABGs) are necessary. C) Slight tracheal bleeding is anticipated. D) The cough reflex is depressed.

D There are several disadvantages of an endotracheal tube. Disadvantages include suppression of the patients cough reflex, thickening of secretions, and depressed swallowing reflexes

A patient has a diagnosis of multiple sclerosis. The nurse is aware that neuromuscular disorders such as multiple sclerosis may lead to a decreased vital capacity. What does vital capacity measure? A) The volume of air inhaled and exhaled with each breath B) The volume of air in the lungs after a maximal inspiration C) The maximal volume of air inhaled after normal expiration D) The maximal volume of air exhaled from the point of maximal inspiration

D Vital capacity is measured by having the patient take in a maximal breath and exhale fully through a spirometer. Vital lung capacity is the maximal volume of air exhaled from the point of maximal inspiration, and neuromuscular disorders such as multiple sclerosis may lead to a decreased vital capacity. Tidal volume is defined as the volume of air inhaled and exhaled with each breath. The volume of air in the lungs after a maximal inspiration is the total lung capacity. Inspiratory capacity is the maximal volume of air inhaled after normal expiration.

A newly graduated nurse is admitting a patient with a long history of emphysema. The new nurses preceptor is going over the patients past lab reports with the new nurse. The nurse takes note that the patients PaCO2 has been between 56 and 64 mm Hg for several months. The preceptor asks the new nurse why they will be cautious administering oxygen. What is the new nurses best response? A) The patients calcium will rise dramatically due to pituitary stimulation. B) Oxygen will increase the patients intracranial pressure and create confusion. C) Oxygen may cause the patient to hyperventilate and become acidotic. D) Using oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia.

D When PaCO2 chronically exceeds 50 mm Hg, it creates insensitivity to CO2 in the respiratory medulla, and the use of oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia

A care conference has been organized for a patient with complex medical and psychosocial needs. When applying the principles of critical thinking to this patients care planning, the nurse should most exemplify what characteristic? A) Willingness to observe behaviors B) A desire to utilize the nursing scope of practice fully C) An ability to base decisions on what has happened in the past D) Openness to various viewpoints

D Willingness and openness to various viewpoints are inherent in critical thinking; these allow the nurse to reflect on the current situation