Exam 1 Test Bank

The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Document the amount of drainage every eight hours. b. Obtain samples of drainage for culture from the system. c. Assess patient pain level associated with the chest tube. d. Check the water-seal chamber for the correct fluid level.

A UAP education includes documentation of intake and output. The other actions are within the scope of practice and education of licensed nursing personnel. .

A patient in metabolic alkalosis is admitted to the emergency department, and pulse oximetry (SpO2) indicates that the O2 saturation is 94%. Which action should the nurse take next? a. Administer bicarbonate. b. Complete a head-to-toe assessment. c. Place the patient on high-flow oxygen. d. Obtain repeat arterial blood gases (ABGs).

C Although the O2 saturation is adequate, the left shift in the oxyhemoglobin dissociation curve will decrease the amount of oxygen delivered to tissues, so high oxygen concentrations should be given. Bicarbonate would worsen the patients condition. A head-to-toe assessment and repeat ABGs may be implemented. However, the priority intervention is to give high-flow oxygen.

A patient has carbon dioxide retention from lung problems. Which type of diet will the nurse most likely suggest for this patient? a. Low-carbohydrate b. Low-caffeine c. High-caffeine d. High-carbohydrate

A A low-carbohydrate diet is best. Diets high in carbohydrates play a role in increasing the carbon dioxide load for patients with carbon dioxide retention. As carbohydrates are metabolized, an increased load of carbon dioxide is created and excreted via the lungs. A low- or high-caffeine diet is not as important as the carbohydrate load. .

A 68-year-old male patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by his spouse. Which action will the nurse take first? a. Check oxygen saturation. b. Assess pupil reaction to light. c. Verify Glasgow Coma Scale (GCS) score. d. Palpate the head for hematoma or bony irregularities

A Airway patency and breathing are the most vital functions, and should be assessed first. The neurologic assessments should be accomplished next and additional assessment after that. .

A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the nurse collect to determine whether a patient is developing postconcussion syndrome? a. Short-term memory b. Muscle coordination c. Glasgow Coma Scale d. Pupil reaction to light

A Decreased short-term memory is one indication of post-concussion syndrome. The other data may be assessed but are not indications of postconcussion syndrome. .

The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect? a. Increased tactile fremitus b. Dry, nonproductive cough c. Hyperresonance to percussion d. A grating sound on auscultation .

A Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal pneumonia typically presents with a loose, productive cough. Adventitious breath sounds such as crackles and wheezes are typical. A grating sound is more representative of a pleural friction rub rather than pneumonia.

A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is receiving 2 L/min of oxygen. Which oxygen delivery device is most appropriate for the nurse to administer the oxygen? a. Nasal cannula b. Simple face mask c. Non-rebreather mask d. Partial non-rebreather mask

A Nasal cannulas deliver oxygen from 1 to 6 L/min. All other devices (simple face mask, non- rebreather mask, and partial non-rebreather mask) are intended for flow rates greater than 6 L/min .

The nurse is caring for a patient with fluid volume overload. Which physiological effect does the nurse most likely expect? a. Increased preload b. Increased heart rate c. Decreased afterload d. Decreased tissue perfusion .

A Preload refers to the amount of blood in the left ventricle at the end of diastole; an increase in circulating volume would increase the preload of the heart. Afterload refers to resistance; increased pressure would lead to increased resistance, and afterload would increase. A decrease in tissue perfusion would be seen with hypovolemia. A decrease in fluid volume would cause an increase in heart rate as the body is attempting to increase cardiac output

When admitting an acutely confused 20-year-old patient with a head injury, which action should the nurse take? a. Ask family members about the patients health history. b. Ask leading questions to assist in obtaining health data. c. Wait until the patient is better oriented to ask questions. d. Obtain only the physiologic neurologic assessment data .

A When admitting a patient who is likely to be a poor historian, the nurse should obtain health history information from others who have knowledge about the patients health. Waiting until the patient is oriented or obtaining only physiologic data will result in incomplete assessment data, which could adversely affect decision making about treatment. Asking leading questions may result in inaccurate or incomplete information. .

Which findings will alert the nurse that stress is present when making a clinical decision? (Select all that apply.) a. Tense muscles b. Reactive responses c. Trouble concentrating d. Very tired feelings e. Managed emotions

A, B, C, D Learn to recognize when you are feeling stressed—your muscles will tense, you become reactive when others communicate with you, you have trouble concentrating, and you feel very tired. Emotions are not managed when stressed. .

The nurse notes new onset confusion in an older patient who is normally alert and oriented. In which order should the nurse take the following actions? a. Obtain the oxygen saturation. b. Check the patients pulse rate. c. Document the change in status. d. Notify the health care provider.

A, B, D, C Assessment for physiologic causes of new onset confusion such as pneumonia, infection, or perfusion problems should be the first action by the nurse. - Airway and oxygenation should be assessed first, then circulation. - After assessing the patient, the nurse should notify the health care provider. - Finally, documentation of the assessments and care should be done.

Which statement by a 40-year-old patient who is being discharged from the emergency department (ED) after a concussion indicates a need for intervention by the nurse? a. I will return if I feel dizzy or nauseated. b. I am going to drive home and go to bed. c. I do not even remember being in an accident. d. I can take acetaminophen (Tylenol) for my headache.

B Following a head injury, the patient should avoid driving and operating heavy machinery. Retrograde amnesia is common after a concussion. The patient can take acetaminophen for headache and should return if symptoms of increased intracranial pressure such as dizziness or nausea occur. .

The nurse observes that the patient's calcium is elevated. When checking the phosphate level, what does the nurse expect to see? a. Increased b. Decreased c. Equal to calcium d. No change in phosphate .

B Phosphate will decrease. Serum calcium and phosphate have an inverse relationship. When one is elevated, the other decreases, except in some patients with end-stage renal disease. . .

The nurse is caring for an infant and is obtaining the patient's vital signs. Which artery will the nurse use to best obtain the infant's pulse? a. Radial b. Brachial c. Femoral d. Popliteal .

B The brachial or apical pulse is the best site for assessing an infant's or a young child's pulse because other peripheral pulses such as the radial, femoral, and popliteal arteries are deep and difficult to palpate accurately . .

Which medications will the nurse teach the patient about whose peptic ulcer disease is associated with Helicobacter pylori? a. Sucralfate (Carafate), nystatin (Mycostatin), and bismuth (Pepto-Bismol) b. Amoxicillin (Amoxil), clarithromycin (Biaxin), and omeprazole (Prilosec) c. Famotidine (Pepcid), magnesium hydroxide (Mylanta), and pantoprazole (Protonix) d. Metoclopramide (Reglan), bethanechol (Urecholine), and promethazine (Phenergan)

B The drugs used in triple drug therapy include a proton pump inhibitor such as omeprazole and the antibiotics amoxicillin and clarithromycin. The other combinations listed are not included in the protocol for H. pyloriinfection. .

A patient who smokes a pack of cigarettes per day tells the nurse, I enjoy smoking and have no plans to quit. Which nursing diagnosis is most appropriate? a. Health seeking behaviors related to cigarette use b. Ineffective health maintenance related to tobacco use c. Readiness for enhanced self-health management related to smoking d. Deficient knowledge related to long-term effects of cigarette smoking

B The patients statement indicates that he or she is not considering smoking cessation. Ineffective health maintenance is defined as the inability to identify, manage, and/or seek out help to maintain health. .

Which cerebrospinal fluid analysis result will be most important for the nurse to communicate to the health care provider? a. Specific gravity 1.007 b. Protein 65 mg/dL (0.65 g/L) c. Glucose 45 mg/dL (1.7 mmol/L) d. White blood cell (WBC) count 4 cells/mL .

B The protein level is high. The specific gravity, WBCs, and glucose values are normal. .

Which information about an 80-year-old man at the senior center is of most concern to the nurse? a. Decreased appetite b. Unintended weight loss c. Difficulty chewing food d. Complaints of indigestion .

B Unintentional weight loss is not a normal finding and may indicate a problem such as cancer or depression. Poor appetite, difficulty in chewing, and complaints of indigestion are common in older patients. These will need to be addressed but are not of as much concern as the weight loss .

A nurse is caring for a group of patients. Which patient will the nurse see first? a. A 17-year-old male who has just returned from outside "for a smoke" who needs a temperature taken b. A 20-year-old male postoperative patient whose blood pressure went from 128/70 to 100/60 c. A 27-year-old male patient reporting pain whose blood pressure went from 124/70 to 130/74 d. An 87-year-old male suspected of hypothermia whose temperature is below normal .

B When a blood pressure drops in a postoperative patient, bleeding may be occurring and lead to shock. The nurse should assess this patient first. Pain will cause the blood pressure to elevate so this is an expected finding, and while it does need to be assessed, it is not the first one to assess. A teenager who has returned from smoking will have to wait at least 20 minutes before a temperature can be taken, so this is not the first one to see. A patient with hypothermia is expected to have a temperature below normal, so this is not the first one to see

Which assessments will the nurse make to monitor a patients cerebellar function (select all that apply)? a. Assess for graphesthesia. b. Observe arm swing with gait. c. Perform the finger-to-nose test. d. Check ability to push against resistance. e. Determine ability to sense heat and cold

B, C The cerebellum is responsible for coordination and is assessed by looking at the patients gait and the finger-to- nose test. The other assessments will be used for other parts of the neurologic assessment. .

A patient has a head injury and damages the hypothalamus. Which vital sign will the nurse monitor most closely? a. Pulse b. Respirations c. Temperature d. Blood pressure .

C Disease or trauma to the hypothalamus or the spinal cord, which carries hypothalamic messages, causes serious alterations in temperature control. The hypothalamus does not control pulse, respirations, or blood pressure. .

A nurse is using the critical thinking skill of evaluation. Which action will the nurse take? a. Examine the meaning of data. b. Support findings and conclusions. c. Review the effectiveness of nursing actions. d. Search for links between the data and the nurse's assumptions. .

C Reviewing the effectiveness of interventions best describes evaluation. Examining the meaning of data is inference. Supporting findings and conclusions provides explanations. Searching for links between the data and the nurse's assumptions describes analysis. .

A patient's heart rate increased from 94 to 164 beats/min. What will the nurse expect? a. Increase in diastolic filling time b. Decrease in hemoglobin level c. Decrease in cardiac output d. Increase in stroke volume .

C With a sustained heart rate greater than 160 beats/min, diastolic filling time decreases, decreasing stroke volume and cardiac output. The hemoglobin level would not be affected. .

The nurse plans to teach a patient and the caregiver how to manage high blood pressure (BP). Which action should the nurse take first? a. Give written information about hypertension to the patient and caregiver. b. Have the dietitian meet with the patient and caregiver to discuss a low sodium diet. c. Teach the caregiver how to take the patients BP using a manual blood pressure cuff. d. Ask the patient and caregiver to select information from a list of high BP teaching topics.

D Because adults learn best when given information that they view as being needed immediately, asking the caregiver and patient to prioritize learning needs is likely to be the most successful approach to home management of health problems. The other actions may also be appropriate, depending on what learning needs the caregiver and patient have, but the initial action should be to assess what the learners feel is important.

When caring for a patient with a history of a total gastrectomy, the nurse will monitor for a. constipation. b. dehydration. c. elevated total serum cholesterol. d. cobalamin (vitamin B12) deficiency. .

D The patient with a total gastrectomy does not secrete intrinsic factor, which is needed for cobalamin (vitamin B12) absorption. Because the stomach absorbs only small amounts of water and nutrients, the patient is not at higher risk for dehydration, elevated cholesterol, or constipation. .

The nurse explaining esomeprazole (Nexium) to a patient with recurring heartburn describes that the medication a. reduces gastroesophageal reflux by increasing the rate of gastric emptying. b. neutralizes stomach acid and provides relief of symptoms in a few minutes. c. coats and protects the lining of the stomach and esophagus from gastric acid. d. treats gastroesophageal reflux disease by decreasing stomach acid production. .

D The proton pump inhibitors decrease the rate of gastric acid secretion. - Pro-motility drugs such as metoclopramide (Reglan) increase the rate of gastric emptying. - Cryoprotective medications such as sucralfate (Carafate) protect the stomach. - Antacids neutralize stomach acid and work rapidly

A nurse who is caring for a patient with a pressure ulcer applies the recommended dressing according to hospital policy. Which standard is the nurse following? a. Fairness b. Intellectual standards c. Independent reasoning d. Institutional practice guidelines

D The standards of professional responsibility that a nurse tries to achieve are the standards cited in Nurse Practice Acts, institutional practice guidelines (hospital/facility policy), and professional organizations' standards of practice (e.g., The American Nurses Association Standards of Professional Performance). Intellectual standards are guidelines or principles for rational thought. Fairness and independent reasoning are two examples of critical thinking attitudes that are designed to help nurses make clinical decisions.

Angiotensin II a. Increases excretion of sodium and water b. Reduces excretion of sodium and water c. Reduces excretion of water d. Major buffer in the extracellular fluid e. Vasoconstricts and stimulates aldosterone release

E

A patient has 250 mL of a jejunostomy feeding with 30 mL of water before and after feeding and 200 mL of urine. Thirty minutes later the patient has 100 mL of diarrhea. At 1300 the patient receives 150 mL of blood and voids another 200 mL. Calculate the patient's intake. Record your answer as a whole number. _____ mL

460 The patient's fluid intake is 250 mL of feeding, 60 mL of water (30 mL before and after), and 150 blood: . Fluid intake includes all liquids that a person eats (e.g., gelatin, ice cream, soup), drinks (e.g., water, coffee, juice), or receives through nasogastric or jejunostomy feeding tubes. IV fluids (continuous infusions and intermittent IV piggybacks) and blood components also are sources of intake. Fluid output includes urine, diarrhea, vomitus, gastric suction, and drainage from postsurgical wounds or other tubes.

Atrial natriuretic peptide a. Increases excretion of sodium and water b. Reduces excretion of sodium and water c. Reduces excretion of water d. Major buffer in the extracellular fluid e. Vasoconstricts and stimulates aldosterone release

A

Heatstroke a. Patient's temperature is 113° F (45° C) with hot, dry skin. b. Patient's blood pressure sitting is 130/60 and 110/40 standing. c. Patient's pulse is 110 beats/min. d. Patient's temperature is 93.2° F (34° C). e. Patient's blood pressure went from 126/76 to 90/50.

A

The health care provider has ordered a hypotonic intravenous (IV) solution to be administered. Which IV bag will the nurse prepare? a. 0.45% sodium chloride (1/2 NS) b. 0.9% sodium chloride (NS) c. Lactated Ringer's (LR) d. Dextrose 5% in Lactated Ringer's (D5LR)

A 0.45% sodium chloride is a hypotonic solution. NS and LR are isotonic. D5LR is hypertonic

A nurse is caring for a patient who has poor tissue perfusion as the result of hypertension. When the patient asks what to eat for breakfast, which meal should the nurse suggest? a. A cup of nonfat yogurt with granola and a handful of dried apricots b. Whole wheat toast with butter and a side of bacon c. A bowl of cereal with whole milk and a banana d. Omelet with sausage, cheese, and onions

A A 2000-calorie diet of fruits, vegetables, and low-fat dairy foods that are high in fiber, potassium, calcium, and magnesium and low in saturated and total fat helps prevent and reduce the effects of hypertension. Nonfat yogurt with granola is a good source of calcium, fiber, and potassium; dried apricots add a second source of potassium. Although cereal and a banana provide fiber and potassium, skim milk should be substituted for whole milk to decrease fat. An omelet with sausage and cheese is high in fat. Butter and bacon are high in fat.

The hospital nurse implements a teaching plan to assist an older patient who lives alone to independently accomplish daily activities. How would the nurse best evaluate the patients long-term response to the teaching? a. Make a referral to the home health nursing department for home visits. b. Have the patient demonstrate the learned skills at the end of the teaching session. c. Arrange a physical therapy visit before the patient is discharged from the hospital. d. Check the patients ability to bathe and get dressed without any assistance the next day

A A home health referral would allow for the assessment of the patients long-term response after discharge. The other actions allow evaluation of the patients short-term response to teaching. .

The day shift nurse at the long-term care facility learns that a patient with dementia experienced sundowning late in the afternoon on the previous two days. Which action should the nurse take? a. Keep blinds open during the daytime hours. b. Provide hourly orientation to time and place. c. Have the patient take a brief mid-morning nap. d. Move the patient to a quieter room late in the afternoon

A A likely cause of sundowning is a disruption in circadian rhythms and keeping the patient active and in daylight will help reestablish a more normal circadian pattern. Moving the patient to a different room might increase confusion. Taking a nap will interfere with nighttime sleep. Hourly orientation will not be helpful in a patient with dementia.

A nurse is caring for a patient with peripheral intravenous (IV) therapy. Which task will the nurse assign to the nursing assistive personnel? a. Recording intake and output b. Regulating intravenous flow rate c. Starting peripheral intravenous therapy d. Changing a peripheral intravenous dressing

A A nursing assistive personnel (NAP) can record intake and output. An RN cannot delegate regulating flow rate, starting an IV, or changing an IV dressing to an NAP .

A middle-aged patient who has diabetes tells the nurse, I want to know how to give my own insulin so I dont have to bother my wife all the time. What is the priority action of the nurse? a. Demonstrate how to draw up and administer insulin. b. Discuss the use of exercise to decrease insulin needs. c. Teach about differences between the various types of insulin. d. Provide handouts about therapeutic and adverse effects of insulin.

A Adult education is most effective when focused on information that the patient thinks is needed right now. All of the indicated information will need to be included when planning teaching for this patient, but the teaching will be most effective if the nurse starts with the patients stated priority topic. .

A patient with newly diagnosed colon cancer has a nursing diagnosis of deficient knowledge about colon cancer. The nurse should initially focus on which learning goal for this patient? a. The patient will select the most appropriate colon cancer therapy. b. The patient will state ways of preventing the recurrence of the cancer. c. The patient will demonstrate coping skills needed to manage the disease. d. The patient will choose methods to minimize adverse effects of treatment.

A Adults learn best when given information that can be used immediately. The first action the patient will need to take after a cancer diagnosis is to choose a treatment option. The other goals may be appropriate as treatment progresses. .

Which patient is most appropriate for the intensive care unit (ICU) charge nurse to assign to a registered nurse (RN) who has floated from the medical unit? a. A 45-year-old receiving IV antibiotics for meningococcal meningitis b. A 25-year-old admitted with a skull fracture and craniotomy the previous day c. A 55-year-old who has increased intracranial pressure (ICP) and is receiving hyperventilation therapy d. A 35-year-old with ICP monitoring after a head injury last week

A An RN who works on a medical unit will be familiar with administration of IV antibiotics and with meningitis. The post-craniotomy patient, patient with an ICP monitor, and the patient on a ventilator should be assigned to an RN familiar with the care of critically ill patients. .

The patient is experiencing angina pectoris. Which assessment finding does the nurse expect when conducting a history and physical examination? a. Experiences chest pain after eating a heavy meal b. Experiences adequate oxygen saturation during exercise c. Experiences crushing chest pain for more than 20 minutes d. Experiences tingling in the left arm that lasts throughout the morning

A Angina pectoris is chest pain that results from limited oxygen supply. Often pain is precipitated by activities such as exercise, stress, and eating a heavy meal and lasts 3 to 5 minutes. Symptoms of angina pectoris are relieved by rest and/or nitroglycerin. Adequate oxygen saturation occurs with rest; inadequate oxygen saturation occurs during exercise. Pain lasting longer than 20 minutes or arm tingling that persists could be a sign of myocardial infarction

A 45-year-old patient has a dysfunction of the cerebellum. The nurse will plan interventions to a. prevent falls. b. stabilize mood. c. avoid aspiration. d. improve memory .

A Because functions of the cerebellum include coordination and balance, the patient with dysfunction is at risk for falls. The cerebellum does not affect memory, mood, or swallowing ability. .

A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan. Which information obtained by the nurse is a priority to communicate to the health care provider before the CT? a. Allergy to shellfish b. Apical pulse of 104 c. Respiratory rate of 30 d. Oxygen saturation of 90%

A Because iodine-based contrast media is used during a spiral CT, the patient may need to have the CT scan without contrast or be pre-medicated before injection of the contrast media. The increased pulse, low oxygen saturation, and tachypnea all indicate a need for further assessment or intervention but do not indicate a need to modify the CT procedure.

A patient has had emphysema (lung disease) for many years. When approached by the nurse, the patient states "I would be better off dead." The patient supports the family, and now because of oxygen dependency the patient must quit work. The patient's spouse will have to go to work. Which action should the nurse take? a. Develop a plan of care for the family. b. Contact psychiatric services for a referral. c. Assure the patient that things will work out. d. Focus the plan of care solely on maximizing patient function.

A Because of the effects of chronic illness, family dynamics often change. The nurse must view the whole family as a patient under stress, planning care to help the family regain its maximal level of functioning and well-being. Psychiatric services may be a part of that plan but do not represent the entire plan. Offering false assurance is never acceptable. Focusing only on the patient will not help the family adjust.

The clinic nurse teaches a patient with a 42 pack-year history of cigarette smoking about lung disease. Which information will be most important for the nurse to include? a. Options for smoking cessation b. Reasons for annual sputum cytology testing c. Erlotinib (Tarceva) therapy to prevent tumor risk d. Computed tomography (CT) screening for lung cancer

A Because smoking is the major cause of lung cancer, the most important role for the nurse is teaching patients about the benefits of and means of smoking cessation. CT scanning is currently being investigated as a screening test for high-risk patients. However, if there is a positive finding, the person already has lung cancer. Erlotinib may be used in patients who have lung cancer, but it is not used to reduce the risk of developing cancer.

The nurse is careful to monitor a patient's cardiac output. Which goal is the nurse trying to achieve? a. To determine peripheral extremity circulation b. To determine oxygenation requirements c. To determine cardiac dysrhythmias d. To determine ventilation status .

A Cardiac output indicates how much blood is being circulated systemically throughout the body to the periphery. The amount of blood ejected from the left ventricle each minute is the cardiac output. - Oxygen status would be determined by pulse oximetry and the presence of cyanosis. - Cardiac dysrhythmias are an electrical impulse monitored through ECG results. - Ventilation status is measured by respiratory rate, pulse oximetry, and capnography. Capnography provides instant information about the patient's ventilation. Ventilation status does not depend solely on cardiac output.

The patient has an intravenous (IV) line and the nurse needs to remove the gown. In which order will the nurse perform the steps, starting with the first one? 1. Remove the sleeve of the gown from the arm without the IV. 2. Remove the sleeve of the gown from the arm with the IV. 3. Remove the IV solution container from its stand. 4. Pass the IV bag and tubing through the sleeve. a. 1, 2, 3, 4 b. 2, 3, 4, 1 c. 3, 4, 1, 2 d. 4, 1, 2, 3

A Change regular gowns by following these steps for maximum speed and arm mobility: (1) To remove a gown, remove the sleeve of the gown from the arm without the IV line, maintaining the patient's privacy. (2) Remove the sleeve of the gown from the arm with the IV line. (3) Remove the IV solution container from its stand, and pass it and the tubing through the sleeve. (If this involves removing the tubing from an EID, use the roller clamp to slow the infusion to prevent the accidental infusion of a large volume of solution or medication.)

After being hit by a baseball, a patient arrives in the emergency department with a possible nasal fracture. Which finding by the nurse is most important to report to the health care provider? a. Clear nasal drainage b. Complaint of nasal pain c. Bilateral nose swelling and bruising d. Inability to breathe through the nose

A Clear nasal drainage may indicate a meningeal tear with leakage of cerebrospinal fluid. This would place the patient at risk for complications such as meningitis. The other findings are typical with a nasal fracture and do not indicate any complications.

A patient with chronic obstructive pulmonary disease (COPD) asks the nurse why clubbing occurs. Which response by the nurse is most therapeutic? a. "Your disease doesn't send enough oxygen to your fingers." b. "Your disease affects both your lungs and your heart, and not enough blood is being pumped." c. "Your disease will be helped if you pursed-lip breathe." d. "Your disease often makes patients lose mental status."

A Clubbing of the nail bed can occur with COPD and other diseases that cause prolonged oxygen deficiency or chronic hypoxemia. Pursed-lipped breathing helps the alveoli stay open but is not the cause of clubbing. Loss of mental status is not a normal finding with COPD and will not result in clubbing. Low oxygen and not low circulating blood volume is the problem in COPD that results in clubbing

Which patient statement indicates that the nurses teaching following a gastroduodenostomy has been effective? a. Vitamin supplements may prevent anemia. b. Persistent heartburn is common after surgery. c. I will try to drink more liquids with my meals. d. I will need to choose high carbohydrate foods. .

A Cobalamin deficiency may occur after partial gastrectomy, and the patient may need to receive cobalamin via injections or nasal spray. Although peptic ulcer disease may recur, persistent heartburn is not expected after surgery and the patient should call the health care provider if this occurs. Ingestion of liquids with meals is avoided to prevent dumping syndrome. Foods that have moderate fat and low carbohydrate should be chosen to prevent dumping syndrome.

A female patient who had a stroke 24 hours ago has expressive aphasia. The nurse identifies the nursing diagnosis of impaired verbal communication. An appropriate nursing intervention to help the patient communicate is to a. ask questions that the patient can answer with yes or no. b. develop a list of words that the patient can read and practice reciting. c. have the patient practice her facial and tongue exercises with a mirror. d. prevent embarrassing the patient by answering for her if she does not respond.

A Communication will be facilitated and less frustrating to the patient when questions that require a yes or no response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond.

A nursing instructor needs to evaluate students' abilities to synthesize data and identify relationships between nursing diagnoses. Which learning assignment is best suited for this instructor's needs? a. Concept mapping b. Reflective journaling c. Lecture and discussion d. Reading assignment with a written summary

A Concept mapping challenges the student to synthesize data and identify relationships between nursing diagnoses. The primary purpose of concept mapping is to better synthesize relevant data about a patient, including assessment data, nursing diagnoses, health needs, nursing interventions, and evaluation measures. Reflective journaling involves thinking back to clarify concepts. Reading assignments and lecture do not best provide an instructor the ability to evaluate students' abilities to synthesize data.

The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment would best evaluate the effectiveness of the therapies? a. Observe for distended neck veins. b. Auscultate for crackles in the lungs. c. Palpate for heaves or thrills over the heart. d. Review hemoglobin and hematocrit values.

A Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations of right ventricular failure such as peripheral edema, jugular venous distention, & right upper-quadrant abdominal tenderness would be expected. Crackles in the lungs are likely to be heard with left-sided heart failure. Findings in cor pulmonale include evidence of right ventricular hypertrophy on electrocardiogram (ECG) & an increase in intensity of the second heart sound. Heaves or thrills are not common with cor pulmonale. Chronic hypoxemia leads to polycythemia & increased total blood volume & viscosity of the blood. The hemoglobin & hematocrit values are more likely to be elevated with cor pulmonale than decreased.

A patient with bacterial pneumonia has rhonchi and thick sputum. What is the nurses most appropriate action to promote airway clearance? a. Assist the patient to splint the chest when coughing. b. Teach the patient about the need for fluid restrictions. c. Encourage the patient to wear the nasal oxygen cannula. d. Instruct the patient on the pursed lip breathing technique.

A Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal oxygen will improve gas exchange, but will not improve airway clearance. Pursed lip breathing is used to improve gas exchange in patients with COPD, but will not improve airway clearance.

On auscultation of a patients lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding? a. Inspiratory crackles at the bases b. Expiratory wheezes in both lungs c. Abnormal lung sounds in the apices of both lungs d. Pleural friction rub in the right and left lower lobes

A Crackles are low-pitched, bubbling sounds usually heard on inspiration. - Wheezes are high-pitched sounds. They can be heard during the expiratory or inspiratory phase of the respiratory cycle. - The lower third of both lungs are the bases, not apices. - Pleural friction rubs are grating sounds that are usually heard during both inspiration and expiration.

The nurse will anticipate preparing a 71-year-old female patient who is vomiting coffee-ground emesis for a. endoscopy. b. angiography. c. barium studies. d. gastric analysis. .

A Endoscopy is the primary tool for visualization and diagnosis of upper gastrointestinal (GI) bleeding. Angiography is used only when endoscopy cannot be done because it is more invasive and has more possible complications. Barium studies are helpful in determining the presence of gastric lesions, but not whether the lesions are actively bleeding. Gastric analysis testing may help with determining the cause of gastric irritation, but it is not used for acute GI bleeding.

Which action will the public health nurse take to reduce the incidence of epidemic encephalitis in a community? a. Encourage the use of effective insect repellents during mosquito season. b. Remind patients that most cases of viral encephalitis can be cared for at home. c. Teach about the importance of prophylactic antibiotics after exposure to encephalitis. d. Arrange for screening of school-age children for West Nile virus during the school year. .

A Epidemic encephalitis is usually spread by mosquitoes and ticks. Use of insect repellent is effective in reducing risk. Encephalitis frequently requires that the patient be hospitalized in an intensive care unit during the initial stages. Antibiotic prophylaxis is not used to prevent encephalitis because most encephalitis is viral. West Nile virus is most common in adults over age 50 during the summer and early fall.

The nurse administers an intravenous (IV) hypertonic solution to a patient. In which direction will the fluid shift? a. From intracellular to extracellular b. From extracellular to intracellular c. From intravascular to intracellular d. From intravascular to interstitial .

A Hypertonic solutions will move fluid from the intracellular to the extracellular (intravascular). A hypertonic solution has a concentration greater than normal body fluids, so water will shift out of cells because of the osmotic pull of the extra particles. Movement of water from the extracellular (intravascular) into cells (intracellular) occurs when hypotonic fluids are administered. Distribution of fluid between intravascular and interstitial spaces occurs by filtration, the net sum of hydrostatic and osmotic pressures

A nurse is teaching a patient about the Speak Up Initiatives. Which information should the nurse include in the teaching session? a. If you still do not understand, ask again. b. Ask a nurse to be your advocate or supporter. c. The nurse is the center of the health care team. d. Inappropriate medical tests are the most common mistakes.

A If you still do not understand, ask again is part of the S portion of the Speak Up Initiatives. Speak up if you have questions or concerns. You (the patient) are the center of the health care team, not the nurse. Ask a trusted family member or friend to be your advocate (advisor or supporter), not a nurse. Medication errors are the most common health care mistakes, not inappropriate medical tests.

A 58-year-old woman has just returned to the nursing unit after an esophagogastroduodenoscopy (EGD). Which action by unlicensed assistive personnel (UAP) requires that the registered nurse (RN) intervene? a. Offering the patient a drink of water b. Positioning the patient on the right side c. Checking the vital signs every 30 minutes d. Swabbing the patients mouth with cold water

A Immediately after EGD, the patient will have a decreased gag reflex and is at risk for aspiration. Assessment for return of the gag reflex should be done by the RN. The other actions by the UAP are appropriate. .

A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate? a. The obstructing plaque is surgically removed from an artery in the neck. b. The diseased portion of the artery in the brain is replaced with a synthetic graft. c. A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed. d. A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque.

A In a carotid endarterectomy, the carotid artery is incised and the plaque is removed. The response beginning, The diseased portion of the artery in the brain is replaced describes an arterial graft procedure. The answer beginning, A catheter with a deflated balloon is positioned at the narrow area describes an angioplasty. The final response beginning, A wire is threaded through the artery describes the mechanical embolus removal in cerebral ischemia (MERCI) procedure.

A 50-year-old patient who underwent a gastroduodenostomy (Billroth I) earlier today complains of increasing abdominal pain. The patient has no bowel sounds and 200 mL of bright red nasogastric (NG) drainage in the last hour. The highest priority action by the nurse is to a. contact the surgeon. b. irrigate the NG tube. c. monitor the NG drainage. d. administer the prescribed morphine

A Increased pain and 200 mL of bright red NG drainage 12 hours after surgery indicate possible postoperative hemorrhage, and immediate actions such as blood transfusion and/or return to surgery are needed. Because the NG is draining, there is no indication that irrigation is needed. Continuing to monitor the NG drainage is not an adequate response. The patient may need morphine, but this is not the highest priority action

The patient is breathing normally. Which process does the nurse consider is working properly when the patient inspires? a. Stimulation of chemical receptors in the aorta b. Reduction of arterial oxygen saturation levels c. Requirement of elastic recoil lung properties d. Enhancement of accessory muscle usage

A Inspiration is an active process, stimulated by chemical receptors in the aorta. Reduced arterial oxygen saturation levels indicate hypoxemia, an abnormal finding. Expiration is a passive process that depends on the elastic recoil properties of the lungs, requiring little or no muscle work. Prolonged use of the accessory muscles does not promote effective ventilation and causes fatigue

The nurse is calculating intake and output on a patient. The patient drinks 150 mL of orange juice at breakfast, voids 125 mL after breakfast, vomits 250 mL of greenish fluid, sucks on 60 mL of ice chips, and for lunch consumes 75 mL of chicken broth. Which totals for intake and output will the nurse document in the patient's medical record? a. Intake 255; output 375 b. Intake 285; output 375 c. Intake 505; output 125 d. Intake 535; output 125

A Intake = 150 mL of orange juice, 60 mL of ice chips (but only counts as 30 since ice chips are half of the amount), and 75 mL of chicken broth; 150 + 30 + 75 = 255. Output = 125 mL of urine (void) and 250 mL of vomitus; 125 + 250 = 375 .

A nurse is assessing internal variables that are affecting the patient's health status. Which area should the nurse assess? a. Perception of functioning b. Socioeconomic factors c. Cultural background d. Family practices

A Internal variables include a person's developmental stage, intellectual background, perception of functioning, and emotional and spiritual factors. External variables influencing a person's health beliefs and practices include family practices, socioeconomic factors, and cultural background. .

The patient with heart failure is restless with a temperature of 102.2° F (39° C). Which action will the nurse take? a. Place the patient on oxygen. b. Encourage the patient to cough. c. Restrict the patient's fluid intake. d. Increase the patient's metabolic rate .

A Interventions during a fever include oxygen therapy. During a fever, cellular metabolism increases and oxygen consumption rises. Myocardial hypoxia produces angina. Cerebral hypoxia produces confusion. Dehydration is a serious problem through increased respiration and diaphoresis. The patient is at risk for fluid volume deficit. Fluids should not be restricted, even though the patient has heart failure; the patient needs fluids at this time due to the fever. Increasing the metabolic rate further would not be advisable. Coughing will increase muscular activity, which will increase fever

A patient has dehydration. While planning care, the nurse considers that the majority of the patient's total water volume exists in with compartment? a. Intracellular b. Extracellular c. Intravascular d. Transcellular

A Intracellular (inside the cells) fluid accounts for approximately two thirds of total body water. Extracellular (outside the cells) is approximately one third of the total body water. Intravascular fluid (liquid portion of the blood) and transcellular fluid are two major divisions of the extracellular compartment. .

A nurse is preparing to teach a kinesthetic learner about exercise. Which technique will the nurse use? a. Let the patient touch and use the exercise equipment. b. Provide the patient with pictures of the exercise equipment. c. Let the patient listen to a video about the exercise equipment. d. Provide the patient with a case study about the exercise equipment. .

A Kinesthetic learners process knowledge by moving and participating in hands-on activities. Return demonstrations and role playing work well with these learners. Patients who are visual-spatial learners enjoy learning through pictures and visual charts to explain concepts. The verbal/linguistic learner demonstrates strength in the language arts and therefore prefers learning by listening or reading information. Patients who learn through logical-mathematical reasoning think in terms of cause and effect, and respond best when required to predict logical outcomes. Specific teaching strategies could include open-ended questioning or problem solving exercises, like a case study.

While preparing a teaching plan, the nurse describes what the learner will be able to accomplish after the teaching session about healthy eating. Which action is the nurse completing? a. Developing learning objectives b. Providing positive reinforcement c. Presenting facts and knowledge d. Implementing interpersonal communication

A Learning objectives describe what the learner will exhibit as a result of successful instruction. Positive reinforcement follows feedback and reinforces good behavior and promotes continued compliance. Interpersonal communication is necessary for the teaching/learning process, but describing what the learner will be able to do after successful instruction constitutes learning objectives. Facts and knowledge will be presented in the teaching session.

The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy tube. Which action by the nurse would best determine if the cuff has been properly inflated? a. Use a manometer to ensure cuff pressure is at an appropriate level. b. Check the amount of cuff pressure ordered by the health care provider. c. Suction the patient first with a fenestrated inner cannula to clear secretions. d. Insert the decannulation plug before the nonfenestrated inner cannula is removed.

A Measurement of cuff pressure using a manometer to ensure that cuff pressure is 20 mm Hg or lower will avoid compression of the tracheal wall and capillaries. Never insert the decannulation plug in a tracheostomy tube until the cuff is deflated and the nonfenestrated inner cannula is removed. Otherwise, the patients airway is occluded. A health care providers order is not required to determine safe cuff pressure. A nonfenestrated inner cannula must be used to suction a patient to prevent tracheal damage occurring from the suction catheter passing through the fenestrated openings.

An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse should notify the health care provider if the patient exhibits which finding? a. Yellow-tinged skin b. Orange-colored sputum c. Thickening of the fingernails d. Difficulty hearing high-pitched voices

A Noninfectious hepatitis is a toxic effect of isoniazid (INH), rifampin, and pyrazinamide, and patients who develop hepatotoxicity will need to use other medications. Changes in hearing and nail thickening are not expected with the four medications used for initial TB drug therapy. Presbycusis is an expected finding in the older adult patient. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider.

The nurse is caring for a hospitalized older patient who has nasal packing in place to treat a nosebleed. Which assessment finding will require the most immediate action by the nurse? a. The oxygen saturation is 89%. b. The nose appears red and swollen. c. The patients temperature is 100.1 F (37.8 C). d. The patient complains of level 8 (0 to 10 scale) pain.

A Older patients with nasal packing are at risk of aspiration or airway obstruction. An O2 saturation of 89% should alert the nurse to further assess for these complications. The other assessment data also indicate a need for nursing action but not as immediately as the low O2 saturation.

A patient had a stroke and must use a cane for support. A nurse is preparing to teach the patient about the cane. Which learning objective/outcome is most appropriate for the nurse to include in the teaching plan? a. The patient will walk to the bathroom and back to bed using a cane. b. The patient will understand the importance of using a cane. c. The patient will know the correct use of a cane. d. The patient will learn how to use a cane.

A Outcomes often describe a behavior that identifies the patient's ability to do something on completion of teaching such as will empty a colostomy bag or will administer an injection. Understand, learn, and know are not behaviors that can be observed or evaluated. .

The nurse cares for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider? a. Oxygen saturation is 88%. b. Blood pressure is 145/90 mm Hg. c. Respiratory rate is 22 breaths/minute when lying flat. d. Pain level is 5 (on 0 to 10 scale) with a deep breath.

A Oxygen saturation would be expected to improve after a thoracentesis. A saturation of 88% indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low oxygen saturation is the priority.

A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment? a. Paradoxic chest movement b. Complaint of chest wall pain c. Heart rate of 110 beats/minute d. Large bruised area on the chest

A Paradoxic chest movement indicates that the patient may have flail chest, which can severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange.

Which action should the nurse in the emergency department anticipate for a 23-year-old patient who has had several episodes of bloody diarrhea? a. Obtain a stool specimen for culture. b. Administer antidiarrheal medication. c. Provide teaching about antibiotic therapy. d. Teach about adverse effects of acetaminophen (Tylenol).

A Patients with bloody diarrhea should have a stool culture for E. coli O157:H7. Antidiarrheal medications are usually avoided for possible infectious diarrhea to avoid prolonging the infection. Antibiotic therapy in the treatment of infectious diarrhea is controversial because it may precipitate kidney complications. Acetaminophen does not cause bloody diarrhea. .

A 42-year-old patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care? a. Encourage family members to remain at the bedside. b. Apply soft restraints to protect the patient from injury. c. Keep the room well-lighted to improve patient orientation. d. Minimize contact with the patient to decrease sensory input.

A Patients with meningitis and disorientation will be calmed by the presence of someone familiar at the bedside. Restraints should be avoided because they increase agitation and anxiety. The patient requires frequent assessment for complications. The use of touch and a soothing voice will decrease anxiety for most patients. The patient will have photophobia, so the light should be dim. .

The nurse needs to obtain a radial pulse from a patient. What must the nurse do to obtain a correct measurement? a. Place the tips of the first two fingers over the groove along the thumb side of the patient's wrist. b. Place the tips of the first two fingers over the groove along the little finger side of the patient's wrist. c. Place the thumb over the groove along the little finger side of the patient's wrist. d. Place the thumb over the groove along the thumb side of the patient's wrist .

A Place the tips of the first two or middle three fingers of the hand over the groove along the radial or thumb side of the patient's inner wrist. Fingertips are the most sensitive parts of the hand to palpate arterial pulsation. The thumb has a pulsation that interferes with accuracy. The groove along the little finger is the ulnar pulse .

The nurse is working in a clinic that is designed to provide health education and immunizations. Which type of preventive care is the nurse providing? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Risk factor prevention

A Primary prevention precedes disease or dysfunction and is applied to people considered physically and emotionally healthy. Primary prevention includes health education programs, immunizations, and physical and nutritional fitness activities. - Secondary prevention focuses on individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. Activities are directed at diagnosis and prompt intervention. - Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability through interventions directed at preventing complications and deterioration. - While risk factor modification is an integral component of health promotion, it is not a type of preventive care.

A nurse obtains a health history from a patient who has a 35 pack-year smoking history. The patient complains of hoarseness and tightness in the throat and difficulty swallowing. Which question is most important for the nurse to ask? a. How much alcohol do you drink in an average week? b. Do you have a family history of head or neck cancer? c. Have you had frequent streptococcal throat infections? d. Do you use antihistamines for upper airway congestion?

A Prolonged alcohol use and smoking are associated with the development of laryngeal cancer, which the patients symptoms and history suggest. Family history is not a risk factor for head or neck cancer. Frequent antihistamine use would be asked about if the nurse suspected allergic rhinitis, but the patients symptoms are not suggestive of this diagnosis. Streptococcal throat infections also may cause these clinical manifestations, but patients with this type of infection will also have pain and a fever.

After a teaching session on taking blood pressures, the nurse tells the patient, "You took that blood pressure like an experienced nurse." Which type of reinforcement did the nurse use? a. Social acknowledgment b. Pleasurable activity c. Tangible reward d. Entrusting

A Reinforcers come in the form of social acknowledgments (e.g., nods, smiles, words of encouragement), pleasurable activities (e.g., walks or play time), and tangible rewards (e.g., toys or food). The entrusting approach is a teaching approach that provides a patient the opportunity to manage self-care. It is not a type of reinforcement.

A family caregiver tells the home health nurse, I feel like I can never get away to do anything for myself. Which action is best for the nurse to take? a. Assist the caregiver in finding respite services. b. Assure the caregiver that the work is appreciated. c. Encourage the caregiver to discuss feelings openly with the nurse as needed. d. Teach the caregiver that family members can also provide excellent patient care.

A Respite services allow family caregivers to have time away from their caregiving responsibilities. The other actions may also be helpful, but the caregivers statement clearly indicates the need for some time away. .

The patient has right-sided heart failure. Which finding will the nurse expect when performing an assessment? a. Peripheral edema b. Basilar crackles c. Chest pain d. Cyanosis .

A Right-sided heart failure results from inability of the right side of the heart to pump effectively, leading to a systemic backup. Peripheral edema, distended neck veins, and weight gain are signs of right-sided failure. Basilar crackles can indicate pulmonary congestion from left-sided heart failure. Cyanosis and chest pain result from inadequate tissue perfusion

The nurse educator teaches students how to be more assertive. Which teaching strategy, if implemented by the nurse educator, would be most effective? a. Role playing b. Peer teaching c. Printed materials d. Lecture-discussion

A Role playing allows the students to practice assertive behavior and receive feedback about how the behavior is perceived. Lecture-discussion, peer-teaching, and printed materials are more useful for other learning needs. .

A nurse is describing a patient's perceived ability to successfully complete a task. Which term should the nurse use to describe this attribute? a. Self-efficacy b. Motivation c. Attentional set d. Active participation

A Self-efficacy, a concept included in social learning theory, refers to a person's perceived ability to successfully complete a task. - Motivation is a force that acts on or within a person (e.g., an idea, an emotion, a physical need) to cause the person to behave in a particular way. - An attentional set is the mental state that allows the learner to focus on and comprehend a learning activity. - Learning occurs when the patient is actively involved in the educational session.

A patient is admitted to the emergency department complaining of sudden onset shortness of breath and is diagnosed with a possible pulmonary embolus. How should the nurse prepare the patient for diagnostic testing to confirm the diagnosis? a. Start an IV so contrast media may be given. b. Ensure that the patient has been NPO for at least 6 hours. c. Inform radiology that radioactive glucose preparation is needed. d. Instruct the patient to undress to the waist and remove any metal objects

A Spiral computed tomography (CT) scans are the most commonly used test to diagnose pulmonary emboli, and contrast media may be given IV. A chest x-ray may be ordered but will not be diagnostic for a pulmonary embolus. Preparation for a chest x-ray includes undressing and removing any metal. Bronchoscopy is used to detect changes in the bronchial tree, not to assess for vascular changes, and the patient should be NPO 6 to 12 hours before the procedure. Positron emission tomography (PET) scans are most useful in determining the presence of malignancy, and a radioactive glucose preparation is used.

Admission vital signs for a brain-injured patient are blood pressure 128/68, pulse 110, and respirations 26. Which set of vital signs, if taken 1 hour after admission, will be of most concern to the nurse? a. Blood pressure 154/68, pulse 56, respirations 12 b. Blood pressure 134/72, pulse 90, respirations 32 c. Blood pressure 148/78, pulse 112, respirations 28 d. Blood pressure 110/70, pulse 120, respirations 30

A Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushings triad. These findings indicate that the intracranial pressure (ICP) has increased, and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process. .

After taking the patient's temperature, the nurse documents the value and the route used to obtain the reading. What is the reason for the nurse's action? a. Temperatures vary depending on the route used. b. Temperatures are readings of core measurements. c. Rectal temperatures are cooler than when taken orally. d. Axillary temperatures are higher than oral temperatures

A Temperatures obtained vary depending on the site used. Rectal temperatures are usually 0.5° C (0.9° F) higher than oral temperatures, and axillary temperatures are usually 0.5° C (0.9° F) lower than oral temperatures. There are core temperature readings and body surface readings. .

In which order will the nurse use the nursing process steps during the clinical decision-making process? 1. Evaluating goals 2. Assessing patient needs 3. Planning priorities of care 4. Determining nursing diagnoses 5. Implementing nursing interventions a. 2, 4, 3, 5, 1 b. 4, 3, 2, 1, 5 c. 1, 2, 4, 5, 3 d. 5, 1, 2, 3, 4

A The American Nurses Association developed standards that set forth the framework necessary for critical thinking in the application of the five-step nursing process: - assessment, - diagnosis, - planning, - implementation, and - evaluation.

A nurse is reviewing the electrocardiogram (ECG) results. Which portion of the conduction system does the nurse consider when evaluating the P wave? a. SA node b. AV node c. Bundle of His d. Purkinje fibers

A The P wave represents the electrical conduction through both atria; the SA node initiates electrical conduction through the atria. The AV node conducts down through the bundle of His and the Purkinje fibers to cause ventricular contraction .

The nurse is caring for a newborn infant in the hospital nursery and notices that the infant is breathing rapidly but is pink, warm, and dry. Which normal respiratory rate will the nurse consider when planning care for this newborn? a. 30 to 60 b. 22 to 28 c. 16 to 20 d. 10 to 15

A The acceptable respiratory rate range for a newborn is 30 to 60 breaths/min. An infant (6 months) is expected to have a rate between 30 and 50 breaths/min. - A toddler's respiratory range is 25 to 32 breaths/min. A child should breathe 20 to 30 times a minute. - An adolescent should breathe 16 to 20 times a minute. - An adult should breathe 12 to 20 times a minute.

A nurse explains the function of the alveoli to a patient with respiratory problems. Which information about the alveoli's function will the nurse share with the patient? a. Carries out gas exchange b. Regulates tidal volume c. Produces hemoglobin d. Stores oxygen

A The alveolus is a capillary membrane that allows gas exchange of oxygen and carbon dioxide during respiration. The alveoli do not store oxygen, regulate tidal volume, or produce hemoglobin .

A patient continues to report postsurgical incision pain at a level of 9 out of 10 after pain medicine is given. The next dose of pain medicine is not due for another hour. What should the critically thinking nurse do first? a. Explore other options for pain relief. b. Discuss the surgical procedure and reason for the pain. c. Explain to the patient that nothing else has been ordered. d. Offer to notify the health care provider after morning rounds are completed.

A The critically thinking nurse should explore all options for pain relief first. The nurse should use critical thinking to determine the cause of the pain and determine various options for pain, not just ordered pain medications. The nurse can act independently to determine all options for pain relief and does not have to wait until after the health care provider rounds are completed. Explaining the cause of the pain does not address options for pain relief.

Which action should the nurse take first when a patient develops a nosebleed? a. Pinch the lower portion of the nose for 10 minutes. b. Pack the affected nare tightly with an epistaxis balloon. c. Obtain silver nitrate that will be needed for cauterization. d. Apply ice compresses over the patients nose and cheeks. .

A The first nursing action for epistaxis is to apply direct pressure by pinching the nostrils. Application of cold packs may decrease blood flow to the area, but will not be sufficient to stop bleeding. Cauterization and nasal packing are medical interventions that may be needed if pressure to the nares does not stop the bleeding, but these are not the first actions to take for a nosebleed.

Which action will the nurse include in the plan of care for a patient with impaired functioning of the left glossopharyngeal nerve (CN IX) and the vagus nerve (CN X)? a. Withhold oral fluid or foods. b. Provide highly seasoned foods. c. Insert an oropharyngeal airway. d. Apply artificial tears every hour

A The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex. A patient with impaired function of these nerves is at risk for aspiration. An oral airway may be needed when a patient is unconscious and unable to maintain the airway, but it will not decrease aspiration risk. Taste and eye blink are controlled by the facial nerve. .

The nurse is preparing a smoking cessation class for family members of patients with lung cancer. The nurse believes that the class will convert many smokers to nonsmokers once they realize the benefits of not smoking. Which health care model is the nurse following? a. Health belief model b. Holistic health model c. Health promotion model d. Maslow's hierarchy of needs

A The health belief model addresses the relationship between a person's beliefs and behaviors. - The holistic health model recognizes the natural healing abilities of the body and incorporates complementary and alternative interventions such as music therapy. - The health promotion model focuses on the following three areas: (1) individual characteristics and experiences, (2) behavior- specific knowledge and affect, and (3) behavioral outcomes, in which the patient commits to or changes a behavior. - Maslow's' hierarchy of needs is based on the theory that all people share basic human needs, and the extent to which basic needs are met is a major factor in determining a person's level of health.

Which coughing technique will the nurse use to help a patient clear central airways? a. Huff b. Quad c. Cascade d. Incentive spirometry .

A The huff cough stimulates a natural cough reflex and is generally effective only for clearing central airways. While exhaling, the patient opens the glottis by saying the word huff. The quad cough technique is for patients without abdominal muscle control such as those with spinal cord injuries. While the patient breathes out with a maximal expiratory effort, the patient or nurse pushes inward and upward on the abdominal muscles toward the diaphragm, causing the cough. With the cascade cough the patient takes a slow, deep breath and holds it for 2 seconds while contracting expiratory muscles. Then he or she opens the mouth and performs a series of coughs throughout exhalation, thereby coughing at progressively lowered lung volumes. This technique promotes airway clearance and a patent airway in patients with large volumes of sputum. Incentive spirometry encourages voluntary deep breathing by providing visual feedback to patients about inspiratory volume. It promotes deep breathing and prevents or treats atelectasis in the postoperative patient.

The nurse assesses a patient with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea over the last 3 days. Which finding is most important for the nurse to report to the health care provider? a. Respirations are 36 breaths/minute. b. Anterior-posterior chest ratio is 1:1. c. Lung expansion is decreased bilaterally. d. Hyperresonance to percussion is present.

A The increase in respiratory rate indicates respiratory distress and a need for rapid interventions such as administration of oxygen or medications. The other findings are common chronic changes occurring in patients with COPD.

Four patients arrive at the emergency department at the same time. Which patient will the nurse see first? a. An infant with temperature of 102.2° F and diarrhea for 3 days b. A teenager with a sprained ankle and excessive edema c. A middle-aged adult with abdominal pain who is moaning and holding her stomach d. An older adult with nausea and vomiting for 3 days with blood pressure 112/60 .

A The infant should be seen first. An infant's proportion of total body water (70% to 80% total body weight) is greater than that of children or adults. Infants and young children have greater water needs and immature kidneys. They are at greater risk for extracellular volume deficit and hypernatremia because body water loss is proportionately greater per kilogram of weight. A teenager with excessive edema from a sprained ankle can wait. A middle-aged adult moaning in pain can wait as can an older adult with a blood pressure of 112/60

A patient is experiencing respiratory acidosis. Which organ system is responsible for compensation in this patient? a. Renal b. Endocrine c. Respiratory d. Gastrointestinal .

A The kidneys (renal) are responsible for respiratory acidosis compensation. A problem with the respiratory system causes respiratory acidosis, so another organ system (renal) needs to compensate. Problems with the gastrointestinal and endocrine systems can cause acid-base imbalances, but these systems cannot compensate for an existing imbalance

The nurse is caring for a diabetic patient in renal failure who is in metabolic acidosis. Which laboratory findings are consistent with metabolic acidosis? a. pH 7.3, PaCO2 36 mm Hg, HCO3- 19 mEq/L b. pH 7.5, PaCO2 35 mm Hg, HCO3- 35 mEq/L c. pH 7.32, PaCO2 47 mm Hg, HCO3- 23 mEq/L d. pH 7.35, PaCO2 40 mm Hg, HCO3- 25 mEq/L

A The laboratory values that reflect metabolic acidosis are pH 7.3, PaCO2 36 mm Hg, HCO3 - 19 mEq/L. A laboratory finding of pH 7.5, PaCO2 35 mm Hg, HCO3 - 35 mEq/L is metabolic alkalosis. pH 7.32, PaCO2 47 mm Hg, HCO3 - 23 mEq/L is respiratory acidosis. pH 7.35, PaCO2 40 mm Hg, HCO3 - 25 mEq/L values are within normal range

To palpate the liver during a head-to-toe physical assessment, the nurse a. places one hand on the patients back and presses upward and inward with the other hand below the patients right costal margin. b. places one hand on top of the other and uses the upper fingers to apply pressure and the bottom fingers to feel for the liver edge. c. presses slowly and firmly over the right costal margin with one hand and withdraws the fingers quickly after the liver edge is felt. d. places one hand under the patients lower ribs and presses the left lower rib cage forward, palpating below the costal margin with the other hand.

A The liver is normally not palpable below the costal margin. The nurse needs to push inward below the right costal margin while lifting the patients back slightly with the left hand. The other methods will not allow palpation of the liver. .

A nurse is caring for a group of patients. Which patient should the nurse see first? a. A patient with hypercapnia wearing an oxygen mask b. A patient with a chest tube ambulating with the chest tube unclamped c. A patient with thick secretions being tracheal suctioned first and then orally d. A patient with a new tracheostomy and tracheostomy obturator at bedside .

A The mask is contraindicated for patients with carbon dioxide retention (hypercapnia) because retention can be worsened; the nurse must see this patient first to correct the problem. All the rest are using correct procedures and do not need to be seen first. A chest tube should not be clamped when ambulating. Clamping a chest tube is contraindicated when ambulating or transporting a patient. Clamping can result in a tension pneumothorax. Use nasotracheal suctioning before pharyngeal suctioning whenever possible. The mouth and pharynx contain more bacteria than the trachea. Keep tracheostomy obturator at bedside with a fresh (new) tracheostomy to facilitate reinsertion of the outer cannula if dislodged

When taking the pulse of an infant, the nurse notices that the rate is 145 beats/min and the rhythm is regular. How should the nurse interpret this finding? a. This is normal for an infant. b. This is too fast for an infant. c. This is too slow for an infant. d. This is not a rate for an infant but for a toddler

A The normal rate for an infant is 120 to 160 beats/min. The rate obtained (145 beats/min) is within the normal range for an infant. The normal rate for a toddler is between 90 and 140 beats/min; 145 is too high for a toddler. .

The health care provider prescription reads "Metoprolol (Lopressor) 50 mg PO daily. Do not give if blood pressure is less than 100 mm Hg systolic." The patient's blood pressure is 92/66. The nurse does not give the medication. Which action should the nurse take? a. Documents that the medication was not given because of low blood pressure b. Does not inform the health care provider that the medication was held c. Does not tell the patient what the blood pressure is d. Documents only what the blood pressure was.

A The nurse must document any interventions initiated as a result of vital sign measurement such as holding an antihypertensive drug. The nurse should inform the patient of the blood pressure value and the need for periodic reassessment of the blood pressure. Documenting the blood pressure only is not sufficient. Any intervention must be documented as well. Abnormal findings must be reported to the nurse in charge or to the health care provider

The nurse is working in a drug rehabilitation clinic and is in the process of admitting a patient for "detox." What should the nurse do next? a. Identify the patient's stage of change. b. Realize that the patient is ready to change. c. Teach the patient that choices will have to change. d. Instruct the patient that relapses will not be tolerated.

A The nurse should identify the stage of change and assess where the patient is currently in this situation. To be most effective, nursing interventions should match the stage of change. The nurse cannot realize the patient is ready for change because only a minority of people are actually in the action stage of changing. While teaching that choices will have to change, it will follow later after the nurse has determined which stage the person is in. As individuals attempt a change in behavior, relapse followed by recycling through the stages occurs frequently.

A nurse is teaching about the goals of Healthy People 2020. Which information should the nurse include in the teaching session? a. Eliminate health disparities in America. b. Eliminate health behaviors in America. c. Eliminate quality of life in America. d. Eliminate healthy life in America.

A The nurse should include eliminating health disparities in America. Healthy People 2020 promotes a society in which all people live long, healthy lives. There are four overarching goals: (1) attain high- quality, longer lives free of preventable disease, disability, injury, and premature death; (2) achieve health equity, eliminate disparities, and improve the health of all groups; (3) create social and physical environments that promote good health for all; and (4) promote quality of life, healthy development, and healthy behaviors across all life stages.

A 68-year-old patient who is hospitalized with pneumonia is disoriented and confused 3 days after admission. Which information indicates that the patient is experiencing delirium rather than dementia? a. The patient was oriented and alert when admitted. b. The patients speech is fragmented and incoherent. c. The patient is oriented to person but disoriented to place and time. d. The patient has a history of increasing confusion over several years.

A The onset of delirium occurs acutely. The degree of disorientation does not differentiate between delirium and dementia. Increasing confusion for several years is consistent with dementia. Fragmented and incoherent speech may occur with either delirium or dementia. .

A patient is being scheduled for endoscopic retrograde cholangiopancreatography (ERCP) as soon as possible. Which actions from the agency policy for ERCP should the nurse take first? a. Place the patient on NPO status. b. Administer sedative medications. c. Ensure the consent form is signed. d. Teach the patient about the procedure.

A The patient will need to be NPO for 8 hours before the ERCP is done, so the nurses initial action should be to place the patient on NPO status. The other actions can be done after the patient is NPO. .

A 40-year-old patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan? a. Apply intermittent pneumatic compression stockings. b. Assist to dangle on edge of bed and assess for dizziness. c. Encourage patient to cough and deep breathe every 4 hours. d. Insert an oropharyngeal airway to prevent airway obstruction.

A The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboembolism (VTE). Activities such as coughing and sitting up that might increase intracranial pressure (ICP) or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.

For a patient who had a right hemisphere stroke the nurse establishes a nursing diagnosis of a. risk for injury related to denial of deficits and impulsiveness. b. impaired physical mobility related to right-sided hemiplegia. c. impaired verbal communication related to speech-language deficits. d. ineffective coping related to depression and distress about disability. .

A The patient with right-sided brain damage typically denies any deficits and has poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. - Right-sided brain damage causes left hemiplegia. - Left-sided brain damage typically causes language deficits. - Left-sided brain damage is associated with depression and distress about the disability.

Which patient in the ear, nose, and throat (ENT) clinic should the nurse assess first? a. A 23-year-old who is complaining of a sore throat and has a muffled voice b. A 34-year-old who has a scratchy throat and a positive rapid strep antigen test c. A 55-year-old who is receiving radiation for throat cancer and has severe fatigue d. A 72-year-old with a history of a total laryngectomy whose stoma is red and inflamed .

A The patients clinical manifestation of a muffled voice suggests a possible peritonsillar abscess that could lead to an airway obstruction requiring rapid assessment and potential treatment. The other patients do not have diagnoses or symptoms that indicate any life-threatening problems. .

A patient who was admitted the previous day with pneumonia complains of a sharp pain of 7 (based on 0 to 10 scale) whenever I take a deep breath. Which action will the nurse take next? a. Auscultate breath sounds. b. Administer the PRN morphine. c. Have the patient cough forcefully. d. Notify the patients health care provider.

A The patients statement indicates that pleurisy or a pleural effusion may have developed and the nurse will need to listen for a pleural friction rub and/or decreased breath sounds. Assessment should occur before administration of pain medications. The patient is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provider.

A patient states, I told my husband I wouldnt buy as much prepared food snacks, so I will go the grocery store to buy fresh fruit, vegetables, and whole grains. When using the Transtheoretical Model of Health Behavior Change, the nurse identifies that this patient is in which stage of change? a. Preparation b. Termination c. Maintenance d. Contemplation

A The patients statement indicating that the plan for change is being shared with someone else indicates that the preparation stage has been achieved. - Contemplation of a change would be indicated by a statement like I know I should exercise. - Maintenance of a change occurs when the patient practices the behavior regularly. - Termination would be indicated when the change is a permanent part of the lifestyle.

The nurse is teaching about the process of passively moving water from an area of lower particle concentration to an area of higher particle concentration. Which process is the nurse describing? a. Osmosis b. Filtration c. Diffusion d. Active transport

A The process of moving water from an area of low particle concentration to an area of higher particle concentration is known as osmosis. Filtration is mediated by fluid pressure from an area of higher pressure to an area of lower pressure. Diffusion is passive movement of electrolytes or other particles down the concentration gradient (from areas of higher concentration to areas of lower concentration). Active transport requires energy in the form of adenosine triphosphate (ATP) to move electrolytes across cell membranes against the concentration gradient (from areas of lower concentration to areas of higher concentration).

The nurse prepares written handouts to be used as part of the standardized teaching plan for patients who have been recently diagnosed with diabetes. What statement would be appropriate to include in the handouts? a. Eating the right foods can help in keeping blood glucose at a near-normal level. b. Polyphagia, polydipsia, and polyuria are common symptoms of diabetes mellitus. c. Some diabetics control blood glucose with oral medications, injections, or nutritional interventions. d. Diabetes mellitus is characterized by chronic hyperglycemia and the associated symptoms than can lead to long-term complications.

A The reading level for patient teaching materials should be at the 5th grade level. The other responses have words with three or more syllables, use many medical terms, and/or are too long. .

A nurse is assessing a patient who is receiving a blood transfusion and finds that the patient is anxiously fidgeting in bed. The patient is afebrile and dyspneic. The nurse auscultates crackles in both lung bases and sees jugular vein distention. On which transfusion complication will the nurse focus interventions? a. Fluid volume overload b. Hemolytic reaction c. Anaphylactic shock d. Septicemia

A The signs and symptoms are concurrent with fluid volume overload. Anaphylactic shock would have presented with urticaria, dyspnea, and hypotension. Septicemia would include a fever. A hemolytic reaction would consist of flank pain, chills, and fever. .

The nurse is caring for a patient who needs oxygen via a nasal cannula. Which task can the nurse delegate to the nursing assistive personnel? a. Applying the nasal cannula b. Adjusting the oxygen flow c. Assessing lung sounds d. Setting up the oxygen

A The skill of applying (not adjusting oxygen flow) a nasal cannula or oxygen mask can be delegated to nursing assistive personnel (NAP). The nurse is responsible for assessing the patient's respiratory system, response to oxygen therapy, and setup of oxygen therapy, including adjustment of oxygen flow rate. .

A nurse is teaching about the transtheoretical model of change. In which order will the nurse place the progression of the stages from beginning to end? 1. Action 2. Preparation 3. Maintenance 4. Contemplation 5. Precontemplation a. 5, 4, 2, 1, 3 b. 2, 5, 4, 3, 1 c. 4, 5, 3, 1, 2 d. 1, 5, 2, 3, 4

A The stages of change in the transtheoretical model of change include five stages. These stages range from no intention to change (precontemplation), considering a change within the next 6 months (contemplation), making small changes (preparation), and actively engaging in strategies to change behavior (action), to maintaining a changed behavior (maintenance stage). .

The nurse completes discharge instructions for a patient with a total laryngectomy. Which statement by the patient indicates that additional instruction is needed? a. I must keep the stoma covered with an occlusive dressing at all times. b. I can participate in most of my prior fitness activities except swimming. c. I should wear a Medic-Alert bracelet that identifies me as a neck breather. d. I need to be sure that I have smoke and carbon monoxide detectors installed.

A The stoma may be covered with clothing or a loose dressing, but this is not essential. An occlusive dressing will completely block the patients airway. The other patient comments are all accurate and indicate that the teaching has been effective. .

A nurse is caring for a diabetic patient with a bowel obstruction and has orders to ensure that the volume of intake matches the output. In the past 4 hours, the patient received dextrose 5% with 0.9% sodium chloride through a 22-gauge catheter infusing at 150 mL/hr and has eaten 200 mL of ice chips. The patient also has an NG suction tube set to low continuous suction that had 300-mL output. The patient has voided 400 mL of urine. After reporting these values to the health care provider, which order does the nurse anticipate? a. Add a potassium supplement to replace loss from output. b. Decrease the rate of intravenous fluids to 100 mL/hr. c. Administer a diuretic to prevent fluid volume excess. d. Discontinue the nasogastric suctioning.

A The total fluid intake and output equals 700 mL, which meets the provider goals. Patients with nasogastric suctioning are at risk for potassium deficit, so the nurse would anticipate a potassium supplement to correct this condition. Remember to record half the volume of ice chips when calculating intake. The other measures would be unnecessary because the net fluid volume is equal.

To assess the functioning of the trigeminal and facial nerves (CNs V and VII), the nurse should a. shine a light into the patients pupil. b. check for unilateral eyelid drooping. c. touch a cotton wisp strand to the cornea. d. have the patient read a magazine or book .

A The trigeminal and facial nerves are responsible for the corneal reflex. The optic nerve is tested by having the patient read a Snellen chart or a newspaper. Assessment of pupil response to light and ptosis are used to check function of the oculomotor nerve. .

When admitting a 42-year-old patient with a possible brain injury after a car accident to the emergency department (ED), the nurse obtains the following information. Which finding is most important to report to the health care provider? a. The patient takes warfarin (Coumadin) daily. b. The patients blood pressure is 162/94 mm Hg. c. The patient is unable to remember the accident. d. The patient complains of a severe dull headache.

A The use of anticoagulants increases the risk for intracranial hemorrhage and should be immediately reported. The other information would not be unusual in a patient with a head injury who had just arrived in the ED. .

Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis? a. Weak, nonproductive cough effort b. Large amounts of greenish sputum c. Respiratory rate of 28 breaths/minute d. Resting pulse oximetry (SpO2) of 85%

A The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern. .

The nurse is creating a plan of care for an obese patient who is suffering from fatigue related to ineffective breathing. Which intervention best addresses a short-term goal the patient could achieve? a. Sleeping on two to three pillows at night b. Limiting the diet to 1500 calories a day c. Running 30 minutes every morning d. Stopping smoking immediately

A To achieve a short-term goal, the nurse should plan a lifestyle change that the patient can make immediately that will have a quick effect. Sleeping on several pillows at night will immediately relieve orthopnea and open the patient's airway, thereby reducing fatigue. Running 30 minutes a day will improve cardiopulmonary health, but a patient needs to build up exercise tolerance. Smoking cessation is another process that many people have difficulty doing immediately. A more realistic short-term goal would be to gradually reduce the number of cigarettes smoked. Limiting caloric intake can help a patient lose weight, but this is a gradual process and is not reasonable for a short- term goal.

A patient who is going to surgery has been taught how to cough and deep breathe. Which evaluation method will the nurse use? a. Return demonstration b. Computer instruction c. Verbalization of steps d. Cloze test

A To demonstrate mastery of the skill, have the patient perform a return demonstration under the same conditions that will be experienced at home or in the place where the skill is to be performed. Computer instruction is use of a programmed instruction format in which computers store response patterns for learners and select further lessons on the basis of these patterns (programs can be individualized). Computer instruction is a teaching tool, rather than an evaluation tool. Verbalization of steps can be an evaluation tool, but it is not as effective as a return demonstration when evaluating a psychomotor skill. The Cloze test, a test of reading comprehension, asks patients to fill in the blanks that are in a written paragraph.

Which information will the nurse include when teaching adults to decrease the risk for cancers of the tongue and buccal mucosa? a. Avoid use of cigarettes and smokeless tobacco. b. Use sunscreen when outside even on cloudy days. c. Complete antibiotic courses used to treat throat infections. d. Use antivirals to treat herpes simplex virus (HSV) infections.

A Tobacco use greatly increases the risk for oral cancer. Acute throat infections do not increase the risk for oral cancer, although chronic irritation of the oral mucosa does increase risk. Sun exposure does not increase the risk for cancers of the buccal mucosa. Human papillomavirus (HPV) infection is associated with an increased risk, but HSV infection is not a risk factor for oral cancer. .

After reviewing the health record for a patient who has multiple risk factors for Alzheimers disease, which topic will be most important for the nurse to discuss with the patient? a. Tobacco use b. Family history c. Head injury history d. Total cholesterol level

A Tobacco use is a modifiable risk factor for Alzheimers disease. The patient will not be able to modify the increased risk associated with family history of Alzheimers disease and past head injury. While the total cholesterol is borderline high, the high HDL indicates that no change is needed in cholesterol management. .

A nurse is caring for a patient with continuous cardiac monitoring for heart dysrhythmias. Which rhythm will cause the nurse to intervene immediately? a. Ventricular tachycardia b. Atrial fibrillation c. Sinus rhythm d. Paroxysmal supraventricular tachycardia

A Ventricular tachycardia and ventricular fibrillation are life-threatening rhythms that require immediate intervention. Ventricular tachycardia is a life-threatening dysrhythmia because of the decreased cardiac output and the potential to deteriorate into ventricular fibrillation or sudden cardiac death. Atrial fibrillation is a common dysrhythmia in older adults and is not as serious as ventricular tachycardia. Sinus rhythm is normal. Paroxysmal supraventricular tachycardia is a sudden, rapid onset of tachycardia originating above the AV node. It often begins and ends spontaneously

The nurse is caring for a patient who has a temperature reading of 100.4° F (38° C). The patient's last two temperature readings were 98.6° F (37° C) and 96.8° F (36° C). Which action will the nurse take? a. Wait 30 minutes and recheck the patient's temperature. b. Assume that the patient has an infection and order blood cultures. c. Encourage the patient to move around to increase muscular activity. d. Be aware that temperatures this high are harmful and affect patient safety

A Waiting 30 minutes and rechecking the patient's temperature would be the most appropriate action in this case. A fever is usually not harmful if it stays below 102.2° F (39° C), & a single temperature reading does not always indicate a fever. In addition to physical signs & symptoms of infection, a fever determination is based on several temperature readings at different times of the day compared with the usual value for that person at that time. Nurses should base actions on knowledge, not on assumptions. Encouraging the patient to increase muscular activity will cause heat production to increase up to 50 times normal. The temperature has decreased & a symptom of infection would be an increase in temperature.

Which statement by the patient indicates that the teaching has been effective for a patient scheduled for radiation therapy of the larynx? a. I will need to buy a water bottle to carry with me. b. I should not use any lotions on my neck and throat. c. Until the radiation is complete, I may have diarrhea. d. Alcohol-based mouthwashes will help clean oral ulcers.

A Xerostomia can be partially alleviated by drinking fluids at frequent intervals. Radiation will damage tissues at the site being radiated but should not affect the abdominal organs, so loose stools are not a usual complication of head and neck radiation therapy. Frequent oral rinsing with nonalcohol-based rinses is recommended. Prescribed lotions and sunscreen may be used on radiated skin, although they should not be used just before the radiation therapy.

A nurse is teaching about risk factors for cardiopulmonary disease. Which risk factor should the nurse describe as modifiable? a. Stress b. Allergies c. Family history d. Gender

A Young and middle-age adults are exposed to multiple cardiopulmonary risk factors: an unhealthy diet, lack of exercise, stress, over-the-counter and prescription drugs not used as intended, illegal substances, and smoking. Reducing these modifiable factors decreases a patient's risk for cardiac or pulmonary diseases. A nonmodifiable risk factor is family history; determine familial risk factors such as a family history of lung cancer or cardiovascular disease. Other nonmodifiable risk factors include allergies and gender

After receiving change-of-shift report on the following four patients, which patient should the nurse see first? a. A 60-year-old patient with right-sided weakness who has an infusion of tPA prescribed b. A 50-year-old patient who has atrial fibrillation and a new order for warfarin (Coumadin) c. A 40-year-old patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due d. A 30-year-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop) scheduled .

A tPA needs to be infused within the first few hours after stroke symptoms start in order to be effective in minimizing brain injury. The other medications should also be given as quickly as possible, but timing of the medications is not as critical. .

The nurse is reviewing laboratory results. Which cation will the nurse observe is the most abundant in the blood? a. Sodium b. Chloride c. Potassium d. Magnesium .

A Sodium is the most abundant cation in the blood. Potassium is the predominant intracellular cation. Chloride is an anion (negatively charged) rather than a cation (positively charged). Magnesium is found predominantly inside cells and in bone. .

A nurse is teaching the staff about alterations in breathing patterns. Which information will the nurse include in the teaching session? (Select all that apply.) a. Apnea—no respirations b. Tachypnea—regular, rapid respirations c. Kussmaul's—abnormally deep, regular, fast respirations d. Hyperventilation—labored, increased in depth and rate respirations e. Cheyne-Stokes—abnormally slow and depressed ventilation respirations f. Biot's—irregular with alternating periods of apnea and hyperventilation respirations

A, B, C - Apnea—Respirations cease for several seconds. Persistent cessation results in respiratory arrest. - Tachypnea—Rate of breathing is regular but abnormally rapid (greater than 20 breaths/min). - Kussmaul's—Respirations are abnormally deep, regular, and increased in rate. - Hyperventilation—Rate and depth of respirations increase; breaths are not labored. Hypocarbia sometimes occurs. - Cheyne-Stokes—Respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation. - Biot's—Respirations are abnormally shallow for 2 to 3 breaths followed by irregular period of apnea

A nurse is asked by a co-worker why patient education/teaching is important. Which statements will the nurse share with the co-worker? (Select all that apply.) a. "Patient education is an essential component of safe, patient-centered care." b. "Patient education is a standard for professional nursing practice." c. "Patient teaching falls within the scope of nursing practice." d. "Patient teaching is documented and part of the chart." e. "Patient education is not effective with children." f. "Patient teaching can increase health care costs."

A, B, C, D Patient education has long been a standard for professional nursing practice. All state Nurse Practice Acts acknowledge that patient teaching falls within the scope of nursing practice. Patient education is an essential component of providing safe, patient-centered care. It is important to document evidence of successful patient education in patients' medical records. Patient education is effective for children. Different techniques must be used with children. Creating a well-designed, comprehensive teaching plan that fits a patient's unique learning needs reduces health care costs, improves quality of care, and ultimately changes behaviors to improve patient outcomes.

Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia (select all that apply)? a. Age b. Blood pressure c. Respiratory rate d. Oxygen saturation e. Presence of confusion f. Blood urea nitrogen (BUN) level

A, B, C, E, F Data collected for the CURB-65 are: - mental status (confusion), - BUN (elevated), - blood pressure (decreased), - respiratory rate (increased), - and age (65 and older). The other information is also essential to assess, but are not used for CURB-65 scoring.

The nurse is reviewing the medical records for five patients who are scheduled for their yearly physical examinations in September. Which patients should receive the inactivated influenza vaccination (select all that apply)? a. A 76-year-old nursing home resident b. A 36-year-old female patient who is pregnant c. A 42-year-old patient who has a 15 pack-year smoking history d. A 30-year-old patient who takes corticosteroids for rheumatoid arthritis e. A 24-year-old patient who has allergies to penicillin and cephalosporins

A, B, D Current guidelines suggest that healthy individuals between 6 months and age 49 receive intranasal immunization with live, attenuated influenza vaccine. Individuals who are pregnant, residents of nursing homes, or are immunocompromised or who have chronic medical conditions should receive inactivated vaccine by injection. The corticosteroid use by the 30-year-old increases the risk for infection.

A nurse meets the following goals: helps a patient maintain health and helps a patient with an illness. Which factors assist the nurse in achieving these goals? (Select all that apply.) a. Understands the challenges of today's health care system b. Identifies actual and potential risk factors c. Has coined the term "illness behavior" d. Minimizes the effects of illnesses e. Experiences compassion fatigue

A, B, D Nurses are in a unique position to assist patients in achieving and maintaining optimal levels of health. Nurses understand the challenges of today's health care system. Nurses can identify actual and potential risk factors that predispose a person or group to illness. Nurses who understand how patients react to illness can minimize the effects of illness and assist patients and their families in maintaining or returning to the highest level of functioning. Nurses did not coin the phrase "illness behavior." While nurses can experience compassion fatigue, it does not help in meeting patient goals.

The nurse is assessing the patient and family for probable familial causes of the patient's hypertension. The nurse begins by analyzing the patient's personal history, as well as family history and current lifestyle situation. Which findings will the nurse consider to be risk factors? (Select all that apply.) a. Obesity b. Cigarette smoking c. Recent weight loss d. Heavy alcohol intake e. Regular exercise sessions

A, B, D Obesity, cigarette smoking, and heavy alcohol consumption are risk factors linked to hypertension. Weight loss and regular exercise can decrease the risk for hypertension. .

The nurse assumes care of a patient who just returned from surgery for a total laryngectomy and radical neck dissection and notes the following problems. In which order should the nurse address the problems? a. The patient is in a side-lying position with the head of the bed flat. b. The patient is coughing blood-tinged secretions from the tracheostomy. c. The nasogastric (NG) tube is disconnected from suction and clamped off. d. The wound drain in the neck incision contains 200 mL of bloody drainage.

A, B, D, C - The patient should first be placed in a semi-Fowlers position to maintain the airway and reduce incisional swelling. - The blood-tinged secretions may obstruct the airway, so suctioning is the next appropriate action. - Then the wound drain should be drained because the 200 mL of drainage will decrease the amount of suction in the wound drain and could lead to incisional swelling and poor healing. - Finally, the NG tube should be reconnected to suction to prevent gastric dilation, nausea, and vomiting.

A nurse is preparing to teach patients. Which patient finding will cause the nurse to postpone a teaching session? (Select all that apply.) a. The patient is hurting. b. The patient is fatigued. c. The patient is mildly anxious. d. The patient is asking questions. e. The patient is febrile (high fever). f. The patient is in the acceptance phase.

A, B, E Any condition (e.g., pain, fatigue) that depletes a person's energy also impairs the ability to learn, so the session should be postponed until the pain is relieved and the patient is rested. Postpone teaching when an illness becomes aggravated by complications such as a high fever or respiratory difficulty. A mild level of anxiety motivates learning. When patients are ready to learn, they frequently ask questions. When the patient enters the stage of acceptance, the stage compatible with learning, introduce a teaching plan.

The patient is being encouraged to purchase a portable automatic blood pressure device to monitor blood pressure at home. Which information will the nurse present as benefits for this type of treatment? (Select all that apply.) a. Patients can actively participate in their treatment. b. Self-monitoring helps with compliance and treatment. c. The risk of obtaining an inaccurate reading is decreased. d. Blood pressures can be obtained if pulse rates become irregular. e. Patients can provide information about patterns to health care providers

A, B, E Self-measurement of blood pressure has several benefits. Sometimes elevated blood pressure is detected in persons previously unaware of a problem. Persons with prehypertension provide information about the pattern of blood pressure values to their health care provider. Patients with hypertension benefit from participating actively in their treatment through self-monitoring, which promotes compliance with treatment. Disadvantages of self-measurement include the risk of inaccurate readings. Electronic devices are not recommended if the patient has an irregular heart rate

The clinic nurse is teaching a patient with acute sinusitis. Which interventions should the nurse plan to include in the teaching session (select all that apply)? a. Decongestants can be used to relieve swelling. b. Blowing the nose should be avoided to decrease the nosebleed risk. c. Taking a hot shower will increase sinus drainage and decrease pain. d. Saline nasal spray can be made at home and used to wash out secretions. e. You will be more comfortable if you keep your head in an upright position.

A, C, D, E The steam and heat from a shower will help thin secretions and improve drainage. Decongestants can be used to relieve swelling. Patients can use either over-the-counter (OTC) sterile saline solutions or home-prepared saline solutions to thin and remove secretions. Maintaining an upright posture decreases sinus pressure and the resulting pain. Blowing the nose after a hot shower or using the saline spray is recommended to expel secretions.

A nurse is teaching a community health promotion class and discusses the flu vaccine. Which information will the nurse include in the teaching session? (Select all that apply.) a. It is given yearly. b. It is given in a series of four doses. c. It is safe for children allergic to eggs. d. It is safe for adults with acute febrile illnesses. e. The nasal spray is given to people over 50. f. The inactivated flu vaccine is given to people over 50.

A, F Annual (yearly) flu vaccines are recommended for all people 6 months and older. The inactivated flu vaccine should be given to these individuals with chronic health problems and those 50 and older. People with a known hypersensitivity to eggs or other components of the vaccine should consult their health care provider before being vaccinated. There is a flu vaccine made without egg proteins that is approved for adults 18 years of age and older. Adults with an acute febrile illness should schedule the vaccination after they have recovered. The live, attenuated nasal spray vaccine is given to people from 2 through 49 years of age if they are not pregnant or do not have certain long- term health problems such as asthma; heart, lung, or kidney disease; diabetes; or anemia.

Aldosterone a. Increases excretion of sodium and water b. Reduces excretion of sodium and water c. Reduces excretion of water d. Major buffer in the extracellular fluid e. Vasoconstricts and stimulates aldosterone release

B

Orthostatic hypotension a. Patient's temperature is 113° F (45° C) with hot, dry skin. b. Patient's blood pressure sitting is 130/60 and 110/40 standing. c. Patient's pulse is 110 beats/min. d. Patient's temperature is 93.2° F (34° C). e. Patient's blood pressure went from 126/76 to 90/50.

B

The nurse will plan to monitor a patient with an obstructed common bile duct for: a. melena. b. steatorrhea. c. decreased serum cholesterol levels. d. increased serum indirect bilirubin levels .

B A common bile duct obstruction will reduce the absorption of fat in the small intestine, leading to fatty stools. Gastrointestinal (GI) bleeding is not caused by common bile duct obstruction. Serum cholesterol levels are increased with biliary obstruction. Direct bilirubin level is increased with biliary obstruction. .

A nurse is administering a blood transfusion. Which assessment finding will the nurse report immediately? a. Blood pressure 110/60 b. Temperature 101.3° F c. Poor skin turgor and pallor d. Heart rate of 100 beats/min

B A fever should be reported immediately and the blood transfusion stopped. All other assessment findings are expected. Blood is given to elevate blood pressure, improve pallor, and decrease tachycardia .

When caring for a patient who is hospitalized with active tuberculosis (TB), the nurse observes a student nurse who is assigned to take care of a patient. Which action, if performed by the student nurse, would require an intervention by the nurse? A. The patient is offered a tissue from the box at the bedside. B. A surgical face mask is applied before visiting the patient. C. A snack is brought to the patient from the unit refrigerator. D. Hand washing is performed before entering the patients room

B A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the patients room because the HEPA mask can filter out 100% of small airborne particles. Hand washing before entering the patients room is appropriate. Because anorexia and weight loss are frequent problems in patients with TB, bringing food to the patient is appropriate. The student nurse should perform hand washing after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue.

The patient was found unresponsive in an apartment and is being brought to the emergency department. The patient has arm, hand, and leg edema, temperature is 95.6° F, and hands are cold secondary to a history of peripheral vascular disease. It is reported that the patient has a latex allergy. What should the nurse do to quickly measure the patient's oxygen saturation? a. Attach a finger probe to the patient's index finger. b. Place a nonadhesive sensor on the patient's earlobe. c. Attach a disposable adhesive sensor to the bridge of the patient's nose. d. Place the sensor on the same arm that the electronic blood pressure cuff is on

B A nonadhesive sensor is best for latex allergy, and the earlobe site is the best choice for this patient with peripheral vascular disease and edema. Select forehead, ear or bridge of nose if an adult patient has a history of peripheral vascular disease. Do not attach probe to finger, ear, forehead, or bridge of nose if area is edematous or skin integrity is compromised. Do not use disposable adhesive probes if the patient has latex allergy. Do not attach probe to fingers that are hypothermic. Do not place the sensor on the same extremity as the electronic blood pressure cuff because blood flow to the finger will be temporarily interrupted when the cuff inflates

The nurse determines that an older-adult patient is at risk for infection due to decreased immunity. Which plan of care best addresses the prevention of infection for the patient? a. Inform the patient of the importance of finishing the entire dose of antibiotics. b. Encourage the patient to stay up-to-date on all vaccinations. c. Schedule patient to get annual tuberculosis skin testing. d. Create an exercise routine to run 45 minutes every day

B A nursing care plan for preventative health measures should be reasonable and feasible. Keeping up-to-date on vaccinations is important because vaccine reduces the severity of illnesses and serious complications. Determine if and when the patient has had a pneumococcal or influenza (flu) vaccine. This is especially important when assessing older adults because of their increased risk for respiratory disease. Although it is important to finish the full course of antibiotics, it is not a preventative health measure. Scheduling annual tuberculosis skin tests does not address prevention and is an unreliable indictor of tuberculosis in older patients. The exercise routine should be reasonable to increase compliance; exercise is recommended only 3 to 4 times a week for 30 to 60 minutes, and walking, rather than running, is an efficient method.

Which action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness? a. Coordinate the transfer of the patient to the operating room. b. Provide discharge instructions about monitoring neurologic status. c. Transport the patient to radiology for magnetic resonance imaging (MRI). d. Arrange to admit the patient to the neurologic unit for 24 hours of observation

B A patient with a minor head trauma is usually discharged with instructions about neurologic monitoring and the need to return if neurologic status deteriorates. MRI, hospital admission, or surgery are not usually indicated in a patient with a concussion. .

A nurse is assessing the ability to learn of a patient who has recently experienced a stroke. Which question/statement will best assess the patient's ability to learn? a. "What do you want to know about strokes?" b. "Please read this handout and tell me what it means." c. "Do you feel strong enough to perform the tasks I will teach you?" d. "On a scale from 1 to 10, tell me where you rank your desire to learn."

B A patient's reading level affects ability to learn. One way to assess a patient's reading level and level of understanding is to ask the patient to read instructions from an educational handout and then explain their meaning. Reading level is often difficult to assess because patients who are functionally illiterate are often able to conceal it by using excuses such as not having the time or not being able to see. Asking patients what they want to know identifies previous learning and learning needs and preferences; it does not assess ability to learn. Motivation (desire to learn) is related to readiness to learn, not ability to learn. Just asking a patient if he or she feels strong is not as effective as actually assessing the patient's strength.

The nurse is admitting a patient with uncontrolled diabetes mellitus. It is the fourth time the patient is being admitted in the last 6 months for high blood sugars. During the admission process, the nurse asks the patient about employment status and displays a nonjudgmental attitude. What is the rationale for the nurse's actions? a. External variables have little effect on compliance. b. A person's compliance is affected by economic status. c. Employment status is an internal variable that impacts compliance. d. Noncompliant patients thrive on the disapproval of authority figures.

B A person's compliance with treatment is affected by economic status. A person tends to give a higher priority to food and shelter than to costly drugs or treatments. External variables can have a major impact on compliance. Employment status is an external variable, not an internal variable. A person generally seeks approval and support from social networks, and this desire for approval affects health beliefs and practices; noncompliance does not occur from thriving on disapproval of authority figures.

In which patient will the nurse expect to see a positive Chvostek sign? a. A 7-year-old child admitted for severe burns b. A 24-year-old adult admitted for chronic alcohol abuse c. A 50-year-old patient admitted for an acute exacerbation of hyperparathyroidism d. A 75-year-old patient admitted for a broken hip related to osteoporosis .

B A positive Chvostek sign is representative of hypocalcemia or hypomagnesemia. Hypomagnesemia is common with alcohol abuse. Hypocalcemia can be brought on by alcohol abuse and pancreatitis (which also can be affected by alcohol consumption). Burn patients frequently experience extracellular fluid volume deficit. Hyperparathyroidism causes hypercalcemia. Immobility is associated with hypercalcemia

Which nursing diagnosis is expected to be appropriate for a patient who has a positive Romberg test? a. Acute pain b. Risk for falls c. Acute confusion d. Ineffective thermoregulation .

B A positive Romberg test indicates that the patient has difficulty maintaining balance with the eyes closed. The Romberg does not test for orientation, thermoregulation, or discomfort. .

A nurse is using Maslow's hierarchy to prioritize care for an anxious patient that is not eating and will not see family members. Which area should the nurse address first? a. Anxiety b. Not eating c. Mental health d. Not seeing family members .

B According to Maslow, in all cases an emergent physiological need takes precedence over a higher- level need. Nutrition is a physiological need and should be addressed first. Anxiety, mental health, and not seeing family members are all higher-level needs. .

A nurse is trying to help a patient begin to accept the chronic nature of diabetes. Which teaching technique should the nurse use to enhance learning? a. Lecture b. Role play c. Demonstration d. Question and answer sessions

B Affective learning deals with expression of feelings and acceptance of attitudes, beliefs, or values. Role play and discussion (one-on-one and group) are effective teaching methods for the affective domain. - Lecture and question and answer sessions are effective teaching methods for the cognitive domain. - Demonstration is an effective teaching method for the psychomotor domain.

An unconscious male patient has just arrived in the emergency department after a head injury caused by a motorcycle crash. Which order should the nurse question? a. Obtain x-rays of the skull and spine. b. Prepare the patient for lumbar puncture. c. Send for computed tomography (CT) scan. d. Perform neurologic checks every 15 minutes

B After a head injury, the patient may be experiencing intracranial bleeding and increased intracranial pressure, which could lead to herniation of the brain if a lumbar puncture is performed. The other orders are appropriate. .

The nurse needs to closely monitor the oxygen status of an older-adult patient undergoing anesthesia because of which age-related change? a. Thinner heart valves cause lipid accumulation and fibrosis. b. Diminished respiratory muscle strength may cause poor chest expansion. c. Alterations in mental status prevent patients' awareness of ineffective breathing. d. An increased number of pacemaker cells make proper anesthesia induction more difficult

B Age-related changes in the thorax that occur from ossification of costal cartilage, decreased space between vertebrae, and diminished respiratory muscle strength lead to problems with chest expansion and oxygenation,whereby the patient will have difficulty excreting anesthesia gas. The nurse needs to monitor the patient's oxygen status carefully to make sure the patient does not retain too much of the drug. Older adults experience alterations in cardiac function as a result of calcification of the conduction pathways, thicker and stiffer heart valves caused by lipid accumulation and fibrosis, and a decrease in the number of pacemaker cells in the SA node. Altered mental status is not a normal age-related change; it indicates possible cardiac and/or respiratory problems

The nurse and the patient who is diagnosed with hypertension develop this goal: The patient will select a 2- gram sodium diet from the hospital menu for the next 3 days. Which evaluation method will be best for the nurse to use when determining whether teaching was effective? a. Have the patient list substitutes for favorite foods that are high in sodium. b. Check the sodium content of the patients menu choices over the next 3 days. c. Ask the patient to identify which foods on the hospital menus are high in sodium. d. Compare the patients sodium intake before and after the teaching was implemented.

B All of the answers address the patients sodium intake, but the desired patient behaviors in the learning objective are most clearly addressed by evaluating the sodium content of the patients menu choices. . .

Which information about a 76-year-old patient is most important for the admitting nurse to report to the patients health care provider? a. Triceps reflex response graded at 1/5 b. Unintended weight loss of 20 pounds c. 10 mm Hg orthostatic drop in systolic blood pressure d. Patient complaint of chronic difficulty in falling asleep

B Although changes in appetite are normal with aging, a 20-pound weight loss requires further investigation. Orthostatic drops in blood pressure, changes in sleep patterns, and slowing of reflexes are normal changes in aging. .

After the nurse provides dietary instructions for a patient with diabetes, the patient can explain the information but fails to make the recommended dietary changes. How would the nurse evaluate the patients situation? a. Learning did not occur because the patients behavior did not change. b. Choosing not to follow the diet is the behavior that resulted from learning. c. The nursing responsibility for helping the patient make dietary changes has been fulfilled. d. The teaching methods were ineffective in helping the patient learn the dietary instructions.

B Although the patient behavior has not changed, the patients ability to explain the information indicates that learning has occurred and the patient is choosing at this time not to change the diet. The patient may be in the contemplation or preparation stage in the Transtheoretical Model. The nurse should reinforce the need for change and continue to provide information and assistance with planning for change.

The nurse is administering a mental status examination to a 48-year-old patient who has hypertension. The nurse suspects depression when the patient responds to the nurses questions with a. Is that right? b. I dont know. c. Wait, let me think about that. d. Who are those people over there?

B Answers such as I dont know are more typical of depression than dementia. The response Who are those people over there? is more typical of the distraction seen in a patient with delirium. The remaining two answers are more typical of a patient with mild to moderate dementia. .

The patient has a temperature of 105.2° F. The nurse is attempting to lower temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. Which technique is the nurse using to lower the patient's temperature? a. Radiation b. Conduction c. Convection d. Evaporation

B Applying an ice pack or bathing a patient with a cool cloth increases conductive heat loss because of the direct contact. Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between the two. Evaporation is the transfer of heat energy when a liquid is changed to a gas. Convection is the transfer of heat away from the body by air movement

The patient had a colostomy placed 1 week ago. When approached by the nurse, the patient and spouse refuse to talk about it and refuse to be taught about how to care for it. How will the nurse evaluate this couple's stage of adjustment? a. Shock b. Withdrawal c. Acceptance d. Rehabilitation

B As the patient and family recognize the reality of a change, they become anxious and may withdraw, refusing to discuss it. This is an adaptive coping mechanism that assists the patient in making the adjustment. Initially, the patient may be shocked by the change. This is followed by withdrawal, acknowledgment, acceptance, and rehabilitation (ready to adapt to the change through use of colostomy bag).

A nurse teaches a patient about atelectasis. Which statement by the patient indicates an understanding of atelectasis? a. "Atelectasis affects only those with chronic conditions such as emphysema." b. "It is important to do breathing exercises every hour to prevent atelectasis." c. "If I develop atelectasis, I will need a chest tube to drain excess fluid." d. "Hyperventilation will open up my alveoli, preventing atelectasis."

B Atelectasis develops when alveoli do not expand. Breathing exercises, especially deep breathing and incentive spirometry, increase lung volume and open the airways, preventing atelectasis. Deep breathing also opens the pores of Kohn between alveoli to allow sharing of oxygen between alveoli. Atelectasis can affect anyone who does not deep breathe. A chest tube is for pneumothorax or hemothorax. It is deep breathing, not hyperventilation, that prevents atelectasis

A patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving nifedipine (Procardia). Which assessment would best indicate to the nurse that the patients condition is improving? a. Blood pressure (BP) is less than 140/90 mm Hg. b. Patient reports decreased exertional dyspnea. c. Heart rate is between 60 and 100 beats/minute. d. Patients chest x-ray indicates clear lung fields.

B Because a major symptom of IPAH is exertional dyspnea, an improvement in this symptom would indicate that the medication was effective. Nifedipine will affect BP and heart rate, but these parameters would not be used to monitor the effectiveness of therapy for a patient with IPAH. The chest x-ray will show clear lung fields even if the therapy is not effective.

Several patients have been hospitalized for diagnosis of neurologic problems. Which patient will the nurse assess first? a. Patient with a transient ischemic attack (TIA) returning from carotid duplex studies b. Patient with a brain tumor who has just arrived on the unit after a cerebral angiogram c. Patient with a seizure disorder who has just completed an electroencephalogram (EEG) d. Patient prepared for a lumbar puncture whose health care provider is waiting for assistance

B Because cerebral angiograms require insertion of a catheter into the femoral artery, bleeding is a possible complication. The nurse will need to check the pulse, blood pressure, and the catheter insertion site in the groin as soon as the patient arrives. Carotid duplex studies and EEG are noninvasive. The nurse will need to assist with the lumbar puncture as soon as possible, but monitoring for hemorrhage after cerebral angiogram has a higher priority

A patient has heart failure and kidney failure. The patient needs teaching about dialysis. Which nursing action is most appropriate for assessing this patient's learning needs? a. Assess the patient's total health care needs. b. Assess the patient's health literacy. c. Assess all sources of patient data. d. Assess the goals of patient care.

B Because health literacy influences how you deliver teaching strategies, it is critical for you to assess a patient's health literacy before providing instruction. The nursing process requires assessment of all sources of data to determine a patient's total health care needs. Evaluation of the teaching process involves determining outcomes of the teaching/learning process and the achievement of learning objectives; assessing the goals of patient care is the evaluation component of the nursing process.

After endotracheal suctioning, the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action should the nurse take first? a. Document the increase in intracranial pressure. b. Ensure that the patients neck is in neutral position. c. Notify the health care provider about the change in pressure. d. Increase the rate of the prescribed propofol (Diprivan) infusion.

B Because suctioning will cause a transient increase in intracranial pressure, the nurse should initially check for other factors that might be contributing to the increase and observe the patient for a few minutes. Documentation is needed, but this is not the first action. There is no need to notify the health care provider about this expected reaction to suctioning. Propofol is used to control patient anxiety or agitation. There is no indication that anxiety has contributed to the increase in intracranial pressure.

Which finding would the nurse expect when assessing the legs of a patient who has a lower motor neuron lesion? a. Spasticity b. Flaccidity c. No sensation d. Hyperactive reflexes .

B Because the cell bodies of lower motor neurons are located in the spinal cord, damage to the neuron will decrease motor activity of the affected muscles. Spasticity and hyperactive reflexes are caused by upper motor neuron damage. Sensation is not impacted by motor neuron lesions. .

After the nurse has received change-of-shift report, which patient should the nurse assess first? a. A patient with pneumonia who has crackles in the right lung base b. A patient with possible lung cancer who has just returned after bronchoscopy c. A patient with hemoptysis and a 16-mm induration with tuberculin skin testing d. A patient with chronic obstructive pulmonary disease (COPD) and pulmonary function testing (PFT) that indicates low forced vital capacity

B Because the cough and gag are decreased after bronchoscopy, this patient should be assessed for airway patency. The other patients do not have clinical manifestations or procedures that require immediate assessment by the nurse. .

To assess for functional deficits, which question will the nurse ask a patient who has been admitted for treatment of a benign occipital lobe tumor? a. Do you have difficulty in hearing? b. Are you experiencing visual problems? c. Are you having any trouble with your balance? d. Have you developed any weakness on one side?

B Because the occipital lobe is responsible for visual reception, the patient with a tumor in this area is likely to have problems with vision. The other questions will be better for assessing function of the temporal lobe, cerebellum, and frontal lobe. .

Upon completion of the assessment, the nurse finds that the patient has quit drinking and has been alcohol free for the past 2 years. Which stage best describes the nurse's assessment finding? a. Contemplation b. Maintenance c. Preparation d. Action

B Because the patient has been alcohol free for 2 years, the patient is in the maintenance stage. These stages range from no intention to change (precontemplation), to considering a change within the next 6 months (contemplation), to making small changes (preparation), to actively engaging in strategies to change behavior (action), to maintaining a changed behavior (maintenance).

A 49-year-old man has been admitted with hypotension and dehydration after 3 days of nausea and vomiting. Which order from the health care provider will the nurse implement first? a. Insert a nasogastric (NG) tube. b. Infuse normal saline at 250 mL/hr. c. Administer IV ondansetron (Zofran). d. Provide oral care with moistened swabs

B Because the patient has severe dehydration, rehydration with IV fluids is the priority. The other orders should be accomplished as quickly as possible after the IV fluids are initiated. .

Which nursing action will be most effective in ensuring daily medication compliance for a patient with mild dementia? a. Setting the medications up monthly in a medication box b. Having the patients family member administer the medication c. Posting reminders to take the medications in the patients house d. Calling the patient weekly with a reminder to take the medication

B Because the patient with mild dementia will have difficulty with learning new skills and forgetfulness, the most appropriate nursing action is to have someone else administer the drug. The other nursing actions will not be as effective in ensuring that the patient takes the medications. .

A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first? a. Document the BP and ICP in the patients record. b. Report the BP and ICP to the health care provider. c. Elevate the head of the patients bed to 60 degrees. d. Continue to monitor the patients vital signs and ICP

B Calculate the cerebral perfusion pressure (CPP): - (CPP = mean arterial pressure [MAP] ICP). MAP = DBP + 1/3 (systolic blood pressure [SBP] diastolic blood pressure [DBP]). - Therefore the (MAP) is 70 and the CPP is 56 mm Hg, which is below the normal of 60 to 100 mm Hg and approaching the level of ischemia and neuronal death. Immediate changes in the patients therapy such as fluid infusion or vasopressor administration are needed to improve the cerebral perfusion pressure. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation will also be done, but they are not the first actions that the nurse should take

The home health nurse recommends that a patient with respiratory problems install a carbon monoxide detector in the home. What is the rationale for the nurse's action? a. Carbon monoxide detectors are required by law in the home. b. Carbon monoxide tightly binds to hemoglobin, causing hypoxia. c. Carbon monoxide signals the cerebral cortex to cease ventilations. d. Carbon monoxide combines with oxygen in the body and produces a deadly toxin

B Carbon monoxide binds tightly to hemoglobin; therefore, oxygen is not able to bind to hemoglobin and be transported to tissues, causing hypoxia. A carbon monoxide detector is not required by law, does not signal the cerebral cortex to cease ventilations, and does not combine with oxygen but with hemoglobin to produce a toxin.

Which item should the nurse offer to the patient who is to restart oral intake after being NPO due to nausea and vomiting? a. Glass of orange juice b. Dish of lemon gelatin c. Cup of coffee with cream d. Bowl of hot chicken broth

B Clear cool liquids are usually the first foods started after a patient has been nauseated. Acidic foods such as orange juice, very hot foods, and coffee are poorly tolerated when patients have been nauseated. .

A 20-year-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take? a. Have the patient gently blow the nose. b. Check the drainage for glucose content. c. Teach the patient that rhinorrhea is expected after a head injury. d. Obtain a specimen of the fluid to send for culture and sensitivity

B Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. Blowing the nose is avoided to prevent CSF leakage

The nurse determines that teaching regarding cobalamin injections has been effective when the patient with chronic atrophic gastritis states which of the following? a. The cobalamin injections will prevent gastric inflammation. b. The cobalamin injections will prevent me from becoming anemic. c. These injections will increase the hydrochloric acid in my stomach. d. These injections will decrease my risk for developing stomach cancer

B Cobalamin supplementation prevents the development of pernicious anemia. Chronic gastritis may cause achlorhydria, but cobalamin does not correct this. The loss of intrinsic factor secretion with chronic gastritis is permanent, and the patient will need lifelong supplementation with cobalamin. The incidence of stomach cancer is higher in patients with chronic gastritis, but cobalamin does not reduce the risk for stomach cancer.

The nurse is educating a student nurse on caring for a patient with a chest tube. Which statement from the student nurse indicates successful learning? a. "I should clamp the chest tube when giving the patient a bed bath." b. "I should report if I see continuous bubbling in the water-seal chamber." c. "I should strip the drains on the chest tube every hour to promote drainage." d. "I should notify the health care provider first, if the chest tube becomes dislodged."

B Correct care of a chest tube involves knowing normal and abnormal functioning of the tube. A constant or intermittent bubbling in the water-seal chamber indicates a leak in the drainage system, and the health care provider must be notified immediately. Stripping the tube is not routinely performed as it increases pressure. If the tubing disconnects from the drainage unit, instruct the patient to exhale as much as possible and to cough. This maneuver rids the pleural space of as much air as possible. Temporarily reestablish a water seal by immersing the open end of the chest tube into a container of sterile water. The chest tube should not be clamped unless necessary; if so, the length of time clamped would be minimal to reduce the risk of pneumothorax

Several weeks after a stroke, a 50-year-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention will be best to include in the initial plan for an effective bladder training program? a. Limit fluid intake to 1200 mL daily to reduce urine volume. b. Assist the patient onto the bedside commode every 2 hours. c. Perform intermittent catheterization after each voiding to check for residual urine. d. Use an external condom catheter to protect the skin and prevent embarrassment.

B Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder. A 1200 mL fluid restriction may lead to dehydration. Intermittent catheterization and use of a condom catheter are appropriate in the acute phase of stroke, but should not be considered solutions for long-term management because of the risks for urinary tract infection (UTI) and skin breakdown.

The nurse is caring for a patient who is being discharged from the hospital after being treated for hypertension. The patient is instructed to take blood pressure 3 times a day and to keep a record of the readings. The nurse recommends that the patient purchase a portable electronic blood pressure device. Which other information will the nurse share with the patient? a. You can apply the cuff in any manner. b. You will need to recalibrate the machine. c. You can move your arm during the reading. d. You will need to use a stethoscope properly

B Electronic devices are easier to manipulate but require frequent recalibration—more than once a year. Because of their sensitivity, improper cuff placement or movement of the arm causes electronic devices to give incorrect readings. The portable home devices include the aneroid sphygmomanometer and electronic digital readout devices that do not require the use of a stethoscope. The cuff will need to be applied correctly, and the patient's arm needs to be still during the reading

Which information will the nurse include for a patient with newly diagnosed gastroesophageal reflux disease (GERD)? a. Peppermint tea may reduce your symptoms. b. Keep the head of your bed elevated on blocks. c. You should avoid eating between meals to reduce acid secretion. d. Vigorous physical activities may increase the incidence of reflux

B Elevating the head of the bed will reduce the incidence of reflux while the patient is sleeping. Peppermint will decrease lower esophageal sphincter (LES) pressure and increase the chance for reflux. Small, frequent meals are recommended to avoid abdominal distention. There is no need to make changes in physical activities because of GERD. .

Which nursing action should be included in the postoperative plan of care for a patient after a laparoscopic esophagectomy? a. Notify the doctor about bloody nasogastric (NG) drainage. b. Elevate the head of the bed to at least 30 degrees. c. Reposition the NG tube if drainage stops. d. Start oral fluids when the patient has active bowel sounds.

B Elevation of the head of the bed decreases the risk for reflux and aspiration of gastric secretions. The NG tube should not be repositioned without consulting with the health care provider. Bloody NG drainage is expected for the first 8 to 12 hours. A swallowing study is needed before oral fluids are started. .

A family member of a 28-year-old patient who has suffered massive abdominal trauma in an automobile accident asks the nurse why the patient is receiving famotidine (Pepcid). The nurse will explain that the medication will a. decrease nausea and vomiting. b. inhibit development of stress ulcers. c. lower the risk for H. pylori infection. d. prevent aspiration of gastric contents.

B Famotidine is administered to prevent the development of physiologic stress ulcers, which are associated with a major physiologic insult such as massive trauma. Famotidine does not decrease nausea or vomiting, prevent aspiration, or prevent H. pylori infection. .

A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. The nurse will anticipate teaching the patient about a. alteplase (tPA). b. aspirin (Ecotrin). c. warfarin (Coumadin). d. nimodipine (Nimotop). .

B Following a transient ischemic attack (TIA), patients typically are started on medications such as aspirin to inhibit platelet function and decrease stroke risk. tPA is used for acute ischemic stroke. Coumadin is usually used for patients with atrial fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage. .

An experienced nurse instructs a new nurse about how to care for a patient with dyspnea caused by a pulmonary fungal infection. Which action by the new nurse indicates a need for further teaching? a. Listening to the patients lung sounds several times during the shift b. Placing the patient on droplet precautions and in a private hospital room c. Increasing the oxygen flow rate to keep the oxygen saturation above 90% d. Monitoring patient serology results to identify the specific infecting organism

B Fungal infections are not transmitted from person to person. Therefore no isolation procedures are necessary. The other actions by the new nurse are appropriate. .

The nurse is caring for a patient with a tracheostomy tube. Which nursing intervention is most effective in promoting effective airway clearance? a. Suctioning respiratory secretions several times every hour b. Administering humidified oxygen through a tracheostomy collar c. Instilling normal saline into the tracheostomy to thin secretions before suctioning d. Deflating the tracheostomy cuff before allowing the patient to cough up secretions

B Humidification from air humidifiers or humidified oxygen tracheostomy collars can help prevent drying of secretions that cause occlusion. Suctioning should be done only as needed; too frequent suctioning can damage the mucosal lining, resulting in thicker secretions. Normal saline should not be instilled into a tracheostomy; research showed no benefit with this technique. The purpose of the tracheostomy cuff is to keep secretions from entering the lungs; the nurse should not deflate the tracheostomy cuff unless instructed to do so by the health care provider.

A nurse is pulled from the surgical unit to work on the oncology unit. Which action by the nurse displays humility and responsibility? a. Refusing the assignment b. Asking for an orientation to the unit c. Admitting lack of knowledge and going home d. Assuming that patient care will be the same as on the other units

B Humility and responsibility are displayed when the nurse realizes lack of knowledge and requests an orientation to the unit. The other answer choices represent inappropriate actions in this situation and are not examples of humility and responsibility. The nurse should explore all options before refusing an assignment. The nurse should not make assumptions. Assuming is not an example of critical thinking. Admitting lack of knowledge is an example of humility, but going home does not illustrate an example of responsibility.

The nurse is caring for a patient who reports feeling light-headed and "woozy." The nurse checks the patient's pulse and finds that it is irregular. The patient's blood pressure is 100/72. It was 113/80 an hour earlier. What should the nurse do? a. Apply more pressure to the radial artery to feel pulse. b. Perform an apical/radial pulse assessment. c. Call the health care provider immediately. d. Obtain arterial blood gases

B If the pulse is irregular, do an apical/radial pulse assessment to detect a pulse deficit. If pulse count differs by more than 2, a pulse deficit exists, which sometimes indicates alterations in cardiac output. The nurse needs to gather as much information as possible before calling the health care provider. The radial pulse is more accurately assessed with moderate pressure. Too much pressure occludes the pulse and impairs blood flow. Arterial blood gases is a laboratory test that measures blood pH and oxygenation status. Arterial blood gases would be appropriate if respirations were abnormal or if pulse oximetry results were severely low.

After evacuation of an epidural hematoma, a patients intracranial pressure (ICP) is being monitored with an intraventricular catheter. Which information obtained by the nurse is most important to communicate to the health care provider? a. Pulse 102 beats/min b. Temperature 101.6 F c. Intracranial pressure 15 mm Hg d. Mean arterial pressure 90 mm Hg

B Infection is a serious consideration with ICP monitoring, especially with intraventricular catheters. The temperature indicates the need for antibiotics or removal of the monitor. The ICP, arterial pressure, and apical pulse are all borderline high but require only ongoing monitoring at this time. .

Propranolol (Inderal), a b-adrenergic blocker that inhibits sympathetic nervous system activity, is prescribed for a patient who has extreme anxiety about public speaking. The nurse monitors the patient for a. dry mouth. b. bradycardia. c. constipation. d. urinary retention

B Inhibition of the fight or flight response leads to a decreased heart rate. Dry mouth, constipation, and urinary retention are associated with peripheral nervous system blockade .

A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first? a. Chest x-ray via stretcher b. Blood cultures from two sites c. Ciprofloxacin (Cipro) 400 mg IV d. Acetaminophen (Tylenol) rectal suppository

B Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic administration. The chest x-ray and acetaminophen administration can be done last. .

A 39-year-old patient with a suspected herniated intervertebral disc is scheduled for a myelogram. Which information is most important for the nurse to communicate to the health care provider before the procedure? a. The patient is anxious about the test. b. The patient has an allergy to shellfish. c. The patient has back pain when lying flat. d. The patient drank apple juice 4 hours earlier

B Iodine-containing contrast medium is injected into the subarachnoid space during a myelogram. The health care provider may need to modify the postmyelogram orders to prevent back pain, but this can be done after the procedure. Clear liquids are usually considered safe up to 4 hours before a diagnostic or surgical procedure. The patients anxiety should be addressed, but this is not as important as the iodine allergy

A diabetic patients arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg; HCO3 18 mEq/L. The nurse would expect which finding? a. Intercostal retractions b. Kussmaul respirations c. Low oxygen saturation (SpO2) d. Decreased venous O2 pressure

B Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis. The low pH and low bicarbonate result indicate metabolic acidosis. Intercostal retractions, a low oxygen saturation rate, and a decrease in venous O2 pressure would not be caused by acidosis.

Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a. Listen to a patients lung sounds for wheezes or rhonchi. b. Label specimens obtained during percutaneous lung biopsy. c. Instruct a patient about how to use home spirometry testing. d. Measure induration at the site of a patients intradermal skin test.

B Labeling of specimens is within the scope of practice of UAP. The other actions require nursing judgment and should be done by licensed nursing personnel.

A patient with diabetic neuropathy requires teaching about foot care. Which learning goal should the nurse include in the teaching plan? a. The nurse will demonstrate the proper technique for trimming toenails. b. The patient will list three ways to protect the feet from injury by discharge. c. The nurse will instruct the patient on appropriate foot care before discharge. d. The patient will understand the rationale for proper foot care after instruction.

B Learning goals should state clear, measurable outcomes of the learning process. Demonstrating technique for trimming toenails and providing instructions on foot care are actions that the nurse will take rather than behaviors that indicate that patient learning has occurred. A learning goal that states that the patient will understand the rationale for proper foot care is too vague and nonspecific to measure whether learning has occurred.

A nurse is determining if teaching is effective. Which finding best indicates learning has occurred? a. A nurse presents information about diabetes. b. A patient demonstrates how to inject insulin. c. A family member listens to a lecture on diabetes. d. A primary care provider hands a diabetes pamphlet to the patient. .

B Learning is the purposeful acquisition of new knowledge, attitudes, behaviors, and skills: patient demonstrates how to inject insulin. A new mother exhibits learning when she demonstrates how to bathe her newborn. A nurse presenting information and a primary care provider handing a pamphlet to a patient are examples of teaching. A family member listening to a lecture does not indicate that learning occurred; a change in knowledge, attitudes, behaviors, and/or skills must be evident.

The nurse is planning a teaching session with a patient newly diagnosed with migraine headaches. To assess a patients readiness to learn, which question should the nurse ask? a. What kind of work and leisure activities do you do? b. What information do you think you need right now? c. Can you describe the types of activities that help you learn new information? d. Do you have any religious beliefs that are inconsistent with the planned treatment?

B Motivation and readiness to learn depend on what the patient values and perceives as important. The other questions are also important in developing the teaching plan, but do not address what information most interests the patient at present. .

The nurse receives the patient's most recent blood work results. Which laboratory value is of greatest concern? a. Sodium of 145 mEq/L b. Calcium of 15.5 mg/dL c. Potassium of 3.5 mEq/L d. Chloride of 100 mEq/L .

B Normal calcium range is 8.4 to 10.5 mg/dL; therefore, a value of 15.5 mg/dL is abnormally high and of concern. The rest of the laboratory values are within their normal ranges: sodium 136 to 145 mEq/L; potassium 3.5 to 5.0 mEq/L; and chloride 98 to 106 mEq/L .

A 30-year-old man is being admitted to the hospital for elective knee surgery. Which assessment finding is most important to report to the health care provider? a. Tympany on percussion of the abdomen b. Liver edge 3 cm below the costal margin c. Bowel sounds of 20/minute in each quadrant d. Aortic pulsations visible in the epigastric area

B Normally the lower border of the liver is not palpable below the ribs, so this finding suggests hepatomegaly. The other findings are within normal range for the physical assessment. .

A 56-year-old patient in the outpatient clinic is diagnosed with mild cognitive impairment (MCI). Which action will the nurse include in the plan of care? a. Suggest a move into an assisted living facility. b. Schedule the patient for more frequent appointments. c. Ask family members to supervise the patients daily activities. d. Discuss the preventive use of acetylcholinesterase medications.

B Ongoing monitoring is recommended for patients with MCI. MCI does not interfere with activities of daily living, acetylcholinesterase drugs are not used for MCI, and an assisted living facility is not indicated for MCI. .

The patient is being admitted to the emergency department with reports of shortness of breath. The patient has had chronic lung disease for many years but still smokes. What will the nurse do? a. Allow the patient to breathe into a paper bag. b. Use oxygen cautiously in this patient. c. Administer high levels of oxygen. d. Give CO2 via mask

B Oxygen must be used cautiously in these types of patients. Hypoxemia helps to control ventilation in patients with chronic lung disease. Because low levels of arterial O2 provide the stimulus that allows a patient to breathe, administration of high oxygen levels may be fatal for patients with chronic lung disease. Patients with chronic lung disease have ongoing hypercarbia (elevated CO2 levels) and do not need to have CO2 administered or "rebreathed" with a paper bag

The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first? a. A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled b. A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath c. A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes d. A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 100.2 F (37.8 C)

B Patients on bed rest who are immobile are at high risk for deep vein thrombosis (DVT). Sudden onset of shortness of breath in a patient with a DVT suggests a pulmonary embolism and requires immediate assessment and action such as oxygen administration. The other patients should also be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration.

The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement, if made by the patient, indicates a good understanding of the instructions? a. I will call the doctor if I still feel tired after a week. b. I will continue to do the deep breathing and coughing exercises at home. c. I will schedule two appointments for the pneumonia and influenza vaccines. d. I'll cancel my chest x-ray appointment if Im feeling better in a couple weeks.

B Patients should continue to cough and deep breathe after discharge. Fatigue is expected for several weeks. The Pneumovax and influenza vaccines can be given at the same time in different arms. Explain that a follow-up chest x-ray needs to be done in 6 to 8 weeks to evaluate resolution of pneumonia.

A nurse is assessing a patient. Which assessment finding should cause a nurse to further assess for extracellular fluid volume deficit? a. Moist mucous membranes b. Postural hypotension c. Supple skin turgor d. Pitting edema

B Physical examination findings of deficit include postural hypotension, tachycardia, thready pulse, dry mucous membranes, and poor skin turgor. Pitting edema indicates that the patient may be retaining excess extracellular fluid. .

A nurse is administering a diuretic to a patient and teaching the patient about foods to increase. Which food choices by the patient will best indicate successful teaching? a. Milk and cheese b. Potatoes and fresh fruit c. Canned soups and vegetables d. Whole grains and dark green leafy vegetables

B Potatoes and fruits are high in potassium. Milk and cheese are high in calcium. Canned soups and vegetables are high in sodium. Whole grains and dark green leafy vegetables are high in magnesium. .

A patient is diagnosed with heart failure after being admitted to the hospital for shortness of breath and fatigue. Which teaching strategy, if implemented by the nurse, is most likely to be effective? a. Assure the patient that the nurse is an expert on management of heart failure. b. Teach the patient at each meal about the amounts of sodium in various foods. c. Discuss the importance of medication control in maintenance of long-term health. d. Refer the patient to a home health nurse for instructions on diet and fluid restrictions.

B Principles of adult education indicate that readiness and motivation to learn are high when facing new tasks (such as learning about the sodium amounts in various food items) and when demonstration and practice of skills are available. Although a home health referral may be needed for this patient, teaching should not be postponed until discharge. Adult learners are independent. The nurse should act as a facilitator for learning, rather than as the expert. Adults learn best when the topic is of immediate usefulness. Long-term goals may not be very motivating.

A patient who has severe Alzheimers disease (AD) is being admitted to the hospital for surgery. Which intervention will the nurse include in the plan of care? a. Encourage the patient to discuss events from the past. b. Maintain a consistent daily routine for the patients care. c. Reorient the patient to the date and time every 2 to 3 hours. d. Provide the patient with current newspapers and magazines.

B Providing a consistent routine will decrease anxiety and confusion for the patient. Reorientation to time and place will not be helpful to the patient with severe AD, and the patient will not be able to read. The patient with severe AD will probably not be able to remember events from the past. .

A patient is pyrexic. Which piece of equipment will the nurse obtain to monitor this condition? a. Stethoscope b. Thermometer c. Blood pressure cuff d. Sphygmomanometer .

B Pyrexia, or fever, occurs because heat loss mechanisms are unable to keep pace with excess heat production, resulting in an abnormal rise in body temperature; therefore, a thermometer is needed. A stethoscope is not used to take a temperature but can be used for apical pulse and blood pressure. A pulse oximeter is used to determine oxygen content in the blood. A sphygmomanometer and blood pressure cuff is used to determine blood pressure and will be used for blood pressure problems

Which information will the nurse include when teaching a patient with peptic ulcer disease about the effect of ranitidine (Zantac)? a. Ranitidine absorbs the gastric acid. b. Ranitidine decreases gastric acid secretion. c. Ranitidine constricts the blood vessels near the ulcer. d. Ranitidine covers the ulcer with a protective material

B Ranitidine is a histamine-2 (H2) receptor blocker, which decreases the secretion of gastric acid. The response beginning, Ranitidine constricts the blood vessels describes the effect of vasopressin. The response Ranitidine absorbs the gastric acid describes the effect of antacids. The response beginning Ranitidine covers the ulcer describes the action of sucralfate (Carafate).

Which action indicates a registered nurse is being responsible for making clinical decisions? a. Applies clear textbook solutions to patients' problems b. Takes immediate action when a patient's condition worsens c. Uses only traditional methods of providing care to patients d. Formulates standardized care plans solely for groups of patients .

B Registered nurses are responsible for making clinical decisions to take immediate action when a patient's condition worsens. Patient care should be based on evidence-based practice, not on tradition. Most patients have health care problems for which there are no clear textbook solutions. Care plans should be individualized for each patient, not just for groups.

A nurse is caring for a patient who was in a motor vehicle accident that resulted in cervical trauma to C4. Which assessment is the priority? a. Pulse b. Respirations c. Temperature d. Blood pressure

B Respirations and oxygen saturation are the priorities. Cervical trauma at C3 to C5 usually results in paralysis of the phrenic nerve. When the phrenic nerve is damaged, the diaphragm does not descend properly, thus reducing inspiratory lung volumes and causing hypoxemia. While pulse and blood pressure are important, respirations are the priority. Temperature is not a high priority in this situation.

Which blood gas result will the nurse expect to observe in a patient with respiratory alkalosis? a. pH 7.60, PaCO2 40 mm Hg, HCO3- 30 mEq/L b. pH 7.53, PaCO2 30 mm Hg, HCO3- 24 mEq/L c. pH 7.35, PaCO2 35 mm Hg, HCO3- 26 mEq/L d. pH 7.25, PaCO2 48 mm Hg, HCO3- 23 mEq/L .

B Respiratory alkalosis should show an alkalotic pH and decreased CO2 (respiratory) values, with a normal HCO3 -. In this case, pH 7.53 is alkaline (normal = 7.35 to 7.45), PaCO is 30 (normal 35 to 45 mm Hg), and HCO3 - is 24 (normal = 22 to 26 mEq/L). A result of pH 7.60, PaCO 40 mm Hg, HCO3 - 30 mEq/L is metabolic alkalosis. pH 7.35, PaCO 35 mm Hg, HCO3 - 26 mEq/L is within normal limits. pH 7.25, PaCO 48 mm Hg, HCO3 - 23 mEq/L is respiratory acidosis

A 2-year-old child is brought into the emergency department after ingesting a medication that causes respiratory depression. For which acid-base imbalance will the nurse most closely monitor this child? a. Respiratory alkalosis b. Respiratory acidosis c. Metabolic acidosis d. Metabolic alkalosis

B Respiratory depression leads to hypoventilation. Hypoventilation results in retention of CO2 and respiratory acidosis. Respiratory alkalosis would result from hyperventilation, causing a decrease in CO2 levels. Metabolic acid-base imbalance would be a result of kidney dysfunction, vomiting, diarrhea, or other conditions that affect metabolic acids

The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patients nose. Which admission order should the nurse question? a. Keep the head of bed elevated. b. Insert nasogastric tube to low suction. c. Turn patient side to side every 2 hours d. Apply cold packs intermittently to face.

B Rhinorrhea may indicate a dural tear with cerebrospinal fluid (CSF) leakage. Insertion of a nasogastric tube will increase the risk for infections such as meningitis. Turning the patient, elevating the head, and applying cold packs are appropriate orders. .

A patient with a chronic cough has a bronchoscopy. After the procedure, which intervention by the nurse is most appropriate? a. Elevate the head of the bed to 80 to 90 degrees. b. Keep the patient NPO until the gag reflex returns. c. Place on bed rest for at least 4 hours after bronchoscopy. d. Notify the health care provider about blood-tinged mucus.

B Risk for aspiration and maintaining an open airway is the priority. Because a local anesthetic is used to suppress the gag/cough reflexes during bronchoscopy, the nurse should monitor for the return of these reflexes before allowing the patient to take oral fluids or food. Blood-tinged mucus is not uncommon after bronchoscopy. The patient does not need to be on bed rest, and the head of the bed does not need to be in the high-Fowlers position.

The patient is admitted to the emergency department of the local hospital from home with reports of chest discomfort and shortness of breath. The patient is placed on oxygen, has labs and blood gases drawn, and is given an electrocardiogram and breathing treatments. Which level of preventive care is this patient receiving? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Health promotion

B Secondary prevention focuses on individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. Activities are directed at diagnosis and prompt intervention. - Primary prevention precedes disease or dysfunction and is applied to people considered physically and emotionally healthy. - Health promotion includes health education programs, immunizations, and physical and nutritional fitness activities for healthy people. - Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability through interventions directed at preventing complications and deterioration.

Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Which response by the nurse is best? a. This type of monitoring system is complex and it is managed by skilled staff. b. The monitoring system helps show whether blood flow to the brain is adequate. c. The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure. d. This monitoring system has multiple benefits including facilitation of cerebrospinal fluid drainage.

B Short and simple explanations should be given initially to patients and family members. The other explanations are either too complicated to be easily understood or may increase the family members anxiety. .

A nurse is caring for a patient whose ECG presents with changes characteristic of hypokalemia. Which assessment finding will the nurse expect? a. Dry mucous membranes b. Abdominal distention c. Distended neck veins d. Flushed skin

B Signs and symptoms of hypokalemia are muscle weakness, abdominal distention, decreased bowel sounds, and cardiac dysrhythmias. Distended neck veins occur in fluid overload. Thready peripheral pulses indicate hypovolemia. Dry mucous membranes and flushed skin are indicative of dehydration and hypernatremia

The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? a. The pulse rate is 102 beats/min. b. The patient has difficulty speaking. c. The blood pressure is 144/86 mm Hg. d. There are fine crackles at the lung bases.

B Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during the procedure. Slightly elevated pulse rate and blood pressure are not unusual because of anxiety associated with the procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility during the procedure. The nurse should have the patient take some deep breaths.

A 26-year-old patient with a family history of stomach cancer asks the nurse about ways to decrease the risk for developing stomach cancer. The nurse will teach the patient to avoid a. emotionally stressful situations. b. smoked foods such as ham and bacon. c. foods that cause distention or bloating. d. chronic use of H2 blocking medications

B Smoked foods such as bacon, ham, and smoked sausage increase the risk for stomach cancer. Stressful situations, abdominal distention, and use of H2 blockers are not associated with an increased incidence of stomach cancer. .

Which nursing action could the registered nurse (RN) working in a skilled care hospital unit delegate to an experienced licensed practical/vocational nurse (LPN/LVN) caring for a patient with a permanent tracheostomy? a. Assess the patients risk for aspiration. b. Suction the tracheostomy when needed. c. Teach the patient about self-care of the tracheostomy. d. Determine the need for replacement of the tracheostomy tube.

B Suctioning of a stable patient can be delegated to LPNs/LVNs. Patient assessment and patient teaching should be done by the RN. .

The nurse is suctioning a patient with a tracheostomy tube. Which action will the nurse take? a. Set suction regulator at 150 to 200 mm Hg. b. Limit the length of suctioning to 10 seconds. c. Apply suction while gently rotating and inserting the catheter. d. Liberally lubricate the end of the suction catheter with a water-soluble solution. .

B Suctioning passes should be limited to 10 seconds to avoid hypoxemia. Suction for a tracheostomy should be set at 100 to 150 mm Hg. Excessive lubrication can clog the catheter or occlude the airway; lubricant is not necessary for oropharyngeal or artificial airway (tracheostomy) suctioning. Suction should never be applied on insertion. .

The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective? a. I will avoid being outdoors whenever possible. b. My husband will be sleeping in the guest bedroom. c. I will take the bus instead of driving to visit my friends. d. I will keep the windows closed at home to contain the germs.

B Teach the patient how to minimize exposure to close contacts and household members. Homes should be well ventilated, especially the areas where the infected person spends a lot of time. While still infectious, the patient should sleep alone, spend as much time as possible outdoors, and minimize time in congregate settings or on public transportation.

Which action will help the nurse determine whether a new patients confusion is caused by dementia or delirium? a. Administer the Mini-Mental Status Exam. b. Use the Confusion Assessment Method tool. c. Determine whether there is a family history of dementia. d. Obtain a list of the medications that the patient usually takes. .

B The Confusion Assessment Method tool has been extensively tested in assessing delirium. The other actions will be helpful in determining cognitive function or risk factors for dementia or delirium, but they will not be useful in differentiating between dementia and delirium. .

A nurse is using the World Health Organization definition of health to provide care. Which area will the nurse focus on while providing care? a. Making sure the patients are disease free b. Making sure to involve the whole person c. Making sure care is strictly personal in nature d. Making sure to focus only on the pathological state

B The World Health Organization (WHO) defines health as a "state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity." Therefore, nurses' attitudes toward health and illness should consider the total person, as well as the environment in which the person lives. All people free of disease are not necessarily healthy. Strictly personal and a focus only on pathological states do not correlate to WHO's definition.

The nurse is caring for an older-adult patient and notes that the temperature is 96.8° F (36° C). How will the nurse interpret this finding? a. The patient has hyperthermia. b. The patient has a normal temperature. c. The patient is suffering from hypothermia. d. The patient is demonstrating increased metabolism

B The average body temperature of older adults is approximately 35° to 36.1° C (95° to 97° F). This is not hypothermia or hyperthermia. Older adults have poor vasomotor control, reduced amounts of subcutaneous tissue, reduced sweat gland activity, and reduced metabolism. The end result is lowered body temperature.

Which information about dietary management should the nurse include when teaching a patient with peptic ulcer disease (PUD)? a. You will need to remain on a bland diet. b. Avoid foods that cause pain after you eat them. c. High-protein foods are least likely to cause you pain. d. You should avoid eating any raw fruits and vegetables

B The best information is that each individual should choose foods that are not associated with postprandial discomfort. Raw fruits and vegetables may irritate the gastric mucosa, but chewing well seems to decrease this problem and some patients may tolerate these foods well. High-protein foods help neutralize acid, but they also stimulate hydrochloric (HCl) acid secretion and may increase discomfort for some patients. Bland diets may be recommended during an acute exacerbation of PUD, but there is little scientific evidence to support their use

The patient is admitted with shortness of breath and chest discomfort. Which laboratory value could account for the patient's symptoms? a. Red blood cell count of 5.0 million/mm3 b. Hemoglobin level of 8.0 g/100 mL c. Hematocrit level of 45% d. Pulse oximetry of 95%

B The concentration of hemoglobin reflects the patient's capacity to carry oxygen, which if low can lead to shortness of breath and chest discomfort. Normal hemoglobin levels range from 14 to 18 g/100 mL in males and from 12 to 16 g/100 mL in females. Hemoglobin of 8.0 is low and indicates a decreased ability to deliver oxygen to meet bodily needs. All other values in the selection are considered normal.

A nurse is teaching staff about the conduction of the heart. In which order will the nurse present the conduction cycle, starting with the first structure? 1. Bundle of His 2. Purkinje network 3. Intraatrial pathways 4. Sinoatrial (SA) node 5. Atrioventricular (AV) node a. 5, 4, 3, 2, 1 b. 4, 3, 5, 1, 2 c. 4, 5, 3, 1, 2 d. 5, 3, 4, 2, 1

B The conduction system originates with the SA node, the "pacemaker" of the heart. The electrical impulses are transmitted through the atria along intraatrial pathways to the AV node. It assists atrial emptying by delaying the impulse before transmitting it through the Bundle of His and the ventricular Purkinje network .

The nurse obtains the following assessment data on an older patient who has influenza. Which information will be most important for the nurse to communicate to the health care provider? a. Fever of 100.4 F (38 C) b. Diffuse crackles in the lungs c. Sore throat and frequent cough d. Myalgia and persistent headache

B The crackles indicate that the patient may be developing pneumonia, a common complication of influenza, which would require aggressive treatment. Myalgia, headache, mild temperature elevation, and sore throat with cough are typical manifestations of influenza and are treated with supportive care measures such as over-the- counter (OTC) pain relievers and increased fluid intake.

The patient's blood pressure is 140/60. Which value will the nurse record for the pulse pressure? a. 60 b. 80 c. 140 d. 200 .

B The difference between the systolic pressure and the diastolic pressure is the pulse pressure. For a blood pressure of 140/60, the pulse pressure is 80 (140 − 60 = 80). 140 is the systolic pressure. 60 is the diastolic pressure. 200 is the systolic (140) added to the diastolic (60), but this has no clinical significance

A patient is admitted to the emergency department with an open stab wound to the left chest. What is the first action that the nurse should take? a. Position the patient so that the left chest is dependent. b. Tape a nonporous dressing on three sides over the chest wound. c. Cover the sucking chest wound firmly with an occlusive dressing. d. Keep the head of the patients bed at no more than 30 degrees elevation.

B The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the patient on the left side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The head of the bed should be elevated to 30 to 45 degrees to facilitate breathing.

Following a laryngectomy a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first? a. Cover stoma with sterile gauze and ventilate through stoma. b. Attempt to reinsert the tracheostomy tube with the obturator in place. c. Assess the patients oxygen saturation and notify the health care provider. d. Ventilate the patient with a manual bag and face mask until the health care provider arrives.

B The first action should be to attempt to reinsert the tracheostomy tube to maintain the patients airway. Assessing the patients oxygenation is an important action, but it is not the most appropriate first action in this situation. Covering the stoma with a dressing and manually ventilating the patient may be an appropriate action if the nurse is unable to reinsert the tracheostomy tube. Ventilating with a facemask is not appropriate for a patient with a total laryngectomy because there is a complete separation between the upper airway and the trachea.

After 2 months of tuberculosis (TB) treatment with isoniazid (INH), rifampin (Rifadin), pyrazinamide (PZA), and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next? a. Teach about treatment for drug-resistant TB treatment. b. Ask the patient whether medications have been taken as directed. c. Schedule the patient for directly observed therapy three times weekly. d. Discuss with the health care provider the need for the patient to use an injectable antibiotic.

B The first action should be to determine whether the patient has been compliant with drug therapy because negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. Assessment is the first step in the nursing process. Depending on whether the patient has been compliant or not, different medications or directly observed therapy may be indicated. The other options are interventions based on assumptions until an assessment has been completed.

The nurse admitting a patient who has a right frontal lobe tumor would expect the patient may have a. expressive aphasia. b. impaired judgment. c. right-sided weakness. d. difficulty swallowing. .

B The frontal lobe controls intellectual activities such as judgment. Speech is controlled in the parietal lobe. Weakness and hemiplegia occur on the contralateral side from the tumor. Swallowing is controlled by the brainstem. .

A 62- year-old man reports chronic constipation. To promote bowel evacuation, the nurse will suggest that the patient attempt defecation a. in the mid-afternoon. b. after eating breakfast. c. right after getting up in the morning. d. immediately before the first daily meal.

B The gastrocolic reflex is most active after the first daily meal. Arising in the morning, the anticipation of eating, and physical exercise do not stimulate these reflexes. .

Which finding for a patient who has a head injury should the nurse report immediately to the health care provider? a. Intracranial pressure is 16 mm Hg when patient is turned. b. Pale yellow urine output is 1200 mL over the last 2 hours. c. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg. d. Ventriculostomy drained 40 mL of cerebrospinal fluid in the last 2 hours .

B The high urine output indicates that diabetes insipidus may be developing, and interventions to prevent dehydration need to be rapidly implemented. The other data do not indicate a need for any change in therapy. .

The patient is reporting moderate incisional pain that was not relieved by the last dose of pain medication. The patient is not due for another dose of medication for another 2 1/2 hours. The nurse repositions the patient, asks what type of music the patient likes, and sets the television to the channel playing that type of music. Which health care model is the nurse using? a. Health belief model b. Holistic health model c. Health promotion model d. Maslow's hierarchy of needs

B The holistic health model recognizes the natural healing abilities of the body and incorporates complementary and alternative interventions such as music therapy. - The health belief model addresses the relationship between a person's beliefs and behaviors. - The health promotion model notes that each person has unique personal characteristics and experiences that affect subsequent actions. - The basic human needs model believes that the extent to which basic needs are met is a major factor in determining a person's level of health. - Maslow's hierarchy of needs is a model that nurses use to understand the interrelationships of basic human needs.

A nurse is teaching a patient about heart failure. Which environment will the nurse use? a. A darkened, quiet room b. A well-lit, ventilated room c. A private room at 85° F temperature d. A group room for 10 to 12 patients with heart failure .

B The ideal environment for learning is a room that is well lit and has good ventilation, appropriate furniture, and a comfortable temperature. Although a quiet room is appropriate, a darkened room interferes with the patient's ability to watch your actions, especially when demonstrating a skill or using visual aids such as posters or pamphlets. A room that is cold, hot, or stuffy makes the patient too uncomfortable to focus on the information being presented. Learning in a group of six or less is more effective and avoids distracting behaviors.

The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed? a. A large air leak in the water-seal chamber b. 400 mL of blood in the collection chamber c. Complaint of pain with each deep inspiration d. Subcutaneous emphysema at the insertion site

B The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. An air leak would be expected immediately after chest tube placement for a pneumothorax. Initially, brisk bubbling of air occurs in this chamber when a pneumothorax is evacuated. The pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with pneumothorax. A small amount of subcutaneous air is harmless and will be reabsorbed.

A nurse is caring for a patient with left-sided hemiparesis who has developed bronchitis and has a heart rate of 105 beats/min, blood pressure of 156/90 mm Hg, and respiration rate of 30 breaths/min. Which nursing diagnosis is a priority? a. Risk for skin breakdown b. Impaired gas exchange c. Activity intolerance d. Risk for infection

B The most important nursing intervention is to maintain airway and circulation for this patient; therefore, Impaired gas exchange is the first nursing priority. Activity intolerance is a concern but is not the priority in this case. Risk for skin breakdown and Risk for infection are also important but do not address an immediate impairment with physiologic integrity .

An unconscious 39-year-old male patient is admitted to the emergency department (ED) with a head injury. The patients spouse and teenage children stay at the patients side and ask many questions about the treatment being given. What action is best for the nurse to take? a. Ask the family to stay in the waiting room until the initial assessment is completed. b. Allow the family to stay with the patient and briefly explain all procedures to them. c. Refer the family members to the hospital counseling service to deal with their anxiety. d. Call the familys pastor or spiritual advisor to take them to the chapel while care is given

B The need for information about the diagnosis and care is very high in family members of acutely ill patients. The nurse should allow the family to observe care and explain the procedures unless they interfere with emergent care needs. A pastor or counseling service can offer some support, but research supports information as being more effective. Asking the family to stay in the waiting room will increase their anxiety

The patient requires temperatures to be taken every 2 hours. Which task will the nurse assign to an RN? a. Using appropriate route and device b. Assessing changes in body temperature c. Being aware of the usual values for the patient d. Obtaining temperature measurement at ordered frequency .

B The nurse is responsible for assessing changes in body temperature. T he nursing assistive personnel can use the appropriate route and device to measure temperature, obtain temperature measurement at ordered frequency, and be aware of the usual values for the patient .

While caring for a hospitalized older-adult female post hip surgery, the nurse is faced with the task of inserting an indwelling urinary catheter, which involves rotating the hip into a contraindicated position. Which action should the nurse take? a. Postpone catheter insertion until the next shift. b. Adapt the positioning technique to the situation. c. Notify the health care provider for a urologist consult. d. Follow textbook procedure with contraindicated position.

B The nurse must use critical thinking skills in this situation to adapt positioning technique. In practice, patient procedures are not always presented as in a textbook, but they are individualized. A urologist consult is not warranted for positioning problems. Postponing insertion of the catheter is not an appropriate action. .

The nurse is preparing to obtain an oxygen saturation reading on a toddler. Which action will the nurse take? a. Secure the sensor to the toddler's earlobe. b. Determine whether the toddler has a latex allergy. c. Place the sensor on the bridge of the toddler's nose. d. Overlook variations between an oximeter pulse rate and the toddler's pulse rate. .

B The nurse should determine whether the patient has a latex allergy because disposable adhesive probes should not be used on patients with latex allergies. Earlobe and bridge of the nose sensors should not be used on infants and toddlers because of skin fragility. Oximeter pulse rate and the patient's apical pulse rate should be the same. Any difference requires re-evaluation of oximeter sensor probe placement and reassessment of pulse rates.

A nurse is reviewing care plans. Which finding, if identified in a plan of care, should the registered nurse revise? a. Patient's outcomes for learning b. Nurse's assumptions about hospital discharge c. Identification of several actual health problems d. Documentation of patient's ability to meet the goal .

B The nurse should not assume when a patient is going to be discharged and document this information in a plan of care. Making assumptions is not an example of a critical thinking skill. The purpose of the nursing process is to diagnose and treat human responses (e.g., patient symptoms, need for knowledge) to actual or potential health problems. Use of the process allows nurses to help patients meet agreed-on outcomes for better health. The patient's outcomes, having several actual health problems, and a description of the patient's abilities to meet the goal are all appropriate to document in the nursing plan of care.

A patient is having trouble reaching the water fountain while holding on to crutches. The nurse suggests that the patient place the crutches against the wall while stabilizing him or herself with two hands on the water fountain. Which critical thinking attitude did the nurse use in this situation? a. Humility b. Creativity c. Risk taking d. Confidence

B The nurse uses creativity in this situation to figure out how the patient can safely get a drink of water. - Humility is recognizing when more information is needed to make a decision. - Confidence is being well prepared to perform nursing care safely. This question best illustrates the attitude of creativity. - Risk taking is demonstrating the courage to speak out or to question orders based on the nurse's own knowledge base.

While the nurse is changing the ties on a tracheostomy collar, the patient coughs, dislodging the tracheostomy tube. Which action will the nurse take first? a. Press the emergency response button. b. Insert a spare tracheostomy with the obturator. c. Manually occlude the tracheostomy with sterile gauze. d. Place a face mask delivering 100% oxygen over the nose and mouth

B The nurse's first priority is to establish a stable airway by inserting a spare trach into the patient's airway; ideally an obturator should be used. The nurse could activate the emergency response team if the patient is still unstable after the tracheostomy is placed. A patient with a tracheostomy breathes through the tube, not the nose or mouth; a face mask would not be an effective method of getting air into the lungs. Manually occluding pressure over the tracheostomy site is not appropriate and would block the patient's only airway.

A patient with newly diagnosed lung cancer tells the nurse, I dont think Im going to live to see my next birthday. Which response by the nurse is best? a. Would you like to talk to the hospital chaplain about your feelings? b. Can you tell me what it is that makes you think you will die so soon? c. Are you afraid that the treatment for your cancer will not be effective? d. Do you think that taking an antidepressant medication would be helpful?

B The nurses initial response should be to collect more assessment data about the patients statement. The answer beginning Can you tell me what it is is the most open-ended question and will offer the best opportunity for obtaining more data. The answer beginning, Are you afraid implies that the patient thinks that the cancer will be immediately fatal, although the patients statement may not be related to the cancer diagnosis. The remaining two answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate.

A patient learns that a normal adult heartbeat is 60 to 100 beats/min after a teaching session with a nurse. In which domain did learning take place? a. Kinesthetic b. Cognitive c. Affective d. Psychomotor

B The patient acquired knowledge, which is cognitive. Cognitive learning includes all intellectual skills and requires thinking. In the hierarchy of cognitive behaviors, the simplest behavior is acquiring knowledge. - Kinesthetic is a type of learner who learns best with a hands-on approach. - Affective learning deals with expression of feelings and development of attitudes, beliefs, or values. - Psychomotor learning involves acquiring skills that require integration of mental and physical activities, such as the ability to walk or use an eating utensil.

A 46-year-old patient with a head injury opens the eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. The nurse records the patients Glasgow Coma Scale score as a. 9. b. 11. c. 13. d. 15

B The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor response. . .

A patient is admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent suction for the past 3 days. Which arterial blood gas values will the nurse expect to observe? a. Respiratory alkalosis b. Metabolic alkalosis c. Metabolic acidosis d. Respiratory acidosis

B The patient is losing acid from the nasogastric tube so the patient will have metabolic alkalosis. Lung problems will produce respiratory alkalosis or acidosis. Metabolic acidosis will occur when too much acid is in the body like kidney failure. .

A patient with possible viral meningitis is admitted to the nursing unit after lumbar puncture was performed in the emergency department. Which action prescribed by the health care provider should the nurse question? a. Elevate the head of the bed 20 degrees. b. Restrict oral fluids to 1000 mL daily. c. Administer ceftriaxone (Rocephin) 1 g IV every 12 hours. d. Give ibuprofen (Motrin) 400 mg every 6 hours as needed for headache

B The patient with meningitis has increased fluid needs, so oral fluids should be encouraged. The other actions are appropriate. Slight elevation of the head of the bed will decrease headache without causing leakage of cerebrospinal fluid from the lumbar puncture site. Antibiotics should be administered until bacterial meningitis is ruled out by the cerebrospinal fluid analysis.

Which intervention will the nurse include in the plan of care for a patient with moderate dementia who had an appendectomy 2 days ago? A. Provide complete personal hygiene care for the patient. B. Remind the patient frequently about being in the hospital. C. Reposition the patient frequently to avoid skin breakdown. D. Place suction at the bedside to decrease the risk for aspiration

B The patient with moderate dementia will have problems with short- and long-term memory and will need reminding about the hospitalization. The other interventions would be used for a patient with severe dementia, who would have difficulty with swallowing, self-care, and immobility. .

The nurse and a licensed practical/vocational nurse (LPN/LVN) are working together to care for a patient who had an esophagectomy 2 days ago. Which action by the LPN/LVN requires that the nurse intervene? a. The LPN/LVN uses soft swabs to provide for oral care. b. The LPN/LVN positions the head of the bed in the flat position. c. The LPN/LVN encourages the patient to use pain medications before coughing. d. The LPN/LVN includes the enteral feeding volume when calculating intake and output

B The patients bed should be in Fowlers position to prevent reflux and aspiration of gastric contents. The other actions by the LPN/LVN are appropriate. .

When assessing a patient with a sore throat, the nurse notes anterior cervical lymph node swelling, a temperature of 101.6 F (38.7 C), and yellow patches on the tonsils. Which action will the nurse anticipate taking? a. Teach the patient about the use of expectorants. b. Use a swab to obtain a sample for a rapid strep antigen test. c. Discuss the need to rinse the mouth out after using any inhalers. d. Teach the patient to avoid use of nonsteroidal antiinflammatory drugs (NSAIDs).

B The patients clinical manifestations are consistent with streptococcal pharyngitis and the nurse will anticipate the need for a rapid strep antigen test and/or cultures. Because patients with streptococcal pharyngitis usually do not have a cough, use of expectorants will not be anticipated. Rinsing the mouth out after inhaler use may prevent fungal oral infections, but the patients assessment data are not consistent with a fungal infection. NSAIDs are frequently prescribed for pain and fever relief with pharyngitis.

The nurse is administering IV fluid boluses and nasogastric irrigation to a patient with acute gastrointestinal (GI) bleeding. Which assessment finding is most important for the nurse to communicate to the health care provider? a. The bowel sounds are hyperactive in all four quadrants. b. The patients lungs have crackles audible to the midchest. c. The nasogastric (NG) suction is returning coffee-ground material. d. The patients blood pressure (BP) has increased to 142/84 mm Hg

B The patients lung sounds indicate that pulmonary edema may be developing as a result of the rapid infusion of IV fluid and that the fluid infusion rate should be slowed. The return of coffee-ground material in an NG tube is expected for a patient with upper GI bleeding. The BP is slightly elevated but would not be an indication to contact the health care provider immediately. Hyperactive bowel sounds are common when a patient has GI bleeding

A 44-year-old man admitted with a peptic ulcer has a nasogastric (NG) tube in place. When the patient develops sudden, severe upper abdominal pain, diaphoresis, and a firm abdomen, which action should the nurse take? a. Irrigate the NG tube. b. Check the vital signs. c. Give the ordered antacid d. Elevate the foot of the bed.

B The patients symptoms suggest acute perforation, and the nurse should assess for signs of hypovolemic shock. Irrigation of the NG tube, administration of antacids, or both would be contraindicated because any material in the stomach will increase the spillage into the peritoneal cavity. Elevating the foot of the bed may increase abdominal pressure and discomfort, as well as making it more difficult for the patient to breathe.

Upon completing a history, the nurse finds that a patient has risk factors for lung disease. How should the nurse interpret this finding? a. A person with the risk factor will get the disease. b. The chances of getting the disease are increased. c. Risk modification will have no effect on disease prevention. d. The disease is guaranteed not to develop if the risk factor is controlled.

B The presence of risk factors does not mean that a disease will develop, but risk factors increase the chances that the individual will experience a particular disease or dysfunction. Control of risk factors does not guarantee that a disease will not develop. However, risk factor modification can assist patients in adopting activities to promote health and decrease risks of illness.

A 68-year-old patient with a bleeding duodenal ulcer has a nasogastric (NG) tube in place, and the health care provider orders 30 mL of aluminum hydroxide/magnesium hydroxide (Maalox) to be instilled through the tube every hour. To evaluate the effectiveness of this treatment, the nurse a. monitors arterial blood gas values daily. b. periodically aspirates and tests gastric pH. c. checks each stool for the presence of occult blood. d. measures the volume of residual stomach contents.

B The purpose for antacids is to increase gastric pH. Checking gastric pH is the most direct way of evaluating the effectiveness of the medication. Arterial blood gases may change slightly, but this does not directly reflect the effect of antacids on gastric pH. Because the patient has upper gastrointestinal (GI) bleeding, occult blood in the stools will appear even after the acute bleeding has stopped. The amount of residual stomach contents is not a reflection of resolution of bleeding or of gastric pH.

The nurse develops a plan of care to prevent aspiration in a high-risk patient. Which nursing action will be most effective? a. Turn and reposition immobile patients at least every 2 hours. b. Place patients with altered consciousness in side-lying positions. c. Monitor for respiratory symptoms in patients who are immunosuppressed. d. Insert nasogastric tube for feedings for patients with swallowing problems.

B The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side- lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds & oxygen saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Conditions that increase the risk of aspiration include decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, & nasogastric intubation with or without tube feeding. With loss of consciousness, the gag & cough reflexes are depressed, & aspiration is more likely to occur. Other high-risk groups are those who are seriously ill, have poor dentition, or are receiving acid-reducing medications.

Which area of the abdomen shown in the accompanying figure will the nurse palpate to assess for splenomegaly? a. 1 b. 2 c. 3 d. 4 .

B The spleen is usually not palpable, but when palpated, it is located in left upper quadrant of abdomen . .

When assessing the temperature of newborns and children, the nurse decides to utilize a temporal artery thermometer. What is the rationale for the nurse's action? a. It is not affected by skin moisture. b. It has no risk of injury to patient or nurse. c. It reflects rapid changes in radiant temperature. d. It is accurate even when the forehead is covered with hair.

B The temporal artery thermometer is especially beneficial when used in premature infants, newborns, and children because there is no risk of injury to the patient or nurse. Temporal artery temperature is a reliable noninvasive measure of core temperature. However, it is inaccurate with head covering or hair on the forehead and is affected by skin moisture such as diaphoresis, or sweating. It provides very rapid measurement and reflects rapid changes in core temperature, not radiant temperature

A female patient has been overweight for most of her life. She has tried dieting in the past and has lost weight, only to regain it when she stopped dieting. The patient is visiting the weight loss clinic/health club because she has decided to do it. She states that she will join right after the holidays, in 3 months. Which stage is the patient displaying? a. Precontemplation b. Contemplation c. Preparation d. Action

B This patient is planning to make the change within the next 6 months and is in the contemplation stage. These stages range from no intention to change (precontemplation), to considering a change within the next 6 months (contemplation), to making small changes (preparation), to actively engaging in strategies to change behavior (action), to maintaining a changed behavior (maintenance).

The nurse is assessing an alert and independent 78-year-old woman for malnutrition risk. The most appropriate initial question is which of the following? a. How do you get to the store to buy your food? b. Can you tell me the food that you ate yesterday? c. Do you have any difficulty in preparing or eating food? d. Are you taking any medications that alter your taste for food?

B This question is the most open-ended, and will provide the best overall information about the patients daily intake and risk for poor nutrition. The other questions may be asked, depending on the patients response to the first question .

Which information about the patient who has had a subarachnoid hemorrhage is most important to communicate to the health care provider? a. The patient complains of having a stiff neck. b. The patients blood pressure (BP) is 90/50 mm Hg. c. The patient reports a severe and unrelenting headache. d. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).

B To prevent cerebral vasospasm and maintain cerebral perfusion, blood pressure needs to be maintained at a level higher than 90 mm Hg systolic after a subarachnoid hemorrhage. A low BP or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP. An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider.

Which equipment will the nurse obtain to assess vibration sense in a diabetic patient who has peripheral nerve dysfunction? a. Sharp pin b. Tuning fork c. Reflex hammer d. Calibrated compass

B Vibration sense is testing by touching the patient with a vibrating tuning fork. The other equipment is needed for testing of pain sensation, reflexes, and two-point discrimination. .

A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient? a. Ask the patient to lie down to complete a full physical assessment. b. Briefly ask specific questions about this episode of respiratory distress. c. Complete the admission database to check for allergies before treatment. d. Delay the physical assessment to first complete pulmonary function tests.

B When a patient has severe respiratory distress, only information pertinent to the current episode is obtained, and a more thorough assessment is deferred until later. Obtaining a comprehensive health history or full physical examination is unnecessary until the acute distress has resolved. Brief questioning and a focused physical assessment should be done rapidly to help determine the cause of the distress and suggest treatment. Checking for allergies is important, but it is not appropriate to complete the entire admission database at this time. The initial respiratory assessment must be completed before any diagnostic tests or interventions can be ordered.

Upon auscultation of the patient's chest, the nurse hears a whooshing sound at the fifth intercostal space. What does this finding indicate to the nurse? a. The beginning of the systolic phase b. Regurgitation of the mitral valve c. The opening of the aortic valve d. Presence of orthopnea

B When regurgitation occurs, there is a backflow of blood into an adjacent chamber. For example, in mitral regurgitation the mitral leaflets do not close completely. When the ventricles contract, blood escapes back into the atria, causing a murmur, or "whooshing" sound. The systolic phase begins with ventricular filling and closing of the aortic valve, which is heard as the first heart sound, S1. Orthopnea is an abnormal condition in which a patient uses multiple pillows when reclining to breathe easier or sits leaning forward with arms elevated

A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure? a. Start a peripheral IV line to administer the necessary sedative drugs. b. Position the patient sitting upright on the edge of the bed and leaning forward. c. Obtain a large collection device to hold 2 to 3 liters of pleural fluid at one time. d. Remove the water pitcher and remind the patient not to eat or drink anything for 6 hours.

B When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and can more easily be located and removed. The patient does not usually require sedation for the procedure, and there are no restrictions on oral intake because the patient is not sedated or unconscious. Usually only 1000 to 1200 mL of pleural fluid is removed at one time. Rapid removal of a large volume can result in hypotension, hypoxemia, or pulmonary edema.

Which nursing actions could the nurse delegate to a licensed practical/vocational nurse (LPN/LVN) who is part of the team caring for a patient with Alzheimers disease (select all that apply)? a. Develop a plan to minimize difficult behavior. b. Administer the prescribed memantine (Namenda). c. Remove potential safety hazards from the patients environment. d. Refer the patient and caregivers to appropriate community resources. e. Help the patient and caregivers choose memory enhancement methods. f. Evaluate the effectiveness of the prescribed enteral feedings on patient nutrition.

B, C LPN/LVN education and scope of practice includes medication administration and monitoring for environmental safety in stable patients. Planning of interventions such as ways to manage behavior or improve memory, referrals, and evaluation of the effectiveness of interventions require registered nurse (RN)level education and scope of practice. .

The patient has new-onset restlessness and confusion. Pulse rate is elevated, as is respiratory rate. Oxygen saturation is 94%. The nurse ignores the pulse oximeter reading and calls the health care provider for orders because the pulse oximetry reading is inaccurate. Which factors can cause inaccurate pulse oximetry readings? (Select all that apply.) a. O2 saturations (SaO2) > 70% b. Carbon monoxide inhalation c. Hypothermic fingers d. Intravascular dyes e. Nail polish f. Jaundice

B, C, D, E, F Inaccurate pulse oximetry readings can be caused by: - outside light sources, - carbon monoxide (caused by smoke inhalation or poisoning), - patient motion, - jaundice, - intravascular dyes (methylene blue), - nail polish, artificial nails, - metal studs, - or dark skin. SpO2 is a reliable estimate of SaO2 when the SaO2 is over 70%.

A nurse is working in the intensive care unit and must obtain core temperatures on patients. Which sites can be used to obtain a core temperature? (Select all that apply.) a. Rectal b. Tympanic c. Esophagus d. Temporal artery e. Pulmonary artery

B, C, E Intensive care units use the core temperatures of the pulmonary artery, esophagus, and urinary bladder. Because the tympanic membrane shares the same arterial blood supply as the hypothalamus, the tympanic temperature is a core temperature. Temporal artery measurements detect the temperature of cutaneous blood flow. Oral, rectal, axillary, and skin temperature sites rely on effective blood circulation at the measurement site

A nurse is following the Ventilator Bundle standards to prevent ventilator-associated pneumonia. Which strategies is the nurse using? (Select all that apply.) a. Head of bed elevation to 90 degrees at all times b. Daily oral care with chlorhexidine c. Cuff monitoring for adequate seal d. Clean technique when suctioning e. Daily "sedation vacations" f. Heart failure prophylaxis

B, C, E The key components of the Institute for Healthcare Improvement (IHI) Ventilator Bundle are: - Elevation of the head of the bed (HOB)—elevation is 30 to 45 degrees; - Daily "sedation vacations" and assessment of readiness to extubate; Peptic ulcer disease prophylaxis; Deep venous thrombosis prophylaxis; - Daily oral care with chlorhexidine. - Monitor cuff pressure frequently to ensure that there is an adequate seal to prevent aspiration of secretions is also included. Sterile technique is used for suctioning when on ventilators. Heart failure prophylaxis is not a component.

The spouse of a 67-year-old male patient with early stage Alzheimers disease (AD) tells the nurse, I am exhausted from worrying all the time. I dont know what to do. Which actions are best for the nurse to take next (select all that apply)? a. Suggest that a long-term care facility be considered. b. Offer ideas for ways to distract or redirect the patient. c. Teach the spouse about adult day care as a possible respite. d. Suggest that the spouse consult with the physician for antianxiety drugs. e. Ask the spouse what she knows and has considered about dementia care options.

B, C, E The stress of being a caregiver can be managed with a multicomponent approach. This includes respite care, learning ways to manage challenging behaviors, and further assessment of what the spouse may already have considered for care options. The patient is in the early stages and does not need long-term placement. Antianxiety medications may be appropriate, but other measures should be tried first. .

A patient is scheduled for a computed tomography (CT) of the chest with contrast media. Which assessment findings should the nurse immediately report to the health care provider (select all that apply)? a. Patient is claustrophobic. b. Patient is allergic to shellfish. c. Patient recently used a bronchodilator inhaler. d. Patient is not able to remove a wedding band. e. Blood urea nitrogen (BUN) and serum creatinine levels are elevated.

B, E Because the contrast media is iodine-based and may cause dehydration and decreased renal blood flow, asking about iodine allergies (such as allergy to shellfish) and monitoring renal function before the CT scan are necessary. The other actions are not contraindications for CT of the chest, although they may be for other diagnostic tests, such as magnetic resonance imaging (MRI) or pulmonary function testing (PFT).

Antidiuretic hormone a. Increases excretion of sodium and water b. Reduces excretion of sodium and water c. Reduces excretion of water d. Major buffer in the extracellular fluid e. Vasoconstricts and stimulates aldosterone release

C

Tachycardia a. Patient's temperature is 113° F (45° C) with hot, dry skin. b. Patient's blood pressure sitting is 130/60 and 110/40 standing. c. Patient's pulse is 110 beats/min. d. Patient's temperature is 93.2° F (34° C). e. Patient's blood pressure went from 126/76 to 90/50.

C

When taking an adult blood pressure, the onset of the sound the nurse hears is at 138, the muffled sound the nurse hears is at 70, and the disappearance of the sound the nurse hears is at 62. How should the nurse record this finding? a. 68 b. 76 c. 138/62 d. 138/70

C 138/62 is the correct reading. The fifth sound marks the disappearance of sound. In adolescents and adults the fifth sound corresponds with the diastolic pressure. The fourth sound becomes muffled and low pitched as the cuff is further deflated. At this point the cuff pressure has fallen below the pressure within the vessel walls; this sound is the diastolic pressure in infants and children. 68 is the pulse pressure of 138/70; 76 is the pulse pressure for 138/62

The nurse suspects the patient has increased afterload. Which piece of equipment should the nurse obtain to determine the presence of this condition? a. Pulse oximeter b. Oxygen cannula c. Blood pressure cuff d. Yankauer suction tip catheter

C A blood pressure cuff is needed. The diastolic aortic pressure is a good clinical measure of afterload. Afterload is the resistance to left ventricular ejection. In hypertension the afterload increases, making cardiac workload also increase. A pulse oximeter is used to monitor the level of arterial oxygen saturation; it will not help determine increased afterload. While an oxygen cannula may be needed to help decrease the effects of increased afterload, it will not help determine the presence of afterload. A Yankauer suction tip catheter is used to suction the oral cavity

A nurse is caring for a group of patients. Which patient will the nurse see first? a. A crying infant with P-165 and R-54 b. A sleeping toddler with P-88 and R-23 c. A calm adolescent with P-95 and R-26 d. An exercising adult with P-108 and R-24 .

C A calm adolescent should have the following findings: P—60-90 and R—16-20. Since both findings are elevated, the nurse should see this patient first. - An infant should have the following findings: P— 120-160 and R—30-50; however, since the infant is crying these values will be elevated and this is normal. - A toddler should have the following findings: P—90-140 and R—25-32; however, since the toddler is sleeping these values can be slightly decreased and this is normal. - An adult should have the following findings: P—60-100 and R—12-20; however, since the adult is exercising these values will be elevated and this is normal

Which action should the nurse take when using critical thinking to make clinical decisions? a. Make decisions based on intuition. b. Accept one established way to provide care. c. Consider what is important in a given situation. d. Read and follow the heath care provider's orders. .

C A critical thinker considers what is important in each clinical situation, imagines and explores alternatives, considers ethical principles, and makes informed decisions about the care of patients. Patient care can be provided in many ways. The use of evidence-based knowledge, or knowledge based on research or clinical expertise, makes you an informed critical thinker. Following health care provider's orders is not considered a critical thinking skill. If your knowledge causes you to question a health care provider's order, do so.

A 58-year-old patient has just been admitted to the emergency department with nausea and vomiting. Which information requires the most rapid intervention by the nurse? a. The patient has been vomiting for 4 days. b. The patient takes antacids 8 to 10 times a day. c. The patient is lethargic and difficult to arouse. d. The patient has undergone a small intestinal resection

C A lethargic patient is at risk for aspiration, and the nurse will need to position the patient to decrease aspiration risk. The other information is also important to collect, but it does not require as quick action as the risk for aspiration. .

The nurse notes that a patient has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which action should the nurse take first? a. Assist the patient to sit upright in a chair. b. Splint the patients chest during coughing. c. Medicate the patient with prescribed morphine. d. Observe the patient use the incentive spirometer.

C A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain (which increases with deep breathing and coughing). The first action by the nurse should be to medicate the patient to minimize incisional pain. The other actions are all appropriate ways to improve airway clearance but should be done after the morphine is given.

A patient has a myocardial infarction. On which primary blood vessel will the nurse focus care to reduce ischemia? a. Superior vena cava b. Pulmonary artery c. Coronary artery d. Carotid artery .

C A myocardial infarction is the lack of blood flow due to obstruction to the coronary artery, which supplies the heart with blood. - The superior vena cava returns blood back to the heart. - The pulmonary artery supplies deoxygenated blood to the lungs. - The carotid artery supplies blood to the brain

A nurse is focusing on temperature regulation of newborns and infants. Which action will the nurse take? a. Apply just a diaper. b. Double the clothing. c. Place a cap on their heads. d. Increase room temperature to 90 degrees .

C A newborn loses up to 30% of body heat through the head and therefore needs to wear a cap to prevent heat loss. Temperature control mechanisms in newborns are immature and respond drastically to changes in the environment; do not increase the room temperature to 90 degrees. Take extra care to protect newborns from environmental temperatures. Provide adequate clothing; do not double the clothing or apply just a diaper

Which finding in the mouth of a patient who uses smokeless tobacco is suggestive of oral cancer? a. Bleeding during tooth brushing b. Painful blisters at the lip border c. Red, velvety patches on the buccal mucosa d. White, curdlike plaques on the posterior tongue .

C A red, velvety patch suggests erythroplasia, which has a high incidence (greater than 50%) of progression to squamous cell carcinoma. The other lesions are suggestive of acute processes (e.g., gingivitis, oral candidiasis, herpes simplex). .

A 68-year-old patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin? a. The patient has dysphasia. b. The patient has atrial fibrillation. c. The patient reports that symptoms began with a severe headache. d. The patient has a history of brief episodes of right-sided hemiplegia.

C A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin use, so the nurse can administer the aspirin. .

A 54-year-old man has just arrived in the recovery area after an upper endoscopy. Which information collected by the nurse is most important to communicate to the health care provider? a. The patient is very drowsy. b. The patient reports a sore throat. c. The oral temperature is 101.6 F. d. The apical pulse is 104 beats/minute.

C A temperature elevation may indicate that a perforation has occurred. The other assessment data are normal immediately after the procedure. .

Which finding by the nurse during abdominal auscultation indicates a need for a focused abdominal assessment? a. Loud gurgles b. High-pitched gurgles c. Absent bowel sounds d. Frequent clicking sounds .

C Absent bowel sounds are abnormal and require further assessment by the nurse. The other sounds may be heard normally. .

The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Assess the patients gag and cough reflexes. b. Determine when the stroke symptoms began. c. Administer the prescribed short-acting insulin. d. Infuse the prescribed IV metoprolol (Lopressor).

C Administration of subcutaneous medications is included in LPN/LVN education and scope of practice. The other actions require more education and scope of practice and should be done by the registered nurse (RN). .

A nurse is teaching a patient about healthy eating habits. Which learning objective/outcome for the affective domain will the nurse add to the teaching plan? a. The patient will state three facts about healthy eating. b. The patient will identify two foods for a healthy snack. c. The patient will verbalize the value of eating healthy. d. The patient will cook a meal with low-fat oil.

C Affective learning deals with expression of feelings and acceptance of attitudes, beliefs, or values. Having the patient value healthy eating habits falls within the affective domain. - Stating three facts or identifying two foods for a healthy snack falls within the cognitive domain. - Cooking falls within the psychomotor domain.

After assisting with a needle biopsy of the liver at a patients bedside, the nurse should a. put pressure on the biopsy site using a sandbag. b. elevate the head of the bed to facilitate breathing. c. place the patient on the right side with the bed flat. d. check the patients postbiopsy coagulation studies .

C After a biopsy, the patient lies on the right side with the bed flat to splint the biopsy site. Coagulation studies are checked before the biopsy. A sandbag does not exert adequate pressure to splint the site .

A nurse reviews blood pressures of several patients. Which finding will the nurse report as prehypertension? a. 98/50 in a 7-year-old child b. 115/70 in an infant c. 120/80 in a middle-aged adult d. 146/90 in an older adult .

C An adult's blood pressure tends to rise with advancing age. The optimal blood pressure for a healthy, middle-aged adult is less than 120/80. Values of 120 to 139/80 to 89 mm Hg are considered prehypertension. Blood pressure greater than 140/90 is defined as hypertension. Blood pressure of 98/50 is normal for a child, whereas 115/70 can be normal for an infant

The health care provider asks the nurse to monitor the fluid volume status of a heart failure patient and a patient at risk for clinical dehydration. Which is the most effective nursing intervention for monitoring both of these patients? a. Assess the patients for edema in extremities. b. Ask the patients to record their intake and output. c. Weigh the patients every morning before breakfast. d. Measure the patients' blood pressures every 4 hours

C An effective measure of fluid retention or loss is daily weights; each kilogram (2.2 pounds) change is equivalent to 1 liter of fluid gained or lost. This measurement should be performed at the same time every day using the same scale and the same amount of clothing. Although intake and output records are important assessment measures, some patients are not able to keep their own records themselves. Blood pressure can decrease with extracellular volume (ECV) deficit but will not necessarily increase with recent ECV excess (heart failure patient). Edema occurs with ECV excess but not with clinical dehydration

The nurse is caring for a patient who has an elevated temperature. Which principle will the nurse consider when planning care for this patient? a. Hyperthermia and fever are the same thing. b. Hyperthermia is an upward shift in the set point. c. Hyperthermia occurs when the body cannot reduce heat production. d. Hyperthermia results from a reduction in thermoregulatory mechanisms

C An elevated body temperature related to the inability of the body to promote heat loss or reduce heat production is hyperthermia. Whereas fever is an upward shift in the set point, hyperthermia results from an overload of the thermoregulatory mechanisms of the body

The nurse is assessing a patient who had a total gastrectomy 8 hours ago. What information is most important to report to the health care provider? a. Absent bowel sounds b. Complaints of incisional pain c. Temperature 102.1 F (38.9 C) d. Scant nasogastric (NG) tube drainage

C An elevation in temperature may indicate leakage at the anastomosis, which may require return to surgery or keeping the patient NPO. The other findings are expected in the immediate postoperative period for patients who have this surgery. .

A nurse auscultates heart sounds. When the nurse hears S2, which valves is the nurse hearing close? a. Aortic and mitral b. Mitral and tricuspid c. Aortic and pulmonic d. Mitral and pulmonic .

C As the ventricles empty, the ventricular pressures decrease, allowing closure of the aortic and pulmonic valves, producing the second heart sound, S2. The mitral and tricuspid produce the first heart sound, S1. - The aortic and mitral do not close at the same time. - The mitral and pulmonic do not close at the same time

Which patient scenario of a surgical patient in pain is most indicative of critical thinking? a. Administering pain-relief medication according to what was given last shift b. Offering pain-relief medication based on the health care provider's orders c. Asking the patient what pain-relief methods, pharmacological and nonpharmacological, have worked in the past d. Explaining to the patient that self-reporting of severe pain is not consistent with the minor procedure that was performed

C Asking the patient what pain-relief methods have worked in the past is an example of exploring many options for pain relief. Non-pharmacological pain-relief methods are available, as are medications for pain. Administering medication based on a previous assessment is not practicing according to standards of care. The nurse is to conduct an assessment each shift on assigned patients and intervene accordingly. Pain is subjective. The nurse should offer pain-relief methods based on the patient's reports without being judgmental.

A 72-year-old patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, I dont need the aspirin today. I dont have a fever. Which action should the nurse take? a. Document that the aspirin was refused by the patient. b. Tell the patient that the aspirin is used to prevent a fever. c. Explain that the aspirin is ordered to decrease stroke risk. d. Call the health care provider to clarify the medication order.

C Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the patients refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider. The aspirin is not ordered to prevent aches and pains. .

An older Asian patient, who is seen at the health clinic, is diagnosed with protein malnutrition. What priority action should the nurse include in the teaching plan? a. Suggest the use of liquid supplements as a way to increase protein intake. b. Encourage the patient to increase the dietary intake of meat, cheese, and milk. c. Ask the patient to record the intake of all foods and beverages for a 3-day period. d. Focus on the use of combinations of beans and rice to improve daily protein intake.

C Assessment is the first step in assisting a patient with health changes. The other answers may be appropriate for the patient, but the nurse will not be able to determine this until the assessment of the patient is complete. .

A nurse is teaching a patient about hypertension. In which order from first to last will the nurse implement the steps of the teaching process? 1. Set mutual goals for knowledge of hypertension. 2. Teach what the patient wants to know about hypertension. 3. Assess what the patient already knows about hypertension. 4. Evaluate the outcomes of patient education for hypertension. a. 1, 3, 2, 4 b. 2, 3, 1, 4 c. 3, 1, 2, 4 d. 3, 2, 1, 4

C Assessment is the first step of any teaching session, then diagnosing, planning (goals), implementation, and evaluation. . .

A 68-year-old male patient with a stroke is unconscious and unresponsive to stimuli. After learning that the patient has a history of gastroesophageal reflux disease (GERD), the nurse will plan to do frequent assessments of the patients a. apical pulse. b. bowel sounds. c. breath sounds. d. abdominal girth

C Because GERD may cause aspiration, the unconscious patient is at risk for developing aspiration pneumonia. Bowel sounds, abdominal girth, and apical pulse will not be affected by the patients stroke or GERD and do not require more frequent monitoring than the routine. .

Which nursing action will be included in the care for a patient who has had cerebral angiography? a. Monitor for headache and photophobia. b. Keep patient NPO until gag reflex returns. c. Check pulse and blood pressure frequently. d. Assess orientation to person, place, and time .

C Because a catheter is inserted into an artery (such as the femoral artery) during cerebral angiography, the nurse should assess for bleeding after this procedure. The other nursing assessments are not necessary after angiography. .

When administering a mental status examination to a patient with delirium, the nurse should A. wait until the patient is well-rested. b. administer an anxiolytic medication. c. choose a place without distracting stimuli. d. reorient the patient during the examination. .

C Because overstimulation by environmental factors can distract the patient from the task of answering the nurses questions, these stimuli should be avoided. The nurse will not wait to give the examination because action to correct the delirium should occur as soon as possible. Reorienting the patient is not appropriate during the examination. Antianxiety medications may increase the patients delirium. .

A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action should the nurse include in the plan of care in collaboration with the speech therapist? a. Leave the tracheostomy inner cannula inserted at all times. b. Place the decannulation cap in the tube before cuff deflation. c. Assess the ability to swallow before using the fenestrated tube. d. Inflate the tracheostomy cuff during use of the fenestrated tube.

C Because the cuff is deflated when using a fenestrated tube, the patients risk for aspiration should be assessed before changing to a fenestrated tracheostomy tube. The decannulation cap is never inserted before cuff deflation because to do so would obstruct the patients airway. The cuff is deflated and the inner cannula removed to allow air to flow across the patients vocal cords when using a fenestrated tube.

The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired self-feeding ability for a left-handed patient with left-sided hemiplegia. Which intervention should be included in the plan of care? a. Provide a wide variety of food choices. b. Provide oral care before and after meals. c. Assist the patient to eat with the right hand. d. Teach the patient the chin-tuck technique.

C Because the nursing diagnosis indicates that the patients imbalanced nutrition is related to the left-sided hemiplegia, the appropriate interventions will focus on teaching the patient to use the right hand for self- feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition. .

Which order from the health care provider will the nurse implement first for a patient who has vomited 1200 mL of blood? a. Give an IV H2 receptor antagonist. b. Draw blood for typing and crossmatching c. Administer 1000 mL of lactated Ringers solution. d. Insert a nasogastric (NG) tube and connect to suction.

C Because the patient has vomited a large amount of blood, correction of hypovolemia and prevention of hypovolemic shock are the priorities. The other actions also are important to implement quickly but are not the highest priorities. .

A 53-year-old male patient with deep partial-thickness burns from a chemical spill in the workplace experiences severe pain followed by nausea during dressing changes. Which action will be most useful in decreasing the patients nausea? a. Keep the patient NPO for 2 hours before and after dressing changes. b. Avoid performing dressing changes close to the patients mealtimes. c. Administer the prescribed morphine sulfate before dressing changes. d. Give the ordered prochlorperazine (Compazine) before dressing changes.

C Because the patients nausea is associated with severe pain, it is likely that it is precipitated by stress and pain. The best treatment will be to provide adequate pain medication before dressing changes. The nurse should avoid doing painful procedures close to mealtimes, but nausea/vomiting that occur at other times also should be addressed. Keeping the patient NPO does not address the reason for the nausea and vomiting and will have an adverse effect on the patients nutrition. Administration of antiemetics is not the best choice for a patient with nausea caused by pain.

A 38-year old woman receiving chemotherapy for breast cancer develops a Candida albicans oral infection. The nurse will anticipate the need for a. hydrogen peroxide rinses. b. the use of antiviral agents. c. administration of nystatin (Mycostatin) tablets. d. referral to a dentist for professional tooth cleaning

C Candida albicans is treated with an antifungal such as nystatin. Oral saltwater rinses may be used but will not cure the infection. Antiviral agents are used for viral infections such as herpes simplex. Referral to a dentist is indicated for gingivitis but not for Candida infection. .

A patient has heart failure and cardiac output is decreased. Which formula can the nurse use to calculate cardiac output? a. Myocardial contractility × Myocardial blood flow b. Ventricular filling time/Diastolic filling time c. Stroke volume × Heart rate d. Preload/Afterload

C Cardiac output can be calculated by multiplying the stroke volume and the heart rate. The other options are not measures of cardiac output. .

Which statement to the nurse from a patient with jaundice indicates a need for teaching? a. I used cough syrup several times a day last week. b. I take a baby aspirin every day to prevent strokes. c. I use acetaminophen (Tylenol) every 4 hours for back pain. d. I need to take an antacid for indigestion several times a week .

C Chronic use of high doses of acetaminophen can be hepatotoxic and may have caused the patients jaundice. The other patient statements require further assessment by the nurse, but do not indicate a need for patient education. .

A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction- control chamber of the collection device. Which action by the nurse is most appropriate? a. Document the presence of a large air leak. b. Notify the surgeon of a possible pneumothorax. c. Take no further action with the collection device. d. Adjust the dial on the wall regulator to decrease suction.

C Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. Increasing or decreasing the vacuum source will not adjust the suction pressure. The amount of suction applied is regulated by the amount of water in this chamber and not by the amount of suction applied to the system.

A patient presents with heatstroke. The nurse uses cool packs, cooling blanket, and a fan. Which technique is the nurse using when the fan produces heat loss? a. Radiation b. Conduction c. Convection d. Evaporation

C Convection is the transfer of heat away from the body by air movement. - Conduction is the transfer of heat from one object to another with direct contact. - Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between the two. - Evaporation is the transfer of heat energy when a liquid is changed to a gas.

A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan? A. Purpose of antibiotic therapy B. Ways to limit oral fluid intake C. Appropriate use of cough suppressants D. Safety concerns with home oxygen therapy

C Cough suppressants are frequently prescribed for acute bronchitis. Because most acute bronchitis is viral in origin, antibiotics are not prescribed unless there are systemic symptoms. Fluid intake is encouraged. Home oxygen is not prescribed for acute bronchitis, although it may be used for chronic bronchitis.

A patient returned from a laparoscopic Nissen fundoplication for hiatal hernia 4 hours ago. Which assessment finding is most important for the nurse to address immediately? a. The patient is experiencing intermittent waves of nausea. b. The patient complains of 7/10 (0 to 10 scale) abdominal pain. c. The patient has absent breath sounds in the left anterior chest. d. The patient has hypoactive bowel sounds in all four quadrants.

C Decreased breath sounds on one side may indicate a pneumothorax, which requires rapid diagnosis and treatment. The nausea and abdominal pain should also be addressed but they are not as high priority as the patients respiratory status. The patients decreased bowel sounds are expected after surgery and require ongoing monitoring but no other action

A nurse is preparing to teach a patient about smoking cessation. Which factors should the nurse assess to determine a patient's ability to learn? a. Sociocultural background and motivation b. Stage of grieving and overall physical health c. Developmental capabilities and physical capabilities d. Psychosocial adaptation to illness and active participation

C Developmental and physical capabilities reflect one's ability to learn. - Sociocultural background and motivation are factors determining readiness to learn. - Psychosocial adaptation to illness and active participation are factors in readiness to learn. - Readiness to learn is related to the stage of grieving. - Overall physical health does reflect ability to learn; however, because it is paired here with stage of grieving (which is a readiness to learn factor), this is incorrect.

The nurse is assessing the patient's respirations. Which action by the nurse is most appropriate? a. Inform the patient that she is counting respirations. b. Do not touch the patient until completed. c. Obtain without the patient knowing. d. Estimate respirations .

C Do not let a patient know that you are assessing respirations. A patient aware of the assessment can alter the rate and depth of breathing. Assess respirations immediately after measuring pulse rate, with your hand still on the patient's wrist as it rests over the chest or abdomen. Respirations are the easiest of all vital signs to assess, but they are often the most haphazardly measured. Do not estimate respirations.

A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the health care provider? a. The Mantoux test had an induration of 7 mm. b. The chest-x-ray showed infiltrates in the lower lobes. c. The patient is being treated with antiretrovirals for HIV infection. d. The patient has a cough that is productive of blood-tinged mucus.

C Drug interactions can occur between the antiretrovirals used to treat HIV infection and the medications used to treat TB. The other data are expected in a patient with HIV and TB. .

When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care? a. Apply an eye patch to the right eye. b. Approach the patient from the right side. c. Place objects needed on the patients left side. d. Teach the patient that the left visual deficit will resolve.

C During the acute period, the nurse should place objects on the patients unaffected side. Because there is a visual defect in the right half of each eye, an eye patch is not appropriate. The patient should be approached from the left side. The visual deficit may not resolve, although the patient can learn to compensate for the defect. .

After the nurse has completed teaching for a patient with newly diagnosed eosinophilic esophagitis about the management of the disease, which patient action indicates that the teaching has been effective? a. Patient orders nonfat milk for each meal. b. Patient uses the prescribed corticosteroid inhaler. c. Patient schedules an appointment for allergy testing d. Patient takes ibuprofen (Advil) to control throat pain.

C Eosinophilic esophagitis is frequently associated with environmental allergens, so allergy testing is used to determine possible triggers. Corticosteroid therapy may be prescribed, but the medication will be swallowed, not inhaled. Milk is a frequent trigger for attacks. NSAIDs are not used for eosinophilic esophagitis

A nurse is teaching a culturally diverse patient with a learning disability about nutritional needs. What must the nurse do first before starting the teaching session? a. Obtain pictures of food. b. Get an interpreter. c. Establish a rapport. d. Refer to a dietitian.

C Establishing trust is important for all patients, especially culturally diverse and learning disabled patients, before starting teaching sessions. Obtaining pictures of food, getting an interpreter, and referring to a dietitian all occur after rapport/trust is established.

A patient has increased intracranial pressure and a ventriculostomy after a head injury. Which action can the nurse delegate to unlicensed assistive personnel (UAP) who regularly work in the intensive care unit? a. Document intracranial pressure every hour. b. Turn and reposition the patient every 2 hours. c. Check capillary blood glucose level every 6 hours. d. Monitor cerebrospinal fluid color and volume hourly

C Experienced UAP can obtain capillary blood glucose levels when they have been trained and evaluated in the skill. Monitoring and documentation of cerebrospinal fluid (CSF) color and intracranial pressure (ICP) require registered nurse (RN) level education and scope of practice. Although repositioning patients is frequently delegated to UAP, repositioning a patient with a ventriculostomy is complex and should be supervised by the RN.

During the neurologic assessment, the patient is unable to respond verbally to the nurse but cooperates with the nurses directions to move his hands and feet. The nurse will suspect a. cerebellar injury. b. a brainstem lesion. c. frontal lobe damage. d. a temporal lobe lesion .

C Expressive speech is controlled by Brocas area in the frontal lobe. The temporal lobe contains Wernickes area, which is responsible for receptive speech. The cerebellum and brainstem do not affect higher cognitive functions such as speech. .

While interviewing a 30-year-old man, the nurse learns that the patient has a family history of familial adenomatous polyposis (FAP). The nurse will plan to assess the patients knowledge about a. preventing noninfectious hepatitis. b. treating inflammatory bowel disease. c. risk for developing colorectal cancer. d. using antacids and proton pump inhibitors.

C Familial adenomatous polyposis (FAP) is a genetic condition that greatly increases the risk for colorectal cancer. Noninfectious hepatitis, use of medications that treat increased gastric pH, and inflammatory bowel disease are not related to FAP. .

The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. When auscultating the patients lungs, which finding would the nurse most likely hear? a. Continuous rumbling, snoring, or rattling sounds mainly on expiration b. Continuous high-pitched musical sounds on inspiration and expiration c. Discontinuous, high-pitched sounds of short duration heard on inspiration d. A series of long-duration, discontinuous, low-pitched sounds during inspiration

C Fine crackles are likely to be heard in the early phase of heart failure. Fine crackles are discontinuous, high- pitched sounds of short duration heard on inspiration. . .

The nurse teaches a patient about pulmonary function testing (PFT). Which statement, if made by the patient, indicates teaching was effective? a. I will use my inhaler right before the test. b. I wont eat or drink anything 8 hours before the test. c. I should inhale deeply and blow out as hard as I can during the test. d. My blood pressure and pulse will be checked every 15 minutes after the test.

C For PFT, the patient should inhale deeply and exhale as long, hard, and fast as possible. The other actions are not needed with PFT. The administration of inhaled bronchodilators should be avoided 6 hours before the procedure. .

The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy for cancer of the lung. Which information should the nurse include about the patients postoperative care? a. Positioning on the right side b. Bed rest for the first 24 hours c. Frequent use of an incentive spirometer d. Chest tube placement with continuous drainage

C Frequent deep breathing & coughing are needed after chest surgery to prevent atelectasis. To promote gas exchange, patients after pneumonectomy are positioned on the surgical side. Early mobilization decreases the risk for postoperative complications such as pneumonia & deep vein thrombosis. In a pneumonectomy, chest tubes may or may not be placed in the space from which the lung was removed. If a chest tube is used, it is clamped & only released by the surgeon to adjust the volume of serosanguineous fluid that will fill the space vacated by the lung. If the cavity overfills, it could compress the remaining lung and compromise the cardiovascular & pulmonary function. Daily chest x-rays can be used to assess the volume & space.

A 46-year-old female with gastroesophageal reflux disease (GERD) is experiencing increasing discomfort. Which patient statement indicates that additional teaching about GERD is needed? a. I take antacids between meals and at bedtime each night. b. I sleep with the head of the bed elevated on 4-inch blocks. c. I eat small meals during the day and have a bedtime snack. d. I quit smoking several years ago, but I still chew a lot of gum.

C GERD is exacerbated by eating late at night, and the nurse should plan to teach the patient to avoid eating at bedtime. The other patient actions are appropriate to control symptoms of GERD. .

Which patient choice for a snack 2 hours before bedtime indicates that the nurses teaching about gastroesophageal reflux disease (GERD) has been effective? a. Chocolate pudding b. Glass of low-fat milk c. Cherry gelatin with fruit d. Peanut butter and jelly sandwich

C Gelatin and fruit are low fat and will not decrease lower esophageal sphincter (LES) pressure. Foods such as chocolate are avoided because they lower LES pressure. Milk products increase gastric acid secretion. High-fat foods such as peanut butter decrease both gastric emptying and LES pressure. .

A nurse is following the goals of Healthy People 2020 to provide care. Which action should the nurse take? a. Allow people to continue current behaviors to reduce the stress of change. b. Focus only on health changes that will lead to better local communities. c. Create social and physical environments that promote good health. d. Focus on illness treatment to provide fast recuperation. .

C Healthy People 2020 includes four goals, one of which is to create social and physical environments that promote good health for all. The goals do not include continuing current behaviors to reduce stress, focusing only on health changes for communities, or focusing on fast recuperation. .

The nurse is evaluating the effectiveness of the intravenous fluid therapy in a patient with hypernatremia. Which finding indicates goal achievement? a. Urine output increases to 150 mL/hr. b. Systolic and diastolic blood pressure decreases. c. Serum sodium concentration returns to normal. d. Large amounts of emesis and diarrhea decrease

C Hypernatremia is diagnosed by elevated serum sodium concentration. Blood pressure is not an accurate indicator of hypernatremia. Emesis and diarrhea will not stop because of intravenous therapy. Urine output is influenced by many factors, including extracellular fluid volume. A large dilute urine output can cause further hypernatremia

Which stroke risk factor for a 48-year-old male patient in the clinic is most important for the nurse to address? a. The patient is 25 pounds above the ideal weight. b. The patient drinks a glass of red wine with dinner daily. c. The patients usual blood pressure (BP) is 170/94 mm Hg. d. The patient works at a desk and relaxes by watching television. .

C Hypertension is the single most important modifiable risk factor. People who drink more than 1 (for women) or 2 (for men) alcoholic beverages a day may increase risk for hypertension. Physical inactivity and obesity contribute to stroke risk but not as much as hypertension. .

A nurse has just received a bag of packed red blood cells (RBCs) for a patient. What is the longest time the nurse can let the blood infuse? a. 30 minutes b. 2 hours c. 4 hours d. 6 hours

C Ideally a unit of whole blood or packed RBCs is transfused in 2 hours. This time can be lengthened to 4 hours if the patient is at risk for extracellular volume excess. Beyond 4 hours there is a risk for bacterial contamination of the blood .

When administering the Mini-Cog exam to a patient with possible Alzheimers disease, which action will the nurse take? a. Check the patients orientation to time and date. b. Obtain a list of the patients prescribed medications. c. Ask the person to use a clock drawing to indicate a specific time. d. Determine the patients ability to recognize a common object such as a pen.

C In the Mini-Cog, patients illustrate a specific time stated by the examiner by drawing the time on a clock face. The other actions may be included in assessment for Alzheimers disease, but are not part of the Mini-Cog exam. .

A patient with heart failure is learning to reduce salt in the diet. When will be the best time for the nurse to address this topic? a. At bedtime, while the patient is relaxed b. At bath time, when the nurse is cleaning the patient c. At lunchtime, while the nurse is preparing the food tray d. At medication time, when the nurse is administering patient medication

C In this situation, because the teaching is about food, coordinating it with routine nursing care that involves food can be effective. Many nurses find that they are able to teach more effectively while delivering nursing care. For example, while hanging blood, you explain to the patient why the blood is necessary and the symptoms of a transfusion reaction that need to be reported immediately. - At bedtime would be a good time to discuss routines that enhance sleep. - At bath time would be a good time to describe skin care and how to prevent pressure ulcers. - At medication time would be a good time to explain the purposes and side effects of the medication.

A nurse is caring for a 5-year-old patient whose temperature is 101.2° F. The nurse expects this patient to hyperventilate. Which factor does the nurse remember when planning care for this type of hyperventilation? a. Anxiety over illness b. Decreased drive to breathe c. Increased metabolic demands d. Infection destroying lung tissues

C Increased body temperature (fever) increases the metabolic rate, thereby increasing carbon dioxide production. The increased carbon dioxide level stimulates an increase in the patient's rate and depth of respiration, causing hyperventilation. Anxiety can cause hyperventilation, but this is not the direct cause from a fever. Sleep causes a decreased respiratory drive; hyperventilation speeds up breathing. The cause of the fever in this question is unknown

The nurses initial action for a patient with moderate dementia who develops increased restlessness and agitation should be to a. reorient the patient to time, place, and person. b. administer a PRN dose of lorazepam (Ativan). c. assess for factors that might be causing discomfort. d. assign unlicensed assistive personnel (UAP) to stay in the patients room.

C Increased motor activity in a patient with dementia is frequently the patients only way of responding to factors like pain, so the nurses initial action should be to assess the patient for any precipitating factors. Administration of sedative drugs may be indicated, but this should not be done until assessment for precipitating factors has been completed and any of these factors have been addressed. Reorientation is unlikely to be helpful for the patient with moderate dementia. Assigning UAP to stay with the patient may also be necessary, but any physical changes that may be causing the agitation should be addressed first.

A patient who had a total laryngectomy has a nursing diagnosis of hopelessness related to loss of control of personal care. Which information obtained by the nurse is the best indicator that this identified problem is resolving? a. The patient lets the spouse provide tracheostomy care. b. The patient allows the nurse to suction the tracheostomy. c. The patient asks how to clean the tracheostomy stoma and tube. d. The patient uses a communication board to request No Visitors.

C Independently caring for the laryngectomy tube indicates that the patient has regained control of personal care and hopelessness is at least partially resolved. Letting the nurse and spouse provide care and requesting no visitors may indicate that the patient is still experiencing hopelessness.

When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, the nurse reports the response as a. flexion withdrawal. b. localization of pain. c. decorticate posturing. d. decerebrate posturing

C Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. - Extension of the arms and legs is decerebrate posturing. - Because the flexion is generalized, it does not indicate localization of pain or flexion withdrawal .

The patient appears to be in no apparent distress, but vital signs taken by assistive personnel reveal an extremely low pulse. The nurse then auscultates an apical pulse and asks the patient whether there is any history of heart problems. The nurse is utilizing which critical thinking skill? a. Evaluation b. Explanation c. Interpretation d. Self-regulation

C Interpretation involves being orderly in data collection, looking for patterns to categorize data, and clarifying uncertain data. This nurse is clarifying the data in this situation. Evaluation involves determining the effectiveness of interventions or care provided. The nurse in this scenario is assessing the patient, not evaluating interventions. Self-regulation is reflecting on experiences. Explanation is supporting findings and conclusions. The nurse in this question is clarifying uncertain data (determining cause of the low pulse), not supporting the finding of a low pulse.

While performing an assessment, the nurse hears crackles in the patient's lung fields. The nurse also learns that the patient is sleeping on three pillows to help with the difficulty breathing during the night. Which condition will the nurse most likely observe written in the patient's medical record? a. Atrial fibrillation b. Myocardial ischemia c. Left-sided heart failure d. Right-sided heart failure

C Left-sided heart failure results in pulmonary congestion, the signs and symptoms of which include shortness of breath, cough, crackles, and paroxysmal nocturnal dyspnea (difficulty breathing when lying flat). - Right-sided heart failure is systemic and results in peripheral edema, weight gain, and distended neck veins. - Atrial fibrillation is often described as an irregularly irregular rhythm; rhythm is irregular because of the multiple pacemaker sites. - Myocardial ischemia results when the supply of blood to the myocardium from the coronary arteries is insufficient to meet myocardial oxygen demands, producing angina or myocardial infarction.

The nurse observes a student who is listening to a patients lungs who is having no problems with breathing. Which action by the student indicates a need to review respiratory assessment skills? a. The student starts at the apices of the lungs and moves to the bases. b. The student compares breath sounds from side to side avoiding bony areas. c. The student places the stethoscope over the posterior chest and listens during inspiration. d. The student instructs the patient to breathe slowly and a little more deeply than normal through the mouth.

C Listening only during inspiration indicates the student needs a review of respiratory assessment skills. At each placement of the stethoscope, listen to at least one cycle of inspiration and expiration. During chest auscultation, instruct the patient to breathe slowly and a little deeper than normal through the mouth. Auscultation should proceed from the lung apices to the bases, comparing opposite areas of the chest, unless the patient is in respiratory distress or will tire easily. If so, start at the bases (see Fig. 26-7). Place the stethoscope over lung tissue, not over bony prominences.

A 68-year-old patient is diagnosed with moderate dementia after multiple strokes. During assessment of the patient, the nurse would expect to find a. excessive nighttime sleepiness. b. difficulty eating and swallowing. c. loss of recent and long-term memory. d. fluctuating ability to perform simple tasks.

C Loss of both recent and long-term memory is characteristic of moderate dementia. Patients with dementia have frequent nighttime awakening. Dementia is progressive, and the patients ability to perform tasks would not have periods of improvement. Difficulty eating and swallowing is characteristic of severe dementia. .

The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medications effectiveness? a. Blood pressure b. Oxygen saturation c. Intracranial pressure d. Hemoglobin and hematocrit

C Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure. It may initially reduce hematocrit and increase blood pressure, but these are not the best parameters for evaluation of the effectiveness of the drug. Oxygen saturation will not directly improve as a result of mannitol administration. .

An 80-year-old who is hospitalized with peptic ulcer disease develops new-onset auditory hallucinations. Which prescribed medication will the nurse discuss with the health care provider before administration? a. Sucralfate (Carafate) b. Omeprazole (Prilosec) c. Metoclopramide (Reglan) d. Aluminum hydroxide (Amphojel)

C Metoclopramide can cause central nervous system (CNS) side effects ranging from anxiety to hallucinations. Hallucinations are not a side effect of proton-pump inhibitors, mucosal protectants, or antacids. .

Which assessment finding will cause the nurse to begin teaching a patient because the patient is ready to learn? a. A patient has the ability to grasp and apply the elastic bandage. b. A patient has sufficient upper body strength to move from a bed to a wheelchair. c. A patient with a below-the-knee amputation is motivated about how to walk with assistive devices. d. A patient has normal eyesight to identify the markings on a syringe and coordination to handle a syringe. .

C Motivation underlies a person's desire or willingness to learn. Motivation is a force that acts on or within a person (e.g., an idea, emotion, or a physical need) to cause the person to behave in a particular way. For example, a patient with a below-the-knee amputation is motivated to learn how to walk with assistive devices, indicating a readiness to learn. Do not confuse readiness to learn with ability to learn. All the other answers are examples of ability to learn because this often depends on the patient's level of physical development and overall physical health. To learn psychomotor skills, a patient needs to possess a certain level of strength, coordination, and sensory acuity. For example, it is useless to teach a patient to transfer from a bed to a wheelchair if he or she has insufficient upper body strength. An older patient with poor eyesight or an inability to grasp objects tightly cannot learn to apply an elastic bandage or handle a syringe.

A patient with a pneumothorax has a chest tube inserted and is placed on low constant suction. Which finding requires immediate action by the nurse? a. The patient reports pain at the chest tube insertion site that increases with movement. b. Fifty milliliters of blood gushes into the drainage device after the patient coughs. c. No bubbling is present in the suction control chamber of the drainage device. d. Yellow purulent discharge is seen leaking out from around the dressing site

C No bubbling in the suction control chamber indicates an obstruction of the drainage system. An obstruction causes increased pressure, which can cause a tension pneumothorax, which can be life threatening. The nurse needs to determine whether the leak is inside the thorax or in the tubing and act from there. Occasional blood gushes from the lung owing to lung expansion, as during a cough; this is reserve drainage. Drainage over 100 mL/hr after 3 hours of chest tube placement is cause for concern. Yellow purulent drainage indicates an infection that should be reported to the health care provider but is not as immediately life threatening as the lack of bubbling in the suction control chamber

Which action should the nurse take to best develop critical thinking skills? a. Study 3 hours more each night. b. Attend all inservice opportunities. c. Actively participate in clinical experiences. d. Interview staff nurses about their nursing experiences. .

C Nursing is a practice discipline. Clinical learning experiences are necessary to acquire clinical decision-making skills. Studying for longer hours, interviewing nurses, and attending inservices do not provide opportunities for clinical decision making, as do actual clinical experiences. .

A 26-year-old woman has been admitted to the emergency department with nausea and vomiting. Which action could the RN delegate to unlicensed assistive personnel (UAP)? a. Auscultate the bowel sounds. b. Assess for signs of dehydration. c. Assist the patient with oral care. d. Ask the patient about the nausea

C Oral care is included in UAP education and scope of practice. The other actions are all assessments that require more education and a higher scope of nursing practice. .

A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which is the best response by the nurse? a. Ask if the patient is experiencing shortness of breath, hives, or itching. b. Ask the patient about any visual abnormalities such as red-green color discrimination. c. Explain that orange discolored urine and tears are normal while taking this medication. d. Advise the patient to stop the drug and report the symptoms to the health care provider.

C Orange-colored body secretions are a side effect of rifampin. The patient does not have to stop taking the medication. The findings are not indicative of an allergic reaction. Alterations in red-green color discrimination commonly occurs when taking ethambutol (Myambutol), which is a different TB medication.

A 71-year-old patient with Alzheimers disease (AD) who is being admitted to a long-term care facility has had several episodes of wandering away from home. Which action will the nurse include in the plan of care? a. Reorient the patient several times daily. b. Have the family bring in familiar items. c. Place the patient in a room close to the nurses station. d. Ask the patient why the wandering episodes have occurred.

C Patients at risk for problems with safety require close supervision. Placing the patient near the nurses station will allow nursing staff to observe the patient more closely. The use of why questions can be frustrating for patients with AD because they are unable to understand clearly or verbalize the reason for wandering behaviors. Because of the patients short-term memory loss, reorientation will not help prevent wandering behavior. Because the patient had wandering behavior at home, familiar objects will not prevent wandering

A nurse is caring for a patient who is taking warfarin (Coumadin) and discovers that the patient is taking garlic to help with hypertension. Which condition will the nurse assess for in this patient? a. Increased cholesterol level b. Distended jugular vein c. Bleeding d. Angina

C Patients taking warfarin (Coumadin) for anticoagulation prolong the prothrombin time (PT)/international normalized ratio (INR) results if they are taking gingko biloba, garlic, or ginseng with the anticoagulant. The drug interaction can precipitate a life-threatening bleed. Increased cholesterol levels are associated with saturated fat dietary intake. A distended jugular vein and peripheral edema are associated with damage to the right side of the heart. Angina is temporary ischemia of the heart muscle

A patient presents to the emergency department with reports of vomiting and diarrhea for the past 48 hours. The health care provider orders isotonic intravenous (IV) therapy. Which IV will the nurse prepare? a. 0.225% sodium chloride (1/4 NS) b. 0.45% sodium chloride (1/2 NS) c. 0.9% sodium chloride (NS) d. 3% sodium chloride (3% NaCl)

C Patients with prolonged vomiting and diarrhea become hypovolemic. A solution to replace extracellular volume is 0.9% sodium chloride, which is an isotonic solution. 0.225% and 0.45% sodium chloride are hypotonic. 3% sodium chloride is hypertonic

An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action, if recommended by the nurse, will be most helpful in reducing the incidence of lung disease? a. Treat workers with pulmonary fibrosis. b. Teach about symptoms of lung disease. c. Require the use of protective equipment. d. Monitor workers for coughing and wheezing.

C Prevention of lung disease requires the use of appropriate protective equipment such as masks. The other actions will help in recognition or early treatment of lung disease but will not be effective in prevention of lung damage. Repeated exposure eventually results in diffuse pulmonary fibrosis. Fibrosis is the result of tissue repair after inflammation.

Which action demonstrates a nurse utilizing reflection to improve clinical decision making? a. Obtains data in an orderly fashion b. Uses an objective approach in patient situations c. Improves a plan of care while thinking back on interventions effectiveness d. Provides evidence-based explanations and research for care of assigned patients .

C Reflection utilizes critical thinking when thinking back on the effectiveness of interventions and how they were performed. It involves purposeful thinking back or recalling a situation to discover its purpose or meaning. The other options are not examples of reflection but do represent good nursing practice. Using an objective approach and obtaining data in an orderly fashion do not involve purposefully thinking back to discover the meaning or purpose of a situation. Providing evidence- based explanations for nursing interventions does not always involve thinking back to discover the meaning of a situation.

A patient has been taught how to change a colostomy bag but is having trouble measuring and manipulating the equipment and has many questions. What is the nurse's next action? a. Refer to a mental health specialist. b. Refer to a wound care specialist. c. Refer to an ostomy specialist. d. Refer to a dietitian.

C Resources that specialize in a particular health need (e.g., wound care or ostomy specialists) are integral to successful patient education. A mental health specialist is helpful for emotional issues rather than for physical problems. A dietitian is a resource for nutritional needs. A wound care specialist provides complex wound care.

A nurse is caring for a patient who smokes and drinks caffeine. Which point is important for the nurse to understand before assessing the patient's blood pressure (BP)? a. Smoking increases BP for up to 3 hours. b. Caffeine increases BP for up to 15 minutes. c. Smoking result in vasoconstriction, falsely elevating BP. d. Caffeine intake should not have occurred 30 to 40 minutes before BP measurement

C Smoking results in vasoconstriction, a narrowing of blood vessels. BP rises when a person smokes and returns to baseline about 15-20 minutes after stopping smoking. Caffeine increases BP for up to 3 hours. Be sure that patient has not ingested caffeine or smoked 20 to 30 minutes before BP measurement. .

The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take? a. Teach about the reason for the blood tests. b. Schedule an appointment for a chest x-ray. c. Teach about the need to get sputum specimens for 2 to 3 consecutive days. d. Instruct the patient to expectorate three specimens as soon as possible.

C Sputum specimens are obtained on 2 to 3 consecutive days for bacteriologic testing for M. tuberculosis. The patient should not provide all the specimens at once. Blood cultures are not used for tuberculosis testing. A chest x-ray is not bacteriologic testing. Although the findings on chest x-ray examination are important, it is not possible to make a diagnosis of TB solely based on chest x-ray findings because other diseases can mimic the appearance of TB.

The charge nurse observes an inexperienced staff nurse caring for a patient who has had a craniotomy for resection of a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene? a. The staff nurse assesses neurologic status every hour. b. The staff nurse elevates the head of the bed to 30 degrees. c. The staff nurse suctions the patient routinely every 2 hours. d. The staff nurse administers an analgesic before turning the patient.

C Suctioning increases intracranial pressure, and should only be done when the patients respiratory condition indicates it is needed. The other actions by the staff nurse are appropriate. .

A nurse attends a seminar on teaching/learning. Which statement indicates the nurse has a good understanding of teaching/learning? a. "Teaching and learning can be separated." b. "Learning is an interactive process that promotes teaching." c. "Teaching is most effective when it responds to the learner's needs." d. "Learning consists of a conscious, deliberate set of actions designed to help the teacher."

C Teaching is most effective when it responds to the learner's needs. It is impossible to separate teaching from learning. Teaching is an interactive process that promotes learning. Teaching consists of a conscious, deliberate set of actions that help individuals gain new knowledge, change attitudes, adopt new behaviors, or perform new skills.

A patient is admitted to a rehabilitation facility following a stroke. The patient has right-sided paralysis and is unable to speak. The patient will be receiving physical therapy and speech therapy. Which level of preventive care is the patient receiving? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Health promotion

C Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability through interventions directed at preventing complications and deterioration. - Secondary prevention focuses on individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. Activities are directed at diagnosis and prompt intervention. - Primary prevention precedes disease or dysfunction and is applied to people considered physically and emotionally healthy. - Health promotion includes health education programs, immunizations, and physical and nutritional fitness activities.

The public health nurse is planning a program to decrease the incidence of meningitis in adolescents and young adults. Which action is most important? a. Encourage adolescents and young adults to avoid crowds in the winter. b. Vaccinate 11- and 12-year-old children against Haemophilus influenzae. c. Immunize adolescents and college freshman against Neisseria meningitides. d. Emphasize the importance of hand washing to prevent the spread of infection.

C The Neisseria meningitides vaccination is recommended for children ages 11 and 12, unvaccinated teens entering high school, and college freshmen. Hand washing may help decrease the spread of bacteria, but it is not as effective as immunization. Vaccination with Haemophilus influenzae is for infants and toddlers. Because adolescents and young adults are in school or the workplace, avoiding crowds is not realistic.

A nurse is teaching the patient with mitral valve problems about the valves in the heart. Starting on the right side of the heart, describe the sequence of the blood flow through these valves. 1. Mitral 2. Aortic 3. Tricuspid 4. Pulmonic a. 1, 3, 2, 4 b. 4, 3, 2, 1 c. 3, 4, 1, 2 d. 2, 4, 1, 3

C The blood flows through the valves in the following direction: - tricuspid, - pulmonic, - mitral, - and aortic. .

The nurse is caring for a patient who has a head injury and fractured right arm after being assaulted. Which assessment information requires the most rapid action by the nurse? a. The apical pulse is slightly irregular. b. The patient complains of a headache. c. The patient is more difficult to arouse. d. The blood pressure (BP) increases to 140/62 mm Hg.

C The change in level of consciousness (LOC) is an indicator of increased intracranial pressure (ICP) and suggests that action by the nurse is needed to prevent complications. The change in BP should be monitored but is not an indicator of a need for immediate nursing action. Headache and a slightly irregular apical pulse are not unusual in a patient after a head injury. .

A patient is being evaluated for Alzheimers disease (AD). The nurse explains to the patients adult children that a. the most important risk factor for AD is a family history of the disorder. b. new drugs have been shown to reverse AD dramatically in some patients. c. a diagnosis of AD is made only after other causes of dementia are ruled out. d. the presence of brain atrophy detected by magnetic resonance imaging (MRI) will confirm the diagnosis of AD. .

C The diagnosis of AD is usually one of exclusion. Age is the most important risk factor for development of AD. Drugs may slow the deterioration but do not reverse the effects of AD. Brain atrophy is a common finding in AD, but it can occur in other diseases as well and does not confirm a diagnosis of AD. .

While caring for a patient with respiratory disease, the nurse observes that the patients SpO2 drops from 93% to 88% while the patient is ambulating in the hallway. What is the priority action of the nurse? a. Notify the health care provider. b. Document the response to exercise. c. Administer the PRN supplemental O2. d. Encourage the patient to pace activity.

C The drop in SpO2 to 85% indicates that the patient is hypoxemic and needs supplemental oxygen when exercising. The other actions are also important, but the first action should be to correct the hypoxemia.

Which nursing intervention is most effective in preventing hospital-acquired pneumonia in an older-adult patient? a. Discontinue the humidification delivery device to keep excess fluid from lungs. b. Monitor oxygen saturation, and frequently auscultate lung bases. c. Assist the patient to cough, turn, and deep breathe every 2 hours. d. Decrease fluid intake to 300 mL a shift .

C The goal of the nursing action should be the prevention of pneumonia; the action that best addresses this is to cough, turn, and deep breathe to keep secretions from pooling at the base of the lungs. Humidification thins respiratory secretions, making them easier to expel and should be used. Monitoring oxygen status is important but is not a method of prevention. Hydration assists in preventing hospital-acquired pneumonia. The best way to maintain thin secretions is to provide a fluid intake of 1500 to 2500 mL/day unless contraindicated by cardiac or renal status. Restricting fluids is contraindicated in this situation since there is no data indicating cardiac or renal disease

The nurse is caring for a patient with idiopathic pulmonary arterial hypertension (IPAH) who is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action by the nurse? a. The oxygen saturation is 94%. b. The blood pressure is 98/56 mm Hg. c. The patients central IV line is disconnected. d. The international normalized ratio (INR) is prolonged.

C The half-life of this drug is 6 minutes, so the nurse will need to restart the infusion as soon as possible to prevent rapid clinical deterioration. The other data also indicate a need for ongoing monitoring or intervention, but the priority action is to reconnect the infusion. .

The patient is found to be unresponsive and not breathing. Which pulse site will the nurse use? a. Radial b. Apical c. Carotid d. Brachial .

C The heart continues to deliver blood through the carotid artery to the brain as long as possible. The carotid pulse is easily accessible during physiological shock or cardiac arrest. The radial pulse is used to assess peripheral circulation or to assess the status of circulation to the hand. The brachial site is used to assess the status of circulation to the lower arm. The apical pulse is used to auscultate the apical area

The nurse reviews the laboratory results for a patient and determines the viscosity of the blood is thick. Which laboratory result did the nurse check? a. Arterial blood gas b. Blood culture c. Hematocrit d. Potassium

C The hematocrit, or the percentage of red blood cells in the blood, determines blood viscosity. Blood cultures determine the causative agent of an infection. Abnormal potassium levels can cause dysrhythmias. Arterial blood gases determine acid-base balance or the pH levels of the blood. .

The nurse is providing a blood pressure clinic for the community. Which group will the nurse most likely address? a. Non-Hispanic Caucasians b. European Americans c. African-Americans d. Asian Americans .

C The incidence of hypertension is greater in diabetic patients, older adults, and African-Americans. The incidence of hypertension (high BP) is higher in African-Americans than in European Americans .

Which action by the nurse will be most effective in decreasing the spread of pertussis in a community setting? a. Providing supportive care to patients diagnosed with pertussis b. Teaching family members about the need for careful hand washing c. Teaching patients about the need for adult pertussis immunizations d. Encouraging patients to complete the prescribed course of antibiotics

C The increased rate of pertussis in adults is thought to be due to decreasing immunity after childhood immunization. Immunization is the most effective method of protecting communities from infectious diseases. Hand washing should be taught, but pertussis is spread by droplets and contact with secretions. Supportive care does not shorten the course of the disease or the risk for transmission. Taking antibiotics as prescribed does assist with decreased transmission, but patients are likely to have already transmitted the disease by the time the diagnosis is made.

A male patient who has right-sided weakness after a stroke is making progress in learning to use the left hand for feeding and other activities. The nurse observes that when the patients wife is visiting, she feeds and dresses him. Which nursing diagnosis is most appropriate for the patient? a. Interrupted family processes related to effects of illness of a family member b. Situational low self-esteem related to increasing dependence on spouse for care c. Disabled family coping related to inadequate understanding by patients spouse d. Impaired nutrition: less than body requirements related to hemiplegia and aphasia

C The information supports the diagnosis of disabled family coping because the wife does not understand the rehabilitation program. There are no data supporting low self-esteem, and the patient is attempting independence. The data do not support an interruption in family processes because this may be a typical pattern for the couple. There is no indication that the patient has impaired nutrition.

A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? a. Monitor the blood pressure. b. Send the patient for a computed tomography (CT) scan. c. Check the respiratory rate and effort. d. Assess the Glasgow Coma Scale score.

C The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, and circulation) are completed. .

A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment has been effective? a. Bronchial breath sounds are heard at the right base. b. The patient coughs up small amounts of green mucus. c. The patients white blood cell (WBC) count is 9000/L. d. Increased tactile fremitus is palpable over the right chest.

C The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed. .

Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has no symptoms of TB. Which information should the occupational health nurse plan to teach the staff nurse? a. Standard four-drug therapy for TB b. Need for annual repeat TB skin testing c. Use and side effects of isoniazid (INH) d. Bacille Calmette-Gurin (BCG) vaccine

C The nurse is considered to have a latent TB infection and should be treated with INH daily for 6 to 9 months. The four-drug therapy would be appropriate if the nurse had active TB. TB skin testing is not done for individuals who have already had a positive skin test. BCG vaccine is not used in the United States for TB and would not be helpful for this individual, who already has a TB infection.

The nurse discusses management of upper respiratory infections (URI) with a patient who has acute sinusitis. Which statement by the patient indicates that additional teaching is needed? a. I can take acetaminophen (Tylenol) to treat my discomfort. b. I will drink lots of juices and other fluids to stay well hydrated. c. I can use my nasal decongestant spray until the congestion is all gone. d. I will watch for changes in nasal secretions or the sputum that I cough up.

C The nurse should clarify that nasal decongestant sprays should be used for no more than 3 days to prevent rebound vasodilation and congestion. The other responses indicate that the teaching has been effective.

The nurse is caring for a small child and needs to obtain vital signs. Which site choice from the nursing assistive personnel (NAP) will cause the nurse to praise the NAP? a. Ulnar site b. Radial site c. Brachial site d. Femoral site

C The nurse will praise the NAP when obtaining the pulse from the brachial site. The brachial or apical pulse is the best site for assessing an infant's or a young child's pulse because other peripheral pulses are deep and difficult to palpate accurately. .

While the nurse is taking a patient history, the nurse discovers the patient has a type of diabetes that results from a head injury and does not require insulin. Which dietary change should the nurse share with the patient? a. Reduce the quantity of carbohydrates ingested to lower blood sugar. b. Include a serving of dairy in each meal to elevate calcium levels. c. Drink plenty of fluids throughout the day to stay hydrated. d. Avoid food high in acid to avoid metabolic acidosis

C The patient has diabetes insipidus, which places the patient at risk for dehydration and hypernatremia. Dehydration should be prevented by drinking plenty of fluids to replace the extra water excreted in the urine. Foods high in acid are not what causes metabolic acidosis. A reduction in carbohydrates to lower blood sugar will not help a patient with diabetes insipidus but it may help a patient with diabetes mellitus. Calcium-rich dairy products would be recommended for a hypocalcemic patient

At his first postoperative checkup appointment after a gastrojejunostomy (Billroth II), a patient reports that dizziness, weakness, and palpitations occur about 20 minutes after each meal. The nurse will teach the patient to a. increase the amount of fluid with meals. b. eat foods that are higher in carbohydrates. c. lie down for about 30 minutes after eating. d. drink sugared fluids or eat candy after meals.

C The patient is experiencing symptoms of dumping syndrome, which may be reduced by lying down after eating. Increasing fluid intake and choosing high carbohydrate foods will increase the risk for dumping syndrome. Having a sweet drink or hard candy will correct the hypoglycemia that is associated with dumping syndrome but will not prevent dumping syndrome.

The nurse is assessing a patient and finds crackles in the lung bases and neck vein distention. Which action will the nurse take first? a. Offer calcium-rich foods. b. Administer diuretic. c. Raise head of bed. d. Increase fluids.

C The patient is in fluid overload. Raising the head of the bed to ease breathing is the first action. Offering calcium-rich foods is for hypocalcemia, not fluid overload. Administering a diuretic is the second action. Increasing fluids is contraindicated and would make the situation worse .

A 47-year-old patient will attempt oral feedings for the first time since having a stroke. The nurse should assess the gag reflex and then a. order a varied pureed diet. b. assess the patients appetite. c. assist the patient into a chair. d. offer the patient a sip of juice.

C The patient should be as upright as possible before attempting feeding to make swallowing easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient. Pureed diets are not recommended because the texture is too smooth. The patient may have a poor appetite, but the oral feeding should be attempted regardless. .

A 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care? a. Encourage coughing and deep breathing. b. Position the patient with knees and hips flexed. c. Keep the head of the bed elevated to 30 degrees. d. Cluster nursing interventions to provide rest periods.

C The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to help reduce ICP. Extreme flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions increases ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic pressure and ICP

Which patient should the nurse assess first after receiving change-of-shift report? a. A patient with nausea who has a dose of metoclopramide (Reglan) due b. A patient who is crying after receiving a diagnosis of esophageal cancer c. A patient with esophageal varices who has a blood pressure of 92/58 mm Hg d. A patient admitted yesterday with gastrointestinal (GI) bleeding who has melena .

C The patients history and blood pressure indicate possible hemodynamic instability caused by GI bleeding. The data about the other patients do not indicate acutely life-threatening complications. .

The nurse considers a nursing diagnosis of ineffective health maintenance related to low motivation for a patient with diabetes. Which finding would the nurse most likely use to support this nursing diagnosis? a. The patient does not perform capillary blood glucose tests as directed. b. The patient occasionally forgets to take the daily prescribed medication. c. The patient states that dietary changes have not made any difference at all. d. The patient cannot identify signs or symptoms of high and low blood glucose.

C The patients motivation to follow a diabetic diet will be decreased if the patient feels that dietary changes do not affect symptoms. The other responses do not indicate that the ineffective health maintenance is caused by lack of motivation. .

After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about a. cerebral aneurysm clipping. b. heparin intravenous infusion. c. oral low-dose aspirin therapy. d. tissue plasminogen activator (tPA).

C The patients symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patients symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA.

A nurse is preparing a patient for nasotracheal suctioning. In which order will the nurse perform the steps, beginning with the first step? 1. Insert catheter. 2. Apply suction and remove. 3. Have patient deep breathe. 4. Encourage patient to cough. 5. Attach catheter to suction system. 6. Rinse catheter and connecting tubing. a. 1, 2, 3, 4, 5, 6 b. 4, 5, 1, 2, 3, 6 c. 5, 3, 1, 2, 4, 6 d. 3, 1, 2, 5, 4, 6

C The steps for nasotracheal suctioning are as follows: - Verify that the catheter is attached to suction; - have the patient deep breathe; - insert the catheter; - apply intermittent suction for no more than 10 seconds and remove; - encourage the patient to cough; - and rinse the catheter and connecting tubing with normal saline

The patient is being admitted to the emergency department following a motor vehicle accident. The patient's jaw is broken with several broken teeth. The patient is ashen, has cool skin, and is diaphoretic (sweating). Which route will the nurse use to obtain an accurate temperature reading? a. Oral b. Axillary c. Tympanic d. Temporal

C The tympanic route is the best choice in this situation. - Oral temperatures are not used for patients who have had oral surgery, trauma, history of epilepsy, or shaking chills. - Axillary temperature is affected by exposure to the environment, including time to place the thermometer. It also requires a long measurement time. - Temporal artery temperature is affected by skin moisture such as diaphoresis or sweating

A nurse who is caring for patient with a tracheostomy tube in place has just auscultated rhonchi bilaterally. If the patient is unsuccessful in coughing up secretions, what action should the nurse take? a. Encourage increased incentive spirometer use. b. Encourage the patient to increase oral fluid intake. c. Put on sterile gloves and use a sterile catheter to suction. d. Preoxygenate the patient for 3 minutes before suctioning.

C This patient needs suctioning now to secure a patent airway. Sterile gloves and a sterile catheter are used when suctioning a tracheostomy. Preoxygenation for 3 minutes is not necessary. Incentive spirometer (IS) use opens alveoli and can induce coughing, which can mobilize secretions. However, the patient with a tracheostomy may not be able to use an incentive spirometer. Increasing oral fluid intake would not moisten and help mobilize secretions in a timely manner.

Which hospitalized patient will the nurse assign to the room closest to the nurses station? a. Patient with Alzheimers disease who has long-term memory deficit b. Patient with vascular dementia who takes medications for depression c. Patient with new-onset confusion, restlessness, and irritability after surgery d. Patient with dementia who has an abnormal Mini-Mental State Examination .

C This patients history and clinical manifestations are consistent with delirium. The patient is at risk for safety problems and should be placed near the nurses station for ongoing observation. The other patients have chronic symptoms that are consistent with their diagnoses but are not at immediate risk for safety issues. .

A 58-year-old woman who recently has been diagnosed with esophageal cancer tells the nurse, I do not feel ready to die yet. Which response by the nurse is most appropriate? a. You may have quite a few years still left to live. b. Thinking about dying will only make you feel worse. c. Having this new diagnosis must be very hard for you. d. It is important that you be realistic about your prognosis.

C This response is open-ended and will encourage the patient to further discuss feelings of anxiety or sadness about the diagnosis. Patients with esophageal cancer have only a low survival rate, so the response You may have quite a few years still left to live is misleading. The response beginning, Thinking about dying indicates that the nurse is not open to discussing the patients fears of dying. The response beginning, It is important that you be realistic, discourages the patient from feeling hopeful, which is important to patients with any life- threatening diagnosis.

A nurse is caring for a cancer patient who presents with anorexia, blood pressure 100/60, and elevated white blood cell count. Which primary purpose for starting total parenteral nutrition (TPN) will the nurse add to the care plan? a. Stimulate the patient's appetite to eat. b. Deliver antibiotics to fight off infection. c. Replace fluid, electrolytes, and nutrients. d. Provide medication to raise blood pressure

C Total parenteral nutrition is an intravenous solution composed of nutrients and electrolytes to replace the ones the patient is not eating or losing. TPN does not stimulate the appetite. TPN does not contain blood pressure medication or antibiotics .

A nurse is teaching a health class about the heart. Which information from the class members indicates teaching by the nurse is successful for the flow of blood through the heart, starting in the right atrium? a. Right ventricle, left ventricle, left atrium b. Left atrium, right ventricle, left ventricle c. Right ventricle, left atrium, left ventricle d. Left atrium, left ventricle, right ventricle

C Un-oxygenated blood flows through the VENAE CAVAE into the RIGHT ATRIUM, where it is pumped down to the RIGHT VENTRICLE; the blood is then pumped out the PULMONARY ARTERY and is returned oxygenated via the PULMONARY VEIN to the LEFT ATRIUM, where it flows to the LEFT VENTRICLE and is pumped out to the rest of the body via the AORTA. .

A 57-year-old man with Escherichia coli O157:H7 food poisoning is admitted to the hospital with bloody diarrhea and dehydration. Which order will the nurse question? a. Infuse lactated Ringers solution at 250 mL/hr. b. Monitor blood urea nitrogen and creatinine daily. c. Administer loperamide (Imodium) after each stool. d. Provide a clear liquid diet and progress diet as tolerated.

C Use of antidiarrheal agents is avoided with this type of food poisoning. The other orders are appropriate. .

A toddler is going to have surgery on the right ear. Which teaching method is most appropriate for this developmental stage? a. Encourage independent learning. b. Develop a problem-solving scenario. c. Wrap a bandage around a stuffed animal's ear. d. Use discussion throughout the teaching session.

C Use play to teach a procedure or activity (e.g., handling examination equipment, applying a bandage to a doll) to toddlers. Encouraging independent learning is for the young or middle adult. Use of discussion is for older children, adolescents, and adults, not for toddlers. Use problem solving to help adolescents make choices. Problem solving is too advanced for a toddler.

The nurse observes edema in a patient who has venous congestion from right heart failure. Which type of pressure facilitated the formation of the patient's edema? a. Osmotic b. Oncotic c. Hydrostatic d. Concentration

C Venous congestion increases capillary hydrostatic pressure. Increased hydrostatic pressure causes edema by causing increased movement of fluid into the interstitial area. Osmotic and oncotic pressures involve the concentrations of solutes and can contribute to edema in other situations, such as inflammation or malnutrition. Concentration pressure is not a nursing term

During the change of shift report a nurse is told that a patient has an occluded left posterior cerebral artery. The nurse will anticipate that the patient may have a. dysphasia. b. confusion. c. visual deficits. d. poor judgment.

C Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle cerebral artery involvement. Cognitive deficits and changes in judgment are more typical of anterior cerebral artery occlusion. .

The charge nurse is observing a new staff nurse who is assessing a patient with a traumatic spinal cord injury for sensation. Which action indicates a need for further teaching of the new nurse about neurologic assessment? a. The new nurse tests for light touch before testing for pain. b. The new nurse has the patient close the eyes during testing. c. The new nurse asks the patient if the instrument feels sharp. d. The new nurse uses an irregular pattern to test for intact touch

C When performing a sensory assessment, the nurse should not provide verbal clues. The other actions by the new nurse are appropriate. .

The nurse is caring for a patient who has been trying to quit smoking. The patient has been smoke free for 2 weeks but had two cigarettes last night and at least two this morning. What should the nurse anticipate? a. The patient does not want to and will never quit smoking. b. The patient must pick up the attempt right where the patient left off. c. The patient will return to the contemplation or precontemplation phase. d. The patient will need to adopt a new lifestyle for change to be effective.

C When relapse occurs, the person will return to the contemplation or precontemplation stage before attempting the change again. The patient cannot pick up the attempt where left off. It is believed that change involves movement through a series of stages (precontemplation, contemplation, preparation, action, and maintenance). Anticipating that the patient does not want to and will never quit is premature. While the patient will need to adopt a new lifestyle for change to be effective, it does not correlate to this scenario since the patient relapsed.

A patient who was admitted to the hospital with hyperglycemia and newly diagnosed diabetes mellitus is scheduled for discharge the second day after admission. When implementing patient teaching, what is the priority action for the nurse? a. Instruct about the increased risk for cardiovascular disease. b. Provide detailed information about dietary control of glucose. c. Teach glucose self-monitoring and medication administration. d. Give information about the effects of exercise on glucose control.

C When time is limited, the nurse should focus on the priorities of teaching. In this situation, the patient should know how to test blood glucose and administer medications to control glucose levels. The patient will need further teaching about the role of diet, exercise, various medications, and the many potential complications of diabetes, but these topics can be addressed through planning for appropriate referrals.

A nurse is teaching an older-adult patient about strokes. Which teaching technique is most appropriate for the nurse to use? a. Speak in a high tone of voice to describe strokes. b. Use a pamphlet about strokes with large font in blues and greens. c. Provide specific information about strokes in short, small amounts. d. Begin the teaching session facing the teaching white board with stroke information.

C With older adults, keep the teaching session short with small amounts of information. Also, if using written material, assess the patient's ability to read and use information that is printed in large type and in a color that contrasts highly with the background (e.g., black 14-point print on matte white paper). Avoid blues and greens because they are more difficult to see. Speak in a low tone of voice (lower tones are easier to hear than higher tones). Directly face the older-adult learner when speaking.

A nurse is caring for a patient with sleep apnea. Which types of ventilator support should the nurse be prepared to administer for this patient? (Select all that apply.) a. Assist-control (AC) b. Pressure support ventilation (PSV) c. Bilevel positive airway pressure (BiPAP) d. Continuous positive airway pressure (CPAP) e. Synchronized intermittent mandatory ventilation (SIMV)

C, D Ventilatory support is achieved using a variety of modes, including continuous positive airway pressure (CPAP) & bilevel positive airway pressure (BiPAP). The purpose of CPAP & BiPAP is to maintain a positive airway pressure & improve alveolar ventilation. This prevents or treats atelectasis by inflating the alveoli, reducing pulmonary edema by forcing fluid out of the lungs back into circulation, & improving oxygenation in those with sleep apnea. AC, PSV, & SIMV are invasive mechanical ventilation & are not routinely used on patients with sleep apnea. AC delivers a set tidal volume (VT) with each breath, regardless of whether the breath was triggered by the patient or the ventilator. Synchronized intermittent mandatory ventilation like AC delivers a minimum number of fully assisted breaths per minute that are synchronized with the patient's respiratory effort. Any breaths taken between volume-cycled breaths are not assisted; the volume of these breaths is determined by the patient's strength, effort, & lung mechanics. PSV mode is often combined with SIMV mode: inspiratory pressure is added to spontaneous breaths to overcome the resistance of the endotracheal tube or to help increase the volume of the patient's spontaneous breaths.

A 63-year-old patient who began experiencing right arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol? a. Obtain computed tomography (CT) scan without contrast. b. Infuse tissue plasminogen activator (tPA). c. Administer oxygen to keep O2 saturation >95%. d. Use National Institute of Health Stroke Scale to assess patient.

C, D, A, B The initial actions should be those that help with airway, breathing, and circulation. Baseline neurologic assessments should be done next. A CT scan will be needed to rule out hemorrhagic stroke before tPA can be administered. . .

Which areas should the nurse assess to determine the effects of external variables on a patient's illness? (Select all that apply.) a. Patient's perception of the illness b. Patient's coping skills c. Socioeconomic status d. Cultural background e. Social support

C, D, E External variables influencing a patient's illness behavior include the visibility of symptoms, social group, cultural background, economic variables, accessibility of the health care system, and social support. Internal variables include the patient's perceptions of symptoms and the nature of the illness, as well as the patient's coping skills and locus of control. .

The nurse plans to provide instructions about diabetes to a patient who has a low literacy level. Which teaching strategies should the nurse use (select all that apply)? a. Discourage use of the Internet as a source of health information. b. Avoid asking the patient about reading abilities and level of education. c. Provide illustrations and photographs showing various types of insulin. d. Schedule one-to-one teaching sessions to practice insulin administration. e. Obtain CDs and DVDs that illustrate how to perform blood glucose testing.

C, D, E For patients with low literacy, visual and hands-on learning techniques are most appropriate. The nurse will need to obtain as much information as possible about the patients reading level in order to provide appropriate learning materials. The nurse should guide the patient to Internet sites established by reputable heath care organizations such as the American Diabetes Association.

Bicarbonate a. Increases excretion of sodium and water b. Reduces excretion of sodium and water c. Reduces excretion of water d. Major buffer in the extracellular fluid e. Vasoconstricts and stimulates aldosterone release

D

Hypothermia a. Patient's temperature is 113° F (45° C) with hot, dry skin. b. Patient's blood pressure sitting is 130/60 and 110/40 standing. c. Patient's pulse is 110 beats/min. d. Patient's temperature is 93.2° F (34° C). e. Patient's blood pressure went from 126/76 to 90/50.

D

A 58-year-old patient with a left-brain stroke suddenly bursts into tears when family members visit. The nurse should a. use a calm voice to ask the patient to stop the crying behavior. b. explain to the family that depression is normal following a stroke. c. have the family members leave the patient alone for a few minutes. d. teach the family that emotional outbursts are common after strokes.

D Patients who have left-sided brain stroke are prone to emotional outbursts that are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patients outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the patients control and asking the patient to stop will lead to embarrassment.

A nurse is reviewing capnography results for adult patients. Which value will cause the nurse to follow up? a. 35 mm Hg b. 40 mm Hg c. 45 mm Hg d. 50 mm Hg .

D 50 mm Hg is abnormal so the nurse will follow up. Normal capnography results are 35 to 45 mm Hg . .

The nurse enters a room to find the patient sitting up in bed crying. How will the nurse display a critical thinking attitude in this situation? a. Provide privacy and check on the patient 30 minutes later. b. Set a box of tissues at the patient's bedside before leaving the room. c. Limit visitors while the patient is upset. d. Ask the patient about the crying.

D A clinical sign or symptom (crying) often indicates a variety of problems. Explore and learn more about the patient so as to make appropriate clinical judgments. This is demonstrating curiosity, which is an attitude of critical thinking. Checking on the patient 30 minutes later, providing tissues, and limiting visitors may be appropriate actions but these actions do not address critical thinking. .

After change-of-shift report on the Alzheimers disease/dementia unit, which patient will the nurse assess first? a. Patient who has not had a bowel movement for 5 days b. Patient who has a stage II pressure ulcer on the coccyx c. Patient who is refusing to take the prescribed medications d. Patient who developed a new cough after eating breakfast .

D A new cough after a meal in a patient with dementia suggests possible aspiration and the patient should be assessed immediately. The other patients also require assessment and intervention, but not as urgently as a patient with possible aspiration or pneumonia. .

A chemotherapy patient has gained 5 pounds in 2 days. Which assessment question by the nurse is most appropriate? a. "Are you following any weight loss program?" b. "How many calories a day do you consume?" c. "Do you have dry mouth or feel thirsty?" d. "How many times a day do you urinate?"

D A rapid gain in weight usually indicates extracellular volume (ECV) excess if the person began with normal ECV. Asking the patient about urination habits will help determine whether the body is trying to excrete the excess fluid or if renal dysfunction is contributing to ECV excess. This is too rapid a weight gain to be dietary; it is fluid retention. Asking about following a weight loss program will not help determine the cause of the problem. Caloric intake does not account for rapid weight changes. Dry mouth and thirst accompany ECV deficit, which would be associated with rapid weight loss

The nurse analyzes the results of a patients arterial blood gases (ABGs). Which finding would require immediate action? a. The bicarbonate level (HCO3) is 31 mEq/L. b. The arterial oxygen saturation (SaO2) is 92%. c. The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg. d. The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.

D All the values are abnormal, but the low PaO2 indicates that the patient is at the point on the oxyhemoglobin dissociation curve where a small change in the PaO2 will cause a large drop in the O2 saturation and a decrease in tissue oxygenation. The nurse should intervene immediately to improve the patients oxygenation. .

A patient with pneumonia has a fever of 101.4 F (38.6 C), a nonproductive cough, and an oxygen saturation of 88%. The patient complains of weakness, fatigue, and needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as the highest priority? a. Hyperthermia related to infectious illness b. Impaired transfer ability related to weakness c. Ineffective airway clearance related to thick secretions d. Impaired gas exchange related to respiratory congestion

D All these nursing diagnoses are appropriate for the patient, but the patients oxygen saturation indicates that all body tissues are at risk for hypoxia unless the gas exchange is improved. . .

A patient being admitted with bacterial meningitis has a temperature of 102.5 F (39.2 C) and a severe headache. Which order for collaborative intervention should the nurse implement first? a. Administer ceftizoxime (Cefizox) 1 g IV . b. Give acetaminophen (Tylenol) 650 mg PO. c. Use a cooling blanket to lower temperature. d. Swab the nasopharyngeal mucosa for cultures.

D Antibiotic therapy should be instituted rapidly in bacterial meningitis, but cultures must be done before antibiotics are started. As soon as the cultures are done, the antibiotic should be started. Hypothermia therapy and acetaminophen administration are appropriate but can be started after the other actions are implemented. .

A nurse is teaching a group of healthy adults about the benefits of flu immunizations. Which type of patient education is the nurse providing? a. Health analogies b. Restoration of health c. Coping with impaired functions d. Promotion of health and illness prevention

D As a nurse, you are a visible, competent resource for patients who want to improve their physical and psychological well-being. In the school, home, clinic, or workplace, you promote health and prevent illness by providing information and skills that enable patients to assume healthier behaviors. Injured and ill patients need information and skills to help them regain or maintain their level of health; this is referred to as restoration of health. Not all patients fully recover from illness or injury. Many have to learn to cope with permanent health alterations; this is known as coping with impaired functions. Analogies supplement verbal instruction with familiar images that make complex information more real and understandable. For example, when explaining arterial blood pressure, use an analogy of the flow of water through a hose.

The nurse will anticipate teaching a patient experiencing frequent heartburn about a. a barium swallow. b. radionuclide tests. c. endoscopy procedures. d. proton pump inhibitors. .

D Because diagnostic testing for heartburn that is probably caused by gastroesophageal reflux disease (GERD) is expensive and uncomfortable, proton pump inhibitors are frequently used for a short period as the first step in the diagnosis of GERD. The other tests may be used but are not usually the first step in diagnosis. .

A patient admitted with possible stroke has been aphasic for 3 hours and his current blood pressure (BP) is 174/94 mm Hg. Which order by the health care provider should the nurse question? a. Keep head of bed elevated at least 30 degrees. b. Infuse normal saline intravenously at 75 mL/hr. c. Administer tissue plasminogen activator (tPA) per protocol. d. Administer a labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg.

D Because elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if mean arterial pressure (MAP) is >130 mm Hg or systolic pressure is >220 mm Hg. Fluid intake should be 1500 to 2000 mL daily to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees, unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient meets the other criteria for tPA use.

A patient arrives in the ear, nose, and throat clinic complaining of a piece of tissue being stuck up my nose and with foul-smelling nasal drainage from the right nare. Which action should the nurse take first? a. Notify the clinic health care provider. b. Obtain aerobic culture specimens of the drainage. c. Ask the patient about how the cotton got into the nose. d. Have the patient occlude the left nare and blow the nose.

D Because the highest priority action is to remove the foreign object from the nare, the nurses first action should be to assist the patient to remove the object. The other actions are also appropriate but should be done after attempting to clear the nose. .

The nurse is working the night shift on a surgical unit and is making 4:00 AM rounds. The nurse notices that the patient's temperature is 96.8° F (36° C), whereas at 4:00 PM the preceding day, it was 98.6° F (37° C). What should the nurse do? a. Call the health care provider immediately to report a possible infection. b. Administer medication to lower the temperature further. c. Provide another blanket to conserve body temperature. d. Realize that this is a normal temperature variation

D Body temperature normally changes 0.5° to 1° C (0.9° to 1.8° F) during a 24-hour period and is usually lowest between 1:00 and 4:00 AM, with a maximum temperature at 4:00 PM, making this variation normal for the time of day. Unless the patient reports being cold, there is no physiological need for providing an extra blanket or medication to lower the body temperature further. There is also no need to call a health care provider to report a normal temperature variation.

The nurse is caring for a patient with hyperkalemia. Which body system assessment is the priority? a. Gastrointestinal b. Neurological c. Respiratory d. Cardiac

D Cardiac is the priority. Hyperkalemia places the patient at risk for potentially serious dysrhythmias and cardiac arrest. Potassium balance is necessary for cardiac function. Respiratory is the priority with hypokalemia. Monitoring of gastrointestinal and neurological systems would be indicated for other electrolyte imbalances

When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral atherosclerosis a. to monitor and record the blood pressure daily. b. that Plavix will dissolve clots in the cerebral arteries. c. that Plavix will reduce cerebral artery plaque formation. d. to call the health care provider if stools are bloody or tarry. .

D Clopidogrel (Plavix) inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients should be advised to notify the health care provider about any signs of bleeding. The medication does not lower blood pressure, decrease plaque formation, or dissolve clots. .

The nurse is using a closed suction device. Which patient will be most appropriate for this suctioning method? a. A 5-year-old with excessive drooling from epiglottitis b. A 5-year-old with an asthma attack following severe allergies c. A 24-year-old with a right pneumothorax following a motor vehicle accident d. A 24-year-old with acute respiratory distress syndrome requiring mechanical ventilation .

D Closed suctioning is most often used on patients who require invasive mechanical ventilation to support their respiratory efforts because it permits continuous delivery of oxygen while suction is performed and reduces the risk of oxygen desaturation. In this case, the acute respiratory distress syndrome requires mechanical ventilation. In the presence of epiglottitis, croup, laryngospasm, or irritable airway, the entrance of a suction catheter via the nasal route causes intractable coughing, hypoxemia, and severe bronchospasm, necessitating emergency intubation or tracheostomy. The 5- year-old child with asthma would benefit from an inhaler. A chest tube is needed for the pneumothorax.

When assessing the respiratory system of an older patient, which finding indicates that the nurse should take immediate action? a. Weak cough effort b. Barrel-shaped chest c. Dry mucous membranes d. Bilateral crackles at lung bases

D Crackles in the lower half of the lungs indicate that the patient may have an acute problem such as heart failure. The nurse should immediately accomplish further assessments, such as oxygen saturation, and notify the health care provider. A barrel-shaped chest, hyperresonance to percussion, and a weak cough effort are associated with aging. Further evaluation may be needed, but immediate action is not indicated. An older patient has a less forceful cough and fewer and less functional cilia. Mucous membranes tend to be drier.

The nurse is caring for a patient with respiratory problems. Which assessment finding indicates a late sign of hypoxia? a. Elevated blood pressure b. Increased pulse rate c. Restlessness d. Cyanosis

D Cyanosis, blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries, is a late sign of hypoxia. Elevated blood pressure, increased pulse rate, and restlessness are early signs of hypoxia. .

The nurse is teaching about the process of exchanging gases through the alveolar capillary membrane. Which term will the nurse use to describe this process? a. Ventilation b. Surfactant c. Perfusion d. Diffusion

D Diffusion is the process of gases exchanging across the alveoli and capillaries of body tissues. - Ventilation is the process of moving gases into and out of the lungs. - Surfactant is a chemical produced in the lungs to maintain the surface tension of the alveoli and keep them from collapsing. - Perfusion is the ability of the cardiovascular system to carry oxygenated blood to tissues and return deoxygenated blood to the heart

An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen? a. Arrange for a friend to administer the medication on schedule. b. Give the patient written instructions about how to take the medications. c. Teach the patient about the high risk for infecting others unless treatment is followed. d. Arrange for a daily noon meal at a community center where the drug will be administered.

D Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen, and arranging a daily meal will help ensure that the patient is available to receive the medication. The other nursing interventions may be appropriate for some patients but are not likely to be as helpful for this patient.

A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6 F with a frequent cough and is complaining of severe pleuritic chest pain. Which prescribed medication should the nurse give first? a. Codeine b. Guaifenesin (Robitussin) c. Acetaminophen (Tylenol) d. Piperacillin/tazobactam (Zosyn)

D Early initiation of antibiotic therapy has been demonstrated to reduce mortality. The other medications are also appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy. .

When a 72-year-old patient is diagnosed with achalasia, the nurse will teach the patient that a. lying down after meals is recommended. b. a liquid or blenderized diet will be necessary. c. drinking fluids with meals should be avoided. d. treatment may include endoscopic procedures. .

D Endoscopic and laparoscopic procedures are the most effective therapy for improving symptoms caused by achalasia. Keeping the head elevated after eating will improve esophageal emptying. A semisoft diet is recommended to improve esophageal emptying. Patients are advised to drink fluid with meals .

A nurse teaches a patient with heart failure healthy food choices. The patient states that eating yogurt is better than eating cake. Which element represents feedback? a. The nurse b. The patient c. The nurse teaching about healthy food choices d. The patient stating that eating yogurt is better than eating cake

D Feedback needs to demonstrate the success of the learner in achieving objectives (i.e., the learner verbalizes information or provides a return demonstration of skills learned). The nurse is the sender. The patient (learner) is the receiver. The teaching is the message. .

The nurse is working on a committee to evaluate the need for increasing the levels of fluoride in the drinking water of the community. Which concept is the nurse fostering? a. Illness prevention b. Wellness education c. Active health promotion d. Passive health promotion

D Fluoridation of municipal drinking water and fortification of homogenized milk with vitamin D are examples of passive health promotion strategies. With active strategies of health promotion, individuals are motivated to adopt specific health programs such as weight reduction and smoking cessation programs. Illness prevention activities such as immunization programs protect patients from actual or potential threats to health. Wellness education teaches people how to care for themselves in a healthy way.

A 42-year-old woman is admitted to the outpatient testing area for an ultrasound of the gallbladder. Which information obtained by the nurse indicates that the ultrasound may need to be rescheduled? a. The patient took a laxative the previous evening. b. The patient had a high-fat meal the previous evening c. The patient has a permanent gastrostomy tube in place. d. The patient ate a low-fat bagel 4 hours ago for breakfast.

D Food intake can cause the gallbladder to contract and result in a suboptimal study. The patient should be NPO for 8 to 12 hours before the test. A high-fat meal the previous evening, laxative use, or a gastrostomy tube will not affect the results of the study. .

A patient with suspected meningitis is scheduled for a lumbar puncture. Before the procedure, the nurse will plan to a. enforce NPO status for 4 hours. b. transfer the patient to radiology. c. administer a sedative medication. d. help the patient to a lateral position

D For a lumbar puncture, the patient lies in the lateral recumbent position. The procedure does not usually require a sedative, is done in the patient room, and has no risk for aspiration. .

The nurse is assessing a patient with emphysema. Which assessment finding requires further follow-up with the health care provider? a. Increased anterior-posterior diameter of the chest b. Accessory muscle used for breathing c. Clubbing of the fingers d. Hemoptysis .

D Hemoptysis is an abnormal occurrence of emphysema, and further diagnostic studies are needed to determine the cause of blood in the sputum. Clubbing of the fingers, barrel chest (increased anterior- posterior chest diameter), and accessory muscle use are all normal findings in a patient with emphysema .

A patient who has a history of chronic obstructive pulmonary disease (COPD) was hospitalized for increasing shortness of breath and chronic hypoxemia (SaO2 levels of 89% to 90%). In planning for discharge, which action by the nurse will be most effective in improving compliance with discharge teaching? a. Start giving the patient discharge teaching on the day of admission. b. Have the patient repeat the instructions immediately after teaching. c. Accomplish the patient teaching just before the scheduled discharge. d. Arrange for the patients caregiver to be present during the teaching.

D Hypoxemia interferes with the patients ability to learn and retain information, so having the patients caregiver present will increase the likelihood that discharge instructions will be followed. Having the patient repeat the instructions will indicate that the information is understood at the time, but it does not guarantee retention of the information. Because the patient is likely to be distracted just before discharge, giving discharge instructions just before discharge is not ideal. The patient is likely to be anxious and even more hypoxemic than usual on the day of admission, so teaching about discharge should be postponed.

The nurse receives the following information about a 51-year-old woman who is scheduled for a colonoscopy. Which information should be communicated to the health care provider before sending the patient for the procedure? a. The patient has a permanent pacemaker to prevent bradycardia. b. The patient is worried about discomfort during the examination. c. The patient has had an allergic reaction to shellfish and iodine in the past. d. The patient refused to drink the ordered polyethylene glycol (GoLYTELY)

D If the patient has had inadequate bowel preparation, the colon cannot be visualized and the procedure should be rescheduled. Because contrast solution is not used during colonoscopy, the iodine allergy is not pertinent. A pacemaker is a contraindication to magnetic resonance imaging (MRI), but not to colonoscopy. The nurse should instruct the patient about the sedation used during the examination to decrease the patients anxiety about discomfort.

A nurse is teaching a patient who has low health literacy about chronic obstructive pulmonary disease (COPD) while giving COPD medications. Which technique is most appropriate for the nurse to use? a. Use complex analogies to describe COPD. b. Ask for feedback to assess understanding of COPD at the end of the session. c. Offer pamphlets about COPD written at the eighth grade level with large type. d. Include the most important information on COPD at the beginning of the session.

D Include the most important information at the beginning of the session for patients with literacy or learning disabilities. Also, use visual cues and simple, not complex, analogies when appropriate. Another technique is to frequently ask patients for feedback to determine whether they comprehend the information. Additionally, provide teaching materials that reflect the reading level of the patient, with attention given to short words and sentences, large type, and simple format (generally, information written on a fifth grade reading level is recommended for adult learners).

A nurse's goal is to provide teaching for restoration of health. Which situation indicates the nurse is meeting this goal? a. Teaching a family member to provide passive range of motion for a stroke patient b. Teaching a woman who recently had a hysterectomy about possible adoption c. Teaching expectant parents about changes in childbearing women d. Teaching a teenager with a broken leg how to use crutches

D Injured or ill patients need information and skills to help them regain or maintain their levels of health. An example includes teaching a teenager with a broken leg how to use crutches. Not all patients fully recover from illness or injury. Many have to learn to cope with permanent health alterations. New knowledge and skills are often necessary for patients and/or family members to continue activities of daily living. Teaching family members to help the patient with health care management (e.g., giving medications through gastric tubes, doing passive range-of-motion exercises) is an example of coping with long-term impaired functions. For a woman with a hysterectomy, teaching about adoption is not restoration of health; restoration of health in this situation would involve activity restrictions and incision care if needed. In childbearing classes, you teach expectant parents about physical and psychological changes in the woman and about fetal development; this is part of health maintenance.

Which intervention will the nurse include in the plan of care for a patient who is diagnosed with a lung abscess? a. Teach the patient to avoid the use of over-the-counter expectorants. b. Assist the patient with chest physiotherapy and postural drainage. c. Notify the health care provider immediately about any bloody or foul-smelling sputum. d. Teach about the need for prolonged antibiotic therapy after discharge from the hospital. .

D Long-term antibiotic therapy is needed for effective eradication of the infecting organisms in lung abscess. Chest physiotherapy and postural drainage are not recommended for lung abscess because they may lead to spread of the infection. Foul smelling and bloody sputum are common clinical manifestations in lung abscess. Expectorants may be used because the patient is encouraged to cough.

The nurse completes discharge teaching for a patient who has had a lung transplant. The nurse evaluates that the teaching has been effective if the patient makes which statement? a. I will make an appointment to see the doctor every year. b. I will stop taking the prednisone if I experience a dry cough. c. I will not worry if I feel a little short of breath with exercise. d. I will call the health care provider right away if I develop a fever.

D Low-grade fever may indicate infection or acute rejection so the patient should notify the health care provider immediately if the temperature is elevated. Patients require frequent follow-up visits with the transplant team. Annual health care provider visits would not be sufficient. Home oxygen use is not an expectation after lung transplant. Shortness of breath should be reported. Low-grade fever, fatigue, dyspnea, dry cough, and oxygen desaturation are signs of rejection. Immunosuppressive therapy, including prednisone, needs to be continued to prevent rejection.

The nurse teaches a patient about discharge instructions after a rhinoplasty. Which statement, if made by the patient, indicates that the teaching was successful? a. I can take 800 mg ibuprofen for pain control. b. I will safely remove and reapply nasal packing daily. c. My nose will look normal after 24 hours when the swelling goes away. d. I will keep my head elevated for 48 hours to minimize swelling and pain.

D Maintaining the head in an elevated position will decrease the amount of nasal swelling. NSAIDs, such as ibuprofen, increase the risk for postoperative bleeding and should not be used postoperatively. The patient would not be taught to remove or reapply nasal packing, which is usually removed by the surgeon on the day after surgery. Although return to a preinjury appearance is the goal of the surgery, it is not always possible to achieve this result, especially in the first few weeks after surgery.

A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action? a. The bedrails at the head and foot of the bed are both elevated. b. The patient receives a regular diet from the dietary department. c. The lights in the patients room are turned off and the blinds are shut. d. Unlicensed assistive personnel enter the patients room without a mask. .

D Meningococcal meningitis is spread by respiratory secretions, so it is important to maintain respiratory isolation as well as standard precautions. Because the patient may be confused and weak, bedrails should be elevated at both the foot and head of the bed. Low light levels in the room decrease pain caused by photophobia. Nutrition is an important aspect of care in a patient with meningitis.

A 62-year-old male patient who requires daily use of a nonsteroidal antiinflammatory drug (NSAID) for the management of severe rheumatoid arthritis has recently developed melena. The nurse will anticipate teaching the patient about a. substitution of acetaminophen (Tylenol) for the NSAID. b. use of enteric-coated NSAIDs to reduce gastric irritation. c. reasons for using corticosteroids to treat the rheumatoid arthritis. d. misoprostol (Cytotec) to protect the gastrointestinal (GI) mucosa.

D Misoprostol, a prostaglandin analog, reduces acid secretion and the incidence of upper GI bleeding associated with NSAID use. Enteric coating of NSAIDs does not reduce the risk for GI bleeding. Corticosteroids increase the risk for ulcer development, and will not be substituted for NSAIDs for this patient. Acetaminophen will not be effective in treating the patients rheumatoid arthritis. .

A lobectomy is scheduled for a patient with stage I nonsmall cell lung cancer. The patient tells the nurse, I would rather have chemotherapy than surgery. Which response by the nurse is most appropriate? a. Are you afraid that the surgery will be very painful? b. Did you have bad experiences with previous surgeries? c. Surgery is the treatment of choice for stage I lung cancer. d. Tell me what you know about the various treatments available.

D More assessment of the patients concerns about surgery is indicated. An open-ended response will elicit the most information from the patient. The answer beginning, Surgery is the treatment of choice is accurate, but it discourages the patient from sharing concerns about surgery. The remaining two answers indicate that the nurse has jumped to conclusions about the patients reasons for not wanting surgery. Chemotherapy is the primary treatment for small cell lung cancer. In nonsmall cell lung cancer, chemotherapy may be used in the treatment of nonresectable tumors or as adjuvant therapy to surgery.

The nurse is caring for a patient who has a pulse rate of 48. His blood pressure is within normal limits. Which finding will help the nurse determine the cause of the patient's low heart rate? a. The patient has a fever. b. The patient has possible hemorrhage or bleeding. c. The patient has chronic obstructive pulmonary disease (COPD). d. The patient has calcium channel blockers or digitalis medication prescriptions.

D Negative chronotropic drugs such as digitalis, beta-adrenergic agents, and calcium channel blockers can slow down pulse rate. Fever, bleeding, hemorrhage, and COPD all increase the body's need for oxygen, leading to an increased heart rate .

A patient is admitted with active tuberculosis (TB). The nurse should question a health care providers order to discontinue airborne precautions unless which assessment finding is documented? A. Chest x-ray shows no upper lobe infiltrates. B. TB medications have been taken for 6 months. C. Mantoux testing shows an induration of 10 mm. D. Three sputum smears for acid-fast bacilli are negative

D Negative sputum smears indicate that Mycobacterium tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route. Chest x-rays are not used to determine whether treatment has been successful. Taking medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Repeat Mantoux testing would not be done because the result will not change even with effective treatment.

Which learning objective/outcome has the highest priority for a patient with life-threatening, severe food allergies that require an EpiPen (epinephrine)? a. The patient will identify the main ingredients in several foods. b. The patient will list the side effects of epinephrine. c. The patient will learn about food labels. d. The patient will administer epinephrine.

D Once you assist in meeting patient needs related to basic survival (how to give epinephrine), you can discuss other topics, such as nutritional needs & side effects of medications. For example, a patient recently diagnosed with coronary artery disease has deficient knowledge related to the illness & its implications. The patient benefits most by first learning about the correct way to take nitroglycerin & how long to wait before calling for help when chest pain occurs. Thus, in this situation, the patient benefits most by first learning about the correct way to take epinephrine. "The patient will learn about food labels" is not objective & measurable & is not correctly written.

The nurse is caring for a patient who has acute pharyngitis caused by Candida albicans. Which action is appropriate for the nurse to include in the plan of care? a. Avoid giving patient warm liquids to drink. b. Assess patient for allergies to penicillin antibiotics. c. Teach the patient about the need to sleep in a warm, dry environment. d. Teach patient to swish and swallow prescribed oral nystatin (Mycostatin).

D Oral or pharyngeal fungal infections are treated with nystatin solution. The goal of the swish and swallow technique is to expose all of the oral mucosa to the anti-fungal agent. Warm liquids may be soothing to a sore throat. The patient should be taught to use a cool mist humidifier. There is no need to assess for penicillin/cephalosporin allergies because Candida albicans infection is treated with antifungals.

The nurse is caring for a patient who was admitted the previous day with a basilar skull fracture after a motor vehicle crash. Which assessment finding is most important to report to the health care provider? a. Complaint of severe headache b. Large contusion behind left ear c. Bilateral periorbital ecchymosis d. Temperature of 101.4 F (38.6 C)

D Patients who have basilar skull fractures are at risk for meningitis, so the elevated temperature should be reported to the health care provider. The other findings are typical of a patient with a basilar skull fracture. .

The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is most important for the nurse to ask before the skin test? a. Is there any family history of TB? b. How long have you lived in the United States? c. Do you take any over-the-counter (OTC) medications? d. Have you received the bacille Calmette-Gurin (BCG) vaccine for TB?

D Patients who have received the BCG vaccine will have a positive Mantoux test. Another method for screening (such as a chest x-ray) will need to be used in determining whether the patient has a TB infection. The other information also may be valuable but is not as pertinent to the decision about doing TB skin testing. .

The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed? a. UAP splint the patients chest during coughing. b. UAP assist the patient to ambulate to the bathroom. c. UAP help the patient to a bedside chair for meals. d. UAP lower the head of the patients bed to 15 degrees.

D Positioning the patient with the head of the bed lowered will decrease ventilation. The other actions are appropriate for a patient with pneumonia. .

A patient who is morbidly obese states, I've recently made some changes in my life. I've decreased my fat intake and I've stopped smoking. Which statement, if made by the nurse, is the best initial response? a. Although those are important, it is essential that you make other changes, too. b. Are you having any difficulty in maintaining the changes you have already made? c. Which additional changes in your lifestyle would you like to implement at this time? d. You have already accomplished changes that are important for the health of your heart.

D Positive reinforcement of the learners achievements is critical in making lifestyle changes. This patient is in the action stage of the Transtheoretical Model, when reinforcement of the changes being made is an important nursing intervention. The other responses are also appropriate, but are not the best initial response. .

A patient has inadequate stroke volume related to decreased preload. Which treatment does the nurse prepare to administer? a. Diuretics b. Vasodilators c. Chest physiotherapy d. Intravenous (IV) fluids

D Preload is affected by the circulating volume; if the patient has decreased fluid volume, it will need to be replaced with fluid or blood therapy. Preload is the amount of blood in the left ventricle at the end of diastole, often referred to as end-diastolic volume. Giving diuretics and vasodilators will make the situation worse. Diuretics causes fluid loss; the patient is already low on fluids or the preload would not be decreased. Vasodilators reduced blood return to the heart, making the situation worse; the patient does not have enough blood and fluid to the heart or the preload would not be decreased. Chest physiotherapy is a group of therapies for mobilizing pulmonary secretions. Chest physiotherapy will not help this cardiovascular problem

The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective? a. I am going to buy a rib binder to wear during the day. b. I can take shallow breaths to prevent my chest from hurting. c. I should plan on taking the pain pills only at bedtime so I can sleep. d. I will use the incentive spirometer every hour or two during the day.

D Prevention of the complications of atelectasis and pneumonia is a priority after rib fracture. This can be ensured by deep breathing and coughing. Use of a rib binder, shallow breathing, and taking pain medications only at night are likely to result in atelectasis. .

A nurse is using professional standards to influence clinical decisions. What is the rationale for the nurse's actions? a. Establishes minimal passing standards for testing b. Utilizes evidence-based practice based on nurses' needs c. Bypasses the patient's feelings to promote ethical standards d. Uses critical thinking for the highest level of quality nursing care .

D Professional standards promote the highest level of quality nursing care. Application of professional standards requires you to use critical thinking for the good of individuals or groups. Bypassing the patient's feelings is not practicing according to professional standards. The primary purpose of professional standards is not to establish minimal passing standards for testing. Patient care should be based on patient needs, not on nurses' needs.

Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness (LOC). Which nursing diagnosis do they determine has the highest priority for the patient? a. Impaired physical mobility related to weakness b. Disturbed sensory perception related to brain injury c. Risk for impaired skin integrity related to immobility d. Risk for aspiration related to inability to protect airway

D Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses are also appropriate, but interventions to prevent aspiration are the priority at this time. .

A postoperative patient and caregiver need discharge teaching. Which actions included in the teaching plan can the nurse delegate to unlicensed assistive personnel (UAP)? a. Evaluate whether the patient and caregiver understand the teaching. b. Show the caregiver how to accurately check the patients temperature. c. Schedule the discharge teaching session with the patient and caregiver. d. Give the patient a pamphlet reinforcing teaching already done by the nurse.

D Providing a pamphlet to a patient to reinforce previously taught material does not require nursing judgment and can safely be delegated to UAP. Demonstration of how to take a temperature accurately, determining the best time for teaching, and evaluation of the success of patient teaching all require judgment and critical thinking and should be done by the registered nurse.

After having a craniectomy and left anterior fossae incision, a 64-year-old patient has a nursing diagnosis of impaired physical mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is to a. cluster nursing activities to allow longer rest periods. b. turn and reposition the patient side to side every 2 hours. c. position the bed flat and log roll to reposition the patient. d. perform range-of-motion (ROM) exercises every 4 hours.

D ROM exercises will help prevent the complications of immobility. Patients with anterior craniotomies are positioned with the head elevated. The patient with a craniectomy should not be turned to the operative side. When the patient is weak, clustering nursing activities may lead to more fatigue and weakness. .

A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first? a. Complete blood count (CBC) b. Chest radiograph (Chest x-ray) c. 12-Lead electrocardiogram (ECG) d. Noncontrast computed tomography (CT) scan .

D Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the less brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.

A 73-year-old patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find? a. Impulsive behavior b. Right-sided neglect c. Hyperactive left-sided tendon reflexes d. Difficulty comprehending instructions

D Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and use of language. The left-side reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a right-side stroke. .

The nurse will anticipate teaching a patient with a possible seizure disorder about which test? a. Cerebral angiography b. Evoked potential studies c. Electromyography (EMG) d. Electroencephalography (EEG) .

D Seizure disorders are usually assessed using EEG testing. Evoked potential is used for diagnosing problems with the visual or auditory systems. Cerebral angiography is used to diagnose vascular problems. EMG is used to evaluate electrical innervation to skeletal muscle. .

When assessing a 53-year-old patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider? a. The patient exhibits nuchal rigidity. b. The patient has a positive Kernigs sign. c. The patients temperature is 101 F (38.3 C). d. The patients blood pressure is 88/42 mm Hg

D Shock is a serious complication of meningitis, and the patients low blood pressure indicates the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernigs sign are expected with bacterial meningitis. The nurse should intervene to lower the temperature, but this is not as life threatening as the hypotension. .

A nurse is preparing to suction a patient. The pulse is 65 and pulse oximetry is 94%. Which finding will cause the nurse to stop suctioning? a. Pulse 75 b. Pulse 80 c. Oxygen saturation 91% d. Oxygen saturation 88%

D Stop when oxygen saturation is 88%. Monitor patient's vital signs and oxygen saturation during procedure; note whether there is a change of 20 beats/min (either increase or decrease) or if pulse oximetry falls below 90% or 5% from baseline. If this occurs, stop suctioning. A pulse rate of 75 is only 10 beats different from the start of the procedure. A pulse rate of 80 is 15 beats different from the start of suctioning. Oxygen saturation of 91% is not 5% from baseline or below 90%

The health care provider prescribes antacids and sucralfate (Carafate) for treatment of a patients peptic ulcer. The nurse will teach the patient to take a. sucralfate at bedtime and antacids before each meal. b. sucralfate and antacids together 30 minutes before meals. c. antacids 30 minutes before each dose of sucralfate is taken. d. antacids after meals and sucralfate 30 minutes before meals

D Sucralfate is most effective when the pH is low and should not be given with or soon after antacids. Antacids are most effective when taken after eating. Administration of sucralfate 30 minutes before eating and antacids just after eating will ensure that both drugs can be most effective. The other regimens will decrease the effectiveness of the medications. .

A nurse is teaching a patient's family member about permanent tube feedings at home. Which purpose of patient education is the nurse meeting? a. Health promotion b. Illness prevention c. Restoration of health d. Coping with impaired functions

D Teach family members to help the patient with health care management (e.g., giving medications through gastric tubes and doing passive range-of-motion exercises) when coping with impaired functions. Not all patients fully recover from illness or injury. Many have to learn to cope with permanent health alterations. Health promotion involves healthy people staying healthy, while illness prevention is prevention of diseases. Restoration of health occurs if the teaching is about a temporary tube feeding, not a permanent tube feeding.

A charge nurse is supervising the care of a new nurse. Which action by a new nurse indicates the charge nurse needs to intervene? a. Making an ethical clinical decision b. Making an informed clinical decision c. Making a clinical decision in the patient's best interest d. Making a clinical decision based on previous shift assessments

D The charge nurse must intervene when the nurse is using previous shift assessments to make a decision; this is inappropriate. Nurses are responsible for assessing their own patients to make decisions. Making informed, ethical decisions in the patient's best interest is practicing responsibly and does not need follow-up from the charge nurse. .

The nurse is preparing to assess the blood pressure of a 3-year-old. How should the nurse proceed? a. Use the diaphragm portion of the stethoscope to detect Korotkoff sounds. b. Obtain the reading before the child has a chance to "settle down." c. Choose the cuff that says "Child" instead of "Infant." d. Explain the procedure to the child .

D The child's cooperation is increased when you or the parent have prepared the child for the unusual sensation of the BP cuff. Most children understand the analogy of a "tight hug on your arm." Different arm sizes require careful and appropriate cuff size selection. Do not choose a cuff based on the name of the cuff. An "Infant" cuff is too small for some infants. Readings are difficult to obtain in restless or anxious infants and children. Allow at least 15 minutes for children to recover from recent activities and become less apprehensive. Korotkoff sounds are difficult to hear in children because of low frequency and amplitude. A pediatric stethoscope bell is often helpful.

After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first? a. A 20-year-old patient whose cranial x-ray shows a linear skull fracture b. A 30-year-old patient who has an initial Glasgow Coma Scale score of 13 c. A 40-year-old patient who lost consciousness for a few seconds after a fall d. A 50-year-old patient whose right pupil is 10 mm and unresponsive to light

D The dilated and non-responsive pupil may indicate an intracerebral hemorrhage and increased intracranial pressure. The other patients are not at immediate risk for complications such as herniation. .

A nurse is using a critical thinking model to provide care. Which component is first that helps a nurse make clinical decisions? a. Attitude b. Experience c. Nursing process d. Specific knowledge base

D The first component of the critical thinking model is a nurse's specific knowledge base. After acquiring a sound knowledge base, the nurse can then apply knowledge to different clinical situations using the nursing process to gain valuable experience. Clinical learning experiences are necessary to acquire clinical decision-making skills. The nursing process competency is the third component of the critical thinking model. Eleven attitudes define the central features of a critical thinker and how a successful critical thinker approaches a problem.

The nurse admits a patient who has a diagnosis of an acute asthma attack. Which statement indicates that the patient may need teaching regarding medication use? a. I have not had any acute asthma attacks during the last year. b. I became short of breath an hour before coming to the hospital. c. Ive been taking Tylenol 650 mg every 6 hours for chest-wall pain. d. Ive been using my albuterol inhaler more frequently over the last 4 days

D The increased need for a rapid-acting bronchodilator should alert the patient that an acute attack may be imminent and that a change in therapy may be needed. The patient should be taught to contact a health care provider if this occurs. The other data do not indicate any need for additional teaching.

While admitting a patient to the medical unit, the nurse determines that the patient is hard of hearing. How should the nurse use this information to plan teaching and learning strategies? a. Motivation and readiness to learn will be affected. b. The family must be included in the teaching process. c. The patient will have problems understanding information. d. Written materials should be provided with verbal instructions.

D The information that the patient is hard of hearing indicates that the nurse should use written and verbal materials in teaching along with other strategies. The patient does not indicate a lack of motivation or an inability to understand new information. The patients decreased hearing does not necessarily imply that the family must be included in the teaching process.

A nurse is caring for a patient who has had a total laryngectomy and radical neck dissection. During the first 24 hours after surgery what is the priority nursing action? a. Monitor for bleeding. b. Maintain adequate IV fluid intake. c. Suction tracheostomy every eight hours. d. Keep the patient in semi-Fowlers position.

D The most important goals after a laryngectomy and radical neck dissection are to maintain the airway and ensure adequate oxygenation. Keeping the patient in a semi-Fowlers position will decrease edema and limit tension on the suture lines to help ensure an open airway. Maintenance of IV fluids and monitoring for bleeding are important, but maintaining an open airway is the priority. Tracheostomy care and suctioning should be provided as needed. During the immediate postoperative period, the patient with a laryngectomy requires frequent suctioning of the tracheostomy tube.

The nurse plans to teach a patient how to manage allergic rhinitis. Which information should the nurse include in the teaching plan? a. Hand washing is the primary way to prevent spreading the condition to others. b. Use of oral antihistamines for 2 weeks before the allergy season may prevent reactions. c. Corticosteroid nasal sprays will reduce inflammation, but systemic effects limit their use. d. Identification and avoidance of environmental triggers are the best way to avoid symptoms.

D The most important intervention is to assist the patient in identifying and avoiding potential allergens. Intranasal corticosteroids (not oral antihistamines) should be started several weeks before the allergy season. Corticosteroid nasal sprays have minimal systemic absorption. Acute viral rhinitis (the common cold) can be prevented by washing hands.

Which assessment should the nurse perform first for a patient who just vomited bright red blood? a. Measuring the quantity of emesis b. Palpating the abdomen for distention c. Auscultating the chest for breath sounds d. Taking the blood pressure (BP) and pulse .

D The nurse is concerned about blood loss and possible hypovolemic shock in a patient with acute gastrointestinal (GI) bleeding. BP and pulse are the best indicators of these complications. The other information is important to obtain, but BP and pulse rate are the best indicators for assessing intravascular volume. .

The nursing assistive personnel (NAP) is taking vital signs and reports that a patient's blood pressure is abnormally low. What should the nurse do next? a. Ask the NAP retake the blood pressure. b. Instruct the NAP to assess the patient's other vital signs. c. Disregard the report and have it rechecked at the next scheduled time. d. Retake the blood pressure personally and assess the patient's condition

D The nursing assistive personnel should report abnormalities to the nurse, who should further assess the patient. The nursing assistive personnel should not retake the blood pressure or other vital signs because the nurse needs to assess the patient. The report cannot be disregarded. Assessment must be done by the nurse .

Which action by a nurse indicates application of the critical thinking model to make the best clinical decisions? a. Drawing on past clinical experiences to formulate standardized care plans b. Relying on recall of information from past lectures and textbooks c. Depending on the charge nurse to determine priorities of care d. Using the nursing process .

D The nursing process competency is the third component of the critical thinking model. In your practice, you will apply critical thinking components during each step of the nursing process. Care plans should be individualized, and recalling facts does not utilize critical thinking skills to make clinical decisions. The new nurse should not rely on the charge nurse to determine priorities of care.

A 73-year-old patient is diagnosed with stomach cancer after an unintended 20-pound weight loss. Which nursing action will be included in the plan of care? a. Refer the patient for hospice services. b. Infuse IV fluids through a central line. c. Teach the patient about antiemetic therapy. d. Offer supplemental feedings between meals.

D The patient data indicate a poor nutritional state and improvement in nutrition will be helpful in improving the response to therapies such as surgery, chemotherapy, or radiation. Nausea and vomiting are not common clinical manifestations of stomach cancer. There is no indication that the patient requires hospice or IV fluid infusions .

A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/minute, blood pressure of 100/60 mmHg, and respirations of 42 breaths/minute. Which action should the nurse take first? a. Administer anticoagulant drug therapy. b. Notify the patients health care provider. c. Prepare patient for a spiral computed tomography (CT). d. Elevate the head of the bed to a semi-Fowlers position.

D The patient has symptoms consistent with a pulmonary embolism (PE). Elevating the head of the bed will improve ventilation and gas exchange. The other actions can be accomplished after the head is elevated (and oxygen is started). A spiral CT may be ordered by the health care provider to identify PE. Anticoagulants may be ordered after confirmation of the diagnosis of PE.

An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action is best for the nurse to take next? a. Milk the chest tube gently to remove any clots. b. Clamp the chest tube momentarily to check for the origin of the air leak. c. Assist the patient to deep breathe, cough, and use the incentive spirometer. d. Set up the patient controlled analgesia (PCA) and administer the loading dose of morphine.

D The patient is unlikely to take deep breaths or cough until the pain level is lower. A chest tube output of 100 mL is not unusual in the first hour after thoracotomy and would not require milking of the chest tube. An air leak is expected in the initial postoperative period after thoracotomy. .

When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient? a. Emergency pericardiocentesis b. Stabilization of the chest wall with tape c. Administration of an inhaled bronchodilator d. Insertion of a chest tube with a chest drainage system

D The patients history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patients clinical manifestations are not consistent with these problems.

A 56-year-old patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for a. surgical endarterectomy. b. transluminal angioplasty. c. intravenous heparin administration. d. tissue plasminogen activator (tPA) infusion.

D The patients history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is having an acute ischemic stroke.

After change-of-shift report, which patient should the nurse assess first? a. 72-year-old with cor pulmonale who has 4+ bilateral edema in his legs and feet b. 28-year-old with a history of a lung transplant and a temperature of 101 F (38.3 C) c. 40-year-old with a pleural effusion who is complaining of severe stabbing chest pain d. 64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion .

D The patients history and symptoms suggest possible tension pneumothorax, a medical emergency. The other patients also require assessment as soon as possible, but tension pneumothorax will require immediate treatment to avoid death from inadequate cardiac output or hypoxemia. .

The nurse performing a focused assessment of left posterior temporal lobe functions will assess the patient for a. sensation on the left side of the body. b. voluntary movements on the right side. c. reasoning and problem-solving abilities. d. understanding written and oral language. .

D The posterior temporal lobe integrates the visual and auditory input for language comprehension. Reasoning and problem solving are functions of the anterior frontal lobe. Sensation on the left side of the body is located in the right postcentral gyrus. Voluntary movement on the right side is controlled in the left precentral gyrus. .

The nurse is concerned about a postoperative patients risk for injury during an episode of delirium. The most appropriate action by the nurse is to a. secure the patient in bed using a soft chest restraint. b. ask the health care provider to order an antipsychotic drug. c. instruct family members to remain with the patient and prevent injury. d. assign unlicensed assistive personnel (UAP) to stay with the patient and offer reorientation.

D The priority goal is to protect the patient from harm. Having a UAP stay with the patient will ensure the patients safety. Visits by family members are helpful in reorienting the patient, but families should not be responsible for protecting patients from injury. Antipsychotic medications may be ordered, but only if other measures are not effective because these medications have many side effects. Restraints are not recommended because they can increase the patients agitation and disorientation.

A nurse is preparing to start peripheral intravenous (IV) therapy. In which order will the nurse perform the steps starting with the first one? 1. Clean site. 2. Select vein. 3. Apply tourniquet. 4. Release tourniquet. 5. Reapply tourniquet. 6. Advance and secure. 7. Insert vascular access device. a. 1, 3, 2, 7, 5, 4, 6 b. 1, 3, 2, 5, 7, 6, 4 c. 3, 2, 1, 5, 7, 6, 4 d. 3, 2, 4, 1, 5, 7, 6

D The steps for inserting an intravenous catheter are as follows: - Apply tourniquet; - select vein; - release tourniquet; - clean site; - reapply tourniquet; - insert vascular access device; - and advance and secure.

A nurse is teaching a patient with a risk for hypertension how to take a blood pressure. Which action by the nurse is the priority? a. Assess laboratory results for high cholesterol and other data. b. Identify that teaching is the same as the nursing process. c. Perform nursing care therapies to address hypertension. d. Focus on a patient's learning needs and objectives.

D The teaching process focuses on the patient's learning needs, motivation, and ability to learn; writing learning objectives and goals is also included. Nursing and teaching processes are not the same. Assessing laboratory results for high cholesterol and performing nursing care therapies are all components of the nursing process, not the teaching process.

Using the illustrated technique, the nurse is assessing for which finding in a patient with chronic obstructive pulmonary disease (COPD)? a. Hyperresonance b. Tripod positioning c. Accessory muscle use d. Reduced chest expansion

D The technique for palpation for chest expansion is shown in the illustrated technique. Reduced chest movement would be noted on palpation of a patients chest with COPD. Hyperresonance would be assessed through percussion. Accessory muscle use and tripod positioning would be assessed by inspection.

The patient requires routine temperature assessment but is confused, easily agitated, and has a history of seizures. Which route will the nurse use to obtain the patient's temperature? a. Oral b. Rectal c. Axillary d. Tympanic .

D The tympanic route is easily accessible, requires minimal patient repositioning, and often can be used without disturbing the patient. It also has a very rapid measurement time. Oral temperatures require patient cooperation and are not recommended for patients with a history of seizures. Rectal temperatures require positioning and may increase patient agitation. Axillary temperatures need long measurement times and continuous positioning. The patient's agitation state may not allow for long periods of attention

The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient? a. Supine with the head of the bed elevated 30 degrees b. In a high-Fowlers position with the left arm extended c. On the right side with the left arm extended above the head d. Sitting upright with the arms supported on an over bed table

D The upright position with the arms supported increases lung expansion, allows fluid to collect at the lung bases, and expands the intercostal space so that access to the pleural space is easier. The other positions would increase the work of breathing for the patient and make it more difficult for the health care provider performing the thoracentesis. .

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a. The patients speech is difficult to understand. b. The patients blood pressure is 144/90 mm Hg. c. The patient takes a diuretic because of a history of hypertension. d. The patient has atrial fibrillation and takes warfarin (Coumadin).

D The use of warfarin probably contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patients care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated.

The laboratory has just called with the arterial blood gas (ABG) results on four patients. Which result is most important for the nurse to report immediately to the health care provider? a. pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97% b. pH 7.35, PaO2 85 mm Hg, PaCO2 45 mm Hg, and O2 sat 95% c. pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98% d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%

D These ABGs indicate uncompensated respiratory acidosis and should be reported to the health care provider. The other values are normal or close to normal.

After change-of-shift report, which patient should the nurse assess first? a. 42-year-old who has acute gastritis and ongoing epigastric pain b. 70-year-old with a hiatal hernia who experiences frequent heartburn c. 53-year-old who has dumping syndrome after a recent partial gastrectomy d. 60-year-old with nausea and vomiting who has dry oral mucosa and lethargy .

D This older patient is at high risk for problems such as aspiration, dehydration, and fluid and electrolyte disturbances. The other patients will also need to be assessed, but the information about them indicates symptoms that are typical for their diagnoses and are not life threatening. .

Which assessment finding will the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL? a. Weak quadriceps muscles b. Decreased deep tendon reflexes c. Light-headedness when standing up d. Tingling of extremities with possible tetany

D This patient has hypocalcemia because the normal calcium range is 8.4 to 10.5 mg/dL. Hypocalcemia causes muscle tetany, positive Chvostek's sign, and tingling of the extremities. Sodium and potassium values are within their normal ranges: sodium 135 to 145 mEq/L; potassium 3.5 to 5.0 mEq/L. Light-headedness when standing up is a manifestation of ECV deficit or sometimes hypokalemia. Weak quadriceps muscles are associated with potassium imbalances. Decreased deep tendon reflexes are related to hypercalcemia or hypermagnesemia

A 72-year-old female patient is brought to the clinic by the patients spouse, who reports that she is unable to solve common problems around the house. To obtain information about the patients current mental status, which question should the nurse ask the patient? a. Are you sad? b. How is your self-image? c. Where were you were born? d. What did you eat for breakfast?

D This question tests the patients short-term memory, which is decreased in the mild stage of Alzheimers disease or dementia. Asking the patient about her birthplace tests for remote memory, which is intact in the early stages. Questions about the patients emotions and self-image are helpful in assessing emotional status, but they are not as helpful in assessing mental state.

The nurse palpates the posterior chest while the patient says 99 and notes absent fremitus. Which action should the nurse take next? a. Palpate the anterior chest and observe for barrel chest. b. Encourage the patient to turn, cough, and deep breathe. c. Review the chest x-ray report for evidence of pneumonia. d. Auscultate anterior and posterior breath sounds bilaterally.

D To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration when the patient repeats a word or phrase such as 99. After noting absent fremitus, the nurse should then auscultate the lungs to assess for the presence or absence of breath sounds. Absent fremitus may be noted with pneumothorax or atelectasis. The vibration is increased in conditions such as pneumonia, lung tumors, thick bronchial secretions, and pleural effusion. Turning, coughing, and deep breathing is an appropriate intervention for atelectasis, but the nurse needs to first assess breath sounds. Fremitus is decreased if the hand is farther from the lung or the lung is hyperinflated (barrel chest).The anterior of the chest is more difficult to palpate for fremitus because of the presence of large muscles and breast tissue.

A 50-year-old man vomiting blood-streaked fluid is admitted to the hospital with acute gastritis. To determine possible risk factors for gastritis, the nurse will ask the patient about a. the amount of saturated fat in the diet. b. any family history of gastric or colon cancer. c. a history of a large recent weight gain or loss. d. use of nonsteroidal antiinflammatory drugs (NSAIDs).

D Use of an NSAID is associated with damage to the gastric mucosa, which can result in acute gastritis. Family history, recent weight gain or loss, and fatty foods are not risk factors for acute gastritis. .

The priority nursing assessment for a 72-year-old patient being admitted with a brainstem infarction is a. reflex reaction time. b. pupil reaction to light. c. level of consciousness. d. respiratory rate and rhythm .

D Vital centers that control respiration are located in the medulla, and these are the priority assessments because changes in respiratory function may be life threatening. The other information will also be collected by the nurse, but it is not as urgent. .

A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, Will I be able to talk normally after surgery? What is the best response by the nurse? a. You will breathe through a permanent opening in your neck, but you will not be able to communicate orally. b. You wont be able to talk right after surgery, but you will be able to speak again after the tracheostomy tube is removed. c. You wont be able to speak as you used to, but there are artificial voice devices that will give you the ability to speak normally. d. You will have a permanent opening into your neck, and you will need to have rehabilitation for some type of voice restoration.

D Voice rehabilitation is planned after a total laryngectomy, and a variety of assistive devices are available to restore communication. Although the ability to communicate orally is changed, it would not be appropriate to tell a patient that this ability would be lost. Artificial voice devices do not permit normal-sounding speech. In a total laryngectomy, the vocal cords are removed, so normal speech is impossible.

In which order will the nurse take the following actions when caring for a patient who develops watery diarrhea and a fever after prolonged omeprazole (Prilosec) therapy? a. Contact the health care provider. b. Assess blood pressure and heart rate. c. Give the PRN acetaminophen (Tylenol). d. Place the patient on contact precautions.

D, B, A, C Proton pump inhibitors including omeprazole (Prilosec) may increase the risk of C. diff (Clostridium difficile) associated colitis. Because the patients history and symptoms are consistent with C. difficile infection, the initial action should be: - initiation of infection control measures to protect other patients. - Assessment of blood pressure and pulse is needed to determine whether the patient has symptoms of hypovolemia and/or shock. - The health care provider should then be notified so that actions such as obtaining stool specimens and antibiotic therapy can be started. - Tylenol may then be administered, but is the lowest priority of the actions

Shock/Hypotension a. Patient's temperature is 113° F (45° C) with hot, dry skin. b. Patient's blood pressure sitting is 130/60 and 110/40 standing. c. Patient's pulse is 110 beats/min. d. Patient's temperature is 93.2° F (34° C). e. Patient's blood pressure went from 126/76 to 90/50.

E