KP

A patient requires an emergency tracheostomy. When caring for the tracheostomy, the nurse should take which of the following actions? 1. Suction every hour 2. Clean the inner cannula after suctioning. 3. Clean site every four hours 4. Hyperextend the patient's neck to maintain patency.

Answer. Clean site every four hours. Cleaning the site very four hours will help prevent infection

The nurse supervises the nursing student caring for the client who had a femoropopliteal bypass graft in the right leg 12 hours ago. The nurse should intervene if the nursing student performs which interventions? 1. The nursing student places the client in a chair for 30 mins. 2. The nursing student checks the pulses in the right leg hourly. 3. The nursing student accurately records intake and output. 4. The nursing student obtains a Doppler evaluation of the client's right leg every two hours. 5. The nursing student instructs the client to cough and deep breathe every hour. 6. The nursing student elevates the client's left leg.

Answer: 1. The nursing student places the client in a chair 30 minutes. 4. The nursing student obtains a Doppler evaluation of the client's right leg every two hours. Bending the hip and knee are contraindicated due to possible thrombus formation. Assess hourly

The nurse instructs a patient about how to prevent a urinary tract information. Which of the following statements, if made by the patients to the nurse, requires further investigation? 1. "I can go all day without emptying my bladder." 2. "I drink 2 L of fluid every day." 3 "I do not use bubble bath." 4. "I drink cranberry juice each day."

Answer: "I can go all day without emptying my bladder." Should empty the bladder every 4 hours even if there is no urge.

The nurse performs discharge teaching for a patient receiving an antihypertensive medication. The nurse determines that further teaching is necessary when the patient makes which of the following statements? 1. "I should take the medication at the same time every day." 2. "I can stop taking the medication when my blood pressure goes down." 3. "The physician will check my blood pressure and may need to change the medication." 4. "When I first start taking the medication, I may feel some drowsiness."

Answer: "I can stop taking the medication when my blood pressure goes down." Usually required to take medication for the rest of their lives; reinforce that patients are not to stop medication even though they have no symptoms and to report any side effects to the physician

The nurse instructs the client diagnosed with chronic kidney disease about the appropriate diet. The nurse determines teaching is effective if the client makes which statement? 1. "I find lemon ice very refreshing." 2. "My spouse fixes the best pork chops." 3. "I have a cheese sandwich every day for lunch." 4. "I eat yogurt for breakfast almost every day."

Answer: "I find lemon ice very refreshing." Chronic kidney disease is slow, progressive loss of kidney function; protein, potassium, sodium, and phosphorus are restricted; important to increase non protein calories; fruit ice is good source of protein-free calories.

The home care nurse visits a patient with a new permanent pacemaker implanted in the area below the left clavicle. It is MOST important for the nurse to respond to which of the following? 1. "It will be good to be back under my electric blanket again when I sleep." 2. "I try to move my left arm around several times a day." 3. "My spouse signed up for a CPR class." 4. "I know my wound is healing because I see drainage from the incision site."

Answer: "I know my wound is healing because I see drainage from the incision site." Drainage form the incision site is indicative of infection, and physician must be notified; other incision site indicators of infection include swelling, warmth, redness, as well as overall fever.

The nurse instructs a patient about hypertension. Which of the following statements, if made by the patient to the nurse, indicates teaching is successful? 1. "I will be able to tell when my blood pressure is elevated." 2. "Hypertension is caused by eating too much salt." 3. "I can discontinue the medication when my blood pressure goes down." 4. "I know that I must see my physician on a regular basis."

Answer: "I know that I must see my physician on a regular basis." Hypertension is a serious condition that must be constantly monitored.

One week after discharge from the hospital, a client with heart failure comes to the cardiac clinic for a follow-up visit. Which of these statements, if made by the client to the nurse, indicates an improvement in the client's condition? 1. "My clothes seem to be too tight." 2. "I only sleep on one pillow." 3. "I'm really worried about going back to work." 4. "I seem to empty my bladder less often than I used to."

Answer: "I only sleep on one pillow." A symptom of HF is orthopnea, or the inability to breathe while lying flat; the client's statement that he uses only one pillow to sleep indicates an improvement in his respiratory function.

The nurse instructs a patient diagnosed with urolithiasis how to prevent calcium stone. Which of the following statements, if made by the patient to the nurse, indicates teaches is successful? 1. "I will drink at least 3,000 ml of fluid each day." 2. "I will eat 2 servings of meat or cheese per day." 3. "I will drink at least two glasses of cranberry juice daily." 4. "I will eat a large amount of citrus fruits each day"

Answer: "I will drink at least 3,000 ml of fluid each day" Should drink fluids in sufficient quantity to produce a dilute urine.

The nurse in the adult day care facility counsels a patient who states that she is having difficulty with stress incontinence. The patient is a 78-year-old female, 5 ft 2 in tall, weighs 180 pounds, and had 4 lives births. Which of the following statements by the nurse is MOST appropriate? 1. "There are some very good adult diapers available." 2. "Let's talk about ways to reduce your weight." 3."You should drink less water" 4. "Incontinence is to be expected at your age."

Answer: "Let's talk about ways to reduce your weight." Increased abdominal pressure caused by obesity contributes to stress incontinence; instruct patient how to perform pelvic muscle exercises

The office nurse prepares a client for a resting electrocardiogram (EKG). Which of the following statements by the client indicates teaching is successful? 1. "I will be asleep during the first part of the test" 2. "I will be asked to look at flickering lights at one point in the test." 3. "The more still I can lie, the better the results will be." 4. "The shocks I will feel are very small and will feel like a tingle."

Answer: "The more still I can lie, the better the results will be." Electrocardiogram (EKG) assesses overall and detailed cardiac function; resting EKG (vs. ambulatory or Holter monitoring or exercise EKG or stress test) requires client to lie as still as possible during the test to ensure the heart is being monitored in its resting or baseline state.

The nurse instructs a client in the outpatient clinic about a stress test. Which of the following statements by the nurse is BEST? 1. "The stress test will assess your overall physical fitness." 2. "The stress test will determine the amount of stress that your heart can tolerate." 3."The stress test will determine the adequacy of your peripheral circulation." 4. "The stress test will enable the physician to evaluate your cardiac output."

Answer: "The stress test will determine the amount of stress that your heart can tolerate." During the treadmill test, the client runs on a motorized treadmill while heart rate and blood pressure are monitored; physician can determine if cardiac ischemia is occurring, and get an estimate of the workload or stress this person's heart can tolerate.

The physician prescribes phenazopyridine hydrochloride (Pytridium) and trimethoprim/ sulfamethoxazole (Septra) for a patient. It is MOST important for the nurse to make which of the following statements to the patient? 1. "You may experience dizziness and lethargy." 2. "Your urine will become bright orange in color." 3. "You will notice that your urine will be more dilute." 4. "You may experience some pain when urinating."

Answer: "Your urine will become bright orange in color." Pyridium discolors urine red or orange and may stain fabrics; red or orange urine could be upsetting to patient who is not prepared to see it.

Which of the following urine outputs BEST indicates to the nurse that a patient's kidneys are functioning normally? 1. 555 ml in 2 hr 2. 30 ml in one hr 3. 1,500 ml in 24 hr 4. 800 ml in 24 hr

Answer: 1,500 ml in 24 hr Normal urinary output

The nurse cares for a patient after a transuretheral resection of the prostate (TURP). The phyician has ordered a continuous bladder irrigation, with the irrigation solution infusing at 30ml/hour. At the end of the 24 hours, the patient's total output is 2,500 ml. The nurse calculates that the patient's actual urine output is which of the following? 1. 1,870 ml. 2. 1,850 ml. 3. 1,780 ml. 4. 1,720 ml.

Answer: 1,780 ml Since 30 ml/hr of solution was introduced over the 24-hr periods, a total of 720 ml was introduced from this exogenous source; the patient voided 1,780 ml of urine.

The order to administer 1,000 D5W, 40 mEq of KCL at 100ml/our using an administer set that delivers 60 drops/mL, the nurse should adjust the flow rate to delivery how many drops/minute?

Answer: 100 gtt/min

The nurse is monitoring a patient receiving treatment for hypertension. Which of the following blood pressure readings indicates to the nurse that the treatment is successful? 1. 120/78. 2. 180/90. 3. 190/100. 4. 170/110.

Answer: 120/78 One of the goals of antihypertensive therapy is to maintain systole blood pressure of 120 or below, and a diastolic pressure below 80.

The nurse performs a blood pressure screening at the local grocery store. The nurse knows that which of the following blood pressure readings indicates stage 1 hypertension? 1. 160/110. 2. 142/88. 3. 130/88 4. 126/80.

Answer: 142/88 Systolic 140-150 mm Hg or diastolic 90-99 mm Hg

The nurse identifies which central venous pressure (CVP) reading indicates fluid overload? 1. 0 mm Hg 2. 3 mm Hg 3. 8 mm Hg 4. 15 mm Hg

Answer: 15 mm Hg Normal CVP readings ranges from 2-8 mm Hg; CVP reading of greater than 9 indicates fluid volume overload.

The nurse cares for a patient after a traditional cholecystectomy. The nurse should contact the physician if which of the following is observed? 1. 800 cc bloody drainage the first day post op. 2. The patient frequently complains of abdominal pain during the first 24 hours. 3. Nasogastric tube connected to intermittent suction the first day postop. 4. Temperature elevation to 100 F the evening of surgery.

Answer: 800 cc bloody drainage the first day postop. This amount of drainage after cholecystectomy would indicate hemorrhage; 50 cc is an appropriate amount of drainage.

A patient diagnosed with type 1 diabetes is scheduled for a right below-the-knee amputation due to gangrenous toe. The patient asks the nurse why the amputation is so extensive. The nurse's response should be based on which of the following? 1. A below the knee amputation ensures enough skin to form a flap over the stump. 2. A below the knee amputation results in better circulation and healing. 3. A below the knee amputation facilitates earliest prosthesis training. 4. A below the knee amputation significantly reduces edema of the residual limb.

Answer: A below the knee amputation results in better circulation and healing. The level of an amputation is based on the adequacy of circulation; to leave tissues that are poorly supplied with blood would cause poor healing and could lead to the development of gangrene.

The nurse cares for a patient receiving aminophylline via continuous IV drip. The nurse understands that aminophylline is... 1. An antimicrobial 2. A mucolytic 3. A bronchodilator 4. An expectorant

Answer: A bronchodilator. Aminophylline is an xanthine derivative that acts as bronchodilator by relaxing smooth muscles; xanthines also simulate the CNS, dilate coronary arteries, and pulmonary vessels, and cause diuresis; side effects include anorexia, nausea and vomiting, gastric pain, nervousness, dizziness, headache, tachycardia, palpitations.

The nurse performs discharge teaching for a patient with angina. It is MOST important for the patient to report which of the following? 1. Pain following sexual activity. 2. A headache after taking nitroglycerin. 3. A change in the character of pain. 4. Pain after eating a large meal.

Answer: A change in the character of the pain. Change in the character of the pain in which the pain would radiate or be accompanied by diaphoresis would be an important sign for a patient and family to recognize.

The nurse knows which client is most likely to manifest symptoms of fluid volume deficit? 1. A client diagnosed with Addison's disease 2. A client diagnosed with cirrhosis of the liver. 3. A client diagnosed with epilepsy. 4. A client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH)

Answer: A client diagnosed with Addison's disease Addison's disease is an adrenal disorder stemming from hyposecretion of hormones from the adrenal gland; symptoms include fatigue, weakness, dehydration, emaciation, weight loss, fluid and electrolyte imbalance, hypotension; while not cause directly by fluid volume deficit, these symptoms are reflective of it; volume depletion issues are a concern in Addisonian crisis; overall treatment for Addison's includes hormone replacement.

The client arrives in the emergency room with an acute asthma attack. Epinephrine is given subcutaneously. Which observation by the nurse BEST indicates the treatment is effective? 1. An increase in the Clint's alertness 2. An increase in the client's pulse rate 3. A decrease in the client's blood pressure and pulse. 4.A decrease in the client's inspiratory difficulty.

Answer: A decrease in the client's inspiratory difficulty. Asthma is a chronic inflammatory disease of the airways that causes reversible airflow obstruction, airway inflammation, and airway hyper-responsiveness; symptoms include cough, chest tightness, wheezing, and dyspnea; it is reversible; decrease inspiratory difficulty indicates effective treatment; epinephrine is a bronchodilator, which relaxes the smooth muscles and decreases difficulty in inspiration.

Aspirin is prescribed for a client. The nurse should administer this medication with which liquid? 1. A glass of milk. 2. A glass of orange juice. 3. A glass of diet soda. 4. A small amount of water.

Answer: A glass of milk. Take with food, milk, or large glass of water to reduce gastrointestinal upset.

The nurse cares for patients on the medical/surgical unit. The nurse expects postural drainage to e ordered for which of the following patients? 1. A patient diagnosed with cystic fibrosis. 2. A patient diagnosed with ascities due to cirrhosis. 3. A patient diagnosed with lymphedema 4. A patient diagnosed with a subdural hematoma.

Answer: A patient diagnosed with cystic fibrosis. Postural drainage is a treatment of choice for cystic fibrosis because of serious respiratory dysfunction; postural drainage involves using gravity, along with percussion and vibration to facilitate drainage of secretions form bronchi and lungs into the trachea where coughing and suctioning can expel them; involves patient assuming a range of positions, most of them with the head down.

The nurse identifies which patient is MOST at risk for developing pneumonia? 1. A patient with a foley catheter 2. A patient with a nasogastric (NG) tube 3. A patient diagnosed with psoriasis 4. A patient diagnosed with Paget's disease

Answer: A patient with a nasogastric (NG) tube. A NG tube is inserted through the nose and ends in the stomach; used for enterial nutrition to deliver liequid nourishment when GI tract acnnot be used; if it is not in proper postion before infusion of food, aspiration into the lungs can result, with subsequent choking and inflammatory process of aspiration pneumonia; tube placement must be verified with aspiration of gastric contents and checking the ph (pH of 0-4 indicates gastric placement, pH of approximately 6 or more indicates placement in the lungs); X-ray may also be used to verify placement in addition, if NG tube becomes obstructed and patient vomits, gastric acid and stomach content can enter the lungs.

The nurse performs preoperative teaching for a patient scheduled for a colostomy. The nurse explains to the patient that 24 hours after the surgery the colostomy drainage will be which of the following? 1. A large amount of bloody output 2. A large amount of liquid stool 3. Formed stool with water. 4. A scant amount of bright bloody drainage.

Answer: A scant amount of bright bloody drainage. Small amount of bleeding at stoma expected; report excessive amounts of bleeding.

The nurse on the surgical unit cares for several clients with new colostomies. Immediately after surgery, the nurse identifies which of the following stomas is expected? 1. A stoma is bluish and dry 2. A stoma is beefy-red.. 3. A stoma is gray and small 4. A stoma is dark and pulsating.

Answer: A stoma is beefy-red Immediately following surgery, the stoma, which is part of the intestine, is brought out to the abdominal wall and appears beefy-red.

The client is admitted to the hospital with a diagnosis of acute kidney injury. The nurse understands which explanation is the most accurate description of the client's condition? 1. A sudden loss of kidney function due to failure of the renal system circulation or to glomerular or tubular damage. 2. A progressive deterioration in kidney function that ends fatally when uremia develops. 3. An inflammation of the kidney pelvis, tubules, and interstitial tissues of one or both kidneys. 4. An inflammation process precipitated by chemical changes in the glomeruli of both kidneys.

Answer: A sudden loss of kidney function due to failure of the renal system circulation or to glomerular or tubular damage. Acute kidney injury is the sudden cessation of kidney function caused by failure of renal system circulation or by glomerular or tubular damage.

The nurse evaluates care given to a patient after a left below the knee amputation. The nurse should intervene if which of the following is observed? 1. A tourniquet is placed in the patient's bedside table. 2. The patient lies on his stomach several times per day. 3. The nurse uses a transfer belt when patient transfers from bed to chair. 4. The patient sits in a chair frequently for short periods of time.

Answer: A tourniquet is placed in the patient's bedside table. Tourniquet is placed in plain sight on the patient's bedside table. hemorrhage due to loosened suture is a threatening problem; if hemorrhage occurs, apply tourniquet and notify physician immediately.

The nurse cares for a patient receiving oxygen per nasal cannula. Which of the following observations requires an IMMEDATE intervention by the nurse? 1.A visitor arrives with a strong odor of cigarettes on the clothing. 2. The electric plug for the suction machine has 3 prongs rather 2. 3. The patient complains of a dry mouth and has a cracked lip. 4. A visitor is putting clear nail polish on the fingernails of the patient.

Answer: A visitor is putting clear nail polish on the fingernails of the patient. No flammable solution containing oil or alcohol should be in a room where oxygen is being delivered; nail polish-clear or not-is such a solution; oils should not be used on a patient receiving oxygen or on the equipment, while oxygen itself does not burn, its presence will be a catalyst supporting and increasing combustion, all electrical equipment must be in perfect condition and grounded; using matches, lighter fluid, or smoking is prohibited.

Total hip arthroplasty is scheduled for a patient with a degenerative joint disease of the left femoral head. It is MOST important for the nurse to place the patient's left leg in which of the following positions? 1. Abducted with toes pointing upward. 2. Elevated on two pillows with knees flexed. 3. Elevated on several pillows with the ankle abducted. 4. Addcuted with ankle joint hyper-extended.

Answer: Abducted with toes pointing upward. Major complication of hip replacement is dislocation of the prosthesis; maintain abduction by placing pillow between the legs; do not stoop or cross legs.

Which sign or symptom, if observed by the nurse, is MOST important to determine if a patient is hypoxic? 1. Cool, bluish, skin 2. Abnormal blood gases 3. Elevated temperature 4. Increased sputum production

Answer: Abnormal blood gases Blood gases measure tissue oxygenation, carbon dioxide removal, and acid-base balance; if a patient has inadequate exchange of oxygen and carbon dioxide, respiratory acidosis occurs.

The nurse performs discharge teaching for a patient with a diagnosis of hepatitis B. Which of the following precautions to prevent the transmission of hepatitis B should be included in the teaching? 1. Burn used paper tissues. 2. Abstain from unprotected sexual intercourse. 3. Use special disinfectant in toilet 4. Avoid touching family members.

Answer: Abstain from unprotected sexual intercourse. Sexual contact is one way to transmit hepatitis B; unless a prospective partner is immune to hepatitis B, by virtue of either having had the disease or having received the vaccination, patient should avoid unprotected sexual intercourse with that person.

The nurse monitors a client recovering from hepatitis B. The nurse understands this client has developed which type of immunity? 1. Antigen 2. Active acquired 3. Antibody 4. Passive accquired

Answer: Active acquired The client has actively acquired immunity, which means since the client had the disease, the client produced antibodies to fight the disease, another example of actively acquired immunity is immunization.

The nurse cares for the client diagnosed with acute myocardial infarction. The client's skin is clammy, blood pressure is 85/50; client appears restless and anxious. Which action should the nurse take FIRST? 1. Take a 12-lead electrocardiogram (ECG). 2. Administer analgesia as ordered. 3. Administer anticoagulants as ordered. 4. Give a brief orientation to the unit.

Answer: Administer analgesia as ordered. Analgesic of choice is IV morphine; reduces pain and anxiety and reduces preload, which decreases the workload of the heart and therefore the pain; pain in the case indicates myocardial ischemia; delaying treatment increases ischemic involvement;

The nurse in the student health services of a college is planning a series of brief presentations on reducing health risks. One of the topics is going to be toxic shock syndrome (TSS). It is MOST important for the nurse to target which of the following groups in marketing this program? 1. Males who abuse drugs. 2. Males who are sexually active. 3. All females. 4. Females who are sexually active.

Answer: All females. Since toxic shock syndrome TSS is primarily concerned with tampon use ans since this is a college-age campus, all women should be targeted; TSS is a type of distributive shock resulting from inadequate vascular tone due to staphylococcus aureus infection; in addition to tampons, various contraceptive devices, postpartum conditions and on menstrual vaginal conditions have been associated with TSS: proper used of tampons including avoidance of those with super-absorbent properties, is a priority; sudden high fever, vomiting, diarrhea, hypotension, and rash are initial symptoms of TSS: preventive education is the focus of the primary care setting.

The client reports a fever for several days prior to admission to the hospital. The client's temperature is 101 F (38.4 C). and the client is started on penicillin therapy. It is essential for the nurse to monitor the client for which finding? 1. Increased blood urea nitrogen (BUN) 2. Allergic reaction. 3. Anemia 4. Decrease appetite.

Answer: Allergic reaction. Allergic reaction or anaphylaxis occurs within an hour, but usually within minutes after administration of penicillin to a client who is hypersensitive; penicillin is not a nephrotoxic antibiotics, so BUN does not have to be monitored.

Which of the following actions is essential for the nurse to take after arterial blood gases are drawn? 1. Apply pressure to puncture site 2. Check and record vital signs 3. Give 100% oxygen 4. Assess for presences of ulnar pulse

Answer: Apply pressure to puncture site Blood gases measure acid/base balance; following arterial puncture, pressure should be applied to the site for a full five minutes by the clock to prevent bleeding or hematoma formation.

An adult is eating lunch and suddenly starts to choke, gasp for breath, and grab the throat. Which of the following actions should the nurse take? 1. Instruct the patient lean forward and administer back blows. 2. Offer the patient water to drink 3. Ask the patient to speak 4. Finger sweep the patient's mouth.

Answer: Ask the patient to speak Assessment if patient is able speak, airway is only partially obstructed; instruct her to take a deep breath and try to cough up object; if patient is unable to speak, airway is obstructed; begin abdominal-thrust maneuver.

The nurse cares for patients in a residential care facility. The nurse notes that a patient is suddenly disoriented to person, place, and time, and is falling. Which of the following actions should the nurse take FIRST? 1. Obtain an order for a vest restraint. 2. Frequently orient the patient to person, place, and time. 3. Instruct the patient to cell the nurses before ambulating. 4. Assess for signs and symptoms of a urinary tract infection.

Answer: Assess for signs and symptoms of a urinary tract infection. Increased mental confusion and unexplained falls may indicate a UTI in the elderly; also may have loss of appetite, nocturia, and dysuria.

Which of the following nursing interventions is MOST appropriate for a patient diagnosed with rheumatoid arthritis? 1. Provide support of flexed joints with pillows and pads. 2. Position the patient on the abdomen several times a day. 3. Massage the inflamed joints alternately with oil and alcohol. 4. Assist the patient with heat application and range-of-motion exercises.

Answer: Assist the patient with heat application and range of motion exercises. The goal of these interventions is to reduce swelling, increase circulation, and diminish stiffness while preserving joint mobility; this is critical for a patient with rheumatoid arthritis.

The nurse identifies it is MOST important to observe for hyperventilation in a patient receiving which mode of mechanical ventilation? 1. Control ventilation (CV) 2. Assist-control ventilation (AC) 3. Synchronous intermittent mandatory ventilation 4. Continuous positive airway pressure (CPAP)

Answer: Assist-control ventilation (AC) Tidal volume and ventilatory rate are pre-set oxygen is delivered without patient effort, but if patient does inspire it will respond to the efford; if patient respiratory rate increases spontaneously, such as because of pain, anxiety or neurologic causes, the machine continues to deliver the pre-set tidal volume with each breath; hyperventilation and respiratory alkalosis result; cause of hyperventilation must be corrected; machine sensitivity may be adjusted.

The nurse performs a home care visit on a client with a fractured right femur. The nurse assesses the client's safety when using crutches. The nurse should intervene if which of the following is observed? 1. When standing, the crutch tips are placed 6 inches in front of and 6 inches to the side of each foot. 2. The client ambulates using a three-point gait. 3. When going down steps, the client stands on the unaffected leg and places the crutches on next stop. 4. Before sitting in a chair, client stands on the unaffected leg and transfers both crutches in the hand opposite the unaffected leg.

Answer: Before sitting in a chair, client stands on the unaffected leg and transfers both crutches in the hand opposite the unaffected leg. To sit position client in front of the chair with backs of legs touching the chair; transfer both crutches to the hand on the unaffected side of the body; support weight on unaffected leg and crutches and lower to the chair.

The nurse performs discharge teaching for a patient who has undergone a laparoscopic cholecystectomy. The nurse should include which of the following instructions? 1. Begin light exercise immediately 2. Limit diet to liquid and soft foods for three days. 3. Contact the physician if there is pain in the right shoulder. 4. Remove adhesive strips over puncture wounds in five days

Answer: Begin light exercise immediately. May begin walking immediately; avoid lifting heavy objects (more than 5 lbs) for 1 week.

An older male comes to the emergency room with a history of urinary frequency, urgency, and low back pain. The nurse recognizes that these are symptoms of which of the following? 1. Benign prostatic hypertrophy. 2. Herniated intervertebral disk. 3. Kidney stones. 4. Renal failure.

Answer: Benign prostatic hypertrophy. Benign prostatic hypertrophy is enlargement of the prostate gland; symptoms include hesitancy, frequency, dysuria, nocturia, retention, and flank pain due to hydronephrosis.

The nurse instructs a client about appropriate foods for a high-protein diet. The nurse determines teaching is effective if the client chooses which menu? 1.Chef salad, crackers, and ice tea. 2. Broiled fish, cream of tomato soup topped with grated cheese and custard 3. Peanut butter and jelly sandwich, chips, and fruit drink. 4. Turkey sandwich with lettuce and tomato, potato salad, and milk.

Answer: Broiled fish, cream of tomato soup topped with grated cheese, and custard. All foods contain protein; increased protein by adding skim milk to soup, add crated cheese to foods, use peanut butter as a spread on fruits and vegetables, use yogurt as topping for fruit and cake.

The nurse cares for a client diagnosed with choleithiasis. It is MOST important to instruct the client to avoid which of the following foods? Apples Cabbage Lettuce Cheese Chocolate Carrots

Answer: Cabbage, Cheese,and Chocolate Avoid gas-forming vegetables such as onions, broccoli, radishes, and beans. Avoid high in cholesterol/fat; also avoid fried fatty foods, cream butter, whole milk. Also avoid egg yolks, and avocado.

The nurse observes a person suddenly collapse on the street. The nurse finds the person unresponsive. Which action should the nurse take FIRST? 1. Check for normal breathing. 2. Call the emergency response number. 3. Deliver two rescue breaths. 4. Begin chest compressions.

Answer: Call the emergency response number. For sudden collapse, call the emergency response number and then begin CPR.

The nurse performs nutritional counseling for a patient who is diagnosed with COPD. It is most important for the nurse to advise the patient to avoid consuming which nutrient in high amounts? 1. Carbohydrates 2. Calories 3. Protein 4. Fats

Answer: Carbohydrates Excessive carb loads can increase CO2 production since they are broken down into glucose, CO2 and water when metabolized; this may render the COPD patient unable to exhale, and hypercapnic (increase CO2 in blood) respiratory failure could then result; COPD illness itself affects oxygen delivery to all tissues; there is decreased ability to exchange gas, decreased oxygenation in blood, increased CO2 levels in blood; COPD patients need a diet high in calories, protein, and less in carbs.

One week following a myocardial infarction, a patient complains to the nurse of fatigue. The nurse notes that the patient is slightly short of breath and the pulse rate is 110 bmp. Which of the following actions by the nurse is BEST? 1. Continue to monitor the patient. 2. Encourage the client to rest more. 3. Check for any edema or weight gain. 4. Administer high-flow oxygen.

Answer: Check for any edema or weight gain. Assessment; fatigue, shortness of breath, and tachycardia are signs of heart failure; nurse should check for signs of edema or weight gain to determine if the patient is retaining fluid form heart failure.

Three hours after arriving at the orthopedic unit, a patient complains about a hot feeling under the cast. Which action should the nurse take FIRST? 1. Instruct the patient to lie still since the cast is newly applied. 2. Check the circulation in the casted extremity and change the patient's position. 3. Take the patient's temperature and observe for other signs of infection. 4. Medicate the patient for pain and notify the doctor of the complaint.

Answer: Check the circulation in the casted extremity and change the patient's position. Heat is a sign of pressure; checking the circulation is appropriate since pressure can limit circulation; it is possible that changing the position might relieve the pressure.

Which nursing measure would be MOST important immediately following cardiac catheterization? 1. Monitor the patient's temperature. 2. Observe the patient for dysrhythmias. 3. Check the extremities for pulses. 4. Encourage coughing and deep breathing.

Answer: Check the extremities for pulses. Following catheterization, trauma to the vessels used for catheterization is the major concern.

The nurse notices that an intravenous infusion is not running. Which action should the nurse take initially? 1. Reposition the patient's arm 2. Check the site 3. Raise the solution 4. Flush the tubing

Answer: Check the site When an intravenous infusion stops running, infiltration is common cause; by checking the site, the nurse can ascertain whether the infusion has infiltrated; if no infiltration present, then the nurse can reposition arm or raise solution; symptoms of infiltration include edema, pain, coolness of the site, decrease in flow; if IV infiltrated, discontinued and start new IV; apply warm compress to infiltrated site, apply sterile dressing, and elevate arm.

Following the transfusion of one unit of packed red blood cells, the nurse prepares to administer another unit. Which is MOST appropriate action for the nurse to take initially? 1. Check the type and cross-match with another nurse 2. Leave the blood at the client's bedside until the health care provider checks it. 3. Flush tubing with normal saline and hang next unit. 4. Run first 50 mL of blood rapidly to check for any reaction.

Answer: Check the type and cross-match with another nurse. Prior to giving blood, two RN's must check the health care provider's order, client's identity, hospital ID name and number, blood component tag and number, blood type and Rh, and the expiration date.

A patient is diagnosed with a tension pneumothroax resulting form the chest hitting the steering wheel in an automobile accident. The emergency department nurse knows that highest priority is given to which? 1. Oxygenation 2. Chest tube insertion 3.Arterial blood gas (ABG) determination 4. Attaching a cardiac monitor

Answer: Chest tube insertion Tension pneumothorax is an extremely serious emergency, even more than an open pneumothorax; motor vehicle accidents and blunt chest trauma are two potential causes; tension pneumothorax results form air moving into the pleural space and not being able to move back out; pressure builds up in the chest and if it is untreated, the heart, trachea, esophagus, and great vessels are shifted toward the unaffected side due to the lung on the affected side collapsing; further compromise of respiratory and circulatory function ensues; immediate intervention is to insert chest tubes with suction drainage in order to convert the tension puneumothorax into an open pneumothroax; thoracentesis to remove air may be used if chest tube is delayed.

The nurse cares for a patient immediately after a femoral-to-popliteal bypass graft. The nurse is MOST concerned if which of the following is observed? 1. Clammy skin. 2. Poor skin turgor. 3. Shortness of breath. 4. Engorged neck veins.

Answer: Clammy skin Hypovolemic shock is due to an inadequate volume of blood due to hemorrhage, severe dehydration, or burns; skin will be cold and clammy because the body redirects blood from the skin, kidneys, and GI tract to the brain and heart; urine output decreases; blood pressure will be decreased and pulse will be elevated.

Which of the following approaches describes the correct technique for the nurse to obtain a urine specimen from a patient who has an indwelling Foley catheter? 1. Empty the contents of the drainage bag, wait 10 minutes, and take a specimen of urine form the drainage bag. 2. Clamp the drainage tube below the port and, using a sterile needle, aspirate a specimen of urine via the port. 3. Swab the tubing where the catheter connects to the drainage bag with Betadine, disconnect the tubing, and collect a specimen of urine directly from the catheter. 4. Take a random specimen of urine from the drainage bag.

Answer: Clamp the drainage tube below the port and using a sterile needle, aspirate a specimen of urine via the port. Sterile technique is used; fresh urine sample obtained will ensure an accurate analysis.

The home care nurse visits a client with a diagnosis of ulcerative colitis. The client complains of perineal irritation due to frequent stools. Which suggestions by the nurse is best? 1. Apply a heat lamp to the perineal area three times per day. 2. Use protective plastic bed pads. 3. Clean the perineal area with soap and water after each bowel movement. 4. Increase roughage in the diet to prevent the frequent stools.

Answer: Clean the perineal area with soap and water after each bowel movement. Keeps the skin free of stool; sitz bath; apply petroleum jelly poor vitamin A and D ointment.

A patient arrives in the emergency room complaining of severe pain in the left leg that is not relieved by rest or medication. On physical examination, the nurse is MOST likely to assess which of the following? 1. Cold, mottled leg. 2. Strong popliteal pulse. 3. Edematous leg. 4. Hot, reddened leg.

Answer: Cold, mottled leg. Pain in the lower extremities not relieved by rest indicates peripheral arterial disease; pain may be described as numbness or burning; pain sometimes relieved by placing leg in dependent position; skin is dry, scaly, dusky, pale, mottled, and cold.

It is MOST important for the nurse to take which action when administering cardiopulmonary resuscitation? 1. Maintain a position close to the victim's side with the knees apart. 2. Compress the chest at least a rate of 100 compression per minute. 3. Give 3 shocks before beginning CPR. 4. Give a rescue breath over 30 seconds.

Answer: Compress the chest at least a rate of 100 compressions per minute. "Push hard and push fast" to maintain blood flow; in order for cardiac compressions to be efficient and effective, there should be vertical pressure through the heel of the hand with each compression; only the heel of the hand should be placed on the sternum; the shoulders should be parallel to the sternum and elbows should be locked to generate enough pressure for even a small person to move the sternum an inch to an inch-and-a half downward, and compress the heart between the sternum and the vertebrae.

The nurse understand that the CABs of CPR stand for which? 1. Compressions, airway, breathing. 2. Compressions, airway, back blows. 3. Circulation, airway, breathing. 4. Carotid pulse, airway, breathing.

Answer: Compressions, airway, breathing. CABs (compression, airway, breathing) of CPR (airway, breathing, circulation) is a method to help remember CPR priorities; first is to restore circulation through compressions; second, assure a patient airway; third, establish breathing.

A patient has a transurethral resection of the prostate (TURP). Twenty-four hours later, the nurse notices that the patient's urine is bright red. Which of the following nursing actions is MOST appropriate? 1. Contact the physician. 2. Continue to monitor the patient. 3. Irrigate the catheter. 4. Remove the catheter.

Answer: Contact the physician. Sign of arterial bleeding; bleeding is expected after surgery; however, it is expected to be darker in color and to have minimal clots; if the color is bright and there is a lot of clotting, there is a possibility of hemorrhage; patient may show other signs of hemorrheage, such as drop in blood pressure, cool, clammy skin, and increased pulse; nurse should also observe for these signs and symptoms.

The nurse expects which of the following modes of mechanical ventilation to be ordered for a patient with severe Guillain-Barre syndrome? 1. Controlled ventilation (CV) 2. Assist-control ventilation (AC) 3. Synchronized intermittent mandatory ventilation (SIMV) 4. Continuous positive airway pressure (CPAP)

Answer: Controlled ventilation (CV) Patients with Guillain-Barre syndrome have flaccidity or weakness that progresses upward from the lower extremities and often includes the trunk, with resultant respiratory compromise and possible failure; motor deficits can progress to total quadriplegia; controlled ventilation is used for patients who are unable to initiate a breath, such as patients with polio or Guillian-Barre; it delivers a set tidal volume of oxygen at a set rate; this is the simplest mode, but is used less frequently than others.

The nurse cares for a patient post-appendectomy, and a full liquid diet is ordered. The nurse determines that the patient's breakfast is appropriate if it includes 1. Only strained clear liquids 2. As much fruit as desired 3. Cooked cereal 4. Yogurt and bananas

Answer: Cooked cereal Full liquid diet includes milk and milk products (pudding, custards) all vegetable juices, all fruit juices, refined or strained cereals (cream o wheat, oatmeal), eggs in custard, butter, margarine, and cream.

The nurse expects which of these laboratory test results to be elevated in a client following an acute myocardial infarcation? 1. Creatine kinase (CK), Troponin T and I, and myoglobin. 2. Blood urea nitrogen (BUN), serum creatinine, and protein-bound iodine. 3. Aspartate aminotransferase (AST) (formerly serum glutamio-oxaloacteic transaminase (SGOT), red blood cell count (RBC), and platelets. 4. Lactic dehydrogenase (LDH), thyroxine, and endorphin levels.

Answer: Creatine kinase (CK), troponin T and I, and myoglobin. Values are increased after an MI; creatine kinase (CK-MB) is an enzyme that is cardiac specific; begins to increase in an hour and peaks in 24 hours; troponin is myocardial muscle protein release when heart muscle damaged; any rise indicates MI; myoglobin is protein found in cardiac and skeletal muscle; normal is less than 90 micrograms/L

A nurse returns to the car after grocery shopping and witnesses a car hit a pedestrian in the parking lot. As the nurse approaches the pedestrian, the pedestrian cries out, "I think my leg is broken!" Which of the following actions should the nurse take FIRST? 1. Ask the client to move the ankle and foot on the affected side. 2. Inspect the client for evidence of bleeding. 3. Cut away the client's pant leg on the affected side. 4. Immobilize the affected leg.

Answer: Cut away the client's pant leg on the affected side. Must be able to inspect the injury for bleeding, swelling, or any deformity.

The nurse cares for a client with a Sengstaken-Blakemore tube to treat bleeding esophageal varcies. The client suddenly develops respiratory distress, Which action should the nurse take FIRST? 1. Auscultate breath sounds. 2.Cut the balloon port on the Sengstaken-Blakemore tube. 3. Obtain and record blood pressure and pulse. 4. Contact the health care provider.

Answer: Cut the ballon port onthe Sengstaken-Blakemore tube Keep a pair of scissors at bedside; cutting the port will deflate the balloon and allow the nurse to remove the tube.

The nurse gives discharge instructions to the family of a patient diagnosed with hepatic encephalopathy. The nurse determines further teaching is necessary if the family makes which of the following statements? 1. We should contact the physician if Dad is restless at night. 2. Cephulac will cause Dad to have 2-3 stools per day. 3. Dad should eat meat at every meal. 4. Cephulac may cause bloating and cramps.

Answer: Dad should eat meat at every meal Low-protein, high-calorie diet; instruct family to observe for and report mental changes.

The nurse in the community health center identifies which of the following types of food is MOST likely to present problems for a client with respiratory difficulties? 1. Fruits 2. Grains 3. Diary 4. Fish

Answer: Dairy Diary products such as milk and cheese are mucus-producing; this would cause problems for persons with respiratory difficulties since it could cause secretions and/or thicken secretions that are already there; the person has difficulty expelling these, making breathing difficult and also providing a medium for bacterial growth; cystic fibrosis, pneumonia, and cerebrovascular accident (CVA) are examples of conditions where secretions are a serious problem.

The nurse reviews staff charting for a patient diagnosed with pleural effusion. The nurse expects to find which notations in the patient's chart? 1. Decreased breath sounds noted in left lower lobe. 2. Lungs clear with breath sounds heard in all areas. 3. Crackles heard in right thoracic area 4. Rhonchi heard on expiration.

Answer: Decreased breath sounds noted in left lower lobe. There would be absent or decreased breath sounds and dull, flat sound when percussed; pleural effusion is the collection of fluid in the pleural space and is a complication of HF, TB, pneumonia, and cancer.

The nurse cares for a client diagnosed with angina. The nurse understands that nitroglycerin is used in the treatment of angina pectoris for which reason? 1. Prevents attacks precipitated by aggravation. 2. Decreases preload. 3. Produces coronary artery dilation. 4. Corrects drug-induced dysrhythmias.

Answer: Decreases preload By dilating the peripheral vessels, blood pressure is decreased thereby decreasing preload; the heart does not have to pump as hard to eject blood and therefore the work load of the hear is decreased relieving angina.

A nurse assess a client who has sustained a burn injury. The burn area is blistered and painful. Which classification BEST describes the burned area. 1. Third degree 2. Full thickness 3. Deep partial thickness 4. Superficial partial thickness

Answer: Deep partial thickness Red in color, moderate edema present, painful, blisters present, no eschar.

The nurse recognizes that the type of edema related to cardiac failure is usually 1. Nonpitting 2. Dependent 3. Painful 4. Severe

Answer: Dependent. Seen with right-sided heart failure and usually noted in the ankles and in the sacral region.

The nurse assess the elderly client at the long-term care facility. The client tells the nurse, "I have recently developed constipation." It is MOST important for the nurse to take which action? 1. Encourage the client to eat more grains and fruit 2. Determine the frequency and characteristics of bowel movements. 3. Instruct the client to increase fluid intake 4. Teach the client about the importance of exercise.

Answer: Determine the frequency and characteristics of bowel movements. Assessment, number of bowel movements varies from one to three per day to three a week; nurse should first determine frequency and characteristics of the client's bowel movements before determining the appropriate interventions.

The client comes to the cardiac clinic reporting of anorexia, nausea, and blurred vision. The nurse understands that these symptoms indicate that the client may be experiencing which condition? 1. Cardiac tamponade. 2. Hypokalemia. 3. Myocardial infarction. 4. Digitalis Toxicity.

Answer: Digitalis toxicity Nausea, vomiting, anorexia, and visual disturbances are all signs of digitalis toxicity as well as bradycardia; check apical rate and hold if below 60/min; normal range for digoxin is 0.5-2.0 ng/mL

The nurse instructs a client with a sigmoid colostomy about how to irrigate the colostomy. Which action should the nurse include in the teaching? 1. Dilate the stoma gently with gloved finger 2. Irrigate the colostomy using 30 mL of normal saline. 3. Continue the irrigation's until no stool is returned. 4. Returns should occur 5-10 min after instilling water.

Answer: Dilate the stoma gently with gloved finger Dilating the stoma gently with a gloved finger is part of routine colostomy irrigation procedure.

The home care nurse visits a client reporting symptoms of a UTI. The nurse is ordered to obtain a midstream urine specimen. On arrival to the home, the client states they collected the specimen 2 hours ago and left it sitting in the bathroom. 1. Label the specimen and send it to the laboratory. 2. Discard the specimen and obtain a new midstream specimen. 3. Determine if the client used appropriate technique to clean the urethral meatus. 4. Determine if the specimen collected was voided midstream.

Answer: Discard the specimen and obtain a new midstream specimen. Obtain a freshly voided specimen collected midstream; instruct client to clean urethra prior to voiding to remove secretions or bacteria

The nurse informs a patient with angina that some common side effects of nitroglycerin include which of the following? 1. Palpitations, hypertension, and tachycardia. 2. Flushing, bradycardia, and muscle weakness. 3. Dizziness, headache, and hypotension. 4. Flushing, vertigo, and seizures.

Answer: Dizziness, headache, and hypotension. Common side effects of nitroglycerin include dizziness, headache,and hypotension; renew every three months, avoid alcoholic beverages, protect drug from light.

After a gastrectomy for stomach cancer, which of the following is the nurse's MOST important consideration in the management of the nasogastric tube? 1. Irrigate the tube immediately 2. Do not irrigate the tube. 3. Irrigate the tube with normal saline only 4. Irrigate the tube with sterile water only

Answer: Do not irrigate the tube. Do not irrigate the tube unless it was specifically ordered because irrigating the tube can put pressure on the suture line

The nurse in the outpatient clinic is instructing a client receiving probenecid (Benemid). It is MOST important for the nurse to make which of the following statements? 1. Drink 6-8 glasses of water each day. 2. Take the medication on an empty stomach. 3. you may take aspirin for minor pain. 4. You are permitted to drink wine with dinner.

Answer: Drink 6-8 glasses of water each day. Probenecid (Benemid) is an antigout medication that increases the excretion of uric acid; increased fluids will increase the excretion of uric acid; side effects include nausea, rash, and constipation.

The nurse identifies which sign or symptom as an early indication of fluid volume excess? 1. Cyanosis 2. Diarrhea 3. Edema 4. Shock

Answer: Edema Edema is the collection of fluid in tissues, is often seen as an early sign of fluid volume overload; other symptoms include increased bounding pulse, elevated blood pressure, dyspnea, crackles.

During peritoneal dialysis, a patient suddenly begins to breathe more rapidly. Which of the following actions should the nurse take FIRST? 1. Discontinue the dialysis procedure. 2. Check the patient's vital signs. 3. Notify the physician. 4. Elevate the head of the bed.

Answer: Elevate the head of the bed. Will decrease the pressure of the dialysate on the diaphragm, and increase the vital capacity of the lungs; draining the cavity of fluid will further decrease the pressure.

The nurse cares for a client with a newly applied plaster cast to the lower extremity. The nurse should take which action? 1. Set up a fan to blow on the cast and turn the patient frequently. 2. Rest the casted leg on the mattress and avoid handling it until has dried. 3. Elevate the leg on pillows and leave the cast open to air. 4. Cover the cast lightly with a sheet and remove it frequently.

Answer: Elevate the leg on pillows and leave the cast open to air. Elevation of the extremity will prevent edema; elevation on pillows will prevent the cast from having contact with a hard surface that might cause pressure; leaving the cast open to air will facilitate drying.

The nurse cares for a patient with a new tracheostomy immediately postop. It is MOST important for the nurse to take which action? 1. Place the patient supine until vital signs are stable 2. Ask the patient which position makes the patient most comfortable. 3. Place the patient with head elevated and neck hyperextended. 4. Elevate the patient's head and turn the head to one side until consciousness returns.

Answer: Elevate the patient's head and turn the head to one side until consciousness returns. Semi' Fowlers position, facilitates respiration, promotes drainage, and prevents edema, and prevent strain on the suture line.

An elderly female patient undergoes an open reduction and internal fixation of the left femoral head after a fracture. Which action by the nurse is BEST? 1. Offer the patient a low-residue diet. 2. Turn the patient to the unoperated side. 3. Instruct the patient to exercise the arms. 4. Encourage the patient to cough and deep breathe q 2 hours.

Answer: Encourage the patient to cough and deep breathe q 2 hours. The respiratory complication of atelectasis is a common occurrence within the first 24 hours postoperatively; to prevent this complication, it is essential for an elderly patient to cough and breathe deeply.

The nurse understands that the cause of essential hypertension is 1. A high-salt diet. 2. Kidney disease. 3. Obesity. 4. Unknown.

Answer: Essential (primary) hypertension accounts for 90-95% of all cases; hypertension may have no symptoms or headache, dizziness, anginal pain; treatment includes medication and lifestyle changes.

The home nurse cares for a client diagnosed with Alzheimer's and urinary incontinence. When implementing the plan for urinary habit training, which of the following actions should the nurse take FIRST? 1. Provide privacy for the client to toilet. 2. Establish the client's voiding pattern. 3. Assist the client to the toilet every two hours. 4. Turn on the water faucet when the client is on the toilet.

Answer: Establish the client's voiding pattern. Keep a record of 3 days about when client voids to determine voiding pattern.

The nurse cares for a patient after rhinoplasty and observes bright red blood on the external dressing, Which action should the nurse take FIRST? 1. Return the patient to the operating room 2. Contact the physician 3. Examine the patient's throat 4. Perform nasophryngeal suctioning

Answer: Examine the patient's throat Assessment is the first step of the nursing process; nurse should observe for bloody drainage in the throat; hemorrheage is an emergency situation that require the physician to repack internal dressing.

In teaching a patient with a below-the-knee amputation to care for the residual limb at home, the nurse should advise the patient to do which of the following? 1. Apply cream daily to the residual limb. 2. Cover the residual limb with a nylon sock. 3. Keep the residual limb elevated. 4. Expose the residual limb to air.

Answer: Expose the residual limb to air. Air exposure will facilitate healing of residual limb.

The school nurse is informed that a sixth grader in the school has been diagnosed with hepatitis A. It is MOST important for the nurse to teach the parents of the classmates to observe the children for which of the following symptoms? 1. Fatigue 2. Increased appetite. 3. Tarry stools 4. Pallor

Answer: Fatigue Symptoms of hepatitis include fatigue, anorexia, right upper quadrant pain, pruritus, jaundice.

The nurse prepares to suction the endotracheal tube of a patient on a mechanical ventilator. Which of the following ventilator settings should be adjusted by the nurse before and after this procedure? 1. Tidal volume 2. Respiratory rate 3. Fraction of inspired oxygen (FIO2) 4. Flow

Answer: Fraction of inspired oxygen (FIO2) Fraction of inspired oxygen is the concentration of oxygen that is delivered to the patient, it is determined by the ABG values and the condition of the patient; the range that can be provided is 21% to 100%; suctioning can cause desaturation or hypoexmia, so hyperoxygenation should be done before and after the procedure to prevent this occurrence; increasing the FIO2 is one way to do this; manually ventilation the patient is another, the nurse must be certain to return the FIO2 to its previous setting once the hyperoxygenation is completed.

The nurse cares for the client 12 hours after aortofemoral bypass. It is MOST important for the nurse to place the client in which position? 1. Sim's 2. High Fowler's with knee gatched. 3. Full supine. 4. Flat prone.

Answer: Full supine. Hip must remain straight to prevent bleeding.

The nurse determines a client has a deep partial thickness burn injury of the back. Which is the BEST initial nursing action? 1. Break the blisters with scalpel using sterile technique. 2. Gently clean and then leave the area alone., 3. Apply a thing layer of petroleum jelly to the area. 4. Wrap snugly with sterile gauze.

Answer: Gently clean and then leave the area alone. For a deep partial thickness burn, gently clean away debris and dirt; blisters form a protective cover, so leave intact, without applying a sterile gauze.

The home care nurse visits a client diagnosed with diverticulitis. The physician orders a clear liquid diet, and the nurse instructs the family about the appropriate foods. The nurse should intervene if the client's family makes which of the following statements? 1. Grandpa can have his daily glass of prune juice. 2. My husband really likes apple juice 3. My dad drinks cranberry juice in the evening. 4. Grandpa can eat a cherry Popsicle with me.

Answer: Grandpa can have his daily glass of prune juice Clear liquid diet allows clear liquids (liquids that the nurse can see through or foods that are fluid at room temperature); prune juice allowed on a full liquid diet; diverticulitis is infection and inflammation of diverticulum; signs include irregular bowel function with episodes of diarrhea, crampy pain in the left lower quadrant, and low-grade fever.

The nurse cares for client receiving a blood transfusion. The nurse is MOST concerned if which is observed? 1. The blood pressure is 130/80 2. The client reports shortness of breath. 3. The client reports pruritus. 4. Hematuria occurs

Answer: Hematuria occurs. Hematuria indicates hemolytic reaction due to ABO incompatibility; other symptoms include nausea, vomiting, hypotension, increased in pulse rate, decreased urinary output; stop transfusion; supportive care, oxygen diphenhydramine, airway management.

The nurse cares for the client with suspected cancer of the bladder. The nurse knows that which finding is most common in the client with a diagnosis of cancer of the bladder? 1. Hematuria 2. Potassium 5.9 mEq/L 3. Painful urination. 4. Left flank pain.

Answer: Hematuria. Predominate sign associated with bladder cancer, hematuria may be gross and is usually intermittent.

The nurse assesses the patient receiving isoniazid (INH). It is MOST important for the nurse to observe for which? 1. Hepatitis 2. Glomerulnoephritis 3. Photosensitivity 4. Deafness

Answer: Hepatitis Hepatitis is a side effect of INH; teach signs of hepatitis and check liver function tests; instruct patient to avoid alcohol; other side effects include peripheral neuritis, rash, and fever.

The nurse identifies which diet BEST meets the nutritional needs of a client diagnosed with cirrhosis? 1. High in calories plus vitamin supplements. 2. High in protein and high in carbohydrates. 3. High in calcium and low in fat. 4. High in iron and low in salt.

Answer: High in protein and high in carbohydrates. Since many alcoholics are malnourished, a high-protein diet is important.

The nurse identifies which is the characteristic sound of breathing in a patient experiencing an acute asthma attack? 1. Murmuring with lubb/dub sounds 2. High-pitched musical-like squeaky sounds. 3. High-pitched harsh, loud, blowing sounds 4. Low-pitched rubbing or grating sounds

Answer: High pitched musical-like squeaky sounds. Describes wheezes, heard primarily during expiration but may also be heard on inspiration; caused by air passing through narrowed airways; auscultated over small airways; heard in cases of acute asthma or chronic emphysema.

An adult male client has a history of diabetes insipidus. The nurse identifies which imbalance is MOST likely to develop if this medical problem recurs? 1. Hypernatremia. 2. Hyponatremia 3. Hyperkalemia 4. Hypokalemia

Answer: Hypernatremia Diabetes insipidus is a disorder of water metabolism caused by a deficiency of antidiuretic hormone, or ADH; large amounts of water are lost from the body causing a buildup of sodium in the body, leading to hypernatremia; sodium greater than 145 mEq/L; symptoms include excessive urine output, chronic severe dehydration, excessive thirst, weakness; record intake and output, monitor urine specific gravity, condition of skin, vital signs, administer Pitressin.

The emergency department nurse knows that which is the MOST frequent underlying cause of tetany? 1. Hypocalcemia 2. Puncture wound form dirty and rusty metal 3. Hypermagnesemia 4. Genetic cardiac defect.

Answer: Hypocalcemia Hypocalcemia is the most common underlying cause of tetany, which is a condition with convulsions, cramps, muscle twitching, sharp flexion of ankle and wrist joints, possible respiratory stridor; calcium-related tetany is treated with IV calcium or calcium gluconate; if need to dilute calcium, use D5W not saline, because saline promotes calcium loss; basic hypocalcemia is treated with calcium supplementation (vitamin D to increase absorption) and dietary measures.

The nurse is caring for a patient with degenerative joint disease (osteoarthritis). The physician orders celecoxib (Celebrex). The nurse is MOST concerned if the patient makes which of the following statements? 1. I am allergic to aspirin. 2. I should take this medication with food. 3. This medication will reduce joint discomfort. 4. I will contact the physician if I have any weight gain.

Answer: I am allergic to aspirin. COX-2 inhibitor; avoid using if patient allergic to aspirin, sulfa, or other NSAIDS; contact physician.

The home care nurse makes a home visit for a client diagnosed with osteoarthritis. The nurse asks the client's spouse if the client having any problems. The nurse should further asses if the spouse makes which statements? 1. I can tell that my husband has been worrying because he is wringing his hands. 2. Last night, my husband carried a big bowl of vegetables to the table using both hands. 3. My husband bends from the knees when he picks the papers up from the floor. 4. My husband only uses a small pillow under his head when he sleeps at night.

Answer: I can tell that my husband has been worrying because he is wringing his hands. To protect joints, the client should avoid a twisting or wringing motion of the hands.

The nurse assesses a client in the outpatient clinic with a diagnosis of R/O ulcerative colitis. During the history, the nurse expects the client to make which of the following statements? 1. I feel intermittent sharp pain in my lower abdomen. 2. I feel an intermittent gnawing pain in my lower abdomen. 3. i feel an intermittent cramping pain in my lower abdomen. 4. I feel a constant crushing pain in my lower abdomen.

Answer: I feel an intermittent cramping pain in my lower abdomen. Pain is usually described as cramping and intermittent; important that the nurse assess character and intensity of pain; pain due to ulcerative colitis usually occurs prior to defecation; obtain diet history and assess for bowel sounds and for areas of tenderness.

The nurse obtains a history from a client suspected of having a duodenal ulcer. The nurse expects the client to make which statement? 1. I have been vomiting bright red blood. 2. I have abdominal pain and tenderness 3. I have frequent loose stools every day 4. I have increased pain after eating.

Answer: I have abdominal pain and tenderness. Duodenal ulcer is erosion of the mucosal wall of the duodenum; epigastric pain is the most common symptom; pain occurs 2-3 hours after eating, and food intake relieves the pain.

The nurse obtains a history from a client suspected of having cirrhosis. Which statement, if made by the client to the nurse, should the nurse recognize as MOST directly related to a client's development of cirrhosis? 1. For the past several weeks I have not slept for more than five hours a night. 2. Since my spouse left me five years ago, I have been eating terribly. 3. I have been drinking about a fifth of vodka a day for the last few months. 4. My spouse as a heavy smoker, and I am concerned about second-hand smoke.

Answer: I have been drinking about a fifth of vodka a day for the last few months. Alcohol has a toxic effect on liver, which causes liver inflammation; signs and symptoms include nausea, vomiting, anorexia, weight loss, flatulence, fatigue, headache, ascites, jaundice, and spider angiomas.

The nurse prepares the client for sigmoidoscopy. The nurse should notify the health care provider if the client makes which statement 1. I took my blood pressure medication with a sip of water this morning 2. I haven't eaten any fruits or vegetables since the day before yesterday. 3. I had good results from the tap water enema this morning 4. I hope that this is easier than the barium enema I had two days ago.

Answer: I hope that this is easier than the barium enema I had two days ago Barium makes it difficult to visualize the colon; no barium studies for three days before a sigmoidoscopy

The nurse instructs a patient about how to use an incentive spirometer. The nurse determines that teaching is effective if the patient makes which statement? 1. I should take a deep breath and blow into the mouthpiece 2. I'm glad that I only have to do this twice a day. 3. I should ask for pain medication prior to using spirometer 4. I should lie down to use the incentive spirometer.

Answer: I should ask for pain medication prior to using spirometer The incentive spirometer is used after thoracic and abdominal surgery to prevent atelectasis, to encourage deep inspirations, assess the patient's level of pain and administer pain medication.

The nurse in the same day surgery prepares a client for discharge after conventional herniorrhaphy. The nurse should intervene if the client makes which statement? 1. I should not strain when having a bowel movement 2. I should cough and deep breathe every two hours. 3. I can walk up and down the stairs as soon as I get home 4. I should call the health care provider if I have an elevated temperature.

Answer: I should cough and deep breathe every two hours. Due to hernia repair, should avoid coughing, deep breathing does not present a problem.

The nurse cares for a client receiving enteral feeding through a nasogastric tube. The health care provider orders isobride 2.5 mg sub-lingual as needed for chest pain.The nurse instructs the client's spouse about the correct administration of the medication. The nurse determines that teaching is effective if the client's spouse makes which statement? 1. I should irrigate the tube with 50 mL of water before giving this medication. 2. I should place the tablet under the client's tongue. 3. I should dissolve this medication in warm water prior to instilling it. 4. I should ask the healthcare provider to change the medication to a liquid form.

Answer: I should place the tablet under the client's tongue. Isosorbibe is an antianginal; sublingual administration is for treatment of angina; PO administration given to prevent angina; buccal or sublingual medication given as ordered to clients with NG tube.

The home care nurse visits a client diagnosed with hepatitis. It is MOST important for the nurse to intervene if the client makes which of the following statements? 1. I take Tylenol when I get a headache. 2. I do not drink wine with meals anymore 3. I keep my fingernails short 4. I was my hands before I eat.

Answer: I take Tylenol when I get a headache. Tylenol is contraindicated because it is hepatotoxic; instruct client to avoid all medications unless unless prescribed by the physician.

The clinic nurse instructs a client in the used of a metered dose inhaler (MDI). Which statement by the client indicates the need for further teaching? 1. I will breathe in deeply and slowly as I press down on the canister. 2. I will hold the mouth piece 2 inches in front of my mouth 3. I will count to 10 on my fingers after I breathe in 4. I will be careful not to shake the canister before I use it

Answer: I will be careful not to shake the canister before I use it. Incorrect understanding; before using the canister it should be shaken vigorously to disperse and mix the aerosol propellant with the medication in order to ensure correct dosage is administered; MDI is a hand held device which enables a person to intermittently give themselves an exact amount of medication in a readily absorable form.

The nurse instructs the client about the bowel preparation, required prior to a sigmoidoscopy. The nurse identifies teaching is successful if the client makes which statements? 1. I can not eat eight hours prior to the test 2. I will be asleep when the test is performed 3. I will have an enema the morning of the test 4. I will have nasogastric suction decompression.

Answer: I will have an enema the morning of the test Sigmoidoscopy is direct visualizaiton of sigmoid colon, rectum, and anal canal; tap water enema or Fleet's given until returns are clear the morning of the procedure.

The nurse instructs a client about how to increase calories in the diet. The nurse determines teaching is effective if the client makes which statement? 1. I will broil all my meats 2. I will eat bread at all my meals 3. I will snack frequently on nuts and dried fruits 4. I only use low-fat salad dressings.

Answer: I will snack frequently on nuts and dried fruits Adds calories; also spread butter and/or cream cheese on rolls and add butter to foods

The clinic nurse counsels a client complaining of low back pain. Which of the following statements, if made by the client to the nurse, requires a follow-up by the nurse? 1. I work full time as a checker at the local grocery store. 2. I sleep on a firm mattress 3. I walk for 30 minutes each day. 4. I sleep on my side with my knees and hips flexed.

Answer: I work full time as a checker at the local grocery store. Clients with low back pain should avoid standing for prolonged periods of time; important to follow-up on this statement by determining how long the client stands each day and how frequently the client is able to rest.

The nurse performs discharge teaching for a patient diagnosed with fractured left femur that is in a cast. The patient asks how to keep the muscles of the legs strong during the time the cast is on the left leg. Which response by the nurse is BEST? 1. It is important to perform active range of motion every day with your left leg 2. I'll teach your mother to perform active assistive range-of-motion exercises. 3. Perform left leg lifts with a 2lb weight attached to your ankle. 4. I'll teach you how to do isometric exercises.

Answer: I'll teach you how to do isometric exercises The only safe method of enhancing muscle strength and venous return is a casted extremity is by isometrics, such as a quadriceps setting or straight leg raises.

The nurse performs teaching for a client diagnosed with asthma. The nurse determines further teaching is necessary if the client makes which statement? 1. I'm going to have to replace my wool rugs and feather pillows. 2. I can no longer rake the leaves or garden like I used to. 3. We are going to have to dust and vacuum more frequently 4. I'm going to have to establish a regular bedtime routine.

Answer: I'm going to have to establish a regular bedtime routine. This is a good health habit but will not prevent asthma.

The nurse cares for clients in the outpatient clinic. The nurse obtains a history on a client reporting diarrhea. It is MOST important for the nurse to follow up on which client statement? 1. I eat alot of processed foods 2. I've been taking cephalexin for the last week 3. I eat small meals four to six times per day 4. I prefer to eat my food cold

Answer: I've been taking cephalexin for the last week Oral antibiotics given for infections may alter the natural flora of the GI tract, this change in normal flora, especially the lack of lactobacillus, often causes diarrhea.

The nurse care fore the client needing a tracheostomy. The client daughter asked the nurse, "Why does my father need a tracheostomy?" The nursed understand that which is the primary reason for performing a tracheostomy? 1. Promotes pulmonary function 2. Improves breathing capabilities 3. Prevents respiratory infections 4. Decreases respiratory tract secretions

Answer: Improves breathing capabilities The main purpose of a tracheostomy is to provide and maintain an airway, which permits the removal of trachobronchial secretions when the patient is unable to cough productively; also permits the positive pressure for ventilation, and prevents aspiration of secretions in the unconscious or paralyzed patient.

The nurse is teaching a patient diagnosed with heart failure about the prescribed medication. The nurse explains the purpose of digoxin (Lanoxin) includes which of the following? 1. Dilate the coronary arteries. 2. Increase the strength of the heart's contractions. 3. Prevent premature ventricular contractions. 4. Increase the rate of myocardial contractions.

Answer: Increase the strength of the heart's contractions. Digitalis increases the force of the heart's contractions by slowing the heart rate and conduction through the AV node

The nurse cares for a patient receiving aminophyilline. The nurse identifies which is a common side effect of aminophylline? 1. Increased respiratory rate 2. Increase pulse rate 3. Decreased respiratory rate 4. Decreased pulse rate

Answer: Increased pulse rate Aminophylline is known to cause tachycardia, nervousness, restlessness, and nausea; must be used cautiously in patients with cardiac impairment.

The nurse cares for a client receiving a blood transfusion. The nurse observes which symptoms if fluid overload occurs during the transfusion? 1. Decreased pulse rate, increased BP, decreased respirations. 2. Increased pulse rate, increased BP, increased respirations. 3. Increased pulse rate, increased BP, decreased respirations. 4 Decreased pulse rate, decreased BP, increased respirations.

Answer: Increased pulse rate, increased BP, increased respirations. If blood transfusion is run rapidly and fluid overload occurs, signs of heart failure will be seen, including increased respirations, increased pulse rate, and increased blood pressure

The nurse cares for a patient after an appendectomy. The day after surgery, the patient has severe abdominal pain, a temperature of 101 F and a rigid abdomen. The nurse suspects that the patient is experiencing which of the following? 1. Anesthesia intolerance. 2. Abnormal pain tolerance 3. Infection of the peritoneal sac 4. Bladder distention

Answer: Infection of the peritoneal sac Peritonitis can be caused by ruptured appendix; signs and symptoms of peritonitis include severe abdominal pain, abdominal rigidity, decreased bowel sounds, nausea and vomiting, increased temp, shock paralytic ileus; monitor vital signs, administer antibiotics and IVs, NG tube to suction, NPO, surgery to correct cause.

The nurse understands that the purpose of a coronary artery bypass graft (CABG) is to 1. Excise the vessel. 2. Insert the graft. 3. Repair the artery. 4. Remove the clot.

Answer: Insert the graft In a bypass procedure, a graft is placed and anastomosed distally and proximally to bypass the obstruction.

The nurse notes that a patient with a Foley catheter complains of discomfort, has moderately distended bladder, and has had 20 ml of urinary drainage in the past hour. What is the FIRST action there nurse should take? 1. Irrigate the catheter. 2. Gently massage the bladder in a distal direction. 3. Inspect the catheter tubing. 4. Briefly raise the drainage bag above the level of the bladder.

Answer: Inspect the catheter tubing. Assessment is first step of nursing process; frequent cause of obstruction of any tubing is kinking of tubing, dependent loops, compression, removing that situation often resolves the problem.

To prepare a client for a paracentesis, it is ESSENTIAL for the nurse to take which action? 1. Administer a cleansing enema. 2. Pre-medicate the client with a narcotic analgesic. 3. Restrict with clients intake of fluids 4. Instruct the client to empty the bladder.

Answer: Instruct the client to empty the bladder. Procedure involves removal of fluid from the client's abdomen through a trocar, client may have bladder injured by the procedure if it is not empty and small.

Which of the following nursing measures is MOST effective for preventing thrombophlebitis for a patient while on bed rest? 1. Elevate the foot of the bed with the knee gatch and pillow. 2. Apply Ace bandages from ankle to thigh. 3. Instruct the patient to flex and point his toes every two hours. 4. Massage the patient's legs, except for the calf area, several times a day.

Answer: Instruct the patient to flex and point his toes every two hours. Flexing and pointing toes will increase venous return and maintain the integrity of his blood vessels and will help prevent thrombophlebitis

The nurse understands that the pain of angina is caused by which of the following? 1. Insufficient oxygen in the heart muscles. 2. Inflammation of the pericardium. 3. Ineffective contractions of the heart muscles. 4. Severe dysrhythmias.

Answer: Insufficient oxygen in the heart muscles. Angina pectoris is caused by ischemia of the myocardium.

A medical surgical unit is being unit is being converted into a cardiac unit due to increasing numbers of clients coming to the hospital with cardiac conditions. The nurse manager reviews with staff the differences between defibrillation and cardioversion. Which should the manager identify as characteristics that these two procedures have in common? 1. Location where procedure is done and use of sedation. 2. Intended action and paddle placement 3. Timing of shock delivery and voltage used. 4. Indication for procedure and informed consent.

Answer: Intended action and paddle placement. The intended action for both defibrillation and cardioversion is to completely depolarize all the myocardial cells at once so the sinoatrial node can reestablish its role as the pacemaker of the heart; paddle placement is the same for both procedures, with one paddle over the right sternal order and the other over the apex of the heart.

Which route of administration should the nurse use when giving Mantoux test? 1. Intradermal injection 2. Subcutaneous injection 3. Localimplantation 4. Intramuscular injection

Answer: Intradermal injection. This is the route to be used for the Mantoux test; the substance used in the Mantoux test is the PPD, or purified protein derivative; a local reaction occurs if the person has been sensitized to the tuberculosis bacteria; positive reaction is an area of induration (hard area under the skin) of 15 mm

The nurse knows that medications is bested absorbed by a client with a major burn injury via which route? 1. Intramuscularly 2. Orally 3. Intravenously 4. Topically.

Answer: Intravenously Fluid shift during emergent post-burn phase causes limited absorption form subcutaneous and intramuscular spaces; administer medication prior to painful procedures; keep environment warm to prevent shivering.

A patient with a chest tube asks the nurse about the bubbling he sees in the water seal chamber of his drainage equipment. Which response by the nurse is the most appropriate? 1. It's supposed to do that 2. It shows your lung has not yet re-expanded 3. Why don't you ask your doctor? 4. What do you think it means?

Answer: It shows your lung has not yet re-expanded

The home care nurse makes a visit to a client receiving enteral feeding through a gastrostomy tube. The client's daughter reports the client has frequent loose stools. Which of the following statements, if made by the daughter to the nurse, warrants further investigation? 1. My dad gets 300 cc of formula in one hour 2. I warm the formula in a basin of hot water 3. I hang a new bag and tubing every 24 hours. 4. It so easy to give liquid medicine through the tube.

Answer: It's so easy to give liquid medicine through the tube. Many liquid medications contain sorbitol; if the client has an allergy to sorbitol it will cause diarrhea; nurse needs to determine what medication the client is receiving and if the medications contain sorbitol.

The nurse identifies which group of symptoms is indicative of a hemolytic transfusion reaction? 1. Hypotension, sudden fever, flushed 2. Kidney pain, hematuria, cyanosis. 3. Urticaria, wheezing, flushed skin. 4. Hives, itching, anaphylaxis

Answer: Kidney pain, hematuria, cyanosis Characteristics of a hemolytic reaction in which the hemolysis or destruction of blood cells occurs; leads to hematuria, cyanosis and kidney pain.

The nurse on the surgical unit cares for a patient after an ileostomy. Which of the following actions should the nurse take FIRST? 1. Empty the ileostomy bag from the bottom. 2. Apply lotion to the skin around the stoma 3. Cover the ileostomy with three layers of gauze. 4. Measure the output and record it in the chart.

Answer: Measure the output and record it in the chart. Assessment, output from the ileostomy is liquid and may be copious; important to assess patient's intake and output.

The nurse instructs a client with a full thickness burn injury of the legs about an appropriate diet. The nurse determines teaching is successful if the client selects which menu? 1. Meat and orange juice 2. Whole grain bread and an apple. 3. Green vegetables and milk. 4. Peanut butter and a banana.

Answer: Meat and orange juice Includes both meat, which is excellent source of protein, and orange juice, which is an excellent source of vitamin C; protein is necessary to offset the catabolism caused by the burn and to promote healing; and vitamin C also promotes wound healing.

An adult is in a motorcycle accident and sustains three fractured ribs and a pneumothroax. A chest tube is inserted. The nurse should take which of the following actions? 1. monitor the fluctuation in the tube 2. pin the tubes to the sheets 3. clamp the tubes when transferring the patient to bed 4. empty the bottles every eight hours.

Answer: Monitor the fluctuation in the tube. Closed drainage system that enables air and blood to drain from the pleural space; cessation of fluctuation may indicate blockage of the tube, or the ling has re-expanded; fluctuation in the tube should be monitored.

The nurse cares for a client diagnosed with acute cholecytitis. The client states, "My stomach hurts all the way up to my right shoulder. I am nauseated and have vomited twice." Which order should the nurse carry out FIRST? 1. Insert nasogastric (NG) tube and attach to intermittent low suction. 2. Trimethobenzamide 200 mg rectally three times daily 3. Morphine 15 mg Im q 4 hrs prn 4. Nothing by mouth

Answer: Morphine 15 mg IM q 4 hrs prn Address pain to make client more comfortable before performing other orders

The nurse instructs a client about how to increase folic acid in the diet. The nurse determines teaching is effective if the client makes which statement? 1. I like oatmeal for breakfast 2. My favorite lunch is spinach salad 3. I will eat more grapes, apples, and bananas each day. 4. I will eat more chicken.

Answer: My favorite lunch is spinach salad. Spinach contains 108mg per half-cup serving, other folate-rich sources include organ meats, broccoli, asparagus, milk, orange juice.

A patient is admitted to the hospital after sustaining severe electrical burn. A tracheostomy is performed, and the patient is unable to use either hand. It is MOST important for the nurse to take which of the following actions? 1. Obtain a closed-circuit video monitor 2. Pad the side rails of the bed 3. Obtain and blow-touch call bell 4. Transfer the patient with a Hoyer lift

Answer: Obtain a blow touch call bell. The patient is unable to use either hand, so the most appropriate way for him to summon the nurse is with a blow-touch call bell.

An older male patient complains to the physician of urinary frequency, urgency, and dysuria. A cystoscopy is performed. After the cystoscopy, which of the following nursing actions has the highest priority? 1. Obtain the patient's vital signs. 2. Report any nausea to the physician. 3. Review the patient's written discharge instructions. 4. Administer a sedative.

Answer: Obtain the patient's vital signs. Assess for bleeding and infection, which indicate complications; cystoscopy is direct visualization of the bladder; monitor character and volume of urine; urine usually pink-tinged; abnormal and pelvic pain indicate trauma.

The nurse evaluates a client's fluid balance. Which finding MOST likely requires an intervention? 1. Output is 300mL less than intake. 2. Output is 800mL less than intake 3. Intake is 1,800mL in 24 hours 4. Intake and output are equal.

Answer: Output is 800 mL less than intake Intake and output should be within 200-300 mL of each other; if client's output is 800 mL less than intake, indicates client retaining fluid, which requires an intervention.

The nurse understands that intermittent claudication is 1. Found in venous insufficiency. 2. Pain caused by cold. 3. Pain caused by walking. 4. Found only in the elderly.

Answer: Pain caused by walking. Intermittent claudication is pain felt in the calves when the patient walks and is seen in arterial insufficiency

The nurse understands which of the following is the principal reason for the use of enzymes inhibitors (Diamox) in a patient with pancreatitis? 1. Pancreatic enzymes are irritating to the liver. 2. Pancreatic enzymes escape into interstitial tissue. 3. Pancreatic enzymes are missing and must be replaces 4. Pancreatic enzymes are inactivated and must be enhanced.

Answer: Pancreatic enzymes escape into interstitial tissue. Interstitial pancreatitis is characterized by swelling of the gland and the escape of its digestive enzymes, lipase and amylase, into the surrounding tissues and into the peritoneal cavity, causing necrosis; Diamox helps inactivate these enzymes to help minimize the damage they would cause to normal tissue.

The spouse of a client with hepatitis B is given hepatitis B immune globulin (HBg). The nurse understands this offers which type of protection? 1. Complete 2. Active acquired. 3. Antigen 4. Passive acquired

Answer: Passive acquired Immune serums, such as HBIg contain gamma globulins in a concentration about 16% and are obtained from hepatitis B- immune persons from the general population; proved rapid but short-lived protection against hepatitis B; close contacts of a client with hepatitis B receive this immunization by intramuscular injection; treatment is usually repeated after 28 to 30 days.

The nurse cares for a patient in balanced suspension traction. The patient complains of pain in the affected extremity, and the nurse administers the prescribed medication. One hour later the patient states, "I don't know why, but the pain isn't getting any better." Which of the following actions should the nurse take FIRST? 1. Contact the physician. 2. Offer the patient a back rub. 3. Assess the level of the patient's pain. 4. Perform a neurovascular assessment.

Answer: Perform a neurovascular assessment. Any early sign of acute compartment syndrome is a sudden inability of pain medication to relieve pain.

When measuring the central venous pressure, it is MOST important for the nurse to take which action? 1. Find out about the previous reading 2. Place the manometer at he level of the right atrium 3. Position the client in an upright position 4. Instruct the client hold the breath during the reading

Answer: Place the manometer at level of the right atrium By placing the level of the manometer at the right atrium, the pressure reading will be equal to the pressure in the right atrium; if the manometer is higher or lower, the reading will be inaccurate; client should lie flat and breathe normally; reading should be taken at the highest level of fluctuation seen during respiration.

A central venous pressure line is inserted in a client. Following the catheter insertion, the client reports dyspnea, shortness of breath, and chest pain. The nurse understands the MOST probable cause of these symptoms is which? 1. Fluid overload 2. Pneumothroax 3. Hypokalemia 4. Pneumonia

Answer: Pneumothorax Pneumothorax is potential complication of the insertion of any central venous pressure line, especially a subclavain line; because of the proximity of the central veins and the lung cavity, pneumothorax can occur due to perforations of the pleura by the catheter; pneumothorax is collapse of a lung due to air in pleural space; symptoms include pain and respiratory distress.

The client with a history of kidney disease is admitted to the hospital reporting weakness and lethargy. The client's electrocardiogram shows sinus bradycardia with a prolonged PR interval. Which lab value does the nurse expect to find? 1. Potassium 3.0 mEq/L 2. Potassium 3.5 mEq/L 3. Potassium 5.0 mEq/L 4. Potassium 8.5 mEq/L

Answer: Potassium 8.5 mEq/L Serum potassium increased in kidney disease; symptoms of hyperkalemia (> 5.0 mEq/L) include muscle weakness, paralysis, nausea, diarrhea, dysrhthmias; EKG changes include heart block, prolonged PR intervals, flattened or absent P waves, and widened QRS complex.

The nurse teaches pursed-lip breathing to a patient diagnosed with COPD. The nurse understands which of the following BEST describes the underlying purpose of this type of breathing? 1. Prevent air trapping 2. Strengthen oral musculature 3. Promote deep relaxation 4. Enhance inspiration capacity

Answer: Prevent air trapping As air is pushed against the small opening between the lips, the resistance created goes backwards and through the airways and pushes them open throughout expiration; pursing lips also prolongs exhalation; all this results in a delay of airway compression or collapse, allowing more air to escape and preventing air trapping; in pursed lip breathing, the patient breathes in deeply through the nose, hold it for a moment, and then exhales slowly through lips that are almost closed or pursed as if the patient were going to whistle; exhalation should be at least twice as long as inhalation.

The nurse cares for a client diagnosed with tuberculosis. The client asked, "Why do I have to take VitaminB6 (pyridoxine)" What explanation does the nurse provide? 1. Promote the absorption of isoniazid 2. Prevent neuritis 3. Alleviate gastrointestinal symptoms 4.Prevent kidney damage.

Answer: Prevent neuritis Neurtitis is a potential complication of isoniazid treatment, pyridoxine is given along with the isoniazid to help prevent neuritis.

A continuous intravenous infusion of heparin is administered to a patient. It is MOST important for the nurse to have which of the following medications available? 1. Digitalis 2. Vitamin K 3. Magnesium sulfate. 4. Protamine sulfate.

Answer: Protamine sulfate. The action of heparin is to interfere with normal blood coagulation; protamine sulfate is the antagonist to heparin and should be kept on hand at all times.

A client is started on warfarin. The nurse instructs the client to regularly obtain blood work to measure which laboratory value? 1. Prothrombin time 2. Clotting time. 3. Partial thromboplastin time. 4. Platelet count.

Answer: Prothrombin time. Warfarin interferes with prothrombin formation; when client is receiving warfarin, prothrombin times should be closely monitored; therapeutic level is 1.5 times the control.

The nurse cares for a client with an amputation with an immediate prosthetic fitting. The nurse should include which of the following in the client's plan of care. 1. Assess drainage from Penrose drains. 2. Observe dressing for signs of excessive bleeding. 3. Elevate the residual limb for no less than 40 hours. 4. Provide cast care on the affected extremity.

Answer: Provide cast care on the affected extremity. Closed rigid cast prevents bleeding, supports soft tissues to control pain, and will prevent contracture; because there is a rigid plaster cast, cast care is required.

After inserting a needle into the gluteal muscle to inject vitamin K, which of the following actions should the nurse perform next? 1. Instruct the patient to contract her muscle 2. Pull back the plunger for aspirate 3. Administer the vitamin K as quickly as possible 4. Pull back the needle while injecting slowly.

Answer: Pull back the plunger and check for aspirate Most important action is to pull back the plunger to make sure that blood does not return, and the needle has not penetrated into a vein.

A client recieves magnesium sulfate IV for treatment of preeclampsia. The nurse knows that it is MOST important to have what at the beside? 1. Oxygen and padded tongue blade 2. Reflex hammer and calcium gluconate. 3. Protamine sulfate and Vitamin K 4. Particulate respirator and suction equipment.

Answer: Reflex hammer and calcium gluconate. Magnesium has CNS depressant effects; reflex hammer needed for monitoring deep tendon reflexes, the lessening or loss of which indicates hypermagnesemia; IV calcium gluconate can block the effects of hypermagnesemia; also, kidney excretion of magnesium can be increased with saline infusions having a diuretic effect, but calcium loss is a side effect and hypoclacemia can intensify hypermagnesemia, so calcium supplements need to be given.

The health care provider orders a clear liquid diet for a client after an appendectomy. The nurse explains to the client a clear liquid diet was ordered for which reason? 1. Provide adequate calories. 2. Relieve thirst and maintain fluid balance. 3. Stimulate the gastrointestinal tract so the client will have bowel movements 4. Provide complete nutrition.

Answer: Relieve thirst and maintain fluid balance. Offer clear fluids or foods that are fluid at body temperature; requires minimal digestion and leaves minimal residue; clear liquids are the initial feeding after surgery or parenteral nutrition.

After cholecystectomy, patient is returned to the unit with a nasogastric tube connected to low intermittent suction,an IV of D5W a T-tube in place, and a Penrose drain. The nurse understands that the purpose of the Penrose drain includes which of the following? 1. Remove accumulated bile and blood after surgery 2. Permit irrigation of the peritoneum with antibiotic solution 3. Provide access to the cystic duct postop 4. Provide a route for alimentation.

Answer: Remove accumulated bile and blood after surgery Duct must be allowed to drain; bile would otherwise drain in the surrounding tissue, be very caustic, and cause problems for the patient.

The nurse cares for an older client admitted to the hospital for persistent vomiting and abdominal pain. A nasogastric (NG) tube is inserted and connected to suction, and an intravenous infusion of 1,000 of D5W with 20 mEq of potassium chloride is started to infuse at 100 mL per hour. The nurse understands potassium chloride has been added to the infusion for which reason? 1. Replaces the potassium lost in the gastric fluid. 2. Replace decreased dietary potassium due to NOP status. 3. Prevent the loss of sodium in the urine. 4. Prevent the loss of potassium in the urine.

Answer: Replaces the potassium lost in the gastric fluid. Clients with NG tubes connected to nasogastric suction lose a large amount of fluids and electrolytes; replacing potassium via an IV will prevent hypokalemia form occurring; symptoms of hypokalemia is (less than 3.5 mEq/L) include muscle weakness, paresthesias, and dysrhythmias, and it increases sensitivity to digitalis; IV potassium irritates and can cause phlebitis; assess IV site q 2 hrs.

The nurse knows that it is essential to have which of the following pieces of equipment at the beside of the patient receiving mechanical ventilation? 1. Resuscitation bag 2. Incentive spirometer 3. Particulate respirator 4. Patient-controlled analgesia (PCA) machine

Answer: Resuscitation bag A manual resuscitation bag, such as an Ambu, must be readily available and visible at the bedside of any patient receiving mechanical ventilation so that the ventilation can be maintained if a machine failure occurs or the patient has another emergency; bags should not be centralized or shared between patients due to cross-contamination and also to possible compromised availability.

A patient asks the nurse, "What is the difference between rheumatoid arthritis and osteoarthritis?" Which of the following responses by the nurse is BEST? 1. Rheumatoid arthritis is progressive and osteoarthritis is not 2. Rheumatoid arthritis is often treated surgically and osteoarthritis is not 3. Rheumatoid arthritis is a systemic disease and osteoarthritis is not 4. There is very little clinical difference between rheumatoid arthritis and osteoarthritis.

Answer: Rheumatoid arthritis is a systemic disease and osteoarthritis is not. Osteoarthritis is wear and tear disease; rheumatoid arthritis is a systemic inflammatory disease that affects the synovial joints as well as the blood vessels causing vasculitis; since it affects connective tissue, can affect any body system with connective tissue.

A client is scheduled for bowel surgery,and the health care provider orders a low-residue diet as a part of the bowel preparation. The nurse instructs the client about foods allowed on a low-residue diet. The nurse determines the teaching is effective if the client chooses which menu? 1. Bouillon grilled cheese sandwich, and grapes. 2. Corned beef, buttered peas, and custard. 3. Roast lamb, buttered rice, and sponge cake. 4. Strained cream of asparagus soup, bacon, and tomato sandwich, and a sugar cookie

Answer: Roast lamb, buttered rich, and sponge cake. Foods allowed included well-cooked tender meats (roast lamb), fish and poultry; milk and mild cheeses, juices without pulp (no prune juice), canned fruit and ripe bananas; white bread or refined bread.

A patient is admitted to the hospital with a diagnosis of acute right upper lobe pneumonia. The patient has a history of chronic bronchitis and type 1 diabetes. Which symptom would the nurse to expect to see? 1. Moist, cool skin 2. Rust-colored sputum 3. Bradycardia 4. Decreased respiratory rate

Answer: Rust-colored sputum Purulent, blood-tinged or rust-colored sputum due to inflammation; increased respirations, dyspnea, pleurtic pain; treatment includes antibiotics, chest physiotherapy, cough and deep breathe every two hours, encourage fluids, assess breath sounds.

The nurse cares for a patient after a traditional cholecystectomy. It is MOST important for the nurse to position the patient in which of the following positions? 1. Side-lying with bed flat 2. Supine with bed flat 3. Semi-Fowler's 4. Knees elevated.

Answer: Semi-Fowler's Semi-Fowler's is optimal for the patient because it will allow her to take the necessary deep breaths that are important to prevent pneumonia after surgery.

A patient is scheduled for rhinoplasty. Postoperatively, it is MOST important for the nurse to place the patient in which of the following positions? 1. Supine 2. Left Sims 3. Modifed Trenedelenburg's 4. Semi-Fowlers

Answer: Semi-Fowlers The patient should be placed in a semi-Fowler's position to decreased edema, promote drainage, and facilitate breathing.

The nurse reviews the records of a client diagnosed with Laennec's cirrhosis. The nurse expects to find which lab value? 1. Serum albumin 4.0g/dL 2. Serum aspirate aminotransferase (AST, SGOT) 38 units 3. Serum alanine amino-transaminase (ALT, SGPT) 600 units 4. Serum lactate dehydrogenase (LDH) 150 units

Answer: Serum alanine amino-transaminase (ALT, SGPT) 600 units Elevation indicates liver damage; normal is 5-35 unites.

The cardiac nurse instructs a patient scheduled to receive a pacemaker about how the usual cardiac conduction cycle flows. Which of the following should the nurse identify as the natural pacemaker of the heart? 1. Atrioventrcular (AV) node. 2. Purkinje fibers. 3. Bundle of His 4. Sinoatrial (SA) node.

Answer: Sinoatrial (SA) node. SA node is the pacemaker of the heart, usually initiating impulses (heartbeats) at 60-100 beats per minute (bpm); it is located in the junction of the superior vena cava and the right atrium; it regulates heart rate, rhythm, and regularity; other components of the conduction pathway have potential to discharge impulses independently, but the SA node releases impulses more rapidly and therefore assumes control over the process.

A client is evaluated in the clinic for rheumatoid arthritis. Which of the following findings should assume the highest priority for the nurse when assessing and planning the client's care? 1. Subcutaneous nodules on the client's right and left forearms. 2. Slight contracture of the right wrist. 3. Mild erythema of finger joints. 4. Bruised area and about 3 mm in diameter on right forearm.

Answer: Slight contracture of the right wrist. Indicates inadequate pain management; give prescribed medications as ordered on time to ensure constant blood levels; alternate rest and activity; position joints properly; ice applied for for acute inflammation; heat (showers and hot packs) used to relieve stiffness.

Which laboratory finding should the nurse expect if a client is diagnosed with a fluid volume deficit? 1. Specific gravity 1.020 2. Specific gravity 1.034 3. Potassium 5.8 mEq/L 4. Potassium 4.8 mEq/L

Answer: Specific gravity 1.034 Specific gravity greater than 1.030 indicates fluid volume deficit; other symptoms include increased temperature, rapid, weak pulse, poor skin turgor, hypotension, dry eye sockets, dry mouth and mucous membranes; nursing considerations: force fluids, provide isotonic IV fluids, daily weights.

The nurse cares for a client with a nasogastric tube in place. The client reports discomfort in the back of the throat. Which action by the nurse is BEST? 1. Move the tube out 2 inches. 2. Change feedings to full liquids 3. Reinsert tube into other nostril. 4. Spray with viscous lidocaine solution.

Answer: Spray with viscous lidocaine solution. Viscous lidocaine is a local anesthetic, spraying it on the irritated surface may relieve the discomfort in the back of the client's throat.

The nurse identifies which group of equipment is essential to have at the beside of a patient with a closed-chest tube drainage system in place? 1. Tape measure, portable scale, Sengstaken-Blakemore tube 2. Penlight, reflex hammer, safety pin 3. sterile connector, sterile petrolatum gauze pad, padded clamp 4. Nasogastric tube, blood glucose monitor, sputum jar

Answer: Sterile connector, sterile petrolatum gauze pad, padded clamp All are related to management of chest tubes, particularly emergencies; sterile connector is used to reestablish drainage system if tubing disconnects from the drainage equipment, gauze pad is used if chest tube dislodges form body of patient, forming a seal so atmospheric air cannot get into the negative pressure thoracic cavity; padded clamp is used, briefly and with extreme caution, to assess for possible air leak and also prior to removing chest tube.

The nurse should lubricate catheter used to suction a patient's tracheostomy with which of the following? 1. Sterile water 2. Mineral oil 3. Hydrogen peroxide 4. K-Y jelly

Answer: Sterile water Sterile water is the preferred lubricant because it won't irritate the tissues; can also use sterile saline

The nurse assesses a patient with a diagnosis of osteoarthritis. The nurse expects to observe which of the following sings/symptoms? 1. Pain on abduction of the hips, waddling gait. 2. Fever, rash, and nodules over bony prominences. 3. Swollen, reddened, painful joint with limitation of motion. 4. Stiffness of the hips, knees, vertebrate, and fingers.

Answer: Stiffness of the hips, knees, vertebrate, and fingers. Osteoarthritis is a wear and tear disease characterized by stiffness in the joints, usually in the hips, vertebrae, and fingers.

When any type of transfusion occurs, which will be the nurse's FIRST action? 1. Recheck the type and cross-match 2. Slow down the transfusion 3. Stop the transfusion 4. Notify the health care provider

Answer: Stop the transfusion Any type of transfusion reaction can be life-threatening; the blood should be stopped immediately if a change in the client's status is noted; keep IV line open by piggy backing normal saline directly into IV line, notify health care provider, observe signs and symptoms, obtain vital signs frequently, administer emergency medications as ordered, obtain urine specimen.

The nurse cares for a patient complaining of sudden onset of severe right flank pain. The patient is diagnosed with urinary calculi. Which of the following nursing actions has the HIGHEST priority? 1. Ensure that the patient remain NPO. 2. Strain all urine through several layers of guaze. 3. Assess the patient's grip strength and pupil reactivity. 4. Obtain a clean-catch urine specimen.

Answer: Strain all urine through several layers of gauze. Urine should be strained to collect any stones that may be passed so that they can be analyzed for composition.

Immediately following thoracentesis, the nurse notices a progressive swelling on the right side of the patient's chest and neck. The nurse knows which of the following conditions is the MOST likely cause of the swelling? 1. Pneumothroax post-thoracentesis 2. Subcutaneous emphysema 3. Lipoma 4. Hematoma formation

Answer: Subcutaneous emphysema Subuctaneous emphysema is a complication of thoracentesis in which air leaks into subcutaneous tissue and cuases swelling; as more air enters the tissue, the swelling progresses. Crepitus is felt as a crackling sensation beneath the fingertips.

The home care nurse visits a client diagnosed with chronic bronchitis. The nurse notes the client is weak and congested. It is MOST important for the nurse to make which statement? 1. Cough as much as you can. The secretions have to come out. 2. If you hold a pillow against you abdomen, the coughing will be easier 3. Take 3 to 4 deep breaths, and as you exhale the last breath, cough 3 times. 4. It does not matter when you cough just do it.

Answer: Take 3 to 4 breaths and as you exhale the last breath, cough 3 times. The client should sit with feet on the floor, lean slightly forward, and take several slow deep breaths through the nose; exhalations should be slow and through pursed lips; during exhalation of the last breath the client should cough several times; mucus is moved up the respiratory tree more effectively with several consecutive coughs than with a single one.

To facilitate communication withe a patient with a tracheostomy, which of these nursing approaches is Best? 1. Tell the patient to nod his head to indicate yes, and shake his head to indicate no. 2. Tell the patient to mouth words so that the nurse can lip-read 3. Have someone who knows the patient stay at the beside to act as interpreter. 4. Ask the patient to anticipate needs and write them down.

Answer: Tell the patient to nod his head to indicate yes, and shake his head to indicate no. Important for nurse to establish a way that patient can communicate; asking yes/no questions and instructing the patient to nod his head to indicate yes and shake his head to indicate no is a practical way for the patient to communicate with the nurse.

An older client has a medical history that includes hypertension. A public health nurse visits the client regularly and on each visit records the vital signs. The nurse expects which of the following finding for this client? 1. Temperature 99.5, blood pressure 140/80, pulse 110, respirations 32. 2. Temperature 98.6, blood pressure 120/80, pulse 78, respirations 16. 3. Temperature 99.9, blood pressure 150/90, pulse 90, respirations 20. 4. Temperature 96.8, blood pressure 160/92, pulse 80, respirations 24.

Answer: Temperature 96.8, blood pressure 160/92, pulse 80, respirations 24. In the elderly, body temperature may decrease; normal temperature for this client; blood pressure of 160/92 would be expected in a patient who has a medical history of hypertension; pulse of 80 would be normal; respirations of 24 normal.

A patient had a transurethral resection of the prostate (TURP). On the third postoperative day, his urinary catheter is removed. Later on that day he complains to the nurse that he is having uncontrolled dribbling after urination. The nurse's response should be based upon the knowledge that 1. Urinary incontinence is abnormal only if pus appears in the urine. 2. Urinary control should rapidly return to normal after catheter removal. 3. Urinary incontinence results from premature catheter removal, and replacement is indicated. 4. Temporary urinary incontinence is not unusual following catheter removal.

Answer: Temporary urinary incontinence is not unusual following catheter removal. Normal to note some dribbling of urine after a urethral catheter has been removed; is a result of the dilation of the sphincter muscles by the catheter.

The nurse cares for a patient 18 hours after gastrectomy. The nurse is MOST concerned if which of the following is observed? 1. The Levin's tube is attached to low continuous suctioning. 2. The patients output during the previous 6 hours was 500 cc 3. The patient asks for pain medication 4. The patient performs deep breathing every two horus.

Answer: The Levin's tube is attached to low continuous suctioning. Levin's tube is a single lumen tube with no air vent, suction should be intermittent, continuous suction appropriate for a Salem tube.

The nurse instructs a group of high school students how to perform the abdominal-thrust maneuver. The nurse determines that teaching is successful if a student makes which comment? 1. The abdominal thrust maneuver dislodges food or other foreign bodies from the airway. 2. The abdominal thrust maneuver involves hitting the person on the back several times. 3. The abdominal thrust maneuver should not be done if the person is pregnant 4. The abdominal thrust maneuver should only be done by a well-trained health care professional.

Answer: The abdominal thrust maneuver dislodges food or other foreign bodies form the airway. Hands crossed at neck is universal sign of chocking; abdominal thrust maneuver is used to dislodge food or other foreign bodies. For pregnant or obese persons place the fist in the middle of the sternum and press backward toward the spine.

A client is being taught how to care for an ileostomy appliance,. Which should the nurse emphasize as MOST important when applying a new bag? 1. The bag sould fit snugly 2. The bag should be long enough 3. Drying powder should be used in the bag. 4. The bag should have an air vent

Answer: The bag should fit snugly Drainage from an ileostoy is constant and liquid, and it contains enzyme; bag must fit snugly to prevent extrusion of this fluid onto the abdomen and excoriation or actual digestion of the skin.

The nurse monitors a client receiving a blood transfusion. The nurse should intervene if which is observed? 1. The blood infuses in three hours 2. The blood is started with normal saline 3. The blood is started 15 minutes after arriving form the blood bank 4. The blood infuses at 10mL/min for the first 15 min.

Answer: The blood infuses at 10mL/min for the first 15 minutes Blood should run slowly at first (no faster than 5 mL/min for the first 15 min); if no reaction, regulate blood to the prescribed rate.

The assess the pulse during adult cardiopulmonary resuscitation (CPR), which site should the nurse assess? 1. The femoral artery. 2. The radial artery. 3. The carotid artery. 4. The brachial artery.

Answer: The carotid artery. Carotid artery is most accessible; if there is a weak pulse, it will most likely be felt in the carotid artery; use for adults and children from the ages of 1-8 years.

A client diagnosed with iron deficiency anemia receives heparin after a venous thromboembolism (VTE) is diagnosed in the left leg. 1. The client passes a black stool. 2. The client is pale. 3. The client has a nosebleed. 4. The client is confused.

Answer: The client has a nosebleed. Bleeding form any body site can indicate hemorrhage, the primary concern with anticoagulant drugs such as heparin; immediate management of the epistaxis (nosebleed) and notification of the health care provider and should occur; if needed protamine sulfate, the specific heparin antagonist, may be given.

The nurse cares for a client admitted with a diagnosis of acute pancreatItis. An IV is begun and the nurse inserts a nasogastric tube and attaches it to intermittent low suction. The nurse gives frequent oral hygiene and administers morphine for reports of pain. Which client behavior indicates to the nurse the medication is effective? 1. The client sleeps for one hour 2. The client frequently changes position in bed 3. The client states there is less nausea. 4. The client does not report thirst

Answer: The client sleeps for one hour. Acute pancreatitits causes severe abdominal pain, pain increases body metabolism, which increases secretion of pancreatic and gastric enzymes, client sleeping indicates morphine is effective; important to evaluate the effectiveness of the medication.

Prednisone 2 mg qd is prescribed for a client with rheumatoid arthritis. What important points should the nurse include when teaching the client about this medication. 1. The health care provider will increase the dose until there is complete relief of symptoms. 2. The dosage of prednisone must be increased and decreased gradually. 3. Some people experience incontinence as a side effect of this medication. 4. Prednisone is a dangerous medication and must be carefully monitored.

Answer: The dosage of prednisone must be increased and decreased gradually. Corticosteriod that acts as an ant inflammatory; long-term effect of chronic steroid therapy includes osteoporosis, cataracts, hypertension, and diabetes; it is important to withdraw this medication gradually to minimize the reaction of the body to the sudden loss of exogenous steroids; with prolonged steroid administration, the adrenal glands are suppressed

The nurse instructs the family of a client diagnosed with hepatitis A about how to prevent the spread of the disease. It is MOST important for the nurse to include which instruction? 1. The family should not share eating utensils and drinking glasses 2. Do not come in contact with the client's blood 3. Do not donate blood during the next year 4. No special precautions are required because family treated with gamma globulin.

Answer: The family should not share eating utensils and drinking glasses. Hepatitis A is a spread by fecal-oral route; client should wash hands before eating and after using the toilet.

The pediatric nurse cares for a 3-year-old child diagnosed with acute laryngotracheobronchitis in a croupette. The nurse is MOST concerned if which of the following is observed? 1. The air inside the croupette is cool 2. The grandmother gives the child a teddy bear. 3. The child has a cap on the head 4. The child appears frightened unless someone is nearby

Answer: The grandmother gives the child a teddy bear. Croupette is a humidified oxygen tent, a teddy bear, while appropriate for his age, can present a breeding ground for microorganisms by its absorption of moisture; also, depending on the materials used in it e.g. wool, polyester, rayon-it could present a fire hazard; vinyl or plastic are the best materials for toys in a croupette; metal and/or electrical ones could cause sparks; attention should also be given to buttons or other choking hazards.

The nurse cares for a patient after a coronary artery bypass graft (CABG). Which observations during the postoperative period MOST concerns to the nurse? 1. The heavy chest tube drainage suddenly stops. 2. The patient is confused, disoriented, agitated. 3. The temperature of the patient is 97.6 F (36.5 C) 4. The patient is coughing poorly.

Answer: The heavy chest tube drainage suddenly stops. Sudden cessation of mediastinal chest tube drainage after a CABG, especially when the drainage was heavy, is a hallmark manifestation of cardiac tamponade; in cardiac tamponade blood and/or fluid collects in the pericardial sac, presses on the heart, and prevents atria and ventricles from filling adequately; cardiac output is thus reduced; emergency sternotomy and volume expanders are the treatment of choice.

The patient diagnosed with cholecystitis is blind. In preparation for surgery, the nurse teaches the patient diaphragmatic breathing. Which is the MOST effective teaching method for the nurse to use? 1. The nurse demonstrates diaphragmatic breathing and then asks the patient do a return demonstration. 2. The nurse discusses the rationale behind postoperative abdominal breathing, outlines the steps, and answers questions. 3. The nurse asks the patient to put both hands on the abdomen and breath in and out while keeping the chest still 4. The nurse asks the patient to tighten and release muscles, progressing form the toes to the head.

Answer: The nurse asks the patient to put both hands on the abdomne and breath in and out while keeping the chest sill.

The nurse cares for an elderly patient admitted with a diagnosis of hepatitis A. The patient is anorexic complains of weakness, is incontient of urine, and involuntary of stool. The nurse determines that care is appropriate if which of the following is observed? 1. The staff caring for the patient follows standard precautions. 2. The patient is offered more frequent feeding during the afternoon and evening hours. 3. The nurse maintains the patient on strict bedrest. 4. The nurse places the patient on contact precautions.

Answer: The nurse places the patient on contact precautions. Hepatitis A spread by fecal-oral contact precautions required due to fecal incontinence; instruct patient in importance of good handwashing.

The nurse prepares a patient for a total hip replacement. Which of the following observations by the nurse necessitates contacting the physician? 1. The patient's hemoglobin is 15g/dL. 2. The patient complains of burning on urination. 3. The patient complains of periodic heart burn. 4. The patient's platelet count is 250,00/mm3

Answer: The patient complains of burning on urination. Indicates a UTI, an infection from any source in the body is contraindication to a total joint replacement.

The nurse cares for a patient after a right below-the-knee amputation. The nurse MOST concerned if which of the following is observed? 1. The patient periodically naps. 2. The patient complains of a throbbing headache. 3. The patient complains of persistent pain at the operative site. 4. The nurse palpates a pulse above the operative site.

Answer: The patient complains of persistent pain at the operative site. Redness, swelling, and pain indicate inflammation and infection; nurse should inspect the limb and drainage, and notify the physician of any signs of infection.

The nurse cares for a patient following a myocardial infarction. Which of the following information, obtained during the health history, is MOST significant when planning for the patient's discharge? 1. The patient takes daily vitamin supplements. 2. The patient has a history of pneumonia. 3. The patient plays golf once a week. 4. The patient has a high-stress job.

Answer: The patient has a high-stress job. High-stress job is a significant risk factor for cardiac disease.

The nurse monitors a patient receiving oxygen per face mask. The nurse is MOST concerned if which is observed? 1. There is condensation in the tubing of the humidifier container 2. The pulse oximetry reading is 92% 3. The patient has a nonproductive cough. 4. The skin under the elastic band is reddened.

Answer: The patient has a nonproductive cough. Nonproductive cough is an early symptom of oxygen toxicity; other early symptoms include congestion, sore throat, substernal discomfort or pain, GI upset, dyspena. This is known as ARDS; treatment of the toxic effects is very difficult, and prevention is a priority.

The nurse cares for a patient immediately after laryngoscopy. It is MOST important for the nurse to interven if which of the following is observed? 1. The patient is talking with the nurse 2. The patient coughs spontaneously 3. The patient is drinking from a straw 4. The patient is moving about in bed.

Answer: The patient is drinking from a straw Anesthesia is used during the procedure; patient should not be taking fluids orally immediately after the procedure to avoid the possibility of aspiration of fluid into the lungs; no fluid should be given until normal swallowing and gag reflex has returned.

The nurse obtains a history from a man admitted to the hospital with COPD. The nurse identifies which of the following factors is related to the patient developing COPD? 1. The patient smoked for more than 30 years. 2. The patient worked in an orchard for 20 years. 3. The patient drinks 4 cans of beer a day 4. The patient had pancreatitis 4 times.

Answer: The patient smoked for more than 30 years. COPD is a group of conditions associated with obstruction of air flow entering or leaving the lungs; chronic bronchitis causes excessive mucus and secretions,which block the airways; emphysema causes destruction of the walls of over-distended alveoli; smoking is the most important risk factor for COPD.

The nurse is planning discharge teaching for a patient diagnosed with peripheral vascular disease. It is MOST important for the nurse to address which of the following? 1. The patient drinks socially. 2. The patient walks two miles a day. 3. The patient takes vitamins daily. 4. The patient smokes heavily.

Answer: The patient smokes heavily. Smoking is a predisposing factor for arterial peripheral vascular disease.

In formulating a nursing care plan for a patient following a myocardial infarction, the nurse should include which of the following? 1. The patient will return to the pre-illness activity. 2. The patient will achieve the optimum level of health. 3. The patient will be free from pain and dysrhythmias. 4. The patient will eliminate all stress from the lifestyle.

Answer: The patient will be free from pain and dysrhythmias. This goal is realistic, achievable, and measurable.

The nurse observes a student nurse suction the right bronchus of a patient via tracheostomy. The nurse determines care is appropriate if the student nurse places the patient's head in which positions? 1. The patient's head turned to the left 2. The patient's head turned to the right 3. The patient's head titled toward the chest 4. The patient's head tilted backward even with the shoulders.

Answer: The patient's head turned to the left When a tracheostomy is suctioned, the head should be positioned to the side opposite form that of the bronchus being suctioned; learning the right bronchus is therefore accomplished by turning patient's head to the left.

The nurse cares for a patient after a total hip replacement due to degenerate joint disease. The nurse should intervene if which of the following is observed? 1. The patient uses an incentive spirometer every 2 hours. 2. The patient is positioned with a pillow between the legs. 3. The patient's heels are lying on the bed with toes pointed upward. 4. The patient moves slowly when getting out of bed.

Answer: The patient's heels are lying on the bed with toes pointed upward. Elderly are prone to pressure sores; keep heels off bed to prevent pressure sores.

A patient is scheduled to have an intravenous pyelogram (IVP). Which of the following information is MOST important for the nurse to obtain prior to the procedure? 1. The date of the patient's last electrocardiogram. 2. The time of the patient's last meal. 3. The patient's history of allergies. 4. The patient's response to emetics.

Answer: The patient's history of allergies. Imperative to know whether the patient is sensitive to iodine because the oil-based radiopaque material used in an IVP contains iodine; this oil-based should also not be given to individuals with known sensitivity to shellfish, because there is a strong relationship between an iodine allergy and a shellfish allergy.

When a nurse administers dopamine via IV drip, which of the following factors is MOST important ? 1. The patient's urinary output. 2. The patient's pre-shock blood pressure. 3. The patient's weight in kilograms. 4. The patient's mental status.

Answer: The patient's weight in kilograms Dopamine is administered according to micorgrams per kilograms per hour; administer via pump titrated to a certain dosage.

Albuterol (Proventil) and baclomethasone (Vanceril) by metered dose inhaler (MDI) are ordered for a patient recently diagnosed with asthma. The patient asks the nurse, "Why do I have to be concerned about which medication I take first and waiting in between medication?" Which is the BEST response by the nurse? 1. That is how your physician wrote the order. 2. You do not have to be concerned. You can take them in whatever way works best for you as long as you take them both. 3. That is the standard way these medications are administered. 4. The proventil will open up the airway so the vanceril can be better absorbed. You wait to allow the Proventil to have its full effect.

Answer: The proventil will open up the airway so that vanceril can better be absorbed. You wait to allow the Proventil to have its full effect The Proventil is a bronchodilator; it will open the airway so the Vanceril, which is a steroid, will be absorbed; the 5 minute wait allows for the airway opening to occur; the steroid functions to directly affect smooth muscle relaxation to enhance the effect of some bronchodilators and also to inhibit inflammaiton that could result in bronchoconstriction.

The nurse performs a home care visit on a client with a diagnosis of right-sided cerebrovascular accident. The client's spouse complains about having frequent loose stools, and the physician diagnosed viral gastroenteritis. The nurse is MOST concerned if which of the following is observed? 1. The spouse washes hands frequently 2.The spouse drinks Gatorade. 3. The spouse uses a separate tube of toothpaste. 4. The spouse prepares lunch for the client.

Answer: The spouse prepares lunch for the client. Due to diarrhea, should not prepare foods that will be eaten by others.

The nurse cares for a patient immediately after a complete cystectomy and ileal conduit. The nurse is MOST concerned if which of the following is observed? 1. The nursing output is 60 ml per hour. 2. The stoma appears red in color. 3. The stoma is edematous. 4. There is a small amount of serosanguineous drainage.

Answer: The stoma is edematous. Edema can cause obstruction of stoma; also observe for excessive bleeding or enlargement of stoma.

The nurse observes a student nurse begin an IV on an eldery client. The nurse should intervene if which action is observed? 1. The student nurse uses a 24-gauge catheter to start IV 2. The student nurse marks the time onthe IV bag with a permanent marker. 3. The student nurse inserts the catheter at a 10 degree angle 4. The student nurse sets the flow rate at 100ml per hour

Answer: The student nurse marks the time on the IV bag with a permanent marker Putting permanent marker straight on the bag can contaminate the solution; so use a time taping.

A client receiving verapamil in the sustained-release form complains of a headache. Which information should the nurse provide the client? 1. This is an unrelated symptom and should be reported. 2. This medication often causes headache. 3. This medication should be stopped until the headache disappears. 4. She should go immediately to the emergency room.

Answer: This medication often causes headache. Verapamil is a calcium channel blocker that sometimes causes headache, constipation, fatigue, and dizziness; non-narcotic analgesia is often prescribed to teat the headache; this side effect seem to diminish over time.

The nurse discovers an unconscious person in the street. The nurse notes that the person is not breathing. The nurse should take which action? 1. Lift the back of the person's neck. 2. Use the thumbs to move the person's lower jaw backward. 3. Turn the person's head to one side. 4. Tilt the person's head back and lift the chin.

Answer: Tilt the person's head back and lift the chin. By tilting the head backward and lifting the chin upward so it points straight up, the upper airway will open; this maneuver removes the tongue from obstructing the airway, a common cause the airway obstruction in unconscious people; sometimes by just performing this maneuver, the person will start breathing again.

The nurse cares for a client admitted to the unit with a diagnosis of acute myocardial infarction. The nurse understand that a cardiac monitor is attached to this patient for which of the following reasons? 1. To monitor patient's condition closely without having to awaken the patient. 2. To prevent another, more serious heart attack for occurring. 3. To verify diagnosis of acute myocardial infarction. 4. To detect any life-threatening changes in the heart rhythm.

Answer: To detect any life-threatening changes in the heart rhythm. Cardiac monitor displays the patient's hear rhythm; by observing this, any abnormalities such as PVC or ventricular fibrillation can be detected.

The nurse of the neurologic unit knows that which is the primary reason for having a patient diagnosed with cardiovascular accident (CVA) position the head flexed slightly forward when sitting upright to eat? 1. To increase the ease of swallowing 2. To decrease the musculature effort of maintaining the head erect. 3. To decrease the anxiety from seeing feeding utensils coming directly at them. 4. To prevent aspiration

Answer: To prevent aspiration When the head is flexed slightly forward when the patient is seated erect it closes the epiglottis, thus preventing aspiration.

The health care provider orders a diet low in protein for the client with chronic kidney disease. The nurse understands this diet is prescribed for which reason? 1. To decrease fluid retention. 2. To prevent diaphoresis. 3. To prevent shock. 4. To prevent hyperkalemia.

Answer: To prevent hyperkalemia. Protein catabolism or breakdown results in the release of cellular potassium into the body fluids; in acute kidney injury, there is no mechanism to remove potassium from the body; severe hyperkalemia alters normal cardiac function; client must decrease the intake of potassium by a diet that is low in potassium.

The nurse prepares a patient for a thoracentesis. The nurse should position the patient in which position. 1. Semi-Fowlers 2. Upright 3. On the affected side 4. Prone

Answer: Upright A thoracentesisis the aspiration of pleural fluid or air form the pleural space; sitting upright on the edge of the bed allows for the best lung expansion, and allows for good access to the area which will be used for procedure.

The outer cannula of a patient's tracheostomy tube is accidentally expelled 36 hours after surgery. Which action should the nurse take FIRST? 1. Contract the physician immediately 2. Cut the tracheostomy neck ties 3. Insert the emergency outer tube that is taped to the head of the bed 4. Ventilate the chest using a manual resuscitation bag.

Answer: Ventilate the chest using a manual resuscitation bag. Nurse should use a manual resuscitation bag to ventilate patient while another staff member contacts the resuscitation team; if nurse tries to insert tube in a new (under 72 hours) tracheostomy, may cause tissue damage because the tract is not matured.

The nurse understand the primary mechanism of aciton of synchronized intermittent mandatory ventilation (SIMV) for a patient requiring respiratory support is which? 1. The delivery of breaths is synchronized with the R wave of the patient 2. A set tidal volume is delivered at a set rate regardless of the breathing efforts of the patient. 3. Positive pressure is intermittently exerted at the end of the ventilator breaths. 4. Ventilator breaths are correlated with patient breathing and patient can breathe naturally in between.

Answer: Ventilator breaths are correlated with patient breathing and patient can breath naturally in between.

The nurse educator conducts an orientation class for new graduate nurses who will be caring for cardiac patients on the medical surgical unit. The educator should remind the nurses that the QRS complex of an electrocardiogram (EKG) reflects which of the following? 1. Atrial depolarization. 2. Ventricular depolarization. 3. Ventricular repolarization. 4. Central venous pressure.

Answer: Ventricular depolarization. The QRS complex represents depolarization of the ventricles; occurs after the atrial depolarization, represented by the P wave, and the subsequent PR segment, which represents the length it takes for the impulse to travel through the AV node, bundle of His system and Purkinje fibers; ventricular depolarization may be conceptualized as ventricular systole.

Blood gas results on a patient with emphysema indicate severe hypoxia. Oxygen therapy is ordered. Which method of oxygen administration will MOST likely be used? 1. Face mask with reservoir 2. Face mask without reservoir 3. Nasal Cannula 4. Venturi Mask

Answer: Venturi mask Venturi masks provide oxygen at specified percentages, which is how oxygen should be administered to patients with COPD or emphysema; keep tubing free of kinks.

The nurse understands that the antagonist of warfarin is which medication? 1. Protamine sulfate. 2. Calcium 3. Imferon. 4. Vitamin K

Answer: Vitamin K Vitamin K is a warfarin antagonist because it promotes blood clotting.

When preparing a patient for peritoneal dialysis, which of the following nursing actions should be taken FIRST? 1. Assess for bruit. 2. Warm the dialysate. 3. Position the patient on the left side. 4. Insert a Foley catheter.

Answer: Warm the dialysate. Dialysate should be warmed to body temperature in order to not disrupt tissue temperature; weigh patient before and after dialysis; dialysate is infused into peritoneal cavity and then drained from abdomen after prescribed amount of time.

The nurse in the outpatient clinic is counseling a client with a diagnosis of cholecytitis. The nurse determines teaching is successful if the client makes which of the following statements? 1. I really like a lot of cream on my oatmeal. 2. We eat a lot of broiled fish and chicken. 3. I can't wait to eat the chocolates my children gave me. 4. My favorite dish is broccoli with cheese sauce.

Answer: We eat a lot of broiled fish and chicken. Broiled lean meats are high in protein and low in fat; cooked fruits, non-gas forming vegetables, bread also allowed.

The nurse cares for a patient diagnosed with active TB. Which of the instructions should the nurse give the patient about follow-up care after discharge from the hospital? 1. We would like you to come to the clinic monthly to recheck your tine test and look for changes in your chest x-ray 2. We would like you to return to the clinic if you experience any side effects from the medication. 3. We would like you to come to the clinic weekly for your INH injections. 4. We would like you to come to the clinic monthly to check the effects of the medications you are taking.

Answer: We would like you to come to the clinic monthly to check the effects of the medication you are taking. Having the patient actually come to the clinic monthly will allow the nurse to personally check for signs of hepatitis, such as jaundice; it also gives the opportunity to explain to the patient why she is taking the medicine.

The health care provider prescribes hydrochlorothiazide 50 mg once a day for a client. When is the best time for the nurse to administer this medication? 1. At 6 a.m. 2. With breakfast. 3. With dinner. 4. At bedtime.

Answer: With breakfast Hydrochlorothiazide should be taken with meals; if given with dinner, diuresis would occur while the patient was sleeping, causing interruptions in sleep.

The nurse in the outpatient clinic is measuring the height of an older woman. The client expresses surprise that these is 1 inch shorter than she used to be. Which of the following statements by the nurse is BEST? 1. You have degenerative joint disease of the knees and that will cause your height to decrease. 2. You have lost height because you have bursitis of the left shoulder 3. You are shorter as a result of Paget's disease. 4. Maybe it is because you were diagnosed with juvenile rheumatoid arthritis.

Answer: You are shorter as a result of Paget's disease. Kyphosis and bowing of the legs are characteristics of Paget's disease, both of which will decrease the patient's height; second most common bone disease of older adults after osteoporosis.

A patient is started on rifampin and isoniazid. Which of the following explanations concerning these medications is Most appropriate for the nurse to give? 1. You will have to take these medicines for the rest of your life. 2. You must isolate yourself from your family while on this medicine. 3. You will have to take this medicine about a year. 4. You will need to take this medicine only when you have symptoms.

Answer: You will have have to take this medicine about a year. These medications are used to treat patients with Tuberculosis. Duration of treatment necessary to eradicate the organism and to prevent relapse; due to drug-resistant strains, multiple drugs are prescribed; drugs used include isoniazid (INH), rifampin, streptomycin, pyazinamide, ethambutol; important to instruct patient and family about the medication and the importance of adhering to the medication regimen.

A client choke on food and becomes cyantoic. Which is the BEST action for the nurse to take? 1. The nurse stands behind the client, and with the palm of the hand delivers one quick blow to the middle of the back. 2. The nurse stands behind the client, wraps arms around the client's waist, and with a fish makes a quick upward thrust into the abdomen. 3. The nurse stands in front of client, puts the palm of the hand between the navel and the rib cage, and presses firmly upward several times. 4. The nurse lays the client on the floor and prepares to initiate cardiopulmonary resuscitation.

Answer:The nurse stands behind the client, wraps arms around the client's waist,and with a fish makes a quick upward thrust into the abdomen. If the person is choking the abdominal-thrust maneuver should be performed; by making a quick upward thrusts, the pressure is increased in the thoracic cavity, and the air is normally trapped in the lungs acts as an upward force to push the obstruction out of the airway.

The nurse performs discharge teaching for a patient diagnosed with COPD. The client asks if the oxygen concentration can be increased during periods of shortness of breath. On what is the nurse's response based? 1. High-flow oxygen interferes with breathing 2. Low-flow oxygen will not improve breathing 3. High-flow oxygen will simulate breathing 4. Low-flow oxygen is more comfortable

Answer: High-flow oxygen interferes with breathing Patients with COPD are stimulated to breath not bey increasing levels of carbon dioxide, but by a decreased level of oxygen in the blood, if high-flow oxygen is provided to these patients, it eliminated their drive to breathe.

The nurse understands which of the following is the cause of respiratory alkalosis? 1. Hyperglycemia 2. Hyperventilation 3. Fluid loss 4. Airway compromise

Answer: Hyperventilation Hyperventilation forma cute anxiety, improper settings on mechanical ventilators, CNS lesions, or stimulant drugs is the cause of respiratory alkalosis from excessive loss of CO2; hypoxemia, such as form being in high altitudes can cause hyperventilation.

The nurse understands fatigue, weakness, and nausea and vomiting are signs of which? 1. Hyponatremia 2. Hypokalemia 4. Hypernatremia 4.Hyperkalemia.

Answer: Hypokalemia Less than 3.5 mEq/L; muscle weakness, paresthesia, fatigue, nausea and vomiting and dysrhythmias, and it increases sensitivity to digitalis.

The nurse identifies nasogastric drainage, vomiting, diarrhea, and the use of diuretics likely caused which electrolyte imbalance? 1. Hypernatremia. 2. Hyperkalemia. 3. Hyponatremia 4. Hypokalemia

Answer: Hypokalemia Nasogastric drainage, vomiting, diarrhea, and the use of diuretics all involve the loss of extracellular fluid, which contains potassium.

The nurse cares for a client receiving digoxin and hydrochlorothiazide. The nurse understands that a major side effect of hydrochlorothiazide includes which? 1. Hypokalemia. 2. Hyperkalemia. 3. Hyponatremia. 4. Oliguria.

Answer: Hypokalemia Thiazide diuretics block reabsorption of sodium and increase the excretion of water and potassium from the body, which can result in hypokalemia

The nurse cares for a patient after the physician performed a sigmoid colostomy due to cancer. The nurse instructs the patient about how to care for the stoma. The nurse knows that teaching is successful if the patient makes which of the following statements? 1. I will drape the area and wash the stoma with hexachlorophene soap. 2. I will clean the stoma vigorously with alcohol wipes and pat dry. 3. I will clean around the stoma withsoap and water and pat dry. 4. I will drape the area and cleanse the stoma with povidone iodine.

Answer: I will clean around the stoma with povidone iodine. Provide adequate cleaning with limited irritation; observe for skin breakdown.

The nurse supervises a staff member insert an indwelling urinary catheter in a female patient. The nurse notes that the catheter is inserted into the patient's vagina. Which of the following actions should the nurse take FIRST? 1. Leave the catheter in place and obtain a new catheterization kit. 2. Instruct the staff member about the correct way to insert a catheter. 3. Remove the catheter and insert a new catheter. 4. Complete an incident report.

Answer: Leave the catheter in place and obtain a new catheterization kit. This misplaced catheter acts as a landmark; obtain a new catheter for the staff member to insert

The nurse is caring for a client receiving methyldopa. The nurse instructs the client about common side effects of methyldopa. Which information should the nurse include? 1. Bronchospasm. 2. Loss of potassium. 3. Loss of libido. 4. Tachycardia.

Answer: Loss of libido. Methyldopa is a centrally acting sympatholytic that reduces peripheral vascular resistance; side effects include drowsiness, sedation, orthostatic hypotension, bradycardia, and loss of libido; do not discontinue abruptly, may cause hypertensive crisis; monitors for fluid retention

The nurse understands which is the goal of a diet for clients with chronic kidney disease? 1. Lowered intake of protein to decrease blood urea nitrogen (BUN). 2. Lowered intake of sugars to decrease blood glucose. 3. Lowered intake of fats to decrease blood triglycerides. 4. Lowered intake of amino acids to decrease triglycerides and serum albumin.

Answer: Lowered intake of protein to decrease blood urea nitrogen (BUN). Clients with chronic kidney disease are in danger of increasing their blood urea nitrogen (BUN) due to the inability of the kidneys to excrete the by-products of protein metabolism.

Which finding in the urine of the client diagnosed with chronic kidney disease is expected by the nurse? 1. Hematuria. 2. Polyuria. 3. Dysuria. 4. Oliguria.

Answer: Oliguria Scanty production of urine by the kidneys is a sign of impending kidney failure.

Immediately following a liver biopsy, the nurse should position the client in which position? 1. On the right side 2. On the left side 3. Prone 4. Supine

Answer: On the right side After a liver biopsy, it is important to prevent leakage of fluid or hemmorrhea form occurring; because of this, the ideal position is to lie directly on the liver with the ribs pushing on the liver; place a pillow under coastal margin; determine prothrombin time, PTT, and platelet count prior to procedure; report abnormal finding to health care provider.

An older man is admitted to the hospital with a diagnosis of heart failure. Which of the following findings is MOST characteristic of heart failure? 1. Pulse 110, respirations 24, blood pressure 100/60. 2. Pulse 100, respirations 16, blood pressure 140/90. 3. Pulse 150, respirations 20, blood pressure 120/80. 4. Pulse 100, respirations, blood pressure 100/70.

Answer: Pulse 110, respirations 24, blood pressure 100/60. HF is a failure of the cardiac muscle to pump sufficient blood to meet the body's metabolic demands; can have right-or left-sided failure; characteristic signs of HF include tachycardia and increased respirations.

The nurse understands which of these factors is MOST likely source of hepatitis D? 1. Eating infected shellfish 2.Overly exerting oneself. 3. Practicing poor hygiene. 4. Receiving a blood transfusion.

Answer: Receiving a blood transfusion. Hepatitis D coinfects with hepatitis B; spread by contact with blood and body fluids.

During an acute bout of gouty arthritis, the nurse should expect the patient's affected foot to appear 1. Pale 2. Red 3. Mottled. 4. Cyanotic

Answer: Red Gout is systemic disease caused by inflammation due to urate deposits in the joints; symptoms include redness due to joint inflammation; joint is extremely painful, inspect joint only; too painful to touch.

The nurse assesses a client who sustained a burn injury in an apartment fire. The nurse is MOST concerned if which is observed? 1. The client has singed nasal hair 2. The client's BP is 106/62 3. The client has blisters on the hands 4. The client's capillary refill time less than 3 seconds.

Answer: The client has singed nasal hair Intraoral burns and signed nasal hairs indicating potentially serious injuries; observe client for progressive hoarseness, brassy cough, drooling or exhibiting difficulty swallowing, crowing, wheezing, or stridor

The nurse cares for patients on the medical unit. Propranolol (Inderal) is ordered for a patient. Which of the following information found in the patient's history should cause the nurse to intervene? 1. The patient has a history of myocardial infarction. 2. The patient has had asthma since childhood. 3. The patient has a history of infective endocarditis. 4. The patient has had hypertension for five years.

Answer: The patient has had asthma since childhood. One of the side effects of inderal is bronchospasm; possible side effect must be avoided in patients with asthma

The nurse cares for an elderly patient eight days after an open reduction and internal fixation of the right hip. The nurse should intervene observed? 1. The patient ate half of the food on the breakfast tray. 2. The patient is not wearing elastic stockings. 3. The patient transfers from the bed to bedside commode with assistance. 4. The patient requires pain medication three times per day.

Answer: The patient is not wearing elastic stockings. DVT is the most common complication; patient should wear elastic stockings or use sequential compression device; encourage fluids.

A patient undergoes a cardiac catheterization. Following the procedure, the nurse discovers that the patient is bleeding from the cut-down site. Which action should the nurse take FIRST? 1. Take the patient's vital signs. 2. Notify the physician. 3. Apply pressure to the site. 4. Reinforce the dressing over the site.

Answer: Apply pressure to the site. The immediate priority at this time is to stop the bleeding; after this is done, the nurse may take the patient's vital signs, notify the physician, and reinforce the dressing over the site; after procedure, client on bed rest for 4-6 hours and the insertion site is kept straight; asses pulses, sensation, bleeding at insertion site.

A client has gastroscopy performed and gastric aspirate taken for analysis. The nurse understands the purpose of a gastric aspirate includes which reasons? 1. Assess acid secretion and bacterial activity in the stomach. 2. Inhibit acid secretion in the stomach. 3. Assess the mucus-producing capacity of the stomach. 4. Introduce gastric-irritating substances.

Answer: Assess acid secretion and bacterial activity in the stomach.

The nurse understand the MOST important factor to maintain adequate circulation is 1. Blood volume. 2. White blood cell count. 3. Aerobic exercise. 4. Effective respiration.

Answer: Blood volume. In order to maintain adequate circulation, an adequate transport medium to carry nutrients and gases throughout the body is needed.

A patient undergoes a transurethral resection of the prostate (TURP). In the immediate postoperative period, which of the following characteristics should the nurse expect when observing the urinary drainage? 1. Bloody 2. Purulent 3. Clear 4. Bright yellow

Answer: Bloody Procedure causes bleeding, therefore the urine would be bloody; a large size catheter is used to facilitate the removal of clots from the bladder.

A client undergoes nasal surgery. The nurse instructs the client to not blow the nose. What is the reason for this instruction? 1. Blowing increases intracranial pressure 2. Blowing decreased the client's oxygen supply 3. Blowing encourages bruising and edema. 4. Blowing may cause a nasal fracture.

Answer: Blowing encourages bruising and edema. Clients undergoing nasal surgery are instructed not to blow their noses in the post-op periods because it can cause bruising and edema. Patients should not blow nose up to 2 weeks after the procedure to prevent bleeding.

Which symptom of liver disease should the nurse expect to see in a client with Laennec's cirrhosis? 1. Cloudy urine. 2. Dark urine 3. Orange-colored stools. 4. Tarry stools

Answer: Dark urine Normally bilirubin is not excreted in urine; urine with abnormal bilirubin is mahogany-colored and has yellow foam when shaken.

The nurse understands the MOST common reason for insertion of a nasogastric rube in a postop client diagnosed with a duodenal ulcer includes which reason? 1. Take samples of gastric acid. 2. Assess the stomach for bleeding. 3. Decompress the stomach. 4.Permit saline irrigations.

Answer: Decompress the stomach The stomach is decompressed postoperatively to prevent distention and pressure on the suture lines.

Several hours after being admitted to the unit, an intravenous lidocaine drip is started for a client diagnosed with acute myocardial infraction. The nurse understands which outcome is the purpose of this medication? 1. Decrease the cardiac workload. 2. Decrease the myocardial irritability. 3. Increase the strength of the heart's contractions. 4. Increase myocardial automaticity.

Answer: Decrease the myocardial irritability. Lidocaine, like other antidysrhythmic drugs, decreases myocardial irritability and decreases myocardial automaticity.

The nurse understand that the primary purpose of promoting rest following a myocardial infarction includes which rational? 1. Facilitate accurate cardiac monitoring. 2. Promote a restful atmosphere. 3. Decrease the workload on the heart. 4. Allow regeneration of the myocardium.

Answer: Decrease the workload on the heart. Client has altered cardiopulmonary tissue perfusion due to MI; rest with limited mobility will decrease the workload of the heart by reducing myocardial oxygen consumption.

The nurse cares for a client during the shock phase after suffering a full thickness burn injury. The nurse understands which finding is expected during this phase? 1. Increased blood pressure 2. Decreased urine output 3. Hypokalemia 4. Decreased pulse

Answer: Decreased urine output Due to fluid shift during emergent phase, urine output is decreased and urine dis concentrated and has a high specific gravity; accurate intake and output is measured and is one of the parameters used to determine the amount of IV fluids; output should be maintained at 30-50 mL/hour

The clinic nurse monitors a client recovering from hepatitis D. The nurse understands which of the following indicates the client is recovering from the illness? 1. Serum asparate aminotransferase 2. Hepatitis B surface antigen. 3. Serum cholesterol. 4. BUN

Answer: Serum asparate aminotransferase Enzymes that are released form liver due to damaged cells, elevated in liver damage; normal is 10-40 U/L

When one nurse is performing CPR on an adult, which is the CORRECT ration of compressions to breaths? 1. 30 compressions to 2 breaths. 2. 30 compressions to 1 breath. 3. 15 compressions to 1 breath. 4. 15 compressions to 2 breaths.

Answer: 30 compressions to 2 breaths. Compression-ventilation ratio for one or two rescuers.

The nurse performs teaching for a patient diagnosed with tuberculosis. The nurse explains that tuberculosis is cause by what? 1. A virus 2. Poor sanitation 3. Poor nutrition 4. A bacterium

Answer: A bacterium Caused by bacterium Mycobacterium tuberculosis, transmitted via the aersol route (coughing, laughing, sneezing, or singing).

The nurse cares for a patient in Buck's traciton. It is MOST important for the nurse to take which of the following actions? 1. Encourage the patient to limit body movements. 2. Allow weights to hang freely at all times. 3. Remove weights to immediately when patient complains of discomfort. 4. Give pain medication regularly.

Answer: Allow weights to hang freely at all times. Important nursing responsibility to maintain traction; the patient needs to be re-positioned frequently to maintain the proper reduction of a fracture; the weights are never removed.

In order to deliver 3,000 mL of D5W in 24 hours using an administration set that delivers 15 drops/mL, the nurse should regulate the flow rate to deliver how many drops/minute?

31 drops/min

The nurse is caring for an elderly patient diagnosed with a fractured femur. The nurse recognizes that which of the following is an early sign of fat embolism? 1. Chest pain and dyspnea. 2. Increased respirations, pulse, and temperature. 3. Altered mental status. 4. Petechiae.

Answer: Altered mental status. Earliest sign due to low arterial oxygen levels; fat embolism more common in men between ages 20 and 40 and adults between the ages of 70 and 80

The nurse cares for a client diagnosed with a fractured right hip. The client's lab values are: Hgb 15, Hct 46%, sodium 140 mEq/L, potassium 6.2 mEq/L, and chloride 100 mEq/L. The nurse is MOST concerned if which is observed? 1. A weight gain of 4 lbs in 1 day 2. An increase in nausea. 3. An increased in muscle irritability 4. An episode of ventricular fibrillation.

Answer: An episode of ventricular fibrillation. Normal potassium is 3.5-5.0; severe hyperkalemia may cause ventricular fibrillation, which is life-threatening and must be treated immediately; think ABC's

The nurse understands that the primary reason for maintaining a constant rate of infusion with parenteral nutrition (PN) is to prevent which complication. 1. The risk of fluid overload. 2. An unstable blood glucose level 3. Potential clotting of the catheter 4. Electrolyte imbalance.

Answer: An unstable blood glucose level The potential problem of administration of PN is the high glucose concentration; body must produced insulin to respond to the glucose level; rate should therefore to kept constant using an infusion pump.

A patient diagnosed with chronic obstructive pulmonary disease (COPD) is drowsy and unable to expectorate secretions. The nurse should take which of the following actions. 1. Force fluids 2. Administer high-flow oxygen via mask 3. Perform nasotracheal suction 4. Perform postural drainage.

Answer Perform nasotracheal suction If patient is unable to expectorate sections, suctioning is appropriate; auscultate breath sounds to determine if suctioning is required.

A patient is diagnosed with angina, and the nurse instructs the patient about care at home. The nurse determines that teaching is effective if the patient makes which of the following statements? 1. "If I have chest pain, I should contact my physician immediately." 2. "If I have chest pain, I should stop my activity and take a nitroglycerin." 3. "I can take another nitroglycerin tablet if chest pain doesn't subside in 30 minutes." 4. "If I have chest pain, I should rest for 30 minutes and then take a nitroglycerin tablet."

Answer: "If I have chest pain, I should stop my activity and take a nitroglycerin tablet." Angina is chest discomfort caused by the heart's inability to provide oxygen to the cardiac muscle; warning sign of ischemia; anginal pain is relieved by rest and nitroglycerin; the first thing the patient should do is rest, and immediately take a nitroglycerin tablet.

The nurse performs diet teaching for a client diagnosed with a myocardial infarction. The nurse determines that teaching is effective if the client selects which of the following menus? 1. Ham and cheese sandwich, milk, apple. 2. Sliced turkey, green beans, pear. 3. Broiled fish, creamed spinach, custard. 4. Broiled chicken, green beans, ice cream.

Answer: Sliced turkey, green beans, pear. Sliced turkey, green beans, and pear are all low in cholesterol and low in salt; other meals are high in cholesterol and salt.

A sexual contact of a patient with hepatitis B is given HBIg. The nurse explains to the contact the purpose of medication is to. 1. Prevent other sexually transmitted diseases. 2. Stimulate his immune system to develop antibodies to hepatitis. 3. Assure that he does not contract hepatitis 4. Temporarily increase the person's resistance to hepatitis.

Answer: Temporarily increase the person's resistance to hepatitis. An injection of pooled human gamma globulin is an example of passive immunity.

The nurse cares for a female with a diagnosis of ulcerative colitis. When reviewing the patient;s chart, the nurse expects to find which of the following lab values? 1. Red blood cell (RBC) 4 million/mm 2. Platelet count 75,000/mm 3. Hemoglobin (Hgb) 18.2 g/dL 4.White blood cell count (WBC) 15,000/mm

Answer: White blood cell count (WBC) 15,000/mm Due to inflammation, WBC's and erythrocyte sedimentation rate will be elevated, sodium, potassium and chloride may be decreased due to frequent diarrhea.