Med Surg III Exam 1 Quizzes

A patient has undergone a resection of her left breast due to invasive breast cancer. Which discharge instruction should the nurse provide to the patient? 1. Limit lifting heavy objects with left arm during the post-op period 2. No follow up care is necessary, the cancer has been removed 3. The patient should consult a plastic surgeon for a complete breast resection 4. Empty your drain every 24 hours

1. Limit lifting heavy objects with left arm during the post-op period

A patient is brought to the ED by ambulance with a gunshot wound to the abdomen. The nurse knows that the most common hollow organ injured in this type of injury is what? Group of answer choices a. Stomach b. Liver c. Small bowel d. Large bowel

c. Small bowel

While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of the patient's closed chest-drainage system. What should the nurse conclude? Group of answer choices a. The system is functioning normally. b. The patient has a pneumothorax. c. The system has an air leak. d. The chest tube is obstructed.

c. The system has an air leak.

A nurse is providing education to a community women's group. Which are true statements regarding the risk of breast cancer? 1. There is no increased risk of developing breast cancer as a patient ages 2. Young girls who experience their first menstrual cycle at age 10 have an increased risk of breast cancer 3. Men have no risk of developing breast cancer 4. A woman who is taking estrogen therapy may have an increased risk of breast cancer

2. Young girls who experience their first menstrual cycle at age 10 have an increased risk of breast cancer 4. A woman who is taking estrogen therapy may have an increased risk of breast cancer

You are caring for a 28 year old male who was involved in a motor vehicle collision. He sustained a chest injury and developed a pneumothorax of his right lower lung. A chest tube was inserted in the emergency department. The patient arrives to the ICU and you are the assigned nurse. He immediately complains of pain and difficulty breathing. Which of the following should the nurse do FIRST? 1. Medicate for pain 2. Increase the amount of supplemental oxygen the patient is receiving via nasal cannula 3. Assess the patient 4. Position the patient upright in the bed

3. Assess the patient

A patient who has undergone valve replacement surgery is being prepared for discharge home. Because the patient will be discharged with a prescription for warfarin (Coumadin), the nurse should educate the patient about which of the following? A)The need for regularly scheduled testing of the patient's International Normalized Ratio (INR) B)The need to learn to sleep in a semi-Fowler's position for the first 6 to 8 weeks to prevent emboli C)The need to avoid foods that contain vitamin K D)The need to take enteric-coated ASA on a daily basis

A Patients who take warfarin (Coumadin) after valve replacement have individualized target INRs; usually between 2 and 3.5 for mitral valve replacement and 1.8 and 2.2 for aortic valve replacement. Natural sources of vitamin K do not normally need to be avoided and ASA is not indicated. Sleeping upright is unnecessary.

Most individuals who have mitral valve prolapse never have any symptoms, although this is not the case for every patient. What symptoms might a patient have with mitral valve prolapse? Select all that apply. A)Anxiety B)Fatigue C)Shoulder pain D)Tachypnea E)Palpitations

A, B, E Most people who have mitral valve prolapse never have symptoms. A few have symptoms of fatigue, shortness of breath, lightheadedness, dizziness, syncope, palpitations, chest pain, and anxiety. Hyperpnea and shoulder pain are not characteristic symptoms of mitral valve prolapse.

The nurse is assessing a patient who sustained significant chest trauma during an MVA. What significant assessment finding suggests tension pneumothorax? A. Tracheal deviation to unaffected side B. Inspiratory stridor C. Diminished breath sounds D. Hyperresonance on percussion

A. Tracheal deviation to unaffected side

A patient has been admitted to the medical unit with signs and symptoms suggestive of endocarditis. The physician's choice of antibiotics would be primarily based on what diagnostic test?A)Echocardiography B)Blood cultures C)Cardiac aspiration D)Complete blood count

B To help determine the causative organisms and the most effective antibiotic treatment for the patient, blood cultures are taken. A CBC can help establish the degree and stage of infection, but not the causative microorganism. Echocardiography cannot indicate the microorganisms causing the infection. Cardiac aspiration is not a diagnostic test.

A client presents to the ER following a motorcycle accident. A nurse assesses the client and notes uncoordinated or paradoxical chest rise and fall as well as multiple bruises across the client's chest and torso, creptius, and tachypnea. Based on this assessment, the nurse should: A. Assist in the placement of a cervical collar B. Anticipate the need to intubate the client C. Provide chest compressions D. Tape the chest wall

B. Anticipate the need to intubate the client Assessment implies multiple broken ribs and potential flail chest. More invasive intervention required in order to manage patient's aiway

A 19 year old patient was seen in the ED after a motorcycle accident for multiple rib fractures that resulted in free floating ribs, paradoxical breathing and inadequate oxygenation. What is this condition called? A. Tension Pneumothorax B. Flail Chest C. Pulmonary contusion D. Subcutaneous emphysema

B. Flail Chest

A patient who has undergone a valve replacement with a mechanical valve prosthesis is due to be discharged home. During discharge teaching, the nurse should discuss the importance of antibiotic prophylaxis prior to which of the following? A)Exposure to immunocompromised individuals B)Future hospital admissions C)Dental procedures D)Live vaccinations

C Following mechanical valve replacement, antibiotic prophylaxis is necessary before dental procedures involving manipulation of gingival tissue, the periapical area of the teeth or perforation of the oral mucosa (not including routine anesthetic injections, placement of orthodontic brackets, or loss of deciduous teeth). There are no current recommendations around antibiotic prophylaxis prior to vaccination, future hospital admissions, or exposure to people who are immunosuppressed.

A patient is undergoing diagnostic testing for mitral stenosis. What statement by the patient during the nurse's interview is most suggestive of this valvular disorder? A)I get chest pain from time to time, but it usually resolves when I rest. B)Sometimes when I'm resting, I can feel my heart skip a beat. C)Whenever I do any form of exercise I get terribly short of breath. D)My feet and ankles have gotten terribly puffy the last few weeks.

C The first symptom of mitral stenosis is often breathing difficulty (dyspnea) on exertion as a result of pulmonary venous hypertension. Patients with mitral stenosis are likely to show progressive fatigue as a result of low cardiac output. Palpitations occur in some patients, but dyspnea is a characteristic early symptom. Peripheral edema and chest pain are atypical

A patient reports pain with inspiration after falling off a skateboard. The physician makes the diagnosis of rib fracture. The nurse prepares to do patient teaching for which treatment? A. Mechanical Ventilation B. Tight bandage around chest C. Coughing and deep breathing D. Potent analgesics for pain

C. Coughing and deep breathing

On arrival to the ED, the patient develops extreme respiratory distress and the MD identifies tension pneumothorax. The nurse prepares to assist with which urgent procedure? A. Endotracheal intubation B. Placement of CT C. Insertion of a 8 inch, 16 or 18 gauge pericardial needle D. Insertion of large bore needle into the intercostal space on affected side

D. Insertion of large bore needle into the intercostal space on affected side

A male patient with multiple injuries is brought to the ED by ambulance. He has had his airway stabilized and is breathing on his own. The ED nurse does not see any active bleeding, but should suspect internal hemorrhage based on what finding? Group of answer choices a. Sudden diaphoresis b. Increased BP with narrowed pulse pressure c. Rapid pulse and decreased capillary refill d. Absence of bruising at contusion sites

c. Rapid pulse and decreased capillary refill

A nurse who provides care on an acute medical unit has observed that physicians are frequently reluctant to refer patients to hospice care. What are contributing factors that are known to underlie this tendency? Select all that apply. Group of answer choices a. Advances in "curative" treatment in late-stage illness b. Ease of making a terminal diagnosis c. Strong association of hospice care with prolonging death d. Financial pressures on health care providers e. Patient reluctance to accept this type of care

a. Advances in "curative" treatment in late-stage illness d. Financial pressures on health care providers e. Patient reluctance to accept this type of care Physicians are reluctant to refer patients to hospice, and patients are reluctant to accept this form of care. Reasons include the difficulties in making a terminal prognosis (especially for those patients with noncancer diagnoses), the strong association of hospice with death, advances in "curative" treatment options in late-stage illness, and financial pressures on health care providers that may cause them to retain rather than refer hospice-eligible patients.

A patient is brought by friends to the ED after being involved in a motor vehicle accident. The patient sustained blunt trauma to the abdomen. What nursing action would be most appropriate for this patient? Group of answer choices a. Immobilize the patient on a backboard. b. Ambulate the patient to expel flatus. c. Place the patient in a left lateral position. d. Place the patient in a high Fowler's position.

a. Immobilize the patient on a backboard.

During the examination of an unconscious patient, the nurse observes that the patient's pupils are fixed and dilated. What is the most plausible clinical significance of the nurse's finding? Group of answer choices a. It indicates an injury at the midbrain level. b. It indicates paralysis of cranial nerve X. c. It indicates paralysis on the right side of the body. d. It suggests onset of metabolic problems.

a. It indicates an injury at the midbrain level.

A patient is scheduled for a myelogram and the nurse explains to the patient that this is an invasive procedure, which assesses for any lesions in the spinal cord. The nurse should explain that the preparation is similar to which of the following neurologic tests? Group of answer choices a. Lumbar puncture b. Cerebral angiography c. EEG d. MRI

a. Lumbar puncture A myelogram is an x-ray of the spinal subarachnoid space taken after the injection of a contrast agent into the spinal subarachnoid space through a lumbar puncture. Patient preparation for a myelogram would be similar to that for lumbar puncture. The other listed diagnostic tests do not involve lumbar puncture.

A client with a spinal cord injury has experienced several hypotensive episodes. How can the nurse best address the client's risk for orthostatic hypotension? Group of answer choices a. Monitor the client's BP before and during position changes. b. Maintain bed rest until normal BP regulation returns. c. Allow the client to initiate repositioning. d. Administer an IV bolus of normal saline prior to repositioning.

a. Monitor the client's BP before and during position changes.

In the course of a focused neurologic assessment, the nurse is palpating the patient's major muscle groups at rest and during passive movement. Data gleaned from this assessment will allow the nurse to describe which of the following aspects of neurologic function? Group of answer choices a. Muscle tone b. Motor symmetry c. Muscle dexterity d. Deep tendon reflexes

a. Muscle tone Muscle tone (the tension present in a muscle at rest) is evaluated by palpating various muscle groups at rest and during passive movement. Data from this assessment do not allow the nurse to ascertain the patient's dexterity, reflexes, or motor symmetry.

You are caring for a patient who has just been told that her stage IV colon cancer has recurred and metastasized to the liver. The oncologist offers the patient the option of surgery to treat the progression of this disease. What type of surgery does the oncologist offer? Group of answer choices a. Palliative b. Reconstructive c. Salvage d. Prophylactic

a. Palliative

A patient is admitted to the ED complaining of abdominal pain. Further assessment of the abdomen reveals signs of peritoneal irritation. What assessment findings would corroborate this diagnosis? Select all that apply. Group of answer choices a. Rebound tenderness b. Ascites c. Changes in bowel sounds d. Copious diarrhea e. Muscular rigidity

a. Rebound tenderness c. Changes in bowel sounds e. Muscular rigidity Signs of peritoneal irritation include abdominal distention, involuntary guarding, tenderness, pain, muscular rigidity, or rebound tenderness along with changes in bowel sounds. Diarrhea and ascites are not signs of peritoneal irritation.

An adult oncology patient has a diagnosis of bladder cancer with metastasis and the patient has asked the nurse about the possibility of hospice care. Which principle is central to a hospice setting? Group of answer choices a. The patient and family should be viewed as a single unit of care. b. Each member of the interdisciplinary team should develop an individual plan of care. c. Terminally ill patients should die in the hospital whenever possible. d. Persistent symptoms of terminal illness should not be treated.

a. The patient and family should be viewed as a single unit of care. Hospice care requires that the patient and family be viewed as a single unit of care. The other listed principles are wholly inconsistent with the principles of hospice care.

Patients with paraplegia are at high risk for impaired skin integrity. Group of answer choices a. True b. False

a. True

The nurse is caring for a patient who has a pleural effusion and who underwent a thoracoscopic procedure earlier in the morning. The nurse should prioritize assessment for which of the following? Group of answer choices a. Sputum production b. Throat discomfort c. Shortness of breath d. Epistaxis

c. Shortness of breath

Assessment is crucial to the care of patients with neurologic dysfunction. What does accurate and appropriate assessment require? Select all that apply. Group of answer choices a. Understanding of the tests used to diagnose neurologic disorders b. The ability to interpret the results of diagnostic tests c. The ability to select mediations for the neurologic dysfunction d. Knowledge of the anatomy of the nervous system e. Knowledge of nursing interventions related to assessment and diagnostic testing

a. Understanding of the tests used to diagnose neurologic disorders d. Knowledge of the anatomy of the nervous system e. Knowledge of nursing interventions related to assessment and diagnostic testing Assessment requires knowledge of the anatomy and physiology of the nervous system and an understanding of the array of tests and procedures used to diagnose neurologic disorders. Knowledge about the nursing implications and interventions related to assessment and diagnostic testing is also essential. Selecting medications and interpreting diagnostic tests are beyond the normal scope of the nurse.

The clinic nurse is caring for a patient whose grandmother and sister have both had breast cancer. She requested a screening test to determine her risk of developing breast cancer and it has come back positive. The patient asks you what she can do to help prevent breast cancer from occurring. What would be your best response? Group of answer choices a. "Research has shown that eating a healthy diet can provide all the protection you need against breast cancer." b. "Research has shown that taking the drug tamoxifen can reduce your chance of breast cancer." c. "Research has shown that exercising at least 30 minutes every day can reduce your chance of breast cancer." d. "Research has shown that there is little you can do to reduce your risk of breast cancer if you have a genetic predisposition."

b. "Research has shown that taking the drug tamoxifen can reduce your chance of breast cancer."

What would the critical care nurse recognize as a condition that may indicate a patient's need to have a tracheostomy? Group of answer choices a. A patient has a respiratory rate of 10 breaths per minute. b. A patient requires permanent ventilation. c. A patient exhibits symptoms of dyspnea. d. A patient has respiratory acidosis.

b. A patient requires permanent ventilation.

An oncology nurse is contributing to the care of a patient who has failed to respond appreciably to conventional cancer treatments. As a result, the care team is considering the possible use of biologic response modifiers (BRFs). The nurse should know that these achieve a therapeutic effect by what means? Group of answer choices a. Promoting the synthesis and release of leukocytes b. Altering the immunologic relationship between the tumor and the patient c. Potentiating the effects of chemotherapeutic agents and radiation therapy d. Focusing the patient's immune system exclusively on the tumor

b. Altering the immunologic relationship between the tumor and the patient

A patient who is undergoing consolidation therapy for the treatment of leukemia has been experiencing debilitating fatigue. How can the nurse best meet this patient's needs for physical activity? a. Teach the patient about the risks of immobility and the benefits of exercise. b. Assist the patient to a chair during awake times, as tolerated. c. Collaborate with the physical therapist to arrange for stair exercises. d. Teach the patient to perform deep breathing and coughing exercises.

b. Assist the patient to a chair during awake times, as tolerated. Sitting is a chair is preferable to bed rest, even if a patient is experiencing severe fatigue. A patient who has debilitating fatigue would not likely be able to perform stair exercises. Teaching about mobility may be necessary, but education must be followed by interventions that actually involve mobility. Deep breathing and coughing reduce the risk of respiratory complications but are not substitutes for physical mobility in preventing deconditioning.

You are a neurotrauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides? Group of answer choices a. Paraplegia b. Autonomic dysreflexia c. Tetraplegia d. Areflexia

b. Autonomic dysreflexia

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

b. Baseline arterial blood gas (ABG) levels

A nurse is caring for a patient who has been diagnosed with leukemia. The nurse's most recent assessment reveals the presence of ecchymoses on the patient's sacral area and petechiae in her forearms. In addition to informing the patient's primary care provider, the nurse should perform what action? a. Initiate measures to prevent venous thromboembolism (VTE). b. Check the patient's most recent platelet level. c. Place the patient on protective isolation. d. Ambulate the patient to promote circulatory function.

b. Check the patient's most recent platelet level. The patient's signs are suggestive of thrombocytopenia, thus the nurse should check the patient's most recent platelet level. VTE is not a risk and this does not constitute a need for isolation. Ambulation and activity may be contraindicated due to the risk of bleeding.

The nurse is caring for a patient has just been given a 6-month prognosis following a diagnosis of extensive stage small-cell lung cancer. The patient states that he would like to die at home, but the team believes that the patient's care needs are unable to be met in a home environment. What might you suggest as an alternative? Group of answer choices a. Discuss a referral for rehabilitation hospital. b. Discuss a referral for hospice care. c. Panel the patient for a personal care home. d. Discuss a referral for acute care.

b. Discuss a referral for hospice care.

The nurse has created a plan of care for a patient who is at risk for increased ICP. The patient's care plan should specify monitoring for what early sign of increased ICP? Group of answer choices a. Projectile vomiting b. Disorientation and restlessness c. Decreased pulse and respirations d. Loss of corneal reflex

b. Disorientation and restlessness

A client is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this client, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this client? Group of answer choices a. Impaired physical mobility related to loss of motor function b. Ineffective breathing patterns related to weakness of the intercostal muscles c. Urinary retention related to inability to void spontaneously d. Risk for impaired skin integrity related to immobility and sensory loss

b. Ineffective breathing patterns related to weakness of the intercostal muscles

A nurse is preparing a patient for scheduled transesophageal echocardiography. What action should the nurse perform? Group of answer choices a. Instruct the patient to drink 1 liter of water before the test. b. Inform the patient that she will remain on bed rest following the procedure. c. Administer IV benzodiazepines and opioids. d. Inform the patient that an access line will be initiated in her femoral artery.

b. Inform the patient that she will remain on bed rest following the procedure. During the recovery period, the patient must maintain bed rest with the head of the bed elevated to 45 degrees. The patient must be NPO 6 hours preprocedure. The patient is sedated to make him or her comfortable, but will not be heavily sedated, and opioids are not necessary. Also, the patient will have a peripheral IV line initiated preprocedure.

A nurse who works in an oncology clinic is assessing a patient who has arrived for a 2-month follow-up appointment following chemotherapy. The nurse notes that the patient's skin appears yellow. Which blood tests should be done to further explore this clinical sign? Group of answer choices a. Platelet count b. Liver function tests (LFTs) c. Complete blood count (CBC) d. Blood urea nitrogen and creatinine

b. Liver function tests (LFTs)

The nurse is caring for a patient with an upper motor neuron lesion. What clinical manifestations should the nurse anticipate when planning the patient's neurologic assessment? Group of answer choices a. Flaccid paralysis b. Loss of voluntary control of movement c. Decreased muscle tone d. Slow reflexes

b. Loss of voluntary control of movement Upper motor neuron lesions do not cause muscle atrophy, flaccid paralysis, or slow reflexes. However, upper motor neuron lesions normally cause loss of voluntary control

A patient is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this patient's care, the nurse would expect to administer what priority medication? Group of answer choices a. Furosemide (Lasix) b. Mannitol (Osmitrol) c. Hydrochlorothiazide (HydroDIURIL) d. Spirolactone (Aldactone)

b. Mannitol (Osmitrol)

A patient has been brought to the ED with multiple trauma after a motor vehicle accident. After immediate threats to life have been addressed, the nurse and trauma team should take what action? Group of answer choices a. Perform diagnostic imaging. b. Perform a rapid physical assessment. c. Establish the circumstances of the accident. d. Initiate health education.

b. Perform a rapid physical assessment. Once immediate threats to life have been corrected, a rapid physical examination is done to identify injuries and priorities of treatment. Health education is initiated later in the care process and diagnostic imaging would take place after a rapid physical assessment. It is not the care team's responsibility to determine the circumstances of the accident.

The nurse is caring for a patient who has returned to the unit following a bronchoscopy. The patient is asking for something to drink. Which criterion will determine when the nurse should allow the patient to drink fluids? Group of answer choices a. Absence of nausea b. Presence of a cough and gag reflex c. Oxygen saturation of ≥92% d. Ability to demonstrate deep inspiration

b. Presence of a cough and gag reflex

An adult patient's abnormal complete blood count (CBC) and physical assessment have prompted the primary care provider to order a diagnostic workup for Hodgkin lymphoma. The presence of what assessment finding is considered diagnostic of the disease? a. Schwann cells b. Reed-Sternberg cells c. Lewy bodies d. Loops of Henle

b. Reed-Sternberg cells The malignant cell of Hodgkin lymphoma is the Reed-Sternberg cell, a gigantic tumor cell that is morphologically unique and thought to be of immature lymphoid origin. It is the pathologic hallmark and essential diagnostic criterion. Schwann cells exist in the peripheral nervous system and Lewy bodies are markers of Parkinson disease. Loops of Henle exist in nephrons.

The nurse's assessment of an older adult client reveals the following data: Lying BP 144/82 mm Hg; sitting BP 121/69 mm Hg; standing BP 98/56 mm Hg. The nurse should consequently identify what nursing diagnosis in the patient's plan of care? Group of answer choices a. Risk for ineffective role performance related to hypotension b. Risk for falls related to orthostatic hypotension c. Risk for ineffective breathing pattern related to hypotension d. Risk for imbalanced fluid balance related to hemodynamic variability

b. Risk for falls related to orthostatic hypotension

A patient with a complex cardiac history is scheduled for transthoracic echocardiography. What should the nurse teach the patient in anticipation of this diagnostic procedure? Group of answer choices a. The patient's pain will be managed aggressively during the procedure. b. The test is noninvasive, and nothing will be inserted into the patient's body. c. The patient will remain on bed rest for 1 to 2 hours after the test. d. The test will provide a detailed profile of the heart's electrical activity.

b. The test is noninvasive, and nothing will be inserted into the patient's body. Before transthoracic echocardiography, the nurse informs the patient about the test, explaining that it is painless.

A medical patient rings her call bell and expresses alarm to the nurse, stating, "I've just coughed up this blood. That can't be good, can it?" How can the nurse best determine whether the source of the blood was the patient's lungs? Group of answer choices a. Perform oral suctioning to see if blood is obtained. b. Try to see if the blood is frothy or mixed with mucus. c. Obtain a sample and test the pH of the blood, if possible. d. Swab the back of the patient's throat to see if blood is present.

b. Try to see if the blood is frothy or mixed with mucus.

The nurse is admitting a patient to the unit who is diagnosed with a lower motor neuron lesion. What entry in the patient's electronic record is most consistent with this diagnosis? Group of answer choices a. "Patient demonstrates hyperactive deep tendon reflexes." b. "Patient exhibits increased muscle tone." c. "Patient demonstrates an absence of deep tendon reflexes." d. "Patient demonstrates normal muscle structure with no evidence of atrophy."

c. "Patient demonstrates an absence of deep tendon reflexes." Lower motor neuron lesions cause flaccid muscle paralysis, muscle atrophy, decreased muscle tone, and loss of voluntary control.

A patient has just been told that her illness is terminal. The patient tearfully states, "I can't believe I am going to die. Why me?" What is your best response? Group of answer choices a. "You have lived a long life." b. "Life can be so unfair." c. "This must be very difficult for you." d. "I know how you are feeling."

c. "This must be very difficult for you." The most important intervention the nurse can provide is listening empathetically. To communicate effectively, the nurse should ask open-ended questions and acknowledge the patient's fears. Deflecting the statement or providing false sympathy must be avoided.

A 58-year-old male patient has been hospitalized for a wedge resection of the left lower lung lobe after a routine chest x-ray shows carcinoma. The patient is anxious and asks if he can smoke. Which statement by the nurse would be most therapeutic? Group of answer choices a. "Smoking is OK right now, but after your surgery it is contraindicated." b. "The doctor left orders for you not to smoke." c. "You are anxious about the surgery. Do you see smoking as helping?" d. "Smoking is the reason you are here."

c. "You are anxious about the surgery. Do you see smoking as helping?"

A patient with advanced leukemia is responding poorly to treatment. The nurse finds the patient tearful and trying to express his feelings, but he is clearly having difficulty. What is the nurse's most appropriate action? a. Tell him that you will give him privacy and leave the room. b. Offer to call pastoral care. c. Ask if he would like you to sit with him while he collects his thoughts. d. Tell him that you can understand how he's feeling.

c. Ask if he would like you to sit with him while he collects his thoughts. Providing emotional support and discussing the uncertain future are crucial. Leaving is incorrect because leaving the patient doesn't show acceptance of his feelings. Offering to call pastoral care may be helpful for some patients but should be done after the nurse has spent time with the patient. Telling the patient that you understand how he's feeling is inappropriate because it doesn't help him express his feelings.

An oncology patient has just returned from the postanesthesia care unit after an open hemicolectomy. This patient's plan of nursing care should prioritize which of the following? Group of answer choices a. Assess the patient hourly for signs of compartment syndrome. b. Assess the patient's fine motor skills once per shift. c. Assess the patient's wound for dehiscence every 4 hours. d. Maintain the patient's head of bed at 45 degrees or more at all times.

c. Assess the patient's wound for dehiscence every 4 hours.

The nurse is performing an initial assessment of an older adult resident who has just relocated to the long-term care facility. During the nurse's interview with the patient, she admits that she drinks around 20 ounces of vodka every evening. What types of cancer does this put her at risk for? Select all that apply. Group of answer choices a. Malignant melanoma b. Brain cancer c. Breast cancer d. Esophageal cancer e. Liver cancer

c. Breast cancer d. Esophageal cancer e. Liver cancer

A brain (B-type) natriuretic peptide (BNP) sample has been drawn from an older adult patient who has been experienced vital fatigue and shortness of breath. This test will allow the care team to investigate the possibility of what diagnosis? Group of answer choices a. Pleurisy b. Cardiomyopathy c. Heart failure d. Valve dysfunction

c. Heart failure The level of BNP in the blood increases as the ventricular walls expand from increased pressure, making it a helpful diagnostic, monitoring, and prognostic tool in the setting of HF.

The nurse is caring for a patient who sustained a moderate head injury following a bicycle accident. The nurse's most recent assessment reveals that the patient's respiratory effort has increased. What is the nurse's most appropriate response? Group of answer choices a. Administer bronchodilators as ordered and monitor the patient's LOC. b. Increase the patient's bed height and reassess in 30 minutes. c. Inform the care team and assess for further signs of possible increased ICP. d. Administer a bolus of normal saline as ordered.

c. Inform the care team and assess for further signs of possible increased ICP.

A patient is undergoing testing to see if he has a pleural effusion. Which of the nurse's respiratory assessment findings would be most consistent with this diagnosis? Group of answer choices a. Increased tactile fremitus, egophony, and a dull sound upon percussion of the chest wall b. Normal tactile fremitus, decreased breath sounds, and a resonant sound upon percussion of the chest wall c. Lung fields dull to percussion, absent breath sounds, and a pleural friction rub d. Decreased tactile fremitus, wheezing, and a hyperresonant sound upon percussion of the chest wall

c. Lung fields dull to percussion, absent breath sounds, and a pleural friction rub

A nurse in the intensive care unit (ICU) receives report from the nurse in the emergency department (ED) about a new patient being admitted with a spinal cord injury received while diving into a lake. The ED nurse reports that his blood pressure is 85/54, heart rate is 53 beats per minute, and his skin is warm and dry. What does the ICU nurse recognize that the patient is probably experiencing? Group of answer choices a. anaphylactic shock b. Septic shock c. Neurogenic shock d. Hypovolemic shock

c. Neurogenic shock

The nurse is caring for a patient who has a history of heart disease. What factor should the nurse identify as possibly contributing to a decrease in cardiac output? Group of answer choices a. A change in position from standing to sitting b. A pulse oximetry reading of 94% c. An increase in preload related to ambulation d. A heart rate of 54 bpm

d. A heart rate of 54 bpm Cardiac output is computed by multiplying the stroke volume by the heart rate. Cardiac output can be affected by changes in either stroke volume or heart rate, such as a rate of 54 bpm.

A patient has completed the full course of treatment for acute lymphocytic leukemia and has failed to respond appreciably. When preparing for the patient's subsequent care, the nurse should perform what action? a. Arrange a meeting between the patient's family and the hospital chaplain. b. Assess the factors underlying the patient's failure to adhere to the treatment regimen. c. Encourage the patient to vigorously pursue complementary and alternative medicine (CAM). d. Identify the patient's specific wishes around end-of-life care.

d. Identify the patient's specific wishes around end-of-life care. Should the patient not respond to therapy, it is important to identify and respect the patient's choices about treatment, including measures to prolong life and other end-of-life measures. The patient may or may not be open to pursuing CAM. Unsuccessful treatment is not necessarily the result of failure to adhere to the treatment plan. Assessment should precede meetings with a chaplain, which may or may not be beneficial to the patient and congruent with the family's belief system.

A patient's most recent diagnostic imaging has revealed that his lung cancer has metastasized to his bones and liver. What is the most likely mechanism by which the patient's cancer cells spread? Group of answer choices a. Hematologic spread b. Angiogenesis c. Invasion d. Lymphatic circulation

d. Lymphatic circulation

The nurse is providing care for a patient who is unconscious. What nursing intervention takes highest priority? Group of answer choices a. Inserting a nasogastric (NG) tube as ordered b. Maintaining accurate records of intake and output c. Providing appropriate pain control d. Maintaining a patent airway

d. Maintaining a patent airway

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

d. Removing excess air and fluid

Patients who are enrolled in hospice care through Medicare are often felt to suffer unnecessarily because they do not receive adequate attention for their symptoms of the underlying illness. What factor most contributes to this phenomenon? Group of answer choices a. Unwillingness of patients and families to acknowledge the patient is terminal b. Unwillingness to overmedicate the dying patient c. Lack of knowledge of patients and families regarding availability of care d. Rules concerning completion of all cure-focused medical treatment

d. Rules concerning completion of all cure-focused medical treatment Because of Medicare rules concerning completion of all cure-focused medical treatment before the Medicare hospice benefit may be accessed, many patients delay enrollment in hospice programs until very close to the end of life. Hospice care does not include an unwillingness to medicate the patient to keep him or her from suffering. Patients must accept that they are terminal before being admitted to hospice care. Lack of knowledge is common; however, this is not why some Medicare patients do not receive adequate attention for the symptoms of their underlying illness.

A 62-year-old woman diagnosed with breast cancer is scheduled for a partial mastectomy. The oncology nurse explained that the surgeon will want to take tissue samples to ensure the disease has not spread to adjacent axillary lymph nodes. The patient has asked if she will have her lymph nodes dissected, like her mother did several years ago. What alternative to lymph node dissection will this patient most likely undergo? Group of answer choices a. Lymphadenectomy b. Needle biopsy c. Open biopsy d. Sentinel node biopsy

d. Sentinel node biopsy

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

d. The cough reflex is depressed.

A medical nurse is providing palliative care to a patient with a diagnosis of end-stage chronic obstructive pulmonary disease (COPD). What is the primary goal of this nurse's care? Group of answer choices a. To provide physical support for the patient b. To support aggressive and innovative treatments for cure c. To help the patient develop a separate plan with each discipline of the health care team d. To improve the patient's and family's quality of life

d. To improve the patient's and family's quality of life The goal of palliative care is to improve the patient's and the family's quality of life. The support should include the patient's physical, emotional, and spiritual well-being. Each discipline should contribute to a single care plan that addresses the needs of the patient and family. The goal of palliative care is not aggressive support for curing the patient. Providing physical support for the patient is also not the goal of palliative care. Palliative care does not strive to achieve separate plans of care developed by the patient with each discipline of the health care team.

The nurse is caring for a patient who has been scheduled for a bronchoscopy. How should the nurse prepare the patient for this procedure? Group of answer choices a. Arrange for the insertion of a peripherally inserted central catheter. b. Administer a bolus of IV fluids. c. Administer nebulized bronchodilators every 2 hours until the test. d. Withhold food and fluids for several hours before the test.

d. Withhold food and fluids for several hours before the test.