Med sure 3 final
A patient will need vascular access for hemodialysis. Which statement by the nurse accurately describes an advantage of a fistula over a graft? A. A fistula is much less likely to clot. B. A fistula increases patient mobility. C. A fistula can accommodate larger needles. D. A fistula can be used sooner after surgery.
A. A fistula is much less likely to clot.
After receiving change-of-shift report on heart failure unit, which patient should the nurse assess first? A. A patient who is cool and clammy, with new onset confusion and restlessness B. A patient who has crackles bilaterally in the lung bases and is receiving oxygen C. A patient who had dizziness after receiving the first dose of captopril (Capoten) D. A patient who is receiving IV nesiritide (Natrecor) and has a blood pressure of 100/62
A. A patient who is cool and clammy, with new onset confusion and restlessness
A few days after experiencing a myocardial infarction (MI) and successful percutaneous coronary intervention, the patient states, "I just had a little chest pain. As soon as I get out of here, I'm going for my vacation as planned." Which reply would be most appropriate for the nurse to make? A. "What do you think caused your chest pain?" B. "Where are you planning to go for your vacation?" C. "Sometimes plans need to change after a heart attack" D. "Recovery from a heart attack takes at least a few weeks"
A. "What do you think caused your chest pain?"
Ordered dose: 50 mcg of Fentanyl of IVP Supplied dose: 200mcg/2mL How many mLs do you give? A. 0.5mL B. 1mL C. 3mL D. 2.5mL
A. 0.5mL
The following male patients recently arrived in the emergency department. Which one should the nurse assess first? A. 19-year-old who is complaining of severe scrotal pain. B. 60-year-old with a nontender ulceration of the glans penis. C. 22-year-old who has purulent urethral drainage and back pain. D. 64-year-old who has dysuria after brachytherapy for prostate cancer.
A. 19-year-old who is complaining of severe scrotal pain.
A 34-year-old female patient with a new ileostomy asks how much drainage to expect. The nurse explains that after the bowel adjusts to the ileostomy, the usual drainage will be about _____ cups. A. 2 B. 3 C. 4 D. 5
A. 2
Several patients call the urology clinic requesting appointments with the health care provider as soon as possible. which patient will the nurse schedule to be seen first? A. 22-year-old who has noticed a firm, nontender lump on his scrotum. B. 35-year-old who is concerned that is scrotum "feels like a bag of worms." C. 40-year-old who has pelvic pain while being treated for chronic prostatitis. D. 70-year-old who is reporting frequent urinary dribbling after a prostatectomy.
A. 22-year-old who has noticed a firm, nontender lump on his scrotum.
A young adult patient who denies any history of smoking is seen in the clinic with a new diagnosis of chronic obstructive pulmonary disease (COPD). It is most appropriate for the nurse to teach the patient about. A. A1- antitrypsin testing. B. Use of the nicotine patch. C. Continuous pulse oximetry. D. Effects of leukotriene modifiers.
A. A1- antitrypsin testing.
A patient with urinary obstruction from benign prostatic hyperplasia (BPH) tells the nurse, "My symptoms are much worse this week." Which response by the nurse is most appropriate? A. "Have you been taking any over-the-counter (OTC) medications recently?" B. "I will talk to the doctor about ordering a prostate specific antigen (PSA) test." C. "Have you talked to the doctor about surgery such as transurethral resection of the prostate (TURP)?" D. "The prostate gland changes in size from day to day, and this may be making your symptoms worse."
A. "Have you been taking any over-the-counter (OTC) medications recently?"
The nurse in the emergency department receives arterial blood gas results for four recently admitted patients with obstructive pulmonary disease. Which patient will require the most rapid action by the nurse? A. 22-year-old with ABG results: pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg. B. 34-year-old with ABG results: pH 7.48, PaCO2 30 mm Hg, and PaO2 65 mm Hg. C. 45-year-old with ABG results: pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg. D. 65-year-old with ABG results: pH 7.31, PaCO2 58 mm Hg, and PaO2 64 mm Hg.
A. 22-year-old with ABG results: pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg.
A 70-year-old patient who has had a transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH) is being discharged from the hospital today. The nurse determines that additional instruction is needed when the patient says which of the following? A. "I should call the doctor if I have incontinence at home." B. "I will avoid driving until I get approval from my doctor." C. "I will increase fiber and fluids in my diet to prevent constipation." D. "I should continue to schedule yearly appointments for prostate exams."
A. "I should call the doctor if I have incontinence at home."
During a visit to a 78-year-old with chronic heart failure, the home care nurse finds that the patient has ankle edema, a 2-kg weight gain over the past 2 days, and complains of, "feeling too tired to get out of bed." Based on these data, the best nursing diagnosis for the patient is A. Activity intolerance related to fatigue B. Disturbed body image related to weight gain C. Impaired skin integrity related to ankle edema D. Impaired gas exchange related to dyspnea on exertion
A. Activity intolerance related to fatigue
The nurse reviews the medication administration record (MAR) for a patient having an acute asthma attack. Which medication should the nurse administer first? A. Albuterol (Proventil) 2.5 mg per nebulizer. B. Methylprednisolone (Solu-Medrol) 60 mg IV. C. Salmeterol (Serevent) 50 mcg per dry-powder inhaler (DPI). D. Triamcinolone (Azmacort) 2 puffs per metered-dose inhaler (MDI).
A. Albuterol (Proventil) 2.5 mg per nebulizer.
A 20-year-old has a mandatory electrocardiogram (ECG) before participating on a college soccer team and is found to have sinus bradycardia, rate 52. Blood pressure (BP) is 114/54, and the student denies any health problems. Which action by the nurse is most appropriate? A. Allow the student to participate on the soccer team B. Refer the student to a cardiologist for further diagnostic testing C. Tell the student to stop playing immediately if any dyspnea occurs D. Obtain more detailed information about the student's family health history
A. Allow the student to participate on the soccer team
A patient with dilated cardiomyopathy has new onset atrial fibrillation that had been unresponsive to drug therapy for several days. The priority teaching needed for this patient would include information about A. Anticoagulant therapy B. Permanent pacemakers C. Electrical cardioversion D. IV adenosine (Adenocard)
A. Anticoagulant therapy
When caring for a patient with a left arm arteriovenous fistula, which action will the nurse include in the plan of care to maintain the patency of the fistula? A. Auscultate for a bruit at the fistula site. B. Assess the quality of the left radial pulse. C. Compare blood pressures in the left and right arms. D. Irrigate the fistula site with saline every 8 to 12 hours.
A. Auscultate for a bruit at the fistula site.
Which information will be included when the nurse is teaching self-management to a patient who is receiving peritoneal dialysis (select all that apply)? A. Avoid commercial salt substitutes. B. Drink 1500 to 2000 mL of fluids daily. C. Take phosphate-binders with each meal. D. Choose high-protein foods for most meals. E. Have several servings of dairy products daily.
A. Avoid commercial salt substitutes. C. Take phosphate-binders with each meal. D. Choose high-protein foods for most meals.
Sodium polystyrene sulfonate (Kayexalate) is ordered for a patient with hyperkalemia. Before administering the medication, the nurse should assess the A. Bowel sounds. B. Blood glucose. C. Blood urea nitrogen (BUN) D. Level of consciousness.
A. Bowel sounds.
A patient complains of gas pains and abdominal distention two days after a small bowel resection. Which nursing action is best to take? A. Encourage the patient to ambulate. B. Instill a mineral oil retention enema. C. Administer the ordered IV morphine sulfate. D. Offer the ordered promethazine (Phenergan) suppository.
A. Encourage the patient to ambulate.
Which nursing action will be included in the plan of care for a 27-year-old male patient with bowel irregularity and a new diagnosis of irritable bowel syndrome (IBS). A. Encourage the patient to express concerns and ask questions about IBS. B. Suggest that the patient increase the intake of milk and other dairy products. C. Educate the patient about the use of alosetron (Lotronex) to reduce symptoms. D. Teach the patient to avoid using nonsteroidal anti-inflammatory drugs (NSAIDs).
A. Encourage the patient to express concerns and ask questions about IBS.
A 51-year-old woman with Crohn's disease who is taking infliximab (Remicade) calls the nurse in the outpatient clinic about new symptoms. Which symptom is most important to communicate to the health care provider? A. Fever. B. Nausea. C. Joint pain. D. Headache.
A. Fever.
The nurse will inform a patient will cancer of the prostate that side effects of leuprolide (Lupron) may include A. Flushing. B. Dizziness. C. Infection. D. Incontinence.
A. Flushing.
A patient in the intensive care unit with acute decompensated heart failure (ADHF) complains of severe dyspnea and is anxious, tachypneic, and tachycardic. All of the following medications have been ordered for the patient. The nurse's priority action will be to A. Give IV morphine sulfate 4 mg B. Give IV diazepam (Valium) 2.5 mg C. Increase nitroglycerin (Tridil) infusion by 5 mcg/min D. Increase dopamine (Intropin) infusion by 2 mcg/kg/min
A. Give IV morphine sulfate 4 mg
Based on the Joint Commission Core Measures for patients with heart failure, which topics should the nurse include in the discharge teaching plan for a patient who has been hospitalized with chronic heart failure (select all that apply) A. How to take and record daily weight B. Importance of limiting aerobic exercise C. Date and time of follow-up appointment D. Symptoms indication worsening heart failure E. Actions and side effects of prescribed medications
A. How to take and record daily weight C. Date and time of follow-up appointment D. Symptoms indication worsening heart failure E. Actions and side effects of prescribed medications
Which action should the nurse include in the plan of care when caring for a patient admitted with acute decompensated heart failure (ADHF) who is receiving nesiritide (Natrecor)? A. Monitor blood pressure frequently B. Encourage patient to ambulate in room C. Titrate nesiritide slowly before stopping D. Teach patient about home use of the drug
A. Monitor blood pressure frequently
After the nurse gives IV atropine to a patient with symptomatic type 1, second-degree atrioventricular (AV) block, which finding indicates that the medication has been effective? A. Increase in the patient's heart rate B. Increase in strength of peripheral pulses C. Decrease in premature atrial contractions D. Decrease in premature ventricular contractions
A. Increase in the patient's heart rate
Which action by a new registered nurse (RN) who is orienting to the progressive care unit indicates a good understanding of the treatment of cardiac dysrhythmias? A. Injects IV adenosine (Adenocard) over 2 seconds to a patient with supraventricular tachycardia B. Obtains the defibrillator and quickly brings it to the bedside of a patient whose monitor shows asystole C. Turns the synchronizer switch to the "on" position before defibrillating a patient with ventricular fibrillation D. Gives the prescribed dose of diltiazem (Cardizem) to a patient with new-onset type II second degree AV block
A. Injects IV adenosine (Adenocard) over 2 seconds to a patient with supraventricular tachycardia
A 76-year-old with benign prostatic hyperplasia (BPH) is agitated and confused, with a markedly distended bladder. Which intervention prescribed by the health care provider should the nurse implement first? A. Insert a urinary retention catheter. B. Schedule an intravenous pyelogram (IVP). C. Draw blood for a serum creatinine level. D. Administer lorazepam (Ativan) 0.5 mg PO.
A. Insert a urinary retention catheter.
A 72-year-old patient with a history of benign prostatic hyperplasia (BPH) is admitted with acute urinary retention and elevated blood urea nitrogen (BUN) and creatinine levels. Which prescribed therapy should the nurse implement first? A. Insert urethral catheter. B. Obtain renal ultrasound. C. Draw a complete blood count. D. Infuse normal saline at 50 mL/hour.
A. Insert urethral catheter.
Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown origin? A. Instruct the patient to call for assistance before getting out of bed B. Explain the association between various dysrhythmias and syncope C. Educate the patient about the need to avoid caffeine and other stimulants D. Tell the patient about the benefits of implantable cardioverter-defibrillators
A. Instruct the patient to call for assistance before getting out of bed
A patient who is experiencing an acute asthma attack is admitted to the emergency department. Which assessment should the nurse complete first? A. Listen to the patient's breath sounds. B. Ask about inhaled corticosteroid use. C. Determine when the dyspnea started. D. Obtain the forced expiratory volume (FEV) flow rate.
A. Listen to the patient's breath sounds.
A 51-year-old male patient has a new diagnosis of Crohn's disease after having frequent diarrhea and a weight loss of 10 pounds (4.5 kg) over 2 months. The nurse will plan to teach about A. Medication use. B. Fluid restriction. C. Enteral nutrition. D. Activity restrictions.
A. Medication use.
A patient who is experiencing an asthma attack develops bradycardia and a decrease in wheezing. Which action should the nurse take first? A. Notify the health care provider. B. Document changes in respiratory status. C. Encourage the patient to cough and deep breathe. D. Administer IV methylprednisolone (Solu-Medrol).
A. Notify the health care provider.
Which nursing action for a patient with chronic obstructive pulmonary disease (COPD) could the nurse delegate to experienced unlicensed assistive personnel (UAP). A. Obtain oxygen saturation using pulse oximetry. B. Monitor for increased oxygen need with exercise. C. Teach the patient about safe use of oxygen at home. D. Adjust oxygen to keep saturation in prescribed parameters.
A. Obtain oxygen saturation using pulse oximetry.
Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires the most immediate action by the nurse? A. Oxygen saturation of 88% B. Weight gain of 1 kg (2.2 lb) C. Heart rate of 106 beats/minute D. Urine output of 50 mL over 2 hours
A. Oxygen saturation of 88%
To determine whether there is a delay in impulse conduction through the atria, the nurse will measure the duration of the patient's A. P wave B. Q wave C. P-R interval D. QRS complex
A. P wave
A patient's cardiac monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious and pulseless. Which action should the nurse take first? A. Perform immediate defibrillation B. Give epinephrine (Adrenalin) IV C. Prepare for endotracheal intubation D. Give ventilations with a bag-valve-mask device
A. Perform immediate defibrillation
The nurse is caring for a patient with cor pulmonale. The nurse should monitor the patient for which expected finding? A. Peripheral edema. B. Elevated temperature. C. Clubbing of the fingers. D. Complaints of chest pain.
A. Peripheral edema.
Which information will the nurse plan to include when teaching a community health group about testicular self-examination? A. Testicular self-examination should be done in a warm room. B. The only structure normally felt in the scrotal sac is the testis. C. Testicular self-examination should be done at least every week. D. Call the health care provider if one testis is larger than the other.
A. Testicular self-examination should be done in a warm room.
Which intervention by a new nurse who is caring for a patient who has just had an implantable cardioverter-defibrillator (ICD) inserted indicates a need for more education about care of patients with ICDs? A. The nurse assists the patient to do active range of motion exercise for all extremities B. The nurse assists the patient to fill out the application for obtaining a Medic Alert ID C. The nurse gives amiodarone (Cordarone) to the patient without first consulting with the health care provider D. The nurse teaches the patient that sexual activity usually can be resumed once the surgical incision is healed
A. The nurse assists the patient to do active range of motion exercise for all extremities
A patient in the oliguric phase after an acute kidney injury has had a 250 mL urine output and an emesis of 100 mL in the past 24 hours. What is the patient's fluid restriction for the next 24 hours?
ANS: 950 mL (all fluid losses for the previous 24 hours + 600 mL for insensible losses).
When analyzing an electrocardiographic (ECG) rhythm strip of a patient with a regular heart rhythm, the nurse counts 30 small blocks from one R wave to the next. The nurse calculates the patient's heart rate as ______.
Ans: 50 (There are 1500 small blocks in a minute, and the nurse will divide 1500 by 30)
The nurse provides dietary teaching for a patient with chronic obstructive pulmonary disease (COPD) who has a low body mass index (BMI). Which patient statement indicates that the teaching has been effective? A. "I will drink lots of fluids with my meals." B. "I can have ice cream as a snack every day." C. "I will exercise for 15 minutes before meals." D. "I will decrease my intake of meat and poultry."
B. "I can have ice cream as a snack every day."
Which patient statement indicates that the nurse's teaching about sulfasalazine (Azulfidine) for ulcerative colitis has been effective? A. "The medications will be tapered if I need surgery." B. "I will need to use a sunscreen when I am outdoors." C. "I will need to avoid contact with people who are sick." D. "The medication will prevent infections that cause the diarrhea."
B. "I will need to use a sunscreen when I am outdoors."
After the nurse teaches the patient about the use of carvedilol (Coreg) in preventing anginal episodes, which statement by a patient indicates that the teaching has been effective? A. "Carvedilol will help my heart muscle work harder" B. "It is important not to suddenly stop taking the carvedilol" C. "I can expect to feel short of breath when taking carvedilol" D. "Carvedilol will increase the blood flow to my heart muscle"
B. "It is important not to suddenly stop taking the carvedilol"
A 74-year-old who is progressing to stage 5 chronic kidney disease asks the nurse, "Do you think I should go on dialysis?" Which initial response by the nurse is best? A. "It depends on which type of dialysis you are considering." B. "Tell me more about what you are thinking regarding dialysis." C. "You are the only one who can make the decision about dialysis." D. "Many people your age use dialysis and have a good quality of life."
B. "Tell me more about what you are thinking regarding dialysis."
A 53-year-old patient with Stage D heart failure and type 2 diabetes asks the nurse whether heart transplant is a possible therapy. Which response by the nurse is most appropriate? A. "Because you have diabetes, you would not be a candidate for a heart transplant." B. "The choice of a patient for a heart transplant depends on many different factors." C. "Your heart failure has not reached the stage in which heart transplants are needed." D. "People who have heart transplants are at risk for multiple complications after surgery."
B. "The choice of a patient for a heart transplant depends on many different factors."
Which instruction should the nurse include in an exercise teaching plan for a patient with chronic obstructive pulmonary disease (COPD)? A. "Stop exercising if you start to feel short of breath." B. "Use the bronchodilator before you start to exercise." C. "Breathe in and out through the mouth while you exercise." D. "Upper body exercise should be avoided to prevent dyspnea."
B. "Use the bronchodilator before you start to exercise."
The nurse in the clinic notes elevated prostate specific antigen (PSA) levels in the laboratory results of these patients. Which patient's PSA result is most important to report to the health care provider? A. A 38-year-old who is being treated for acute prostatitis. B. A 48-year-old whose father died of metastatic prostate cancer. C. A 52-year-old who goes on long bicycle rides every weekend. D. A 75-year-old who uses saw palmetto to treat benign prostatic hyperplasia (BPH).
B. A 48-year-old whose father died of metastatic prostate cancer.
The nurse receives a change-of-shift report on the following patients with chronic obstructive pulmonary disease (COPD). Which patient should the nurse assess first? A. A patient with loud expiratory wheezes. B. A patient with a respiratory rate of 38 breaths/minute. C. A patient who has a cough productive of thick, green mucous. D. A patient with jugular venous distention and peripheral edema.
B. A patient with a respiratory rate of 38 breaths/minute.
A 19-year-old student comes to the student health center at the end of the semester complaining that, "My heart is skipping beats." An electrocardiogram (ECG) shows occasional premature ventricular contractions (PVCs). What action should the nurse take next? A. Start supplemental O2 at 2 to 3 L/min via nasal cannula B. Ask the patient about current stress level and caffeine use C. Ask the patient about any history of coronary artery disease D. Have the patient taken to the hospital emergency department (ED)
B. Ask the patient about current stress level and caffeine use
After a total proctocolectomy and permanent ileostomy, the patient tells the nurse, "I cannot manage all these changes. I don't want to look at the stoma." What is the best action by the nurse? A. Reassure the patient that ileostomy care will become easier. B. Ask the patient about the concerns with stoma management. C. Develop a detailed written list of ostomy care tasks for the patient. D. Postpone any teaching until the patient adjusts to the ileostomy.
B. Ask the patient about the concerns with stoma management.
A 27-year-old man who has testicular cancer is being admitted for a unilateral orchiectomy. The patient does not talk to his wife and speaks to the nurse only to answer the admission questions. Which action is best for the nurse to take? A. Teach the patient and the wife that impotence is unlikely after unilateral orchiectomy. B. Ask the patient if he has any questions or concerns about the diagnosis and treatment. C. Document the patient's lack of communication on the chart and continue preoperative care. D. Inform the patient's wife that concerns about sexual function are common with this diagnosis.
B. Ask the patient if he has any questions or concerns about the diagnosis and treatment.
A 71-year-old male patient tells the nurse that growing old causes constipation so he has been using a suppository for constipation every morning. Which action should the nurse take first? A. Encourage the patient to increase oral fluid intake. B. Assess the patient about risk factors for constipation. C. Suggest that the patient increase intake of high-fiber foods. D. Teach the patient that a daily bowel movement is unnecessary.
B. Assess the patient about risk factors for constipation.
A patient has arrived for a scheduled hemodialysis session. Which nursing action is most appropriate for the registered nurse (RN) to delegate to a dialysis technician? A. Teach the patient about fluid restrictions. B. Check blood pressure before starting dialysis. C. Assess for causes for an increase in predialysis weight. D. Determine the ultrafiltration rate for the hemodialysis.
B. Check blood pressure before starting dialysis.
During routine hemodialysis, the 68-year-old patient complains of nausea and dizziness. Which action should the nurse take first? A. Slow down the rate of dialysis. B. Check the patient's blood pressure (BP). C. Review the hematocrit (Hct) level. D. Give prescribed PRN antiemetic drugs.
B. Check the patient's blood pressure (BP).
A patient being admitted with an acute exacerbation of ulcerative colitis reports crampy abdominal pain and passing 15 or more bloody stools a day. The nurse will plan to A. Administer IV metoclopramide (Reglan). B. Discontinue the patient's oral food intake. C. Administer cobalamin (vitamin B12) injections. D. Teach the patient about total colectomy surgery.
B. Discontinue the patient's oral food intake.
A 58-year-old patient who has been recently diagnosed with benign prostatic hyperplasia (BPH) tells the nurse that he does not want to have a transurethral resection of the prostate (TURP) because it might affect his ability to maintain an erection during intercourse. Which action should the nurse take? A. Provide teaching about medications for erectile dysfunction. B. Discuss that TURP does not commonly affect erectile function. C. Offer reassurance that sperm production is not affected by TURP. D. Discuss alternative methods of sexual expression besides intercourse.
B. Discuss that TURP does not commonly affect erectile function.
A 24-year-old woman with Crohn's disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, fecal-smelling urine. What information will the nurse add to a general teaching plan about UTIs in order to individualize the teaching for this patient? A. Bacteria in the perianal area can enter the urethra. B. Fistulas can form between the bowel and bladder. C. Drink adequate fluids to maintain normal hydration. D. Empty the bladder before and after sexual intercourse.
B. Fistulas can form between the bowel and bladder.
Which assessment finding in a patient who has received omalizumab (Xolair) is most important to report immediately to the health care provider? A. Pain at injection site. B. Flushing and dizziness. C. Peak flow reading 75% of normal. D. Respiratory rate of 22 breaths/minute.
B. Flushing and dizziness.
Which action should the nurse perform when preparing a patient with a supraventricular tachycardia for cardioversion who is alert and has a blood pressure of 110/66 mm Hg? A. Turn the synchronizer switch to the "off" position B. Give a sedative before cardioversion is implemented C. Set the defibrillator/cardioverter energy to 360 joules D. Provide assisted ventilations with a bag-valve-make device
B. Give a sedative before cardioversion is implemented
The nurse will determine that teaching a 67-year-old man to irrigate his new colostomy has been effective if the patient A. Inserts the irrigation tubing 4 to 6 inches into the stoma. B. Hangs the irrigating container 18 inches above the stoma. C. Stops the irrigation and removes the irrigating cone if cramping occurs. D. Fills the irrigating container with 1000 to 2000 mL of lukewarm tap water.
B. Hangs the irrigating container 18 inches above the stoma.
The health care provider prescribes finasteride (Proscar) for a 67-year-old patient who has benign prostatic hyperplasia (BPH). When teaching the patient about the drug, the nurse informs him that A. He should change position from lying to standing slowly to avoid dizziness. B. His interest in sexual activity may decrease while he is taking the medication. C. Improvement in the obstructive symptoms should occur within about 2 weeks. D. He will need to monitor his blood pressure frequently to assess for hypertension.
B. His interest in sexual activity may decrease while he is taking the medication.
A patient has ST segment changes that support an acute inferior wall myocardial infarction. Which lead would be best for monitoring the patient? A. I B. II C. V2 D. V6
B. II
A 48-year-old patient with stage 2 chronic kidney disease (CKD) is scheduled for an intravenous pyelogram (IVP). Which order for the patient will the nurse question? A. NPO for 6 hours before the procedure. B. Ibuprofen (Advil) 400 mg PO PRN for pain. C. Dulcolax suppository 4 hours before procedure. D. Normal saline 500 mL IV infused before procedure.
B. Ibuprofen (Advil) 400 mg PO PRN for pain.
A 71-year-old patient who has benign prostatic hyperplasia (BPH) with urinary retention is admitted to the hospital with elevated blood urea nitrogen (BUN) and creatinine. Which prescribed therapy should the nurse implement first? A. Infuse normal saline at 50 mL/hr. B. Insert a urinary retention catheter. C. Draw blood for a complete blood count. D. Schedule a pelvic computed tomography (CT) scan.
B. Insert a urinary retention catheter.
The clinic nurse makes a follow-up telephone call to a patient with asthma. The patient reports having a baseline peak flow reading of 600 L/minute and the current peak flow is 420 L/minute. Which action should the nurse take first? A. Tell the patient to go to the hospital emergency department. B. Instruct the patient to use the prescribed albuterol (Proventil) C. Ask about recent exposure to any new allergens or asthma triggers. D. Question the patient about use of the prescribed inhaled corticosteroids.
B. Instruct the patient to use the prescribed albuterol (Proventil)
A patient is receiving 35% oxygen via a Venturi mask. To ensure the correct amount of oxygen delivery, which action by the nurse is most important? A. Teach the patient to keep mask on at all times. B. Keep the air entrainment ports clean and unobstructed. C. Give a high enough flow rate to keep the bag from collapsing. D. Drain moisture condensation from the oxygen tubing every hour.
B. Keep the air entrainment ports clean and unobstructed.
The nurse in the dialysis clinic is reviewing the home medications of a patient with chronic kidney disease (CKD). Which medication reported by the patient indicates that patient teaching is required? A. Multivitamin with iron. B. Magnesium hydroxide. C. Acetaminophen (Tylenol). D. Calcium phosphate (PhosLo).
B. Magnesium hydroxide.
The nurse is admitting a patient diagnosed with an acute exacerbation of chronic obstructive pulmonary disease (COPD). What is the best way for the nurse to determine the appropriate oxygen flow rate? A. Minimize oxygen use to avoid oxygen dependency. B. Maintain the pulse oximetry level at 90% or greater. C. Administer oxygen according to the patient's level of dyspnea. D. Avoid administration of oxygen at a rate of more than 2 L/minute.
B. Maintain the pulse oximetry level at 90% or greater.
The nurse is planning care for a patient with severe heart failure who has developed elevated blood urea nitrogen (BUN) and creatinine levels. The primary collaborative treatment goal in the plan will be A. Augmenting fluid volume. B. Maintaining cardiac output. C. Diluting nephrotoxic substances. D. Preventing systemic hypertension.
B. Maintaining cardiac output.
Which nursing action will the nurse include in the plan of care for a 35-year-old male patient admitted with an exacerbation of inflammatory bowel disease (IBD)? A. Restrict oral food intake. B. Monitor stools for blood. C. Ambulate four times daily. D. Increase dietary fiber intake.
B. Monitor stools for blood.
The emergency department nurse is evaluating the effectiveness of therapy for a patient who has received treatment during an asthma attack. Which assessment finding is the best indicator that the therapy has been effective? A. No wheezes are audible. B. Oxygen saturation is >90%. C. Accessory muscle use has decreased. D. Respiratory rate is 16 breaths/minute.
B. Oxygen saturation is >90%.
After receiving change-of-shift report on a heart failure unit, which patient should the nurse assess first? A. Patient who is taking carvedilol (Coreg) and has a heart rate of 58 B. Patient who is taking digoxin and has a potassium level of 3.1 mEq/L C. Patient who is taking isosorbide dinitrate/hydralazine (BiDil) and has a headache D. Patient who is taking captopril (Capoten) and has a frequent nonproductive cough
B. Patient who is taking digoxin and has a potassium level of 3.1 mEq/L
Which information will the nurse monitor in order to determine the effectiveness of prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD)? A. Blood pressure. B. Phosphate level. C. Neurologic status. D. Creatinine clearance.
B. Phosphate level.
A 42-year-old patient admitted with acute kidney injury due to dehydration has oliguria, anemia, and hyperkalemia. Which prescribed actions should the nurse take first? A. Insert a urinary retention catheter. B. Place the patient on a cardiac monitor. C. Administer epoetin alfa (Epogen, Procrit). D. Give sodium polystyrene sulfonate (Kayexalate).
B. Place the patient on a cardiac monitor.
Before administration of captopril (Capoten) to a patient with stage 2 chronic kidney disease (CKD), the nurse will check the patient's A. Glucose. B. Potassium. C. Calcium. D. Phosphate.
B. Potassium.
A 58-year-old man with blunt abdominal trauma from a motor vehicle crash undergoes peritoneal lavage. If the lavage returns brown fecal drainage, which action will the nurse plan to take next? A. Auscultate the bowel sounds. B. Prepare the patient for surgery. C. Check the patient's oral temperature. D. Obtain information about the accident.
B. Prepare the patient for surgery.
Which finding by the nurse for a patient with a nursing diagnosis of impaired gas exchange will be most useful in evaluating the effectiveness of treatment? A. Even, unlabored respirations. B. Pulse oximetry reading of 92%. C. Respiratory rate of 18 breaths/minute. D. Absence of wheezes, rhonchi, or crackles.
B. Pulse oximetry reading of 92%.
When a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30, the nurse will expect an assessment finding of A. Persistent skin tenting. B. Rapid, deep respirations. C. Bounding peripheral pulses. D. Hot, flushed face and neck.
B. Rapid, deep respirations.
When caring for a patient with continuous bladder irrigation after having transurethral resection of the prostate, which action could the nurse delegate to unlicensed assistive personnel (UAP)? A. Teach the patient how to perform Kegel exercises. B. Report any complaints of pain or spasms to the nurse. C. Monitor for increases in bleeding or presence of clots. D. Increase the flow rate of the irrigation if clots are noted.
B. Report any complaints of pain or spasms to the nurse.
Which intervention will be included in the plan of care for a male patient with acute kidney injury (AKI) who has a temporary vascular access catheter in the left femoral vein? A. Start continuous pulse oximetry. B. Restrict physical activity to bed rest. C. Restrict the patient's oral protein intake. D. Discontinue the urethral retention catheter.
B. Restrict physical activity to bed rest.
Which prescribed intervention for a 61-year-old female patient with chronic short bowel syndrome will the nurse question? A. Ferrous sulfate (Feosol) 325 mg daily. B. Senna (Senokot) 1 tablet every day. C. Psyllium (Metamucil) 2.1 grams 3 times daily. D. Diphenoxylate with atropine (Lomotil) prn loose stools.
B. Senna (Senokot) 1 tablet every day.
A 25-year-old male patient has been admitted with a severe crushing injury after an industrial accident. Which laboratory result will be most important to report to the health care provider? A. Serum creatinine level 2.1 mg/dL. B. Serum potassium level 6.5 mEq/L. C. White blood cell count 11,500/uL D. Blood urea nitrogen (BUN) 56 mg/dL.
B. Serum potassium level 6.5 mEq/L.
A patient whose heart monitor shows sinus tachycardia, rate 132, is apneic and has no palpable pulses. What is the first action that the nurse should take? A. Perform synchronized cardioversion B. Start cardiopulmonary resuscitation (CPR) C. Administer atropine per agency dysrhythmia protocol D. Provide supplemental oxygen via non-rebreather mask
B. Start cardiopulmonary resuscitation (CPR)
A patient with chronic obstructive pulmonary disease (COPD) has rhonchi throughout the lung fields and a chronic, nonproductive cough. Which nursing intervention will be most effective? A. Change the oxygen flow rate to the highest prescribed rate. B. Teach the patient to use the Flutter airway clearance device. C. Reinforce the ongoing use of pursed lip breathing techniques. D. Teach the patient about consistent use of inhaled corticosteroids.
B. Teach the patient to use the Flutter airway clearance device.
Which information in the patient's history indicates to the nurse that the patient is not an appropriate candidate for kidney transplantation? A. The patient has type 1 diabetes. B. The patient has metastatic lung cancer. C. The patient has a history of chronic hepatitis C infection. D. The patient is infected with the human immunodeficiency virus.
B. The patient has metastatic lung cancer.
The nurse teaches a patient about pursed lip breathing. Which action by the patient would indicate to the nurse that further teaching is needed? A. The patient inhales slowly through the nose. B. The patient puffs up the cheeks while exhaling. C. The patient practices by blowing through a straw. D. The patient's ratio of inhalation to exhalation is 1:3.
B. The patient puffs up the cheeks while exhaling.
The nurse is assessing a patient 4 hours after a kidney transplant. Which information is most important to communicate to the health care provider? A. The urine is 900 to 1100 mL/hr. B. The patient's central venous pressure (CVP) is decreased. C. The patient has a level 7 (0 to 10 point scale) incisional pain. D. The blood urea nitrogen (BUN) and creatinine levels are elevated.
B. The patient's central venous pressure (CVP) is decreased.
A female patient with chronic kidney disease (CKD) is receiving peritoneal dialysis with 2 L inflows. Which information should the nurse report immediately to the health care provider? A. The patient has an outflow volume of 1800 mL. B. The patient's peritoneal effluent appears cloudy. C. The patient has abdominal pain during the inflow phase. D. The patient's abdomen appears bloated after the inflow.
B. The patient's peritoneal effluent appears cloudy.
A 38-year-old patient who had a kidney transplant 8 years ago is receiving the immunosuppressants tacrolimus (Prograf), cyclosporine (Sandimmune), and a prednisone (Deltasone). Which assessment data will be of most concern to the nurse? A. The blood glucose is 144 mg/dL. B. There is a nontender axillary lump. C. The patient's skin is thin and fragile. D. The patient's blood pressure is 150/92.
B. There is a nontender axillary lump.
A 62-year-old female patient has been hospitalized for 8 days with acute kidney injury (AKI) caused by dehydration. Which information will be most important for the nurse to report to the health care provider? A. The creatinine level is 3.0 mg/dL. B. Urine output over an 8-hour period is 2500 mL. C. The blood urea nitrogen (BUN) level is 67 mg/dL. D. The glomerular filtration rate is <30 mL/min/1.73m2
B. Urine output over an 8-hour period is 2500 mL.
The nurse is titrating the IV fluid infusion rate immediately after a patient has had kidney transplantation. Which parameter will be most important for the nurse to consider? A. Heart rate. B. Urine output. C. Creatinine clearance. D. Blood urea nitrogen (BUN) level.
B. Urine output.
The nurse notes that a patient's cardiac monitor shows that every other beat is earlier than expected, has no visible P wave, and has a QRS complex that is wide and bizarre in shape. How will the nurse document the rhythm? A. Ventricular couplets B. Ventricular bigeminy C. Ventricular R-on-T phenomenon D. Multifocal premature ventricular contractions
B. Ventricular bigeminy
A 26-year-old woman is being evaluated for vomiting and abdominal pain. Which question from the nurse will be most useful in determining the cause of the patient's symptoms? A. "What type of foods do you eat?" B. "Is it possible that you are pregnant?" C. "Can you tell me more about the pain?" D. "What is your usual elimination pattern?"
C. "Can you tell me more about the pain?"
A patient with heart failure has a new order for captopril (Capoten) 12.5 mg PO. After administrating the first dose and teaching the patient about the drug, which statement by the patient indicates that teaching has been effective? A. "I will be sure to take the medication with food." B. "I will need to eat more potassium-rich foods in my diet." C. "I will call for help when I need to get up to use the bathroom." D. "I will expect to feel more short of breath for the next few days."
C. "I will call for help when I need to get up to use the bathroom."
Which statement by a 62-year-old patient with stage 5 chronic kidney disease (CKD) indicates that the nurse's teaching about management of CKD has been effective? A. "I need to get most of my protein from low-fat dairy products." B. "I will increase my intake of fruits and vegetables to 5 per day." C. "I will measure my urinary output each day to help calculate the amount I can drink." D. "I need to take erythropoietin to boost my immune system and help prevent infection."
C. "I will measure my urinary output each day to help calculate the amount I can drink."
A patient has a junctional escape rhythm on the monitor. The nurse will expect the patient to have a heart rate of ______ beats/minute. A. 15 to 20 B. 20 to 40 C. 40 to 60 D. 60 to 100
C. 40 to 60
IV sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to titrate the nitroprusside rate if the patient develops A. Ventricular ectopy B. A dry, hacking cough C. A systolic BP >90 mm Hg. D. A heart rate <50 beats/minute
C. A systolic BP >90 mm Hg.
A patient seen in the asthma clinic has recorded daily peak flows that are 75% of the baseline. Which action will the nurse plan to take next? A. Increase the dose of the leukotriene inhibitor. B. Teach the patient about the use of oral corticosteroids. C. Administer a bronchodilator and recheck the peak flow. D. Instruct the patient to keep the next scheduled follow-up appointment.
C. Administer a bronchodilator and recheck the peak flow.
Which treatment for a patient with NSTEMIis a priority? A. Defibrillation B. Aspirin C. Amiodarone D. Adenosine
C. Amiodarone
A patient with chronic heart failure who is taking a diuretic and an angiotensin-converting enzyme (ACE) inhibitor and who is on a low-sodium diet tells the home health nurse about a 5-pound weight gain in the last 3 days. The nurse's priority action will be to A. Have the patient recall the dietary intake for the last 3 days B. Ask the patient about the use of the prescribed medications C. Assess the patient for clinical manifestations of acute heart failure D. Teach the patient about the importance of restricting dietary sodium
C. Assess the patient for clinical manifestations of acute heart failure
A patient with a history of chronic heart failure is admitted to the emergency department (ED) with severe dyspnea and a dry, hacking cough. Which action should the nurse do first? A. Auscultate the abdomen B. Check the capillary refill C. Auscultate the breath sounds D. Assess the level of orientation
C. Auscultate the breath sounds
Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute shortness of breath has heart failure? A. Serum troponin B. Arterial blood gas C. B-type natriuretic peptide D. 12-lead electrocardiogram
C. B-type natriuretic peptide
Which topic will the nurse plan to include in discharge teaching for a patient with systolic heart failure and an ejection fraction of 33%? A. Need to begin an aerobic exercise program several times weekly B. Use of salt substitutes to replace table salt when cooking and at the table C. Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors D. Importance of making an annual appointment with the primary care provider
C. Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors
After reviewing the electronic medical record for a patient who had transurethral resection of the prostate the previous day, which information requires the most rapid action by the nurse? A. Elevated temperature. B. Respiratory rate and lung sounds. C. Bladder spams and decreased urine output. D. No prescription for antihypertensive drugs.
C. Bladder spams and decreased urine output.
An outpatient who has chronic heart failure returns to the clinic after 2 weeks of therapy with metoprolol (Toprol XL). Which assessment finding is most important for the nurse to report to the health care provider? A. 2+ pitting edema B. Heart rate of 56 beats/minute C. Blood pressure (BP) of 88/42 mm Hg D. Complaints of fatigue
C. Blood pressure (BP) of 88/42 mm Hg
A patient who has acute glomerulonephritis is hospitalized with hyperkalemia. Which information will the nurse monitor to evaluate the effectiveness of the prescribed calcium gluconate IV? A. Urine volume. B. Calcium level. C. Cardiac rhythm. D. Neurologic status.
C. Cardiac rhythm.
A patient with acute kidney injury (AKI) has longer QRS intervals on the electrocardiogram (ECG) than were noted on the previous shift. Which action should the nurse take first? A. Notify the patient's health care provider. B. Document the QRS interval measurement. C. Check the medical record for most recent potassium level. D. Check the chart for the patient's current creatinine level.
C. Check the medical record for most recent potassium level.
A patient with chronic obstructive pulmonary disease (COPD) has poor gas exchange. Which action by the nurse would be most appropriate? A. Have the patient rest in bed with the head elevated to 15 to 20 degrees. B. Ask the patient to rest in bed in a high-Fowler's position with the knees flexed. C. Encourage the patient to sit up at the bedside in a chair and lean slightly forward. D. Place the patient in the Trendelenburg position with several pillows behind the head.
C. Encourage the patient to sit up at the bedside in a chair and lean slightly forward.
A patient who is on the progressive care unit develops atrial flutter, rate 150, with associated dyspnea and chest pain. Which action that is included in the hospital dysrhythmia protocol should the nurse do first? A. Obtain a 12-lead electrocardiogram (ECG) B. Notify the health care provider of the change in rhythm C. Give supplemental O2 at 2 to 3 L/min via nasal cannula D. Assess the patient's vital signs including oxygen saturation
C. Give supplemental O2 at 2 to 3 L/min via nasal cannula
A 37-year-old female patient is hospitalized with acute kidney injury (AKI). Which information will be most useful to the nurse in evaluating improvement in kidney function? A. Urine volume. B. Creatinine level. C. Glomerular filtration rate (GFR). D. Blood urea nitrogen (BUN) level.
C. Glomerular filtration rate (GFR).
A 55-year-old patient with end-stage kidney disease (ESKD) is scheduled to receive a prescribed dose of epoetin alfa (Procrit). Which information should the nurse report to the health care provider before giving the medication? A. Creatinine 1.6 mg/dL. B. Oxygen saturation 89%. C. Hemoglobin level 13 g/dL. D. Blood pressure 98/56 mm Hg.
C. Hemoglobin level 13 g/dL.
Which assessment finding may indicate that a patient is experiencing adverse effects to a corticosteroid prescribed after kidney transplantation? A. Postural hypotension. B. Recurrent tachycardia. C. Knee and hip joint pain. D. Increased serum creatinine.
C. Knee and hip joint pain.
A patient who is receiving dobutamine (Dobutrex) for the treatment of acute decompensated heart failure (ADHF) has the following nursing interventions included in the plan of care. Which action will be most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? A. Assess the IV insertion site for signs of extravasation B. Teach the patient the reasons for remaining on bed rest C. Monitor the patient's blood pressure and heart rate every hour D. Titrate the rate to keep the systolic blood pressure >90 mm Hg
C. Monitor the patient's blood pressure and heart rate every hour
A 64-year-old male patient who has had progressive chronic kidney disease (CKD) for several years has just begun regular hemodialysis. Which information about diet will the nurse include in patient teaching? A. Increased calories are needed because glucose is lost during hemodialysis. B. Unlimited fluids are allowed because retained fluid is removed during hemodialysis. C. More protein is allowed because urea and creatinine are removed by dialysis. D. Dietary potassium is not restricted because the level is normalized by dialysis.
C. More protein is allowed because urea and creatinine are removed by dialysis.
The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide (HydroDIURIL). Appropriate instructions for the patient include A. Limit dietary sources of potassium B. Take the hydrochlorothiazide before bedtime C. Notify the health care provider if nausea develops D. Skip the digoxin if the pulse is below 60 beats/minute
C. Notify the health care provider if nausea develops
Which diet choice by the patient with an acute exacerbation of inflammatory bowel disease (IBD) indicates a need for more teaching? A. Scrambled eggs. B. White toast and jam. C. Oatmeal with cream. D. Pancakes with syrup.
C. Oatmeal with cream.
Which nursing action can the registered nurse (RN) delegate to an experienced unlicensed assistive personnel (UAP) working as a telemetry technician on the cardiac care unit? A. Decide whether a patient's heart rate of 116 requires urgent treatment B. Monitor a patient's level of consciousness during synchronized cardioversion C. Observe cardiac rhythms for multiple patients who have telemetry monitoring D. Select the best lead for monitoring a patient admitted with acute coronary syndrome
C. Observe cardiac rhythms for multiple patients who have telemetry monitoring
A patient with chronic obstructive pulmonary disease (COPD) has a nursing diagnosis of imbalanced nutrition: less than body requirements. Which intervention would be most appropriate for the nurse to include in the plan of care? A. Encourage increased intake of whole grains. B. Increase the patient's intake of fruits and fruit juices. C. Offer high-calorie snacks between meals and at bedtime. D. Assist the patient in choosing foods with high vegetable and mineral content.
C. Offer high-calorie snacks between meals and at bedtime.
A patient who has chronic heart failure tells the nurse, "I was fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!" the nurse will document this assessment finding as A. Orthopnea B. Pulsus alternans C. Paroxysmal nocturnal dyspnea D. Acute bilateral pleural effusion
C. Paroxysmal nocturnal dyspnea
What should be assessed first after a renal arteriogram? A. Cardiac rhythm B. Urine output C. Peripheral limb skin temperature D. Airway/respiratory
C. Peripheral limb skin temperature
Which menu choice by the patient who is receiving hemodialysis indicates that the nurse's teaching has been successful? A. Split-pea soup, English muffin, and nonfat milk. B. Oatmeal with cream, half a banana, and herbal tea. C. Poached eggs, whole-wheat toast, and apple juice. D. Cheese sandwich, tomato soup, and cranberry juice.
C. Poached eggs, whole-wheat toast, and apple juice.
A 53-year-old man is scheduled for an annual physical exam. The nurse will plan to teach the patient about the purpose of A. Urinalysis collection. B. Uroflowmetry studies. C. Prostate specific antigen (PSA) testing. D. Transrectal ultrasound scanning (TRUS).
C. Prostate specific antigen (PSA) testing.
While admitting an 82-year-old with acute decompensated heart failure to the hospital, the nurse learns that the patient lives alone and sometimes confuses the "water pill" with the "heart pill." When planning for the patient's discharge the nurse will facilitate a A. Consult with a psychologist B. Transfer to a long-term care facility C. Referral to a home health care agency D. Arrangements for around-the-clock care
C. Referral to a home health care agency
After the insertion of an arteriovenous graft (AVG) in the right forearm, a 54-year-old patient complains of pain and coldness of the right fingers. Which action should the nurse take? A. Teach the patient about normal AVG function. B. Remind the patient to take a daily low-dose aspirin tablet. C. Report the patient's symptoms to the health care provider. D. Elevate the patient's arm on pillows to above the heart level.
C. Report the patient's symptoms to the health care provider.
A patient newly diagnosed with asthma is being discharged. The nurse anticipates including which topic in the discharge teaching? A. Use of long-acting b-adrenergic medications. B. Side effects of sustained-release theophylline. C. Self-administration of inhaled corticosteroids. D. Complications associated with oxygen therapy.
C. Self-administration of inhaled corticosteroids.
A patient with diabetes who has bacterial pneumonia is being treated with IV gentamicin (Garamycin) 60 mg IV BID. The nurse will monitor for adverse effects of the medication by evaluating the patient's A. Blood glucose. B. Urine osmolality. C. Serum creatinine. D. Serum potassium.
C. Serum creatinine.
Before administration of calcium carbonate (Caltrate) to a patient with chronic kidney disease (CKD), the nurse should check laboratory results for A. Potassium level. B. Total cholesterol. C. Serum phosphate. D. Serum creatinine.
C. Serum phosphate.
A patient has recently started on digoxin (Lanoxin) in addition to furosemide (Lasix) and captopril (Capoten) for the management of heart failure. Which assessment finding by the home health nurse is a priority to communicate to the health care provider? A. Presence of 1 to 2+ edema in the feet and ankles B. Palpable liver edge 2 cm below the ribs on the ride side C. Serum potassium of 3.0 mEq/L after 1 week of therapy D. Weight increase from 120 pounds to 122 pounds over 3 days
C. Serum potassium of 3.0 mEq/L after 1 week of therapy
The nurse working on the heart failure unit knows that teaching an older female patient with newly diagnosed heart failure is effective when the patient states that A. She will take furosemide (Lasix) every day at bedtime B. The nitroglycerin patch is applied when any chest pain develops C. She will call the clinic if her weight goes from 124 to 128 pounds in a week D. An additional pillow can help her sleep if she is feeling short of breath at night
C. She will call the clinic if her weight goes from 124 to 128 pounds in a week
A licensed practical/vocational nurse (LPN/LVN) is caring for a patient with stage 2 chronic kidney disease. Which observation by the RN requires an intervention? A. The LPN/LVN administers the erythropoietin subcutaneously. B. The LPN/LVN assists the patient to ambulate out in the hallway. C. The LPN/LVN administers the iron supplement and phosphate binder with lunch. D. The LPN/LVN carries a tray containing low-protein foods into the patient's room.
C. The LPN/LVN administers the iron supplement and phosphate binder with lunch.
Which action by a 70-year-old patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD? A. The patient leaves the catheter exit site without a dressing. B. The patient plans 30 to 60 minutes for a dialysate exchange. C. The patient cleans the catheter while taking a bath each day. D. The patient slows the inflow rate when experiencing abdominal pain.
C. The patient cleans the catheter while taking a bath each day.
The nurse interviews a patient with a new diagnosis of chronic obstructive pulmonary disease (COPD). Which information is most helpful in confirming a diagnosis of chronic bronchitis? A. The patient tells the nurse about a family history of bronchitis. B. The patient's history indicates a 30 pack-year cigarette history. C. The patient complains about a productive cough every winter for 3 months. D. The patient denies having any respiratory problems until the last 12 months.
C. The patient complains about a productive cough every winter for 3 months.
The nurse teaches a patient with chronic bronchitis about a new prescription for Advair Diskus (combined fluticasone and salmeterol). Which action by the patient would indicate to the nurse that teaching about medication administration has been successful? A. The patient shakes the device before use. B. The patient attaches a spacer to the Diskus. C. The patient rapidly inhales the medication. D. The patient performs huff coughing after inhalation.
C. The patient rapidly inhales the medication.
The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). Which information obtained from the patient would prompt the nurse to consult with the health care provider before administering the prescribed theophylline? A. The patient reports a recent 15-pound weight gain. B. The patient denies any shortness of breath at present. C. The patient takes cimetidine (Tagamet) 150 mg daily. D. The patient complains about coughing up green mucus.
C. The patient takes cimetidine (Tagamet) 150 mg daily.
The nurse takes an admission history on a patient with possible asthma who has new-onset wheezing and shortness of breath. Which information may indicate a need for change in therapy? A. The patient has chronic inflammatory bowel disease. B. The patient has a history of pneumonia 6 months ago. C. The patient takes propranolol (Inderal) for hypertension. D. The patient uses acetaminophen (Tylenol) for headaches.
C. The patient takes propranolol (Inderal) for hypertension.
A 22-year-old female patient with an exacerbation of ulcerative colitis is having 15 to 20 stools daily and has excoriated perianal skin. Which patient behavior indicates that teaching regarding maintenance of skin integrity has been effective? A. The patient uses incontinence briefs to contain loose stools. B. The patient asks for antidiarrheal medication after each stool. C. The patient uses witch hazel compresses to decrease irritation. D. The patient cleans the perianal area with soap after each meal.
C. The patient uses witch hazel compresses to decrease irritation.
Which information will the nurse include when teaching a patient who is scheduled for a radiofrequency catheter ablation for treatment of atrial flutter? A. The procedure will prevent or minimize the risk for sudden cardiac death B. The procedure will use cold therapy to stop the formation of the flutter waves C. The procedure will use electrical energy to destroy areas of the conduction system D. The procedure will stimulate the growth of new pathways between the atria
C. The procedure will use electrical energy to destroy areas of the conduction system
A client is receiving vancomycin for MRSA df the elbow. Which of the following patient complaints is most concerning? A. Mild pain at the site of infection B. Anxious about diagnosis C. Tinnitus (ringing of the ears) D. Urine is light yellow color
C. Tinnitus (ringing of the ears)
The nurse taking a focused health history for a patient with possible testicular cancer will ask the patient about a history of A. Testicular torsion. B. Testicular trauma. C. Undescended testicles. D. Sexually transmitted infection (STI).
C. Undescended testicles.
The nurse assesses a patient with a history of asthma. Which assessment finding indicates that the nurse should take immediate action? A. Pulse oximetry reading of 91%. B. Respiratory rate of 26 breaths/minute. C. Use of accessory muscles in breathing. D. Peak expiratory flow rate of 240 L/minute.
C. Use of accessory muscles in breathing.
A patient is scheduled for pulmonary function testing. Which action should the nurse take to prepare the patient for this procedure? A. Give the rescue medication immediately before testing. B. Administer oral corticosteroids 2 hours before the procedure. C. Withhold bronchodilators for 6 to 12 hours before the examination. D. Ensure that the patient has been NPO for several hours before the test.
C. Withhold bronchodilators for 6 to 12 hours before the examination.
A 55-year-old patient with increasing dyspnea is being evaluated for a possible diagnosis of chronic obstructive pulmonary disease (COPD). When teaching a patient about pulmonary function testing (PFT) for this condition, what is the most important question to ask? A. "Are you claustrophobic?" B. "Are you allergic to shellfish?" C. "Do you have any metal implants or prostheses?" D. "Have you taken any bronchodilators in the past 6 hours?"
D. "Have you taken any bronchodilators in the past 6 hours?"
Which question from the nurse would help determine if a patient's abdominal pain might indicate irritable bowel syndrome? A. "Have you been passing a lot of gas?" B. "What foods affect your bowel patterns?" C. "Do you have any abdominal distention?" D. "How long have you had abdominal pain?"
D. "How long have you had abdominal pain?"
After providing a patient with discharge instructions on the management of a new permanent pacemaker, the nurse knows that teaching has been effective when the patient states A. "I will avoid cooking with a microwave oven or being near one in use" B. "It will be 1 month before I can take a bath or return to my usual activities" C. "I will notify the airlines when I make a reservation that I have a pacemaker" D. "I won't lift the arm on the pacemaker side up very high until I see the doctor"
D. "I won't lift the arm on the pacemaker side up very high until I see the doctor"
You have ordered 500mg of vancomycin in 250mL of 0.9NS to run over 1 hour. Your drop factor is 10. How many drops per minute should be administered? (Round to the nearest whole number) A. 41.67 gtts/min B. 250 gtts/min C. 84 gtts/min D. 42 gtts/min
D. 42 gtts/min
The nurse has received change-of-shift report about the following patients on the progressive care unit. Which patient should the nurse see first? A. A patient who is in sinus rhythm, rate 98, after having electrical cardioversion 2 hours ago B. A patient with new onset atrial fibrillation, rate 88, who has a first dose of warfarin (Coumadin) due C. A patient with second-degree atrioventricular (AV) block, type 1, rate 60, who is dizzy when ambulating D. A patient whose implantable cardioverter-defibrillator (ICD) fired two times today who has a dose of amiodarone (Cordarone) due
D. A patient whose implantable cardioverter-defibrillator (ICD) fired two times today who has a dose of amiodarone (Cordarone) due
Following an acute myocardial infarction, a previously healthy 63-year-old develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about A. Digitalis preparations B. B-adrenergic blockers C. Calcium channel blockers D. Angiotensin-converting enzyme (ACE) inhibitors
D. Angiotensin-converting enzyme (ACE) inhibitors
A 27-year-old female patient is admitted to the hospital for evaluation of right lower quadrant abdominal pain with nausea and vomiting. Which action should the nurse take? A. Encourage the patient to sip clear liquids. B. Assess the abdomen for rebound tenderness. C. Assist the patient to cough and deep breathe. D. Apply an ice pack to the right lower quadrant.
D. Apply an ice pack to the right lower quadrant.
A patient develops sinus bradycardia at a rate of 32 beats/minute, has a blood pressure (BP) of 80/42 mm Hg, and is complaining of feeling faint. Which action should the nurse take next? A. Recheck the heart rhythm and BP in 5 minutes B. Have the patient perform the Valsalva maneuver C. Give the scheduled dose of diltiazem (Cardizem) D. Apply the transcutaneous pacemaker (TCP) pads
D. Apply the transcutaneous pacemaker (TCP) pads
Which information about continuous bladder irrigation will the nurse teach to a patient who is being admitted for a transurethral resection of the prostate (TURP)? A. Bladder irrigation decreases the risk of postoperative bleeding. B. Hydration and urine output are maintained by bladder irrigation. C. Antibiotics are infused continuously through the bladder irrigation. D. Bladder irrigation prevents obstruction of the catheter after surgery.
D. Bladder irrigation prevents obstruction of the catheter after surgery.
A patient's cardiac monitor shows sinus rhythm, rate 64. The P-R interval is 0.18 seconds at 1:00 am, 0.22 seconds at 2:30 pm, and 0.28 seconds at 4:00 pm. Which action should the nurse take next? A. Place the transcutaneous pacemaker pads on the patient B. Administer atropine sulfate 1 mg IV per agency dysrhythmia protocol C. Document the patient's rhythm and assess the patient's response to the rhythm D. Call the health care provider before giving the next dose of metoprolol (Lopressor)
D. Call the health care provider before giving the next dose of metoprolol (Lopressor)
A patient who has just been admitted with pulmonary edema is scheduled to receive the following medications. Which medication should the nurse question before giving? A. Furosemide (Lasix) 60 mg B. Captopril (Capoten) 25 mg C. Digoxin (Lanoxin) 0.125 mg D. Carvedilol (Coreg) 3.125 mg
D. Carvedilol (Coreg) 3.125 mg
A patient with severe chronic obstructive pulmonary disease (COPD) tells the nurse, "I wish I were dead! I'm just a burden on everybody." Based on this information, which nursing diagnosis is most appropriate? A. Complicated grieving related to expectation of death. B. Ineffective coping related to unknown outcome of illness. C. Deficient knowledge related to lack of education about COPD. D. Chronic low self-esteem related to increased physical dependence.
D. Chronic low self-esteem related to increased physical dependence.
The nurse will plan to teach a patient with Crohn's disease who has megaloblastic anemia about the need for A. Oral ferrous sulfate tablets. B. Regular blood transfusions. C. Iron dextran (Imferon) infusions. D. Cobalamin (B12) spray or injections.
D. Cobalamin (B12) spray or injections.
A 47-year-old female patient is transferred from the recovery room to a surgical unit after a transverse colostomy. The nurse observes the stoma to be deep pink with edema and a small amount of sanguineous drainage. The nurse should A. Place ice packs around the stoma. B. Notify the surgeon about the stoma. C. Monitor the stoma every 30 minutes. D. Document stoma assessment findings.
D. Document stoma assessment findings.
A patient has a normal cardiac rhythm and a heart rate of 72 beats/minute. The nurse determines that the P-R interval is 0.24 seconds. The most appropriate intervention by the nurse would be to A. Notify the health care provider immediately B. Give atropine per agency dysrhythmia protocol C. Prepare the patient for temporary pacemaker insertion D. Document the finding and continue to monitor the patient
D. Document the finding and continue to monitor the patient
To determine the severity of the symptoms for a 68-year-old patient with benign prostatic hyperplasia (BPH) the nurse will ask the patient about A. Blood in the urine. B. Lower back or hip pain. C. Erectile dysfunction (ED). D. Force of the urinary stream.
D. Force of the urinary stream.
Postural drainage with percussion and vibration is ordered twice daily for a patient with chronic bronchitis. Which intervention should the nurse include in the plan of care? A. Schedule the procedure 1 hour after the patient eats. B. Maintain the patient in the lateral position for 20 minutes. C. Perform percussion before assisting the patient to the drainage position. D. Give the ordered albuterol (Proventil) before the patient receives the therapy.
D. Give the ordered albuterol (Proventil) before the patient receives the therapy.
A patient complains of leg cramps during hemodialysis. The nurse should first? A. Massage the patient's legs. B. Reposition the patient supine. C. Give acetaminophen (Tylenol). D. Infuse a bolus of normal saline.
D. Infuse a bolus of normal saline.
A 64-year-old woman who has chronic constipation asks the nurse about the use of psyllium (Metamucil). Which information will the nurse include in the response? A. Absorption of fat-soluble vitamins may be reduced by fiber-containing laxatives. B. Dietary sources of fiber should be eliminated to prevent excessive gas formation. C. Use of this type of laxative to prevent constipation does not cause adverse effects. D. Large amounts of fluid should be taken to prevent impaction or bowel obstruction.
D. Large amounts of fluid should be taken to prevent impaction or bowel obstruction.
After a transurethral resection of the prostate (TURP), a 64-year-old patient with continuous bladder irrigation complains of painful bladder spasms. The nurse observes clots in the urine. Which action should the nurse take first? A. Increase the flow rate of the bladder irrigation. B. Administer the prescribed IV morphine sulfate. C. Give the patient the prescribed belladonna and opium suppository. D. Manually instill and then withdraw 50 mL of saline into the catheter.
D. Manually instill and then withdraw 50 mL of saline into the catheter.
When teaching the patient with newly diagnosed heart failure about a 2000-mg sodium diet, the nurse explains that foods to be restricted include A. Canned and frozen fruits B. Fresh or frozen vegetables C. Eggs and other high-protein foods D. Milk, yogurt, and other milk products
D. Milk, yogurt, and other milk products
A patient hospitalized with chronic obstructive pulmonary disease (COPD) is being discharged home on oxygen therapy. Which instruction should the nurse include in the discharge teaching? A. Storage of oxygen tanks will require adequate space in the home. B. Travel opportunities will be limited because of the use of oxygen. C. Oxygen flow should be increased if the patient has more dyspnea. D. Oxygen use can improve the patient's prognosis and quality of life.
D. Oxygen use can improve the patient's prognosis and quality of life.
After receiving change-of-shift report, which patient should the nurse assess first? A. Patient who is scheduled for the drain phase of a peritoneal dialysis exchange. B. Patient with stage 4 chronic kidney disease who has an elevated phosphate level. C. Patient with stage 5 chronic kidney disease who has a potassium level of 3.4 mEq/L. D. Patient who has just returned from having hemodialysis and has a heart rate of 124/min.
D. Patient who has just returned from having hemodialysis and has a heart rate of 124/min.
A young adult patient with cystic fibrosis (CF) is admitted to the hospital with increased dyspnea. Which intervention should the nurse include in the plan of care? A. Schedule a sweat chloride test. B. Arrange for a hospice nurse visit. C. Place the patient on a low-sodium diet. D. Perform chest physiotherapy every 4 hours.
D. Perform chest physiotherapy every 4 hours.
A patient who was admitted with a myocardial infarction experiences a 45-second episode of ventricular tachycardia, then converts to sinus rhythm with a heart rate of 98 beats/minute. Which of the following actions should the nurse take next? A. Immediately notify the health care provider B. Document the rhythm and continue to monitor the patient C. Perform synchronized cardioversion per agency dysrhythmia protocol D. Prepare to give IV amiodarone (Cordarone) per agency dysrhythmia protocol
D. Prepare to give IV amiodarone (Cordarone) per agency dysrhythmia protocol
When analyzing the rhythm of a patient's electrocardiogram (ECG), the nurse will need to investigate further upon finding a(n) A. Isoelectric ST segment B. P-R interval of 0.18 second C. Q-T interval of 0.38 second D. QRS interval of 0.14 second
D. QRS interval of 0.14 second
A 76-year-old patient who has been diagnosed with stage 2 prostate cancer chooses the option of active surveillance. The nurse will plan to A. Vaccinate the patient with sipuleucel-T (Provenge). B. Provide the patient with information about cryotherapy. C. Teach the patient about placement of intraurethral stents. D. Schedule the patient for annual prostate-specific antigen testing.
D. Schedule the patient for annual prostate-specific antigen testing.
Which laboratory result for a patient with multifocal premature ventricular contractions (PVCs) is most important for the nurse to communicate to the health care provider? A. Blood glucose 243 mg/dL B. Serum chloride 92 mEq/L C. Serum sodium 134 mEq/L D. Serum potassium 2.9 mEq/L
D. Serum potassium 2.9 mEq/L
A patient with chronic obstructive pulmonary disease (COPD) has a nursing diagnosis of impaired breathing pattern related to anxiety. Which nursing action is most appropriate to include in the pan of care? A. Titrate oxygen to keep saturation at least 90%. B. Discuss a high-protein, high-calorie diet with the patient. C. Suggest the use of over-the-counter sedative medications. D. Teach the patient how to effectively use pursed lip breathing.
D. Teach the patient how to effectively use pursed lip breathing.
The nurse teaches a patient how to administer formoterol (Perforomist) through a nebulizer. Which action by the patient indicates a good understanding of the teaching? A. The patient attaches a spacer before using the inhaler. B. The patient coughs vigorously after using the inhaler. C. The patient activates the inhaler at the onset of expiration. D. The patient removes the facial mask when misting has ceased.
D. The patient removes the facial mask when misting has ceased.
The nurse teaches a patient who has asthma about peak flow meter use. Which action by the patient indicates that teaching was successful? A. The patient inhales rapidly through the peak flow meter mouthpiece. B. The patient takes montelukast (Singulair) for peak flows in the red zone. C. The patient calls the health care provider when the peak flow is in the green zone. D. The patient uses albuterol (Proventil) metered dose inhaler (MDI) for peak flows in the yellow zone.
D. The patient uses albuterol (Proventil) metered dose inhaler (MDI) for peak flows in the yellow zone.
The nurse completes an admission assessment on a patient with asthma. Which information given by the patient is most indicative of a need for a change in therapy? A. The patient uses albuterol (Proventil) before any aerobic exercise. B. The patient says that the asthma symptoms are worse every spring. C. The patient's heart rate increases after using the albuterol (Proventil) inhaler. D. The patient's only medications are albuterol (Proventil) and salmeterol (Serevent).
D. The patient's only medications are albuterol (Proventil) and salmeterol (Serevent).
The nurse will anticipate that a 61-year-old patient who has an enlarged prostate detected by digital rectal examination (DRE) and an elevated prostate specific antigen (PSA) level will need teaching about A. Cystourethroscopy. B. Uroflowmetry studies. C. Magnetic resonance imaging (MRI). D. Transrectal ultrasonography (TRUS).
D. Transrectal ultrasonography (TRUS).
Which information will the nurse include in the asthma teaching plan for a patient being discharged? A. Use the inhaled corticosteroid when shortness of breath occurs. B. Inhale slowly and deeply when using the dry powder inhaler (DPI) C. Hold your breath for 5 seconds after using the bronchodilator inhaler. D. Tremors are an expected side effect of rapidly acting bronchodilators.
D. Tremors are an expected side effect of rapidly acting bronchodilators.
The nurse needs to quickly estimate the heart rate for a patient with a regular heart rhythm. Which method will be best to use? A. Count the number of large squares in the R-R interval and divide by 300 B. Print a 1-minute electrocardiogram (ECG) strip and count the number of QRS complexes C. Calculate the number of small squares between one QRS complex and the next and divide into 1500 D. Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10
D. Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10
The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, P-R interval not measurable, ventricular rate 162, R-R interval regular, and QRS complex wide and distorted, QRS duration 0.18 second. The nurse interprets the patient's cardiac rhythm as A. Atrial flutter B. Sinus tachycardia C. Ventricular fibrillation D. Ventricular tachycardia
D. Ventricular tachycardia
The nurse develops a teaching plan to help increase activity tolerance at home for an older adult with severe chronic obstructive pulmonary disease (COPD). Which instructions would be most appropriate for the nurse to include in the plan of care? A. Stop exercising when short of breath. B. Walk until pulse rate exceeds 130 beats/minute. C. Limit exercise to activities of daily living (ADLs). D. Walk 15 to 20 minutes daily at least 3 times/week.
D. Walk 15 to 20 minutes daily at least 3 times/week.
Which information will the nurse include in teaching a patient who had a proctocolectomy and ileostomy for ulcerative colitis? A. Restrict fluid intake to prevent constant liquid drainage from the stoma. b. Use care when eating high-fiber foods to avoid obstruction of the ileum. c. Irrigate the ileostomy daily to avoid having to wear a drainage appliance. d. Change the pouch every day to prevent leakage of contents onto the skin.
b. Use care when eating high-fiber foods to avoid obstruction of the ileum.
Which statement by a client at risk for CKD indicates a need for further teaching? A. I should take naproxen for my arthritis B. I should take lisinopril C. I should limit my protein intake D. I should limit my sodium intake
A. I should take naproxen for my arthritis
An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse should notify the health care provider if the patient exhibits which finding? A. Yellow-tinged sclera B. Orange-colored sputum C. Thickening of the fingernails D. Difficulty hearing high-pitched voices
A. Yellow-tinged sclera
Three days after experiencing a myocardial infarction (MI), a patient who is scheduled for discharge asks for assistance with hygiene activities, saying, "I am too nervous to take care of myself." Based on this information, which nursing diagnosis is appropriate? A. Ineffective coping related to anxiety B. Activity intolerance related to weakness C. Denial related to lack of acceptance of the MI D. Disturbed personal identity related to understanding of illness
A. Ineffective coping related to anxiety
The nurse teaches a 27-year-old woman with systemic lupus erythematous about stress and its effect on immune function and autoimmune diseases. Which statement by the patient indicates further teaching is necessary? A. "I can stop my medication if I learn to use relaxation techniques." B. "Excess alcohol consumption may cause flare-ups of my disease." C. "I will exercise to reduce stress, and I should have fewer colds and flu." D. "If I learn to decrease stress in my life, I may be able to take a smaller dose of my medications."
A. "I can stop my medication if I learn to use relaxation techniques."
When caring for a patient who has just arrived on the medical-surgical unit after having cardiac catheterization, which nursing intervention should the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? A. Give the scheduled aspirin and lipid-lowering medication B. Perform the initial assessment of the catheter insertion site C. Teach the patient about the usual post-procedure plan of care D. Titrate the heparin infusion according to the agency protocol
A. Give the scheduled aspirin and lipid-lowering medication
Which of the following are treatments for microvascular angina? (Select all that apply) A. Aspirin B. Amiodarone C. Digoxin D. Oxygen E. Simvastatin
A. Aspirin D. Oxygen E. Simvastatin
The nurse is caring for a 62 y/o man after a transurethral resection of the prostate (TURP). Which instructions should the nurse include in the teaching plan? A. Avoid straining during dedication. B. Restrict fluids to prevent incontinence. C. Sexual functioning will not be affected. D. Prosthetic examinations are not needed after surgery.
A. Avoid straining during dedication
Which treatment(s) are likely for a COPD or asthma client in respiratory distress? (Select all that apply) A. BiPap oxygen therapy B. Duoneb (albuterol/atrovert nebulized) treatment C. Furosemide (Lasix) IV push D. Dexamethasone (Decadron) IV push E. Metoprolol (Lopressor) PO
A. BiPap oxygen therapy B. Duoneb (albuterol/atrovert nebulized) treatment D. Dexamethasone (Decadron) IV push
The nurse plans a presentation for community members about how to decrease the risk for antibiotic-resistant infections. Which information will the nurse include in the teaching plan (select all that apply)? A. Continue taking antibiotics until all the medication is gone. B. Antibiotics may sometimes be prescribed to prevent infection. C. Unused antibiotics that are more than a year old should be discarded. D. Antibiotics are effective in treating influenza associated with high fevers.
A. Continue taking antibiotics until all the medication is gone. B. Antibiotics may sometimes be prescribed to prevent infection.
Which of the following labs will be most important to monitor for a client with benign prostatic hyperplasia (BPH)? A. Creatinine B. Platelet count C. Hemoglobin D. Glucose
A. Creatinine
Which of the following will be important to teach a client with end stage renal disease? (Select all that apply) A. Dairy products are high in phosphate and should be limited. B. Urine output should be measured to calculate how much the client can drink C. Increase intake of leafy green vegetables D. Orange and apple juice should be avoided E. Iron and phosphorus-binders should be taken
A. Dairy products are high in phosphate and should be limited. B. Urine output should be measured to calculate how much the client can drink
Which of the following is the best indicator of improved kidney function after an acute kidney injury? A. GFR 92 B. BUN 25 C. Create 0.8 D. Urine specific gravity 1.040
A. GFR 92
A patient who has recently started taking pravastatin (Pravachol) and niacin (Nicobid) reports the following symptoms to the nurse. Which is the most important to communicate to the health care provider? A. Generalized muscle aches and pains B. Dizziness when changing positions quickly C. Nausea when taking the drugs before eating D. Flushing and pruritus after taking the medications
A. Generalized muscle aches and pains
Which of the following medications should be given prior to synchronized cardio version for a-fib w/ RVR? (Select all that apply) A. Heparin B. Ativan C. Atropine D. Morphine E. Amiodarone
A. Heparin B. Ativan D. Morphine
A hospitalized patient has just been diagnosed with diarrhea due to C. Diff. Which nursing interventions should be included in the patient's plan of care? (Select all that apply) A. Initiate contact isolation precautions. B. Place the patient on a clear liquid diet. C. Disinfect the room with 10% bleach solution. D. Teach any visitors to wear gloves and gowns. E. Wash hands before and after patient or bodily fluid contact.
A. Initiate contact isolation precautions. C. Disinfect the room with 10% bleach solution. D. Teach any visitors to wear gloves and gowns. E. Wash hands before and after patient or bodily fluid contact.
The nurse is conducting discharge teaching for a patient with metastatic lung cancer who was admitted with a bowel impaction. Which of the following instructions would be most helpful to prevent further episodes of constipation? A. Maintain a high intake of fluid and fiber in the diet. B. Reduce intake of medications causing constipation. C. Eat several small meals per day to maintain bowel motility. D. Sit upright during meals to increase bowel motility by gravity.
A. Maintain a high intake of fluid and fiber in the diet.
Which information about a patient who has been receiving thrombolytic therapy for an acute myocardial infarction (AMI) is most important for the nurse to communicate to the health care provider? A. No change in the patient's chest pain B. An increase in troponin levels from baseline C. A large bruise at the patient's IV insertion site D. A decrease in ST-segment elevation on the electrocardiogram
A. No change in the patient's chest pain
Which of the following are complications of COPD? (Select all that apply) A. Right-sided heart failure B. Hypertension C. Status Asthmaticus D. Acute respiratory failure E. Depression and anxiety
A. Right-sided heart failure D. Acute respiratory failure E. Depression and anxiety
A patient who is being admitted to the emergency department with intermittent chest pain gives the following list of medications to the nurse. Which medication has the most immediate implications for the patient's care? A. Sildenafil (Viagra) B. Furosemide (Lasix) C. Captopril (Capoten) D. Warfarin (Coumadin)
A. Sildenafil (Viagra)
A 25-year-old female patient with systemic lupus erythematous (SLE) who has a facial rash and alopecia tells the nurse, "I never leave my house because I hate the way I look." Which one of the following nursing diagnoses should the nurse plan interventions for? A. Social isolation B. Activity intolerance C. Impaired skin integrity D. Impaired social interaction
A. Social isolation
Which heart rhythm requires immediate intervention? A. Stable ventricular tachycardia. B. Atrial fibrillation. C. Stable bradycardia. D. Tachycardia.
A. Stable ventricular tachycardia.
Which of the following are likely to be seen in a patient experiencing an asthma attack? (Select all that apply) A. Tachypnea B. Dyspnea C. Diffuse crackles D. Accessory muscle use E. Chest pain
A. Tachypnea B. Dyspnea D. Accessory muscle use E. Chest pain
The nurse is caring for a patient who was admitted to the coronary care unit following and acute myocardial infarction (AMI) and percutaneous coronary intervention the previous day. Teaching for this patient would include A. When cardiac rehabilitation will begin B. The typical emotional responses to AMI C. Information regarding discharge medications D. The pathophysiology of coronary artery disease
A. When cardiac rehabilitation will begin
An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse should notify the health care provider if the patient exhibits which finding? A. Yellow-tinged sclera B. Orange-colored sputum C. Thickening of the fingernails D. Difficulty hearing high-pitched voices
A. Yellow-tinged sclera
When caring for a patient who is recovering from a sudden cardiac death (SCD) event and has no evidence of an acute myocardial infarction (AMI), the nurse will anticipate teaching the patient that A. Sudden cardiac death events rarely reoccur B. Additional diagnostic testing will be required C. Long-term anticoagulation therapy will be needed D. Limited physical activity after discharge will be needed to prevent future events
B. Additional diagnostic testing will be required
A patient is recovering from a myocardial infarction (MI) and develops chest pain on day 3 that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take next? A. Assess the feet for pedal edema B. Palpate the radial pulses bilaterally C. Auscultate for a pericardial friction rub D. Check the heart monitor for dysrhythmias
C. Auscultate for a pericardial friction rub
To improve the physical activity level for a mildly obese 71-year old patient, which action should the nurse plan to take? A. Stress that weight loss is a major benefit of increased exercise B. Determine what kind of physical activities the patient usually enjoys C. Tell the patient that older adults should exercise for no more than 20 minutes at a time D. Teach the patient to include a short warm-up period at the beginning of physical activity
B. Determine what kind of physical activities the patient usually enjoys
Which assessment finding by the nurse caring for a patient who has had coronary artery bypass grafting using a right radial graft is most important to communicate to the health care provider? A. Complaints of incisional chest pain B. Pallor and weakness of the right hand C. Fine crackles heard at both lung bases D. Redness on both sides of the sternal incision
B. Pallor and weakness of the right hand
Which patient at the cardiovascular clinic requires the most immediate action by the nurse? A. Patient with type 2 diabetes whose current blood glucose level is 145 mg/dL B. Patient with stable angina whose chest pain has recently increased in frequency C. Patient with familial hypercholesterolemia and a total cholesterol of 465 mg/dL D. Patient with chronic hypertension whose blood pressure today is 172/98 mm Hg
B. Patient with stable angina whose chest pain has recently increased in frequency
You are caring for a patient who goes into asystole. What actions do you take after assessing the client and confirming the rhythm? (Select all that apply) A. Intubate the client B. Perform CPR C. Ensure IV latency D. Prepare client for defibrillation E. Call for help.
B. Perform CPR C. Ensure IV latency E. Call for help
When evaluating the effectiveness of preoperative teaching with a patient scheduled for coronary artery bypass graft (CABG) surgery using the internal mammary artery, the nurse determines that additional teaching is needed when the patient says which of the following? A. "They will need to circulate my blood with a machine during the surgery" B. "I will have small incisions in my leg where they will remove the vein" C. "They will use an artery near my heart to go around the area that is blocked" D. "I will need to take an aspirin every day after the surgery to keep the graft open"
B. "I will have small incisions in my leg where they will remove the vein"
A patient who is recovering from an acute myocardial infarction (AMI) asks the nurse about when sexual intercourse can be resumed. Which response by the nurse is best? A. "Most patients are able to enjoy intercourse without any complications" B. "Sexual activity uses about as much energy as climbing two flights of stairs" C. "The doctor will provide sexual guidelines when your heart is strong enough" D. "Holding and cuddling are good ways to maintain intimacy after a heart attack"
B. "Sexual activity uses about as much energy as climbing two flights of stairs"
The nurse is preparing to insert a nasogastric tube into a patient with a suspected small intestinal obstruction that is vomiting. the patient asks the nurse why this procedure is necessary. What response by the nurse is most appropriate? A. "The tube is just a standard procedure before many types of surgery to the abdomen." B. "The tube will help to drain the stomach contents and prevent further vomiting." C. "The tube will push past the area that is blocked and thus help to stop the vomiting." D. "The tube will let us measure your stomach contents to let us know how much fluid we should give you."
B. "The tube will help to drain the stomach contents and prevent further vomiting."
The nurse supervises a student nurse who is assigned to take care of a patient with active tuberculosis (TB). Which action, if performed by the student nurse, would require an intervention by the nurse? A. The patient is offered a tissue from the box at bedside B. A surgical face mask is applied before visiting the patient C. A snack is brought to the patient from the unit refrigerator. D. Hand washing is performed before entering the patient's room
B. A surgical face mask is applied before visiting the patient
Which actions could the nurse delegate to unlicensed assistive personnel (UAP) who are providing care for a patient who is at risk for venous thromboembolism? A. Monitor for any bleeding after anticoagulation therapy is started. B. Apply sequential compression device whenever the patient is in bed. C. Ask the patient about use of herbal medicines or dietary supplements. D. Instruct the patient to call immediately if any shortness of breath occurs.
B. Apply sequential compression device whenever the patient is in bed.
When titrating IV nitroglycerin (Tridil) for a patient with a myocardial infarction (MI), which action will the nurse take to evaluate the effectiveness of the medication? A. Monitor heart rate B. Ask about chest pain C. Check blood pressure D. Observe for dysrhythmias
B. Ask about chest pain
When admitting a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI) to the intensive care unit, which action should the nurse perform first? A. Obtain the blood pressure B. Attach the cardiac monitor C. Assess the peripheral pulses D. Auscultate the breath sounds
B. Attach the cardiac monitor
The nurse will suspect that the patient with stable angina is experiencing a side effect of the prescribed metoprolol (Lopressor) if the A. Patient is restless and agitated B. Blood pressure is 90/54 mm Hg C. Patient complains about feeling anxious D. Cardiac monitor shows a heart rate of 61 beats/minute
B. Blood pressure is 90/54 mm Hg
Diltiazem (Cardizem) is ordered for a patient with newly diagnosed Prinzmetal's (variant) angina. While teaching the patient, the nurse will include the information that diltiazem will A. Reduce heart palpitations B. Decrease spasm of the coronary arteries C. Increase the force of the heart contractions D. Help prevent plaque from forming in the coronary arteries
B. Decrease spasm of the coronary arteries
A young woman who has Crohn's disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, fecal-smelling urine. What information will the nurse add to a general teaching plan about UTIs in order to individualize the teaching for this patient? A. Bacteria in the perianal area can enter the urethra. B. Fistulas can form between the bowel and bladder. C. Drink adequate fluids to maintain normal hydration. D. Empty the bladder before and after sexual intercourse
B. Fistulas can form between the bowel and bladder.
The nurse has experienced a recent increase in the incidence of hospital care-associated infections (HAIs) on the unit. Which nursing action action should be prioritized in the response to this trend? A. use of gloves during patient contact. B. Frequent and thorough hand washing. C. Prophylactic, broad-spectrum antibiotics D. Fitting and appropriate use of N95 masks
B. Frequent and thorough hand washing
Which statement by a client with COPD indicates a need for further teaching? A. I should let someone else do the barbecuing B. I only eat twice per day, but I eat a large high-calorie meal at night. C. I should increase my oxygen when I'm exercising if I feel short of breath. D. I should use Nicolette or a nicotine patch to help me stop smoking
B. I only eat twice per day, but I eat a large high-calorie meal at night.
Which statement by a client with ESRD indicates a need for further teaching? A. I should restrict my potassium intake. B. I should take my Renagel and Feosol with meals. C. I need to stop eating potato chips. D. If my weight suddenly increases, I should tell my doctor.
B. I should take my Renagel and Feosol with meals.
A client with chronic kidney disease is admitted with constipation. Which one of the following medication orders do you question? A. Psyllium (Metamucil) B. Magnesium Citrate (Citroma) C. Docusate Sodium (Colace) D. Polythylene Glycol (MiraLAX)
B. Magnesium Citrate (Citroma)
Interpret these ABG results: pH: 7.45 PaCO2: 28 HCO3: 35 PaO2: 94 A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis
B. Metabolic alkalosis
The nurse is planning to administer a transfusion of packed RBCs to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to unlicensed assistive personnel (UAP)? A. Verify the patient identification (ID) according to hospital policy. B. Obtain the temperature, blood pressure, and pulse before the transfusion. C. Double-check the product numbers on the packed RBCs with the patient ID band. D. Monitor the patient for shortness of breath
B. Obtain the temperature, blood pressure, and pulse before the transfusion.
The nurse and unlicensed assistive personnel (UAP) on the telemetry unit are caring for four patients. Which nursing action can be delegated to the UAP? A. Teaching a patient scheduled for exercise electrocardiography about the procedure B. Placing electrodes in the correct position for a patient who is to receive ECG monitoring C. Checking the catheter insertion site for a patient who is recovering from a coronary angiogram D. Monitoring a patient who has just returned to the unit after a transesophageal echocardiogram
B. Placing electrodes in the correct position for a patient who is to receive ECG monitoring
A client admitted with a diagnosis of atrial fibrillation with rapid ventricular response is on diltiazem (Cardizem) drip. Order states to titrate for HR <100 and SBP >110. A UAP on your unit reports that his current BP is 112/84 and HR is 52. The client is asymptomatic. What is your priority action? A. Stop the infusion and call the provider. B. Slow down infusion and monitor for response. C. Nothing, the client is asymptomatic. D. Prepare to administer atropine.
B. Slow down infusion and monitor for response.
The registered nurse (RN) caring for an HIV-positive patient admitted with TB can delegate which action to unlicensed assistive personnel (UAP)? A. Teach the patient how to dispose of tissues with respiratory secretions B. Stock the patient's room with the necessary personal protective equipment C. Interview the patient to obtain the names of family members and close contacts. D. Tell the patient's family members the reason for the use of airborne precautions.
B. Stock the patient's room with the necessary personal protective equipment
Which assessment data collected by the nurse who is admitting a patient with chest pain suggest that the pain is caused by an acute myocardial infarction (AMI)? A. The pain increases with deep breathing B. The pain has lasted longer than 30 mins C. The pain is relieved after the patient takes nitroglycerin D. The pain is reproducible when the patient raises the arms
B. The pain has lasted longer than 30 mins
Which of the following complications might you see with AKI? (Select all that apply) A. Cardiac arrhythmia B. Tingling sensation in fingers C. Bone fractures D. Peripheral edema E. Altered mental status.
B. Tingling sensation in fingers. D. Peripheral edema E. Altered mental status.
After the nurse has finished teaching a patient about the use of sublingual nitroglycerin (Nitrostat), which patient statement indicates that the teaching has been effective? A. "I can expect some nausea as a side effect of nitroglycerin" B. "I should only take the nitroglycerin if I start to have chest pain" C. "I will call an ambulance if I still have pain after taking 3 nitroglycerin 5 minutes apart" D. "Nitroglycerin helps prevent a clot from forming and blocking blood flow to my heart"
C. "I will call an ambulance if I still have pain after taking 3 nitroglycerin 5 minutes apart"
A patient who had bladder surgery 2 days ago develops acute decompensated heart failure (ADHF) with severe dyspnea. Which action by the nurse would be indicated first? A. Perform a bladder scan to assess for urinary retention. B. Restrict the patient's oral fluid intake to 500 mLs per day C. Assist the patient to a sitting position with arms on the overbed table. D. Instruct the patient to use pursed-lip breathing until the dyspnea subsides.
C. Assist the patient to a sitting position with arms on the overbed table
In preparation for discharge, the nurse teaches a patient with chronic stable angina how to use the prescribed short-acting and long-acting nitrates. Which patient statement indicates that the teaching has been effective? A. "I will check my pulse rate before I take any nitroglycerin tablets" B. "I will put the nitroglycerin patch on as soon as I get any chest pain" C. "I will stop what I am doing and sit down before I put the nitroglycerin under my tongue" D. "I will be sure to remove the nitroglycerin patch before taking any sublingual nitroglycerin"
C. "I will stop what I am doing and sit down before I put the nitroglycerin under my tongue"
A female patient's complex symptomatology over the past year has led to a diagnosis of systemic lupus erythematous (SLE). Which statement demonstrates the patient's need for further teaching about the disease? A. "I'll try my best to stay out of the sun this summer." B. "I know that I have a high chance of getting arthritis." C. "I'm hoping surgery will be an option for me in the future." D. "I understand I'm going be vulnerable to infections and illnesses."
C. "I'm hoping surgery will be an option for me in the future."
A 24-year-old female patient with systemic lupus erythematous (SLE) tells the nurse she wants to have a baby and is considering getting pregnant. Which response by the nurse is most appropriate? A. "Temporarily remission of your signs and symptoms is common during pregnancy." B. "Autoantibodies transferred to the baby during pregnancy will cause heart defects." C. "Infertility can result from some medications used to control your disease." D. "The baby is at high risk for neonatal lupus erythematous being diagnosed at birth."
C. "Infertility can result from some medications used to control your disease."
A patient with ST-segment elevation in three contiguous electrocardiographic (ECG) leads is admitted to the emergency department (ED) and diagnoses as having an ST-segment-elevation-myocardial infarction (STEMI). Which question should the nurse ask to determine whether the patient is a candidate for thrombolytic therapy? A. "Do you have any allergies?" B. "Do you take aspirin on a daily basis?" C. "What time did your chest pain begin?" D. "Can you rate your chest pain using a 0 to 10 scale?"
C. "What time did your chest pain begin?"
Acetaminophen elixir is ordered for a 6 week old child. Order: 10mg/kg Child's weight: 5.7kg Dose provided: 160mg/5mL How many mLs should you give? (Round to the nearest tenth). A. 180m: B. 18mL C. 1.8mL D. 17mL
C. 1.8mL
During the administration of the thrombolytic agent to a patient with an acute myocardial infarction (AMI), the nurse should stop the drug infusion if the patient experiences A. Bleeding from the gums B. Increase in blood pressure C. A decrease in level of consciousness D. A nonsustained episode of ventricular tachycardia
C. A decrease in level of consciousness
A new client patient with joint swelling and pain is being tested for systemic lupus erythematous (SLE). Which test will provide the most specific findings for the nurse to review? A. Rheumatoid factor (RF) B. Antinuclear antibody (ANA) C. Anti-smith antibody (Anti-Sm) D. Lupus erythematous (LE) cell prep
C. Anti-smith antibody (Anti-Sm)
The nurse teaches a 30 y/o man with a family history of prostate cancer about dietary factors associated with prostate cancer. The nurse determines that teaching is successful if the patient selects which menu? A. Grilled steak, French fries, and a vanilla shake. B. Hamburger with cheese, pudding, and coffee. C. Baked chicken, peas, apple slices, and skim milk. D. Grilled cheese sandwich, onion rings, and hot tea.
C. Baked chicken, peas, apple slices, and skim milk.
The nurse obtains the following data when assessing a patient who experienced an ST-segment-elevation myocardial infarction (STEMI) 2 days previously. Which information is most important to report to the health care provider? A. The troponin level is elevated B. The patient denies ever having a heart attack C. Bilateral crackles are auscultated in mid-lower lobes D. The patient has occasional premature atrial contractions (PACs)
C. Bilateral crackles are auscultated in mid-lower lobes
The nurse is caring for a patient who has been receiving warfarin (Coumadin) and digoxin (Lanoxin) as treatment for atrial fibrillation. Because the warfarin has been disconnected before surgery, the nurse should diligently assess the patient for which complication early in the postoperative period until the medication is resumed? A. Decreased C/O B. Increased blood pressure C. Cerebral or pulmonary emboli D. Excessive bleeding from incision or IV sites
C. Cerebral or pulmonary emboli
What is the top nursing diagnosis for a client with A-fib w/ RVR? A. Activity intolerance B. Impaired gas exchange C. Decreased cardiac output D. Anxiety
C. Decreased cardiac output
A patient who has chest pain as admitted to the emergency department (ED) and all of the following are ordered. Which one should the nurse arrange to be completed first? A. Chest x-ray B. Troponin level C. Electrocardiogram (ECG) D. Insertion of a peripheral IV
C. Electrocardiogram (ECG)
A patient who is taking rifampin (Rifadin) for TB calls the clinic and reports having orange discolored urine and tears. Which response by the nurse reflects accurate knowledge about the mediation and that patient's illness? A. Ask the patient about any visual changes in red-green color discrimination B. Question the patient about experiencing SOB, hives, or itching C. Explain that orange discolored urine and tears are normal while taking this medication D. Advise the patient to stop the drug and report it to the MD.
C. Explain that orange discolored urine and tears are normal while taking this medication
Which supplement should a person receiving Erythropoietin be sure to take? A. Renagel B. PhosLo C. Feosol D. Os-Cal
C. Feosol
Following an acute myocardial infarction (AMI), a patient ambulates in the hospital hallway. When the nurse is evaluating the patient's response to the activity, which assessment data would indicate that the exercise level should be decreased? A. Blood pressure (BP) changes from 118/60 to 126/68 mm Hg B. Oxygen saturation drops from 99% to 95% C. Heart rate increases from 66 to 92 D. Respiratory rate goes from 14 to 20 breaths/minute
C. Heart rate increases from 66 to 92
Which nursing intervention will be most effective when assisting the patient with coronary artery disease (CAD) to make appropriate dietary changes? A. Give the patient a list of low-sodium, low-cholesterol foods that should be included in the diet B. Emphasize the increased risk for heart problems unless the patient makes the dietary changes C. Help the patient modify favorite high-fat recipes by using monosaturated oils when possible D. Inform the patient that a diet containing no saturated fat and minimal salt will be necessary
C. Help the patient modify favorite high-fat recipes by using monosaturated oils when possible
Heparin is ordered for a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI). What is the purpose of the heparin? A. Heparin enhances platelet aggregation B. Heparin decreases coronary artery plaque size C. Heparin prevents the development of new clots in the coronary arteries D. Heparin dissolves clots that are blocking blood flow in the coronary arteries
C. Heparin prevents the development of new clots in the coronary arteries
While assessing a 68-yr-old with ascites, the nurse also notes jugular vein distention (JVD) with the head of the patient's bed elevated 45 degrees. The nurse knows this finding indicates A. Decreased fluid volume B. Jugular vein atherosclerosis C. Increased right atrial pressure D. Incompetent jugular vein valves
C. Increased right atrial pressure
When caring for a preoperative patient on the day of surgery, which actions included in the plan of care can the nurse delegate to an unlicensed assistive personnel (UAP)? (Select all that apply). A. Teach incentive spirometer use B. Explain routine preoperative care. C. Obtain and document baseline vital signs. D. Remove nail polish and apply pulse oximeter E. Transport the patient by stretcher to the operating room.
C. Obtain and document baseline vital signs. D. Remove nail polish and apply pulse oximeter E. Transport the patient by stretcher to the operating room.
A patient with diabetes mellitus and chronic stable angina has a new order for captopril (Capoten). The nurse should teach the patient that the primary purpose of captopril is to A. Lower heart rate B. Control blood glucose levels C. Prevent changes in heart muscle D. Reduce the frequency of chest pain
C. Prevent changes in heart muscle
Which task can the nurse delegate to an unlicensed assistive personnel (UAP) in the care of a patient who has recently undergone prostatectomy? A. Assessing the patient's incision B. Irrigating the patient's Foley catheter C. Reporting complaints of pain or bladder spasms D. Evaluating the patient's pain and selecting analgesia
C. Reporting complaints of pain or bladder spasms
Which electrocardiographic (ECG) change is most important for the nurse to report to the health care provider when caring for a patient with chest pain? A. Inverted P wave B. Sinus tachycardia C. ST-segment elevation D. First-degree atrioventricular block
C. ST-segment elevation
Which of the following might indicate a client is in the diuretic phase of AKI? A. Urine output 100mL in the last 2 hours. B. Peaked T-waves on ECG C. Tenting of the skin D. Decreased BUN
C. Tenting of the skin
A patient is one day postoperative following a transurethral resection of the prostate (TURP). Which event is not an expected normal finding in the care of this patient? A. The patient requires two tablets of Tylenol #3 during the night. B. The patient complains of fatigue and claims to have minimal appetite. C. The patient has continuous bladder irrigation (CBI) infusing, but output has decreased. D. The patient has expressed anxiety about his planned discharge home the following day.
C. the patient has continuous bladder irrigation (CBI) infusing, but output has decreased.
Which statement(s) by a client with asthma are most concerning? (Select all that apply) A. "I only use my albuterol inhaler when I need it." B. "I should seek medical attention if my wheezing doesn't get better after using my albuterol inhaler at home." C. "I ingest marijuana sometimes." D. "I have been intubated several times in the past." E. "I should use my Servant (salmeterol) inhaler when I am having an asthma attack."
D. "I have been intubated several times in the past." E. "I should use my Servant (salmeterol) inhaler when I am having an asthma attack."
Which statement made by a patient with coronary artery disease after the nurse has completed teaching about therapeutic lifestyle changes (TLC) diet indicates that further teaching is needed? A. "I will switch from whole milk to 1% milk" B. "I like salmon and I will plan to eat it more often" C. "I can have a glass of wine with dinner if I want one" D. "I will miss being able to eat peanut butter sandwiches"
D. "I will miss being able to eat peanut butter sandwiches"
A patient develops third-degree heart block and reports feeling chest pressure and SOB. Which instructions should the nurse provide to the patient before initiating emergency transcutaneous pacing? A. "The device will convert your HR and rhythm back to normal." B " The device is inserted through a large vein and threaded into your heart." C. "The device uses overdrive pacing to slow the heart to a normal rate." D. "The device delivers a current through your skin that can be uncomfortable."
D. "The device delivers a current through your skin that can be uncomfortable."
After receiving change-of-shift report about the following four patients, which patient should the nurse assess first? A. 39-year old with pericarditis who is complaining of sharp, stabbing chest pain B. 56-year old with variant angina who is to receive a dose of nifedipine (Procardia) C. 65-year old who had a myocardial infarction (MI) 4 days ago and is anxious about the planned discharge D. 59-year old with unstable angina who has just returned to the unit after having a percutaneous coronary intervention (PCI)
D. 59-year old with unstable angina who has just returned to the unit after having a percutaneous coronary intervention (PCI)
A patient who has had chest pain for several hours is admitted with a diagnosis of rule out acute myocardial infarction (AMI). Which laboratory test should the nurse monitor to help determine whether the patient has had an AMI? A. Myoglobin B. Homocysteine C. C-reactive protein D. Cardiac-specific troponin
D. Cardiac-specific troponin
When caring for a patient with acute coronary syndrome who has returned to the coronary care unit after having angioplasty with stent placement, the nurse obtains the following assessment data. Which data indicate the need for immediate action by the nurse? A. Heart rate 102 beats/min B. Pedal pulses 1+ bilaterally C. Blood pressure 103/54 mm Hg D. Chest pain 7 on a 0 to 10 point scale
D. Chest pain 7 on a 0 to 10 point scale
A patient admitted to the coronary care unit (CCU) with an ST-segment elevation myocardial infarction (STEMI) is restless and anxious. The blood pressure is 86/40 and heart rate is 123. Based on this information, which nursing diagnosis is a priority for the patient? A. Acute pain related to myocardial infarction B. Anxiety related to perceived threat of death C. Stress overload related to acute change in health D. Decreased cardiac output related to cardiogenic shock
D. Decreased cardiac output related to cardiogenic shock
A client with ulcerative colitis is admitted for an exacerbation. The lab results reveal elevated BUN and hemoglobin values. What is the most likely explanation for these labs? A. Anemia B. A blood clotting disorder C. Infection D. Dehydration
D. Dehydration
When developing a teaching plan for a 61-year-old man with the following risk factors for coronary artery disease (CAD), the nurse should focus on the A. Family history of coronary artery disease B. Increased risk associated with the patient's gender C. Increased risk of cardiovascular disease as people age D. Elevation of the patient's low-density lipoprotein (LDL) level
D. Elevation of the patient's low-density lipoprotein (LDL) level
A patient with hyperlipidemia has a new order for colesevelam (Welchol). Which nursing action is most appropriate when giving the medication? A. Have the patient take this medication with an aspirin B. Administer the medication at the patient's usual bedtime C. Have the patient take the colesevelam with a sip of water D. Give the patient's other medications 2 hours after the colesevelam
D. Give the patient's other medications 2 hours after the colesevelam
The nurse is caring for a patient with ineffective airway clearance. What is the priority nursing action to assist this patient expectorate thick lung secretions? A. Humidify the oxygen as able. B. Administer cough suppressant Q4hrs. C. Teach patient to splint the affected area. D. Increase fluid intake to 3L/day if tolerated
D. Increase fluid intake to 3L/day if tolerated
The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best indicator that the treatment has been effective? A. Weight loss of 2 pounds in 24 hours B. Hourly urine output greater than 60 mL C. Reduction in patient complaints of chest pain D. Reduced dyspnea with the head of bed at 30 degrees
D. Reduced dyspnea with the head of bed at 30 degrees
A patient had a non-ST-segment-elevation myocardial infarction (NSTEMI) 3 days ago. Which nursing intervention included in the plan of care is most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? A. Evaluation of the patient's response to walking in the hallway B. Completion of the referral form for a home health nurse follow-up C. Education of the patient about the pathophysiology of heart disease D. Reinforcement of teaching about the purpose of prescribed medications
D. Reinforcement of teaching about the purpose of prescribed medications
Which of the following assessment findings is most concerning? A. Audible expiratory and inspiratory wheezes in all lung fields. B. Accessory muscle use. C. Dyspnea with exertion. D. Severely diminished breath sounds.
D. Severely diminished breath sounds.
Nadolol (Corgard) is prescribed for a patient with chronic stable angina and left ventricular dysfunction. To determine whether the drug is effective, the nurse will monitor for A. Decreased blood pressure and heart rate B. Fewer complaints of having cold hands and feet C. Improvement in the strength of the distal pulses D. The ability to do daily activities without chest pain
D. The ability to do daily activities without chest pain
Which information given by a patient admitted with chronic stable angina will help the nurse confirm this diagnosis? A. The patient states that the pain "wakes me up at night" B. The patient rates the pain at a level 3 to 5 (0 to 10 scale) C. The patient states that the pain has increased in frequency over the last week D. The patient states that the pain "goes away" with one sublingual nitroglycerin tablet
D. The patient states that the pain "goes away" with one sublingual nitroglycerin tablet
