NC 1 Exam 1 NCLEX questions

A patient is undergoing surgery with a brachial plexus block to the right wrist. The patient voices concerns about anesthesia awareness. What is the best response by the nurse? a) "Because of the type of anesthesia used, you may be aware of what is going on around you." b) "The entire surgical team will monitor for anesthesia awareness and treat it appropriately." c) "Anesthesia awareness is not a concern with type of surgery you are having." d) "Advances in medicines used decrease the chance of anesthesia awareness. What are your major concerns?

a) "Because of the type of anesthesia used, you may be aware of what is going on around you." Explanation: Anesthesia awareness is a complication of general anesthesia. The patient is undergoing surgery with a local conduction block, not general surgery. Honest discussion of awareness is needed so patients know what to expect while they are in the operating room. Although the entire surgical team should be monitoring for anesthesia awareness, it is not relevant to the surgical procedure being performed. Telling the patient that anesthesia awareness is not a concern is dismissive of the patient's feelings.

A 66-year-old client presents to the emergency room (ER) complaining of a severe headache and mild nausea for the last 6 hours. Upon assessment, the patient's BP is 210/120 mm Hg. The patient has a history of HTN for which he takes 1.0 mg clonidine (Catapres) twice daily for. Which of the following questions is most important for the nurse to ask the patient next? a) "Have you taken your prescribed Catapres today?" b) "Do you have a dry mouth or nasal congestion?" c) "Did you take any medication for your headache?" d) "Are you having chest pain or shortness of breath?"

a) "Have you taken your prescribed Catapres today?" Explanation: The nurse must ask if the patient has taken his prescribed Catapres. Patients need to be informed that rebound hypertension can occur if antihypertensive medications are suddenly stopped. Specifically, a side effect of Catapres is rebound or withdrawal hypertension. Although the other questions may be asked, it is most important to inquire if the patient has taken his prescribed HTN medication given the patient's severely elevated BP.

The nurse understands the definition of pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage." Which of the following comments when made by the patient confirms patient understanding of the fundamental concepts of pain? Select all that apply. a) "I am tired of living with this nagging pain; I'm not sure how much longer I can go on." b) "I would love to go to church, but my back pain is too uncomfortable to make it through the service." c) "I used to walk every day for exercise; pain in my knee made me stop walking." d) "I feel good in knowing that my doctor will determine when and how I get pain medication." e) "I will depend on you and your experience to treat my pain, as you feel appropriate."

a) "I am tired of living with this nagging pain; I'm not sure how much longer I can go on.", b) "I would love to go to church, but my back pain is too uncomfortable to make it through the service.", c) "I used to walk every day for exercise; pain in my knee made me stop walking." Explanation: A fundamental concept of pain is that pain is a complex phenomenon that can affect a person's psychosocial, emotional, and physical functioning. Helplessness is an emotional response to pain. Inability to continue normal activities, such as going to church, is a psychosocial consequence of pain. Inability to perform normal exercise because of pain is a physical restriction related to pain. Pain is highly personal and subjective. The patient's report is the most reliable indicator of pain. The patient works with the nurse and doctor to establish a pain management regimen.

The nurse is caring for a client diagnosed with bulimia. The client is being treated for a serum potassium level of 2.9 mEq/L. Which of the following statements made by the patient indicates the need for further teaching? a) "I can use laxatives and enemas but only once a week." b) "I will be sure to buy frozen vegetables when I grocery shop." c) "A good breakfast for me will include milk and a couple of bananas." d) "I will take a potassium supplement daily as prescribed."

a) "I can use laxatives and enemas but only once a week." Explanation: The patient is experiencing hypokalemia most likely due to the diagnosis of bulimia. Hypokalemia is defined as a serum K+ level below 3.5 mEq/L [3.5 mmol/L], and usually indicates a deficit in total potassium stores. Patients diagnosed with bulimia frequently suffer increased potassium loss through self-induced vomiting, misuse of laxatives, diuretics, and enemas; thus, the patient should avoid laxatives and enemas. Prevention measures may involve encouraging the patient at risk to eat foods rich in potassium (when the diet allows) including fruit juices and bananas, melon, citrus fruits, fresh and frozen vegetables, lean meats, milk, and whole grains. If the hypokalemia is caused by abuse of laxatives or diuretics, patient education may help alleviate the problem.

The nurse is caring for a patient newly diagnosed with hypertension. Which of the following statements if made by the patient indicates the need for further teaching? a) "If I take my blood pressure and it is normal, I don't have to take my BP pills." b) "I think I'm going to sign up for a yoga class twice a week to help reduce my stress." c) "I will consult a dietician to help get my weight under control." d) "When getting up from bed, I will sit for a short period prior to standing up."

a) "If I take my blood pressure and it is normal, I don't have to take my BP pills." Explanation: The patient needs to understand the disease process and how lifestyle changes and medications can control hypertension. The patient must take his/her medication as directed. A normal BP indicates the medication is producing its desired effect. The other responses do not indicate the need for further teaching.

A parent of a 16-year-old patient asks the nurse, "How could the surgeon operate without my consent?" What is the best response given by the nurse? a) "Your child had life-threatening injuries that required immediate surgery." b) "The surgical procedure being performed does not require consent." c) "Two doctors decided your child needed the surgery, therefore we did not need to get consent." d) "We obtained consent from your child after your child requested the surgery."

a) "Your child had life-threatening injuries that required immediate surgery." Explanation: In an emergency, it may be necessary for the surgeon to operate as a lifesaving measure without the patient's or parent's informed consent. Informed consent must be obtained before any invasive procedure. A minor cannot consent for a surgical procedure. Two doctors' opinions do not overrule the need to obtain informed consent

The nurse is teaching a patient diagnosed with hypertension about the DASH diet. How many servings of meat, fish, and poultry should a patient consume per day? a) 2 or fewer b) 7 or 8 c) 2 or 3 d) 4 or 5

a) 2 or fewer Explanation: Two or fewer servings of meat, fish, and poultry are recommended in the DASH diet

Which of the following statements is true regarding gestational diabetes? a) A glucose challenge test should be performed between 24 and 28 weeks. b) There is a low risk for perinatal complications. c) It occurs in most pregnancies. d) Its onset is usually in the first trimester.

a) A glucose challenge test should be performed between 24 and 28 weeks. Explanation: A glucose challenge test should be performed between 24 and 48 weeks. It occurs in 2% to 5% of all pregnancies. Onset is usually in the second or third trimester. There is an above-normal risk for perinatal complications.

Which of the following, approved by the United States Food and Drug Administration, is the only use for lidocaine 5% patch (Lidoderm)? a) Postherpetic neuralgia b) Diabetic neuropathy c) General anesthesia d) Epidural anesthesia

a) Postherpetic neuralgia Explanation: A lidocaine 5% (Lidoderm) patch has been shown to be effective in postherpetic neuralgia. Lidoderm has not been approved for epidural anesthesia, general anesthesia, or diabetic neuropathy.

The nurse is triaging the surgical patients. Which patient would the nurse document as urgent for surgical care? a) A patient with an acute gallbladder infection b) A patient with severe bleeding c) A patient needing cataract surgery d) A patient scheduled for cosmetic surgery

a) A patient with an acute gallbladder infection Explanation: An acute gallbladder infection is considered an urgent surgical procedure. Cosmetic surgery and cataract surgery are not considered urgent surgical procedures. Severe bleeding could be considered an emergent surgical procedure.

When a person who has been taking opioids becomes less sensitive to the drug's analgesic properties, that person is said to have developed which of the following? a) A tolerance b) A dependence c) An addiction d) A balanced analgesia

a) A tolerance Explanation: Tolerance is characterized by the need for increasing dose requirements to maintain the same level of pain relief. Addiction refers to a behavioral pattern of substance use characterized by a compulsion to take the drug primarily to experience its psychic effects. Dependence occurs when a patient who has been taking opioids experiences a withdrawal syndrome when the opioids are discontinued. Balanced analgesia occurs when the patient is using more than one form of analgesia concurrently to obtain more pain relief with fewer side effects.

The nurse has been assigned to care for the following patients. Which patient is at the highest risk for a fluid and electrolyte imbalance? a) An 82-year-old woman who receives all nutrition via tube feedings. Her medications include carvedilol (Coreg) and torsemide (Demadex). b) A 45-year-old man who had a laparoscopic appendectomy 24 hours ago being advanced to a regular diet. c) A 79-year-old man admitted with a diagnosis of pneumonia. d) A 66-year-old woman who had an open cholecystectomy with a T-tube placed that is draining 125 mL of bile per shift.

a) An 82-year-old woman who receives all nutrition via tube feedings. Her medications include carvedilol (Coreg) and torsemide (Demadex). Explanation: The 82-year-old patient has three risk factors: advanced age, tube feedings, and diuretic usage (Demadex). This patient has the highest risk for fluid and electrolyte imbalances. The 45-year-old man has the risk factor of surgery but is not the patient at the highest risk. The 79-year-old patient has the risk factor of advanced age but is not the patient at the highest risk. The 66-year-old patient has the risk factors of age and the bile drain but is not the patient at the highest risk.

A 78-year-old woman is undergoing right hip surgery to repair a hip fracture. What nursing action is appropriate during the intraoperative phase? a) Appropriately position the patient using adequate padding and support. b) Maintain an operating room temperature of 18°C to prevent hypothermia. c) Discuss the need for higher doses of anesthetic agents with the anesthesiologist. d) Withhold pain medication due to decreased renal functioning

a) Appropriately position the patient using adequate padding and support. Explanation: Adequate padding and support should be used to prevent positioning injuries. The older adult is has lower bone mass, which increases the risk of intraoperative positioning injuries. Pain medication can still be used, just in smaller doses, due to decreased liver and kidney functioning. For the same reason as pain medication, lower doses of anesthetic agents are used with the older adult. The operating room is usually maintained from 20°C to 24°C; 18°C is lower than the recommended temperature and can promote hypothermia in the older adult who already has impaired thermoregulation and is prone to hypothermia

When the nurse observes that the postoperative patient demonstrates a constant low level of oxygen saturation via the O2 saturation monitor, although the patient's breathing appears normal what action should the nurse take first? a) Assess the patient's heart rhythm and nail beds. b) Apply oxygen. c) Document the findings. d) Notify the physician.

a) Assess the patient's heart rhythm and nail beds. Explanation: A patient may demonstrate low oxygenation readings due to wearing certain colors of nail polish or irregular heart rate such as atrial fibrillation. These items should be assessed to ensure the accuracy of the oxygen reading. Once the reading is confirmed as accurate, then the nurse may need to apply oxygen, notify the physician, and document the findings.

What is the priority action by the scrub nurse when the surgeon is starting to close the surgical wound? a) Obtain a sponge count. b) Prepare the needed sutures. c) Handing needed equipment to the surgeon. d) Label the tissue specimen.

a) Obtain a sponge count. Explanation: Standards call for the scrub nurse and the circulating nurse to obtain a sponge count at the beginning of the surgery when the surgical wound is being sutured and when the skin is being sutured. Tissue specimens should be labeled when obtained. The sutures should be ready prior to the surgeon needing them. While the scrub nurse hands equipment to the surgeon, the sponge count is a higher priority action.

A patient is admitted to the health care center with abdominal pain, nausea, and vomiting. The medical reports indicate a history of type 1 diabetes. The nurse suspects the patient's symptoms to be that of diabetic ketoacidosis (DKA). Which of the following actions will help the nurse confirm the diagnosis? a) Assessing the patient's breath odor b) Assessing for excessive sweating c) Assessing the patient's ability to take a deep breath d) Assessing the patient's ability to move all extremities

a) Assessing the patient's breath odor Explanation: DKA is commonly preceded by a day or more of polyuria, polydipsia, nausea, vomiting, and fatigue with eventual stupor and coma if not treated. The breath has a characteristic fruity odor due to the presence of ketoacids. Checking the patient's breath will help the nurse confirm the diagnosis.

A patient with type 1 diabetes complains about waking up in the middle of the night nervous and confused, with tremors, sweating, and a feeling of hunger. Morning fasting blood sugar readings have been 110 to 140 mg/dL; the patient admits to exercising excessively and skipping meals over the past several weeks. Based on these symptoms, the nurse will plan to instruct the patient to do which of the following? a) Check blood glucose at 3:00 in the morning. b) Administer an increased dose of neutral protamine Hagedorn (NPH) insulin in the evening. c) Skip the evening NPH insulin dose on days when exercising and skipping meals. d) Eat a complex carbohydrate snack in the evening before bed.

a) Check blood glucose at 3:00 in the morning. Explanation: In the Somogyi effect, the patient has normal or elevated blood glucose at bedtime, a decrease at 2 to 3 am to hypoglycemic levels, and a subsequent increase caused by the production of counterregulatory hormones. It is important to check the blood glucose in the early morning hours to detect the initial hypoglycemia.

Which of the following nursing interventions should a nurse perform when caring for a patient who is prescribed opiate therapy for pain? a) Do not administer if respirations are less than 12 per minute. b) Monitor weight, vital signs, and serum glucose level. c) Monitor blood counts and liver function tests. d) Avoid caffeine or other stimulants, such as decongestants.

a) Do not administer if respirations are less than 12 per minute. Explanation: The nurse should not administer the prescribed opiate therapy if respirations are less than 12 per minute. The nurse should instruct a patient who is prescribed psychostimulants to avoid caffeine or other stimulants, such as decongestants. The nurse should monitor weight, vital signs, and serum glucose level when administering corticosteroids. When administering anticonvulsants, the nurse should also monitor blood counts and liver function tests.

Which of the following would be included in the teaching plan for a patient diagnosed with diabetes mellitus? a) Elevated blood glucose levels contribute to complications of diabetes, such as diminished vision. b) Once insulin injections are started in the treatment of type 2 diabetes, they can never be discontinued. c) The only diet change needed in the treatment of diabetes is to stop eating sugar. d) Sugar is found only in dessert foods.

a) Elevated blood glucose levels contribute to complications of diabetes, such as diminished vision. Explanation: Diabetic retinopathy is the leading cause of blindness among people between 20 and 74 years of age in the United States; it occurs in both type 1 and type 2 diabetes. When blood glucose levels are well controlled, the potential for complications of diabetes is reduced.

It is important for the nurse to encourage the patient diagnosed with hypertension to rise slowly from a sitting or lying position for which of the following reasons? a) Gradual changes in position provide time for the heart to increase rate of contraction to resupply oxygen to the brain. b) Gradual changes in position provide time for the heart to reduce its rate of contraction to resupply oxygen to the brain. c) Gradual changes in position help reduce the heart's work to resupply oxygen to the brain. d) Gradual changes in position help reduce the blood pressure to resupply oxygen to the brain.

a) Gradual changes in position provide time for the heart to increase rate of contraction to resupply oxygen to the brain. Explanation: It is important for the nurse to encourage the patient to rise slowly from a sitting or lying position because gradual changes in position provide time for the heart to increase its rate of contraction to resupply oxygen to the brain and not blood pressure or heart rate

A nurse on the surgical team has been assigned the role of scrub nurse. What action by the scrub nurse is appropriate? a) Handing instruments to the surgeon and assistants b) Keeping all records and adjusting lights c) Leading the surgical team in a debriefing session d) Coordinating activities of other personnel

a) Handing instruments to the surgeon and assistants Explanation: The responsibilities of a scrub nurse are to assist the surgical team by handing instruments to the surgeon and assistants, preparing sutures, receiving specimens for laboratory examination, and counting sponges and needles. Responsibilities of a circulating nurse include leading the surgical team in a debriefing session, keeping records, adjusting lights, and coordinating activities of other personnel

The nurse is assigned to care for a patient with a serum phosphorus level of 5.0 mg/dL. The nurse anticipates that the patient will also experience which of the following electrolyte imbalances? a) Hypocalcemia b) Hyponatremia c) Hypermagnesemia d) Hyperchloremia

a) Hypocalcemia Explanation: The patient is experiencing an elevated serum phosphorus level. Hyperphosphatemia is defined as a serum phosphorus level that exceeds 4.5 mg/dL (1.45 mmol/L). Because of the reciprocal relationship between phosphorus and calcium, a high serum phosphorus level tends to cause a low serum calcium concentration.

A patient with diabetes mellitus is receiving an oral antidiabetic agent. The nurse observes for which of the following symptoms when caring for this patient? a) Hypoglycemia b) Polyuria c) Polydipsia d) Blurred vision

a) Hypoglycemia Explanation: The nurse should observe the patient receiving an oral antidiabetic agent for the signs of hypoglycemia. The time when the reaction might occur is not predictable and could be from 30 to 60 minutes to several hours after the drug is ingested

About which of the following issues should the nurse inform patients who use pain medications on a regular basis? a) Inform the primary health care provider about the use of salicylates before any procedure, and avoid OTC analgesics consistently without consulting a physician. b) Avoid harsh sunlight for 2 hours after administering analgesic agents or salicylates. c) Minimize the intake of fiber during the therapy. d) Consume the medications just before or along with meals.

a) Inform the primary health care provider about the use of salicylates before any procedure, and avoid OTC analgesics consistently without consulting a physician. Explanation: Patients should be advised to inform the primary health care provider or dentist before any procedure when they use pain medications, especially salicylates or nonsteroidal anti-inflammatory agents, on a regular basis. OCT analgesic agents, such as aspirin, ibuprofen, or acetaminophen, should not be avoided consistently to treat chronic pain without consulting a physician. Pain medications administered 30 to 45 minutes before meals may enable the patient to consume an adequate intake, while a high-fiber diet may help ease constipation related to narcotic analgesics. Patients need not avoid harsh sunlight after administering analgesic agents because these drugs do not cause photosensitivity.

The preferred route of administration of medication in the most acute care situations is through which of the following routes? a) Intravenous (IV) b) Intramuscular c) Subcutaneous d) Epidural

a) Intravenous (IV) Explanation: IV is the preferred parenteral route in most acute care situations because it is much more comfortable for the patient, and peak serum levels and pain relief occur more rapidly and reliably. Epidural administration is used to control postoperative and chronic pain. Subcutaneous administration results in slow absorption of medication. Intramuscular administration of medication is absorbed more slowly than IV-administered medication.

A patient is admitted to the intensive care unit (ICU) with a diagnosis of hypertension emergency/crisis. The patient's blood pressure (BP) is 200/130 mm Hg. The nurse is preparing to administer IV Nitropress (nitroprusside). Upon assessment, which of the following patient findings requires immediate intervention by the nurse? a) Left arm numbness and weakness b) Nausea and severe headache c) Urine output of 40 cc/mL over the last hour d) Chest pain score of 3/10 (on a scale of 1 to 10)

a) Left arm numbness and weakness Explanation: Hypertensive emergencies are acute, life-threatening BP elevations that require prompt treatment in an intensive care setting because of the serious target organ damage that may occur. The finding of left arm numbness and weakness may indicate the patient is experiencing neurological symptoms associated with an ischemic stroke because of the severely elevated BP and requires immediate interventions. A urine output of 40 mL/h is within normal limits. The other findings are likely caused by the hypertension and require intervention, but they do not require action as urgently as the neurologic changes

A patient continuously states, "I know all will go well." What cognitive coping strategy should the nurse document? a) Optimistic self-recitation b) Distraction c) Imagery d) Music therapy

a) Optimistic self-recitation Explanation: When that patient verbalizes this statement, it is an optimistic response. Imagery occurs when the patient concentrates on a pleasant experience or restful scene. Distraction occurs when the patient thinks of an enjoyable story or recites a favorite poem or song. Music therapy would be an incorrect answer.

A postanesthesia care unit (PACU) nurse is caring for a patient with the following assessment data: pale, cool, moist skin; thready pulse of 122; blood pressure 78/60; urine output of 25 mL/h; temperature 99.2°F. What interventions by the nurse are appropriate? Select all that apply. a) Maintain a patent airway. b) Apply a warming blanket. c) Administer blood products per orders. d) Apply oxygen per orders. e) Frequently monitor neurological status. f) Raise the head of the bed 30 degrees

a) Maintain a patent airway., e) Frequently monitor neurological status., c) Administer blood products per orders., d) Apply oxygen per orders. Explanation: The patient is demonstrating signs and symptoms of shock. The patient in shock may lose the ability to protect his or her airway. Frequently neurological assessment can provide information related to decrease oxygen to the brain. Administering the blood products may reverse the signs and symptoms of shock. There is an increased need for oxygen when in shock, so it is appropriate to apply oxygen. The head of the bed should not be elevated. The patient should be lying flat or in the Trendelenburg position. Applying a warming blanket when the patient is not hypothermic may cause vasodilation, which could further decrease blood pressure and perfusion to vital organs

The nurse teaches the patient which of the following guidelines regarding lifestyle modifications for hypertension? a) Maintain adequate dietary intake of fruits and vegetables b) Stop alcohol intake c) Reduce smoking to no more than four cigarettes per day d) Limit aerobic physical activity to 15 minutes, three times per week

a) Maintain adequate dietary intake of fruits and vegetables Explanation: Guidelines include adopting the dietary approaches to stop hypertension (DASH) eating plan: consume a diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of saturated and total fat, dietary sodium reduction: reduce dietary sodium intake to no more than 100 mmol/day (2.4 g sodium or 6 g sodium chloride), and physical activity: engage in regular aerobic physical activity such as brisk walking (at least 30 min/day, most days of the week), Moderate alcohol consumption: limit consumption to no more than two drinks (eg, 24 oz beer, 10 oz wine, or 3 oz 80-proof whiskey) per day in most men and to no more than 1 drink per day in women and lighter-weight people. Tobacco: should be avoided because anyone with high blood pressure is already at increased risk for heart disease, and smoking amplifies this risk

What is the highest priority nursing intervention for a patient in the immediate postoperative phase? a) Maintaining a patent airway b) Monitoring vital signs at least every 15 minutes c) Assessing for hemorrhage d) Assessing urinary output every hour

a) Maintaining a patent airway Explanation: All interventions listed are correct. The highest priority intervention is maintaining a patent airway. Without a patent airway, the other interventions of monitoring vital signs and urinary output, along with assessing for hemorrhage, become secondary to the possibility of a lack of oxygen.

A patient has undergone hernia repair surgery without complications. In the immediate postoperative period, which of the following actions by the nurse is most appropriate? a) Monitor vital signs every 15 minutes b) Assessing pupillary response every 5 minutes c) Obtaining arterial blood gas every 5 minutes d) Measuring urinary output every 15 minutes

a) Monitor vital signs every 15 minutes Explanation: The pulse rate, blood pressure, and respiration rate are recorded at least every 15 minutes for the first hour and every 30 minutes for the next 2 hours. Obtaining an arterial blood gas every 5 minutes is painful to the patient unless a special device is inserted to obtain arterial blood samples. Without complications, this is not indicated for the patient. Urinary output is monitored frequently but usually measured hourly. While it may be necessary to assess pupillary response during the immediate postoperative phase, it does not need to be done every 5 minutes.

The nurse is caring for a postoperative patient with an indwelling urinary catheter. The hourly urinary output at 9 am is 80 mL. The nurse assesses the hourly urinary output at 10 am at 20 mL. What is the highest priority action by the nurse? a) Notify the physician. b) Irrigate the catheter with sterile normal saline. c) Reassess the output at 11 am. d) Document the findings.

a) Notify the physician. Explanation: If the patient has an indwelling urinary catheter, hourly outputs are monitored and rates of less than 30 mL/h are reported. Any urinary output less than 30 mL/h should be reported to the physician immediately. The urinary output will be reassessed at 11 am but waiting to notify the physician could cause harm to the patient. The findings should be documented but this is not the highest priority. A urinary catheter may need to be irrigated but a postoperative patient with a low urinary output is demonstrating a complication that needs to be reported immediately.

The nurse is conducting a preoperative assessment on a patient scheduled for gallbladder surgery. The patient reports having a frequent cough producing green sputum for 3 days and denies fever. Upon auscultation, the nurse notes rhonchi throughout the right lung with an occasional expiratory wheeze. Respiratory rate is 20, temperature is 99.8 taken orally, heart rate is 87, and blood pressure is 124/70. What is the nurse's best action? a) Notify the surgeon to possibly delay the surgery. b) Document the findings and continue the patient through the preoperative phase. c) Notify the primary physician about the assessment findings. d) Wait 1 hour and complete the assessment again.

a) Notify the surgeon to possibly delay the surgery. Explanation: A respiratory infection can delay a nonemergent surgical procedure because the infection can increase the risk for respiratory complications. Therefore, the nurse should notify the surgeon about delaying the surgery. The primary physician may be called to care for the assessment findings but that should be done only after the surgeon has been notified. Continuing through the preoperative phase without notifying the surgeon and waiting 1 hour is not appropriate.

During the preoperative assessment, the patient states he is allergic to avocados, bananas, and hydrocodone (Vicodin). What is the priority action by the nurse? a) Notify the surgical team to remove all latex-based items. b) Notify the physician regarding postoperative pain medications. c) Notify the nurse manager to follow up on the procedure. d) Notify the dietary department.

a) Notify the surgical team to remove all latex-based items. Explanation: Allergies to avocados and bananas may indicate an allergy to latex. Although it is necessary to notify the dietary department and physician, it is not an immediate threat, as the patient is NPO (nothing by mouth) and pain medication will be ordered postoperatively. The nurse manager does not need to be notified of the patient's allergies.

A patient receiving moderate sedation for a minor surgical procedure begins to vomit. What should the nurse do first? a) Roll the patient on his or her side. b) Suction the mouth. c) Provide a basin. d) Administer an antiemetic medication.

a) Roll the patient on his or her side. Explanation: The patient must be rolled to the side to prevent aspiration. All the other interventions are correct for a vomiting sedated patient, but the highest priority is in preventing aspiration.

The nurse is conducting a service project for a local elderly community group on the topic of hypertension. The nurse will relay that risk factors and cardiovascular problems related to hypertension include which of the following? Select all that apply. a) Smoking b) Obesity (BMI ≥ 30 kg/m2) c) Age ≥55 in men d) Elevated high-density lipoprotein (HDL) cholesterol e) Decreased low-density lipoprotein (LDL) levels.

a) Smoking, b) Obesity (BMI ≥ 30 kg/m2), c) Age ≥55 in men Explanation: Major risk factors (in addition to hypotension) include smoking, dyslipidemia (high LDL, low HDL cholesterol), diabetes mellitus, impaired renal function, obesity, physical inactivity, age (older than 55 years for men, 65 years for women), and family history of cardiovascular disease.

The nurse is educating a patient scheduled for elective surgery. The patient currently takes aspirin daily. What education should the nurse provide in regard to the medication? a) Stop taking the aspirin 7 days before the surgery, unless otherwise directed by your physician. b) Take half doses of the aspirin until 1 week after surgery. c) Continue to take the aspirin as ordered. d) Aspirin should be increased until 3 days before surgery, and then it should be discontinued until 3 days after surgery.

a) Stop taking the aspirin 7 days before the surgery, unless otherwise directed by your physician. Explanation: Aspirin should be stopped at least 7 to 10 days before surgery. The other directions provided are incorrect.

The nurse is educating a community group regarding types of surgery. A member of the group asks the nurse to describe a type of surgery that is curative. What response by the nurse is true? a) The excision of a tumor b) A biopsy c) The placement of gastrostomy tube d) A face-lift

a) The excision of a tumor Explanation: An example of a curative surgical procedure is the excision of a tumor. A biopsy, a face-lift, and the placement of a gastrostomy tube are not examples of curative surgical procedures.

A patient with cancer is being treated on the oncology unit for bilateral breast cancer. The patient is undergoing chemotherapy. The nurse notes the patient's serum calcium level is 12.3 mg/ dL. Given this laboratory finding, the nurse should suspect which of the following statements? a) The patient's malignancy is causing the electrolyte imbalance. b) The patient may be developing hyperaldosteronism. c) The patient has a history of alcohol abuse. d) The patient's diet is lacking in calcium-rich food products.

a) The patient's malignancy is causing the electrolyte imbalance. Explanation: The patient's laboratory findings indicate hypercalcemia. Hypercalcemia is defined as a calcium level greater than 10.2 mg/dL (2.6 mmol/L).The most common causes of hypercalcemia are malignancies and hyperparathyroidism. Malignant tumors can produce hypercalcemia by a variety of mechanisms. The patient's calcium level is elevated; there is no indication that the patient's diet is lacking in calcium-rich food products. Hyperaldosteronism is not associated with a calcium imbalance. Alcohol abuse is associated with hypocalcemia.

A recently extubated postoperative patient starts to gag and make vomiting sounds. What action should the nurse do first? a) Turn patient on her side. b) Provide emesis basin. c) Administer antiemetic. d) Obtain suction equipment

a) Turn patient on her side. Explanation: The nurse should turn the patient on her side to avoid aspiration. The nurse may need to obtain suction equipment, provide an emesis basin, or administer and antiemetic but the first priority is protecting the patient's airway by preventing aspiration.

The nurse would identify which of the following vitamin deficiencies to prevent the complication of hemorrhaging during surgery? a) Vitamin K b) Zinc c) Magnesium d) Vitamin A

a) Vitamin K Explanation: Vitamin K is important for normal blood clotting. Vitamin A and zinc deficiencies would affect the immune system, whereas a magnesium deficiency would delay wound healing.

Which of the following actions when preformed by the nurse indicates understanding of one basic principle of providing effective pain management? a) Wakening a new postoperative patient to take his or her pain medication b) Continuing to provide around the clock pain medications 72 hours following a surgical procedure c) Administering pain medications on a PRN (as needed) basis d) Administering a dose of an analgesic agent via patient-controlled analgesia (PCA) during rounds

a) Wakening a new postoperative patient to take his or her pain medication Explanation: Awakening postoperative patients with moderate-to-severe pain to take pain medication is especially important during the first 24 to 48 hours after surgery to keep pain under control. The PCA is an interactive method of pain management that allows patients to treat their pain by self-administering doses of analgesic agents and should not be used by the nurse.

The nurse is instructing a patient with recurrent hyperkalemia about following a potassium-restricted diet. Which of the following patient statements indicates the need for additional instruction? a) "I need to check if my cola beverage has potassium in it." b) "I will not salt my food, instead I'll use salt substitute." c) "Bananas have a lot of potassium in them, I'll stop buying them." d) "I'll drink cranberry juice with my breakfast instead of coffee."

b) "I will not salt my food, instead I'll use salt substitute." Explanation: The patient should avoid salt substitutes. The nurse must caution patients to use salt substitutes sparingly if they are taking other supplementary forms of potassium or potassium-conserving diuretics. Potassium-rich foods to be avoided include many fruits and vegetables, legumes, whole-grain breads, lean meat, milk, eggs, coffee, tea, and cocoa. Conversely, foods with minimal potassium content include butter, margarine, cranberry juice or sauce, ginger ale, gumdrops or jellybeans, hard candy, root beer, sugar, and honey. Labels of cola beverages must be checked carefully because some are high in potassium and some are not.

A patient with type 2 diabetes has recently been placed on acarbose (Precose); the nurse is explaining how to take this medication. The teaching is determined to be effective based on which of the following statements? a) "It does not matter what time of day I take this medication." b) "I will take this medication in the morning, with my first bite of breakfast." c) "This medication needs to be taken after the midday meal." d) "I will take this medication in the morning, 15 minutes before breakfast."

b) "I will take this medication in the morning, with my first bite of breakfast." Explanation: Alpha-glucosidase inhibitors, such as acarbose (Precose) and miglitol (Glyset), delay absorption of complex carbohydrates in the intestine and slow entry of glucose into systemic circulation. They must be taken with the first bite of food to be effective.

A 16-year-old patient newly diagnosed with type 1 diabetes has a very low body weight despite eating regular meals. The patient is upset because friends frequently state, "You look anorexic." Which of the following statements would be the best response by the nurse to help this patient understand the cause of weight loss due to this condition? a) "You may be having undiagnosed infections causing you to lose extra weight." b) "Your body is using protein and fat for energy instead of glucose." c) "I will refer you to a dietician who can help you with your weight." d) "Don't worry about what your friends think; the carbohydrates you eat are being quickly digested, increasing your metabolism."

b) "Your body is using protein and fat for energy instead of glucose." Explanation: Persons with type 1 diabetes, particularly those in poor control of the condition, tend to be thin because when the body cannot effectively utilize glucose for energy (no insulin supply), it begins to break down protein and fat as an alternate energy source. Patients may be underweight at the onset of type 1 diabetes because of rapid weight loss from severe hyperglycemia. The goal initially may be to provide a higher-calorie diet to regain lost weight and blood glucose control.

A patient is ordered to receive hypotonic IV solution to provide free water replacement. Which of the following solutions will the nurse anticipate administering? a) 0.9% NaCl b) 0.45% NaCl c) Lactated Ringer's solution d) 5% NaCl

b) 0.45% NaCl Explanation: Half-strength saline (0.45%) is hypotonic. Hypotonic solutions are used to replace cellular fluid because it is hypotonic compared with plasma. Another is to provide free water to excrete body wastes. At times, hypotonic sodium solutions are used to treat hypernatremia and other hyperosmolar conditions. Lactated Ringer's solution and normal saline (0.9% NaCl) are isotonic. A solution that is 5% NaCl is hypertonic.

The nurse is administering lispro (Humalog) insulin. Based on the onset of action, how soon should the nurse administer the injection prior to breakfast? a) 1 to 2 hours b) 10 to 15 minutes c) 30 to 40 minutes d) 3 hours

b) 10 to 15 minutes Explanation: The onset of action of rapid-acting Humalog is within 10 to 15 minutes. It is used for rapid reduction of glucose level

The nurse is caring for a client who is prescribed diuretic medication for the treatment of hypertension. The nurse recognizes that which of the following medications conserves potassium? a) Chlorothiazide (Diuril) b) Spironolactone (Aldactone) c) Chlorthalidone (Hygroton) d) Furosemide (Lasix)

b) Spironolactone (Aldactone) Explanation: Aldactone is known as a potassium-sparing diuretic. Lasix causes loss of potassium from the body. Diuril causes mild hypokalemia. Hygroton causes mild hypokalemia.

A patient presents to the Emergency Department experiencing a severe anxiety attack and is hyperventilating. The nurse would expect the patient's pH value to be which of the following? a) 7.30 b) 7.50 c) 7.45 d) 7.35

b) 7.50 Explanation: The patient is experiencing respiratory alkalosis. Respiratory alkalosis is a clinical condition in which the arterial pH is greater than 7.45 and the PaCO2 is less than 38 mm Hg. Respiratory alkalosis is always caused by hyperventilation, which causes excessive "blowing off" of CO2 and, hence, a decrease in the plasma carbonic acid concentration. Causes include extreme anxiety, hypoxemia, early phase of salicylate intoxication, Gram-negative bacteremia, and inappropriate ventilator settings.

A patient is being treated in a substance abuse unit of a local hospital. The nurse understands that when a patient has compulsive behavior to use a drug for its psychic effect, the patient needs to be monitored for which of the following? a) Placebo effect b) Addiction c) Dependence d) Tolerance

b) Addiction Explanation: Addiction is a behavioral pattern of substance use characterized by a compulsion to take the substance primarily to experience its psychic effects. Placebo effect is analgesia that results from the expectation that a substance will work, not from the actual substance itself. Dependence occurs when a patient who has been taking opioids experiences a withdrawal syndrome when the opioids are discontinued. Tolerance occurs when a person who has been taking opioids becomes less sensitive to their analgesic properties.

The nurse is caring for a patient with a metabolic acidosis (pH 7.25). Which of the following values is useful to the nurse in determining whether the cause of the acidosis is due to acid gain or to bicarbonate loss? a) PaCO2 b) Anion gap c) Serum sodium level d) Bicarbonate level

b) Anion gap Explanation: Metabolic acidosis is a common clinical disturbance characterized by a low pH (increased H+ concentration) and a low plasma bicarbonate concentration. It can be produced by a gain of hydrogen ion or a loss of bicarbonate. It can be divided clinically into two forms, according to the values of the serum anion gap: high anion gap acidosis and normal anion gap acidosis. A patient diagnosed with metabolic acidosis is determined to have normal anion gap metabolic acidosis if the anion gap is within this normal range. An anion gap greater than 16 mEq (16 mmol/L) (the normal value for an anion gap is 8-12 mEq/L (8-12 mmol/L) without potassium in the equation. If potassium is included in the equation, the normal value for the anion gap is 12-16 mEq/L (12-16 mmol/L) and suggests an excessive accumulation of unmeasured anions and would indicate high anion gap metabolic acidosis as the type. An anion gap occurs because not all electrolytes are measured. More anions are left unmeasured than cations. A low or negative anion gap may be attributed to hypoproteinemia. Disorders that cause a decreased or negative anion gap are less common compared to those related to an increased or high anion gap

The nurse is caring for a patient in the postanesthesia care unit (PACU) with the following vital signs, pulse 115, respiration 20, temperature 97.2°F oral, blood pressure 84/50. What should the nurse do first? a) Review the patient's preoperative vital signs. b) Assess for bleeding. c) Increase rate of IV fluids. d) Notify the physician.

b) Assess for bleeding. Explanation: The patient is tachycardic with a low blood pressure; thus assessing for hemorrhage is the priority action. While the physician may need to be notified, the nurse needs to be able to communicate a complete picture of the patient, which would include bleeding, when calling the physician. The rate of IV fluid administration should be adjusted according to a physician order. The nurse should review prior vital signs but only after the immediate threat of hemorrhage is assessed

The nurse is caring for a patient who was admitted with fluid volume excess (FVE). Which of the following nursing assessments should the nurse include in the ongoing monitoring of the patient? Select all that apply. a) Skin assessment for edema and turgor b) Blood pressure, heart rate, and rhythm c) Strength testing for muscle wasting d) Nutritional status and diet e) Intake and output, urine volume, and color

b) Blood pressure, heart rate, and rhythm, e) Intake and output, urine volume, and color, a) Skin assessment for edema and turgor Explanation: To assess for FVE the nurse measures: blood pressure, heart rate and rhythm, breath sounds, skin assessment for edema and turgor, inspection of neck veins, intake and output, daily weights, urine volume and color, dyspnea, and thirst are assessments that will assist the nurse in identifying improvement or worsening of the fluid volume excess. In addition, the nurse will be able to identify potential fluid volume deficit from overtreatment of the fluid volume excess.

When taking a patient history, the nurse notes that the patient has been taking herbal remedies in addition to acetaminophen for several years. Based on the admission history, the nurse understands that the patient is experiencing which of the following types of pain after an amputation? a) Phantom pain b) Chronic pain c) Breakthrough pain d) Acute pain

b) Chronic pain Explanation: Chronic pain persists over a course of time, in this case several years. Acute pain has a relatively short duration. Breakthrough pain is acute exacerbations of pain periodically experienced by patients with a normally controlled pain management regimen. Patients who have a history of amputation commonly report phantom pain in the amputated extremity.

Which of the following should be included in the teaching plan for a patient receiving glargine (Lantus), "peakless" basal insulin? a) Administer the total daily dosage in two doses. b) Do not mix with other insulins. c) It is rapidly absorbed, has a fast onset of action. d) Draw up the drug first, then add regular insulin.

b) Do not mix with other insulins. Explanation: Because glargine is in a suspension with a pH of 4, it cannot be mixed with other insulins because this would cause precipitation. When administering glargine (Lantus) insulin it is very important to read the label carefully and to avoid mistaking Lantus insulin for Lente insulin and vice versa.

The nurse is assessing a patient for local complication of IV therapy. Local complications include which of the following? Select all that apply. a) Air embolism b) Extravasation c) Hematoma d) Phlebitis e) Infection

b) Extravasation, c) Hematoma, d) Phlebitis Explanation: Local complications of IV therapy include infiltration and extravasation, phlebitis, thrombophlebitis, hematoma, and clotting of the needle. Systemic complications occur less frequently but are usually more serious than local complications and include circulatory overload, air embolism, febrile reaction, and infection.

During a follow-up visit 3 months following a new diagnosis of type 2 diabetes, a patient reports exercising and following a reduced-calorie diet. Assessment reveals that the patient has only lost 1 pound and did not bring the glucose-monitoring record. Which of the following tests will the nurse plan to obtain? a) Urine dipstick for glucose b) Glycosylated hemoglobin level c) Oral glucose tolerance test d) Fasting blood glucose level

b) Glycosylated hemoglobin level Explanation: Glycosylated hemoglobin is a blood test that reflects average blood glucose levels over a period of approximately 2 to 3 months. When blood glucose levels are elevated, glucose molecules attach to hemoglobin in red blood cells. The longer the amount of glucose in the blood remains above normal, the more glucose binds to hemoglobin and the higher the glycated hemoglobin level becomes.

Which of the following should be incorporated into the patient teaching plan to prevent deep vein thrombosis? a) Prolonged dangling at the edge of the bed b) Hourly leg exercises c) Use of blanket rolls for elevation of the lower extremities d) Fluid restriction

b) Hourly leg exercises Explanation: The benefits of early ambulation and hourly leg exercises in preventing deep vein thrombosis cannot be overemphasized. It is important to avoid the use of blanket rolls, pillow rolls, or any form of elevation that constricts vessels under the knees. Prolonged dangling can be dangerous and is not recommended in susceptible patients because the pressure under the knees can impede circulation. Dehydration adds to the risk of thrombosis formation.

A patient is undergoing general anesthesia. The nurse anesthetist starts to administer the anesthesia. The patient starts giggling and kicking her legs. What stage of anesthesia would the nurse document related to the findings? a) IV b) II c) I d) III

b) II Explanation: Stage II is the excitement stage that is characterized by struggling, shouting, and laughing. Stage I is the beginning of anesthesia during which the patient breathes in the anesthetic mixture and feelings of warmth, dizziness, and detachment occur. Stage III is surgical anesthesia characterized by unconsciousness and quietness. Surgical anesthesia is reached by continued administration of anesthetic vapor and gas. Stage IV is medullary depression.

A patient with a magnesium level of 2.6 mEq/L is being treated on a medical-surgical unit. Which of the following treatments should the nurse anticipate will be used? a) Dialysis b) IV furosemide (Lasix) c) Oral magnesium oxide (MagOx) d) Fluid restriction

b) IV furosemide (Lasix) Explanation: The nurse should anticipate the administration of Lasix for the treatment of hypermagnesemia. Administration of loop diuretics (e.g., furosemide) and sodium chloride or lactated Ringer's IV solution enhances magnesium excretion in patients with adequate renal function. Fluid restriction is contraindicated. The patient should be encouraged to increase fluids to promote the excretion magnesium by way of the urine. MagOx is contraindicated as it would further elevate the patient's serum magnesium level. In acute emergencies, when the magnesium level is severely elevated, hemodialysis with a magnesium-free dialysate can reduce the serum magnesium to a safe level within hours.

Prostaglandins are chemical substances with which of the following properties? a) Inhibition of the transmission of pain b) Increased sensitivity of pain receptors c) Reduction of the perception of pain d) Inhibition of the transmission of noxious stimuli

b) Increased sensitivity of pain receptors Explanation: Prostaglandins are believed to increase sensitivity to pain receptors by enhancing the pain-provoking effect of bradykinin. Endorphins and enkephalins reduce or inhibit transmission or perception of pain. Morphine and other opioid medications inhibit the transmission of noxious stimuli by mimicking enkephalin and endorphin.

A nurse is teaching a patient recovering from diabetic ketoacidosis (DKA) about management of "sick days." The patient asks the nurse why it is important to monitor the urine for ketones. Which of the following statements is the nurse's best response? a) Ketones are formed when insufficient insulin leads to cellular starvation. As cells rupture, they release these acids into the blood. b) Ketones accumulate in the blood and urine when fat breaks down. Ketones signal a deficiency of insulin that will cause the body to start to break down stored fat for energy. c) When the body does not have enough insulin hyperglycemia occurs. Excess glucose is broken down by the liver, causing acidic byproducts to be released. d) Excess glucose in the blood is metabolized by the liver and turned into ketones, which are an acid

b) Ketones accumulate in the blood and urine when fat breaks down. Ketones signal a deficiency of insulin that will cause the body to start to break down stored fat for energy. Explanation: Ketones (or ketone bodies) are byproducts of fat breakdown, and they accumulate in the blood and urine. Ketones in the urine signal a deficiency of insulin and control of type 1 diabetes is deteriorating. When almost no effective insulin is available, the body starts to break down stored fat for energy

The nurse is caring for a patient with severe diarrhea. The nurse recognizes that the patient is at-risk for developing which of the following acid-base imbalances? a) Respiratory acidosis b) Metabolic acidosis c) Respiratory alkalosis d) Metabolic alkalosis

b) Metabolic acidosis Explanation: The patient is at risk for developing metabolic acidosis. Metabolic acidosis is caused by diarrhea, lower intestinal fistulas, ureterostomies, and use of diuretics; early renal insufficiency; excessive administration of chloride; and the administration of parenteral nutrition without bicarbonate or bicarbonate-producing solutes (e.g., lactate).

A patient is postoperative hour 8 following an appendectomy and is anxious stating, "Something is not right. My pain is worse than ever and my stomach is swollen." Blood pressure is 88/50, pulse is 115, and respirations are 24 and labored. Abdomen is soft and distended. No obvious bleeding noted. What action by the nurse is most appropriate? a) Ambulate the patient to reduce abdominal distention. b) Notify the physician. c) Administer morphine per orders. d) Inform the patient this is the normal progression following abdominal surgery

b) Notify the physician. Explanation: The physician should be notified of the findings. The patient may be hemorrhaging internally and may need to return to surgery. The patient may be in need of pain medication but morphine will lower the blood pressure further and may cause further complications. Ambulating the patient increases the risk of injury because the patient may experience orthostatic hypotension. What the patient is experiencing is not the normal progression following abdominal surgery.

A patient is administered succinylcholine and propofol (Diprivan) for induction of anesthesia. One hour after administration, the patient is demonstrating muscle rigidity with a heart rate of 180. What should the nurse do first? a) Administer dantrolene sodium (Dantrium). b) Notify the surgical team. c) Obtain cooling blankets. d) Document the assessment findings.

b) Notify the surgical team. Explanation: Tachycardia and muscle rigidity is often the earliest sign of malignant hyperthermia. Early recognition of malignant hyperthermia increases survival. The nurse would document the findings, administer dantrolene sodium (Dantrium), obtain cooling blankets as part of the treatment for malignant hyperthermia, but the nurse would need to ensure the surgical team is aware of the findings first.

A high school football player hurts his foot while playing a game. He complains of intense pain with muscle spasms and swelling of the toe. Which of the following pain assessment tools will the nurse most likely use to assess the patient's pain level? a) Verbal Descriptor Scales (VDS) b) Numeric Rating Scale (NRS) c) Visual Analog Scale (VAS) d) Wong-Baker FACES Pain Rating Scale

b) Numeric Rating Scale (NRS) Explanation: The NRS is most appropriate for this patient. The VDS requires the patient to use words or phrases; in this situation, intense pain may affect the patient's ability to use this scale appropriately. The FACES scale is most often used in adults and children as young as 3 years of age. The VAS is impractical for use in daily clinical practice.

A patient is undergoing a perineal surgical procedure. Which of the following actions by the nurse is appropriate? a) Place the patient in Sims' position. b) Place the patient in lithotomy position. c) Place the patient in a dorsal recumbent position. d) Place the patient in the Trendelenburg position.

b) Place the patient in lithotomy position. Explanation: The lithotomy position is used for nearly all perineal, rectal, and vaginal surgeries. The Trendelenburg position is usually used for surgery on the lower abdomen and pelvis. Sims' or lateral position is used for renal surgery. The dorsal recumbent position is the usual position for surgical procedures.

A patient is scheduled for elective surgery. To prevent the complication of hypotension and cardiovascular collapse, the nurse should report the use of what medication? a) Warfarin (Coumadin) b) Prednisone (Deltasone) c) Erythromycin (Ery-Tab) d) Hydrochlorothiazide (HydroDIURIL)

b) Prednisone (Deltasone) Explanation: Patients who have received corticosteroids are at risk of adrenal insufficiency. Insufficiency related to corticosteroids can cause circulatory collapse and hypotension. Hydrochlorothiazide and erythromycin can cause respiratory complications. Warfarin will increase the risk of bleeding.

A nurse is teaching a diabetic support group about the causes of type 1 diabetes. The teaching is determined to be effective when the group is able to attribute which of the following factors as a cause of type 1 diabetes? a) Obesity b) Presence of autoantibodies against islet cells c) Rare ketosis d) Altered glucose metabolism

b) Presence of autoantibodies against islet cells Explanation: There is evidence of an autoimmune response in type 1 diabetes. This is an abnormal response in which antibodies are directed against normal tissues of the body, responding to these tissues as if they were foreign. Autoantibodies against islet cells and against endogenous (internal) insulin have been detected in people at the time of diagnosis and even several years before the development of clinical signs of type 1 diabetes

An obese patient is scheduled for open abdominal surgery. What priority education should the nurse provide this patient? a) Venous thromboembolism prevention b) Prevention of respiratory complications c) Prevention of wound dehiscence d) Wound care and infection prevention

b) Prevention of respiratory complications Explanation: All answers are correct but the obese patient has an increased susceptibility to respiratory complications, and maintaining a patent airway would be the priority.

A nurse is caring for a patient with acute renal failure and hypernatremia. Which of the following actions can be delegated to the nursing assistant? a) Teach the patient about increased fluid intake. b) Provide oral care every 2-3 hours. c) Monitor for signs and symptoms of dehydration. d) Assess the patient's daily weights for trends

b) Provide oral care every 2-3 hours. Explanation: Providing oral care for the patient every 23 hours is within the scope of practice of a nursing assistant. The other actions should be completed by the registered nurse.

A 35-year-old female patient has been diagnosed with hypertension. The patient is a stock broker, smokes daily, and is also a diabetic. During a follow-up appointment, the patient states that she finds it cumbersome and time consuming to visit the doctor regularly just to check her blood pressure (BP). As the nurse, which of the following aspects of patient teaching would you recommend? a) Advising a smoking cessation b) Purchasing a self-monitoring BP cuff c) Discussing methods for stress reduction d) Administering glycemic control

b) Purchasing a self-monitoring BP cuff Explanation: Because this patient finds it time consuming to visit the doctor just for a blood pressure reading, as the nurse, you can suggest the use of an automatic cuff at a local pharmacy, or purchasing a self-monitoring cuff. Discussing methods for stress reduction, advising a smoking cessation, and administering glycemic control would constitute patient education in managing hypertension

Which of the following route of medication administration should the nurse consider first in an NPO (nothing by mouth) postoperative patient following IV removal? a) Subcutaneous b) Rectal c) Topical d) Intrathecal

b) Rectal Explanation: The rectal route of analgesic administration is an alternative route when oral or IV analgesic agents are not an option. The rectum allows passive diffusion of medications and absorption into the systemic circulation. Topical agents produce effects in the tissues immediately under the site of application. Intrathecal catheters for acute pain management are used most often for providing anesthesia or a single bolus dose of an analgesic agent. The subcutaneous route of administration is not recommended in this situation.

Which actions should a nurse perform to prevent deep vein thrombosis when caring for a postsurgical patient? a) Instruct the patient to prop pillow under the knees. b) Reinforce the need to perform leg exercises every hour when awake. c) Maintain bed rest. d) Administer prophylaxis high-dose heparin

b) Reinforce the need to perform leg exercises every hour when awake. Explanation: The nurse should reinforce the need to perform leg exercises every hour when awake. Maintaining bed rest increases the pooling of blood in the lower extremities, increasing the risk for deep vein thrombosis. The patient may be given low-dose heparin for prophylaxis treatment but not a high-dose heparin. The nurse should instruct the patient not to prop a pillow under the knees because the patient can constrict the blood vessels.

When caring for a postsurgical patient, the nurse observes that the client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock? a) Encouraging the patient to breathe deeply b) Reinforcing dressing or applying pressure if bleeding is frank c) Elevating the head of the bed d) Monitoring vital signs every 15 minutes

b) Reinforcing dressing or applying pressure if bleeding is frank Explanation: The nurse should reinforce the dressing or apply pressure if bleeding is frank. The nurse should keep the head of the bed flat unless it is contraindicated. Encouraging the patient to breathe deeply will not help manage and minimize hemorrhage and shock. Monitoring the vital signs every 15 minutes is an appropriate nursing intervention but will not minimize hemorrhage and shock; it will just help to determine the extent and progression of the problem.

The nurse is caring for a patient diagnosed with hyperchloremia. Signs and symptoms of hyperchloremia include which of the following? Select all that apply. a) Hypotension b) Tachypnea c) Dehydration d) Lethargy e) Weakness

b) Tachypnea, e) Weakness, d) Lethargy Explanation: The signs and symptoms of hyperchloremia are the same as those of metabolic acidosis: hypervolemia and hypernatremia. Tachypnea; weakness; lethargy; deep, rapid respirations; diminished cognitive ability; and hypertension occur. If untreated, hyperchloremia can lead to a decrease in cardiac output, dysrhythmias, and coma. A high chloride level is accompanied by a high sodium level and fluid retention.

What action during a surgical procedure requires immediate intervention by the circulating nurse? a) The anesthesiologist monitoring blood gas levels b) The scrub nurse calling the blood bank to obtain blood products c) The surgeon reaching within the sterile field to obtain equipment d) The registered nurse's first assistant suturing the surgical wound

b) The scrub nurse calling the blood bank to obtain blood products Explanation: The scrub nurse is "scrubbed" in and should only come in contact with sterile equipment. Using the phone to call the blood bank is the responsibility of the circulating nurse and it would break the sterility of the scrub nurse. The surgeon has "scrubbed" and should only touch within sterile fields. The anesthesiologist should monitor blood gas levels as needed, and it is appropriate for the registered nurse first assistant to suture the surgical wound.

A patient receives a daily injection of glargine (Lantus) insulin at 7:00 am. When should the nurse monitor this patient for a hypoglycemic reaction? a) Between 4:00 and 6:00 pm b) This insulin has no peak action and does not cause a hypoglycemic reaction. c) Between 7:00 and 9:00 pm d) Between 8:00 and 10:00 am

b) This insulin has no peak action and does not cause a hypoglycemic reaction. Explanation: Peakless basal or very long-acting insulins are approved by the Food and Drug Administration for use as a basal insulin—that is, the insulin is absorbed very slowly over 24 hours and can be given once a day. It has is no peak action

The nurse is educating patients requiring surgery for various ailments on the perioperative experience. What education provided by the nurse is most appropriate? a) Intraoperative techniques used to perform the surgery b) Three phases of surgery and safety measures for each phase c) Risks and benefits of the surgical procedures d) Expected pain levels and narcotic pain medication used to treat the pain

b) Three phases of surgery and safety measures for each phase Explanation: The perioperative period includes the preoperative, intraoperative, and postoperative phases. Specific safety guidelines are followed for all surgical patients. The information provided should be general enough to be informative about surgery and should not focus on individual surgeries, as all the patients are having different surgeries. Intraoperative techniques, expected pain levels, and pain medication are specific to the patient and type of surgery. The risks and benefits of the surgical procedure should be discussed by the physician.

A patient is brought to the operating room for an elective surgery. What is the priority action by the circulating nurse? a) Obtain a sponge and syringe count. b) Verify consent. c) Document start of surgery. d) Acquire ordered blood products.

b) Verify consent. Explanation: Without consent, surgery cannot be performed. Documentation of the start of surgery can only happen once the surgery has started. Blood products must be administered within an allotted time frame and therefore should not be acquired unless needed. The sponge and syringe count is a safety issue that should be completed before surgery and while the wound is being sutured, but the patient has not consented, the surgery should not take place.

The nurse is analyzing the arterial blood gas (AGB) results of a patient diagnosed with severe pneumonia. Which of the following ABG results indicates respiratory acidosis? a) pH: 7.32, PaCO2: 40 mm Hg, HCO3-: 18 mEq/L b) pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L c) pH: 7.42, PaCO2: 45 mm Hg, HCO3-: 22 mEq /L d) pH: 7.50, PaCO2: 30 mm Hg, HCO3-: 24 mEq/L

b) pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L Explanation: Respiratory acidosis is a clinical disorder in which the pH is less than 7.35 and the PaCO2 is greater than 42 mm Hg and a compensatory increase in the plasma HCO3- occurs. It may be either acute or chronic. The ABG of pH: 7.32, PaCO2: 40 mm Hg, HCO3- : 18 mEq/L indicates metabolic acidosis. The ABGs of pH: 7.50, PaCO2: 30 mm Hg, and HCO3- : 24 mEq/L indicate respiratory alkalosis. The ABGs of pH 7.42, PaCO2: 45 mm Hg, and HCO3- : 22 mEq/L indicate a normal result/no imbalance.

A 1,200-calorie diet and exercise are prescribed for a patient with newly diagnosed type 2 diabetes. The nurse is teaching the patient about meal planning using exchange lists. The teaching is determined to be effective based on which of the following statements? a) "For dinner I ate 2 ounces of sliced turkey, 1 cup mashed sweet potatoes, half a cup of carrots, half a cup of peas, a 3-ounce dinner roll, 1 medium banana, and a diet soda." b) "For dinner I ate 4-ounces of sliced roast beef on a bagel with lettuce, tomato, and onion, 1 ounce low-fat cheese, 1 tablespoon mayonnaise, 1 cup fresh strawberry shortcake, and unsweetened iced tea." c) "For dinner I ate a 3-ounce hamburger on a bun, with ketchup, pickle, and onion, a green salad with 1 teaspoon Italian dressing, 1 cup of watermelon, and a diet soda." d) "For dinner I ate 2 cups of cooked pasta with 3-ounces of boiled shrimp, 1 cup plum tomatoes, half a cup of peas and garlic-wine sauce, 2 cups fresh strawberries, and ice water with lemon."

c) "For dinner I ate a 3-ounce hamburger on a bun, with ketchup, pickle, and onion, a green salad with 1 teaspoon Italian dressing, 1 cup of watermelon, and a diet soda." Explanation: There are six main exchange lists: bread/starch, vegetable, milk, meat, fruit, and fat. Foods within one group (in the portion amounts specified) contain equal numbers of calories and are approximately equal in grams of protein, fat, and carbohydrate. Meal plans can be based on a recommended number of choices from each exchange list. Foods on one list may be interchanged with one another, allowing for variety while maintaining as much consistency as possible in the nutrient content of foods eaten. Example: 2 starch = 2 slices bread or a hamburger bun, 3 meat = 3 oz lean beef patty, 1 vegetable = green salad, 1 fat = 1 tbsp salad dressing, 1 fruit = 1¼ cup watermelon; "free" items like diet soda are optional.

The nurse is caring for a female client who has had 25 mg of oral hydrochlorothiazide added to her medication regimen for the treatment of hypertension (HTN). Which of the following instructions should the nurse give the patient? a) "You may develop dry mouth or nasal congestion while on this medication." b) "Take this medication before going to bed." c) "Increase the amount of fruits and vegetables you eat." d) "You may drink alcohol while taking this medication."

c) "Increase the amount of fruits and vegetables you eat." Explanation: Thiazide diuretics cause loss of sodium, potassium, and magnesium. The patient should be encouraged to eat fruits and vegetables which are high in potassium. Diuretics cause increased urination; the patient should not take the medication prior to going to bed. Thiazide diuretics to not cause dry mouth or nasal congestion. Postural hypotension (side effect) may be potentiated by alcohol.

A new scrub technician is being orientated to the operating room. The scrub technician states to the nurse, "You can skip the fire safety information because I have worked in hospitals for the last 10 years." What is the best response by the nurse? a) "OK, but you will be required to review the hospital's policy on fire safety on your own." b) "This is a requirement of your job, just tough through it." c) "The operating room has some unique circumstances that increases the chances of fire." d) "I know this information is not exciting but I'm required to cover this information with you."

c) "The operating room has some unique circumstances that increases the chances of fire." Explanation: The operating room environment has some unique characteristics that do increase the chance of fires, such as drapes that allow oxygen concentration. By engaging the new employee to understand the underlying reason for fire safety in the operating room, the new employee will develop a greater understanding and appreciation for fire safety. If fire safety is only presented as a requirement for the job then the employee may not understand the importance of fire safety. The hospital's policy for fire safety is broad; the employee would need to review the fire safety policies specifically for the operating room.

The nurse is completing a preoperative assessment. The nurse notices the patient is tearful and constantly wringing hands. The patient states, "I'm really nervous about this surgery. Do you think it will be ok?" What is the nurse's best response? a) "What family support do you have after the surgery?" b) "No one has ever died from the procedure you are having." c) "What are your concerns?" d) "You have nothing to worry about; you have the best surgical team."

c) "What are your concerns?" Explanation: Asking the patient about their concerns is an open-ended therapeutic technique. It allows the patient to guide the conversation and address their emotional state. Asking about family support is changing the subject and is nontherapeutic. Discussing the surgical team and the low death rate associated with a procedure is minimizing the patient's feelings and is nontherapeutic.

A 77-year-old woman presents to the local community center for a blood pressure screening. The women's blood pressure is recorded as 180/90 mm Hg. The woman has a history of hypertension, but she currently is not taking her medications. Which of the following questions is most appropriate for the nurse to ask the patient first? a) "What medications are you prescribed?" b) "Are you able to get to your pharmacy to pick up your medications?" c) "Why is it that you are not taking your medications?" d) "Are you having trouble paying for your medication?"

c) "Why is it that you are not taking your medications?" Explanation: It is important for the nurse to first ascertain if the reason why the patient is not taking her medications. Adherence to the therapeutic program may be more difficult for older adults. The medication regimen can be difficult to remember, and the expense can be a challenge. Monotherapy (treatment with a single agent), if appropriate, may simplify the medication regimen and make it less expensive. The other questions are appropriate, but the priority is to determine why the medication regimen is not being followed.

The nurse is caring for a patient in the intensive care unit (ICU) following a saltwater near-drowning event. The client is restless, lethargic, and demonstrating tremors. Additional assessment findings include swollen dry tongue, flushed skin, and peripheral edema. The nurse anticipated that the patient's serum sodium value would be which of the following? a) 145 mEq/L b) 135 mEq/L c) 155 mEq/L d) 125 mEq/L

c) 155 mEq/L Explanation: The patient is experiencing signs and symptoms (S/S) of hypernatremia. Hypernatremia is a serum sodium level higher than 145 mEq/L (145 mmol/L). A cause of hypernatremia is near drowning in seawater (which contains a sodium concentration of approximately 500 mEq/L). S/S of hypernatremia include thirst, elevated body temperature, swollen dry tongue and sticky mucous membranes, hallucinations, lethargy, restlessness, irritability, simple partial or tonic-clonic seizures, pulmonary edema, hyperreflexia, twitching, nausea, vomiting, anorexia, elevated pulse, and elevated blood pressure.

Nociception includes four specific processes: transduction, transmission, perception, and modulation. Which of the following actions illustrates the nociception process of pain transmission? a) A surgeon making an incision to perform surgery b) A patient taking tramadol (Ultram) to enhance pain management c) A child quickly removing a hand when touching a hot object d) A mother in labor utilizing imagery to reduce pain

c) A child quickly removing a hand when touching a hot object Explanation: Transduction, the first process involved in nociception, refers to the processes by which noxious stimuli, such as a surgical incision, release of a number of excitatory compounds which move pain along the pain pathway. Transmission, the second process involved in nociception, is responsible for a rapid reflex withdrawal from painful stimulus. The third process involved in nociception is perception. Imagery is based on the belief that the brain processes can strongly influence pain perception. A dual mechanism analgesic agent, such as tramadol (Ultram), involves many different neurochemicals as in the process of modulation.

The nurse understands that which of the following is true about tolerance and addiction? a) Tolerance to opioids is uncommon. b) The nurse must be primarily concerned about development of addiction by the patient in pain. c) Although patients may need increasing levels of opioids, they are not addicted. d) Addiction to opioids commonly develops.

c) Although patients may need increasing levels of opioids, they are not addicted. Explanation: Physical tolerance usually occurs in the absence of addiction. Tolerance to opioids is common. Addiction to opioids is rare, and should never be the primary concern for a patient in pain.

A home health nurse is visiting a patient who has been taking the same dose of hydrocodone/acetaminophen (Lortab) for 2 months. To monitor for the presence of expected side effects of this medication, what should the nurse include in the assessment of the patient? a) Observe respiratory rate and depth. b) Assess level of consciousness. c) Ask about the patient's bowel pattern. d) Take the patient's blood pressure.

c) Ask about the patient's bowel pattern. Explanation: Opioids can result in delayed gastric emptying, slowed bowel motility, and decreased peristalsis, all of which result in slow-moving, hard stool that is difficult to pass. Constipation is a very common side effect of narcotics that continues to be a problem, even with chronic administration. Although respiratory depression, decreased level of consciousness, and hypotension are common side effects of acute use of narcotics, these effects are not expected to occur with chronic usage at the same dose.

A PACU nurse receives a postoperative patient who received general anesthesia with a hard plastic oral airway in place. The patient has clear lung sounds, even and unlabored respirations of 16, and an oxygen saturation of 98%. The patient is minimally responsive to painful stimuli. What action by the nurse is most appropriate? a) Notify the physician of impaired neurological status. b) Remove the oral airway. c) Continue with frequent patient assessments. d) Obtain vital signs, including pulse oximetry, every 5 minutes.

c) Continue with frequent patient assessments. Explanation: An immediate postoperative patient may be transferred to the PACU with a hard plastic oral airway. The airway should not be removed until the patient is showing signs of gagging or choking. The neurological status is appropriate for a patient that received general anesthesia. There is no information provided that requires the patient to have vitals taken more frequently than the standard 15 minutes. The nurse should continue with frequent patient assessments

The anesthesiologist administered a transsacral conduction block. Which of the following documentation by the nurse is consistent with the anesthesia being administered? a) Unresponsive to verbal or tactile stimuli b) No movement in right lower leg c) Denies sensation to perineum and lower abdomen d) Yelling and pulling at equipment

c) Denies sensation to perineum and lower abdomen Explanation: A transsacral block produces anesthesia of the perineum, and occasionally, the lower abdomen. Yelling and pulling at equipment can be related to the excitement phase of general anesthesia. Unresponsive to verbal or tactile stimuli and no movement in the right lower leg are not consistent with a transsacral conduction block.

A patient has been prescribed a Fentanyl patch for pain control. The nurse understands that this patch should be replaced how often? a) Every 48 hours b) Every 24 hours c) Every 72 hours d) Every 36 hours

c) Every 72 hours Explanation: Fentanyl patches should be replaced every 72 hours. The other timeframes are incorrect

A nurse is preparing to discharge a patient with coronary artery disease (CAD) and hypertension (HTN) who is at risk for type 2 diabetes. Which of the following information is important to include in the discharge teaching? a) How to self-inject insulin b) How to monitor ketones daily c) How to control blood glucose through lifestyle modification with diet and exercise d) How to recognize signs of diabetic ketoacidosis (DKA)

c) How to control blood glucose through lifestyle modification with diet and exercise Explanation: Persons at high risk for type 2 diabetes receive standard lifestyle recommendations plus metformin, standard lifestyle recommendations plus placebo, or an intensive program of lifestyle modifications. The 16-lesson curriculum of the intensive program of lifestyle modifications focuses on weight reduction of greater than 7% of initial body weight and physical activity of moderate intensity. It also includes behavior modification strategies designed to help patients achieve the goals of weight reduction and participation in exercise. These findings demonstrate that type 2 diabetes can be prevented or delayed in persons at high risk for the disease

An anxious preoperative surgical patient is encouraged to concentrate on a pleasant experience or restful scene. What cognitive coping strategy would the nurse document as being used? a) Optimistic self-recitation b) Progressive muscular relaxation c) Imagery d) Distraction

c) Imagery Explanation: Imagery has proven effective for anxiety in surgical patients. Optimistic self-recitation is practiced when the patient is encouraged to recite optimistic thoughts such as, "I know all will go well." Distraction is employed when the patient is encouraged to think of an enjoyable story or recite a favorite poem. Progressive muscular relaxation requires contracting and relaxing muscle groups and is a physical coping strategy as opposed to a cognitive strategy.

A patient with fractured skull after falling from a ladder requires surgery. The nurse should anticipate transporting the patient to surgery during what time frame? a) In 1 week b) In 1 day c) Immediately d) In 48-72 hours

c) Immediately Explanation: Emergent surgery occurs when the patient requires immediate attention. A fractured skull is an indication for emergent surgery. An urgent surgery occurs when the patient requires prompt attention, usually within 24-30 hours. Any surgery scheduled beyond 30 hours is classified as required or elective and a fractured skull does not meet the requirements for elective or required surgery.

An obese patient is undergoing abdominal surgery. A surgical resident states, "The amount of fat we have to cut through is disgusting" during the procedure. What is the best response by the nurse? a) Ignore the comment. b) Discuss concerns regarding the comments with the charge nurse. c) Inform the resident that all communication needs to remain professional. d) Report the resident to the attending surgeon

c) Inform the resident that all communication needs to remain professional. Explanation: The nurse must advocate for the patient, especially when the patient cannot speak for themselves. By informing the resident that all communication needs to be professional, the nurse is addressing the comment at that moment in time, advocating for the patient. Ignoring the comment is not appropriate. The nurse may need to address the concerns of unprofessional communication with the attending surgeon or the charge nurse if the behavior continues. The best action is to address the behavior when it is happening

When caring for a patient who has risk factors for fluid and electrolyte imbalances, which of the following assessment findings is the highest priority for the nurse to follow up? a) Blood pressure 96/53 mm Hg b) Weight loss of 4 lb c) Irregular heart rate d) Mild confusion

c) Irregular heart rate Explanation: Irregular heart rate may indicate a potentially life-threatening cardiac dysrhythmia. Potassium, magnesium, and calcium imbalances may cause dysrhythmias. Weight loss is a good indicator of the amount of fluid lost, but following up on potential cardiac dysrhythmias is a higher priority. Confusion may occur with dehydration and hyponatremia, but following up on potential cardiac dysrhythmias is a higher priority. The blood pressure is slightly lower than normal but is not life threatening. Following up on potential cardiac dysrhythmias is a higher priority.

The nurse is educating new employees regarding the wearing of masks in the operating room. What information should the nurse provide? Select all that apply. a) Masks must be worn at all times in the semirestricted zone. b) Masks can be worn outside the surgical department if the surgery is less than 5 minutes away. c) Masks should cover the nose and mouth completely. d) You must change masks between treating patients. e) When not using the mask, you can wear it around your neck. f) Masks should be tight fitting.

c) Masks should cover the nose and mouth completely., d) You must change masks between treating patients., f) Masks should be tight fitting. Explanation: Masks are changed between patients. Regardless of time, the masks should not be worn outside the surgical department. Masks should fit tightly and cover the nose and the mouth completely. The mask must be either on or off; it must not be allowed to hang around the neck. Masks must be worn at all times in the restricted zone. The semirestricted zone requires scrubs and cap.

What is the priority action when the circulating nurse is completing a second verification of the surgical procedure and surgical site? a) Discuss the surgical procedure and surgical site with the patient. b) Review the complications and allergies with the anesthesiologist. c) Obtain the attention of all members of the surgical team. d) Ask the surgeon if the marked surgical site is correct.

c) Obtain the attention of all members of the surgical team. Explanation: The second verification of the surgical procedure and surgical site should include all members of the surgical team. This verification should be done at one time with all members of the team involved. The marked surgical site is confirmed with all members of the surgical team, not just the surgeon or patient. Complications, allergies, and anticipated problems are also discussed among the entire surgical team.

The nurse has medicated a postoperative patient for complaints of nausea. Which medication would the nurse document as having been given? a) Propofol (Diprivan) b) Prednisone (Deltasone) c) Ondansetron (Zofran) d) Warfarin (Coumadin)

c) Ondansetron (Zofran) Explanation: Odansetron (Zofran) is an antiemetic and one of the most commonly prescribed medications for nausea and vomiting. Warfarin (Coumadin) is an anticoagulant. Prednisone (Deltasone) is a corticosteroid. Propofol (Diprivan) is an anesthetic agent.

A patient is scheduled to have a cholecystectomy. Which of the nurse's finding is least likely to contribute to surgical complications? a) Diabetes b) Urinary tract infection c) Osteoporosis d) Pregnancy

c) Osteoporosis Explanation: Osteoporosis is most likely not going to contribute to complications related to a cholecystectomy. Pregnancy decreases maternal reserves. Diabetes increases wound-healing problems and risks for infection. Urinary tract infection decreases the immune system, increasing the chance for infections.

A list of commonly used medications for a particular surgical procedure is provided to the nurse. The anesthesiologist announces the administration of a nondepolarizing muscle relaxant. Which of the following medications should the nurse document as having been administered? a) Succinylcholine (Anectine) b) Fentanyl (Sublimaze) c) Pancuronium (Pavulon) d) Morphine sulfate

c) Pancuronium (Pavulon) Explanation: Pavulon is a nondepolarizing muscle relaxant. Succinylcholine is a polarizing muscle relaxant. Fentanyl and morphine sulfate are opioid analgesic agents

The nurse is analyzing the electrocardiographic (ECG) rhythm tracing of a patient experiencing hypercalcemia. Which of the following ECG changes is typically associated with this electrolyte imbalance? a) Peaked T waves b) Prolonged QT intervals c) Prolonged PR intervals d) Elevated ST segments

c) Prolonged PR intervals Explanation: Cardiovascular changes associated with hypercalcemia may include a variety of dysrhythmias (e.g., heart blocks) and shortening of the QT interval and the ST segment. The PR interval is sometimes prolonged. The other changes are not associated with an elevated serum calcium level

The circulating nurse is unsure if proper technique was followed when placing an object in the sterile field during a surgical procedure. What is the best action by the nurse? a) Mark the patient's chart for future review of infections. b) Remove the item from the sterile field. c) Remove the entire sterile field from use. d) Ask another nurse to review the technique used.

c) Remove the entire sterile field from use. Explanation: If there is any doubt about the maintenance of sterility, the field should be considered not sterile. Because the object in question was placed in the sterile field, the sterile field must be removed from use. Removing the individual item is not appropriate, as the field was potentially contaminated. Reviewing the patient's chart at a later date does not decrease the chance of infection. Although another nurse could observe the technique used to put objects in a sterile field, it does not solve the immediate concern.

Hypertension that can be attributed to an underlying cause is termed which of the following? a) Isolated systolic b) Primary c) Secondary d) Essential

c) Secondary Explanation: Secondary hypertension may be caused by a tumor of the adrenal gland (eg, pheochromocytoma). Primary hypertension has no known underlying cause. Essential hypertension has no known underlying cause. Isolated systolic hypertension is demonstrated by readings in which the systolic pressure exceeds 140 mm Hg and the diastolic measurement is normal or near normal (less than 90 mm Hg)

The nurse is participating in the care of a patient who had a peripherally inserted central catheter (PICC) inserted in the right arm. Following catheter placement, the nurse should complete which of the following actions? a) Administer the prescribed IV fluids. b) Assess the patient's blood pressure (BP) on the right arm. c) Send the patient for a chest x-ray. d) Obtain written consent for the procedure

c) Send the patient for a chest x-ray. Explanation: A chest x-ray is needed to confirm the placement of catheter tip prior to initiation of ordered infusion. Consent should be obtained prior to the procedure, not after the procedure. No BPs should be taken on the extremity where the catheter is placed.

The nurse is caring for a patient prescribed Bumex (bumetanide) for the treatment of stage 2 hypertension. Which of the following indicates the patient is experiencing an adverse effect of the medication? a) Blood glucose value of 160 mg/dL b) Urine output of 90 cc/mL 1 hour after medication administration c) Serum potassium value of 3.0 mEq/L d) Electrocardiogram (EGG) tracing demonstrating peaked T waves

c) Serum potassium value of 3.0 mEq/L Explanation: Bumex is a loop diuretic that can cause fluid and electrolyte imbalances. Patients taking these medications may experience a low serum potassium level. ECG changes associated with an elevated serum potassium levels include peaked T waves. Diuresis is a desired effect postadministration of Bumex. The serum glucose level is elevated and requires intervention; however, this elevation is not associated with the administration of Bumex.

What pain assessment scale would be best to use with a 5-year-old child? a) A Numerical Pain Scale b) A pain assessment scale is inappropriate for a 5-year-old child. c) The FACES scale d) A Visual Analog Scale

c) The FACES scale Explanation: The FACES scale was developed for use in children. It consists of six pictures depicting faces ranging from content to distressed. The child points to the face that best shows how much he or she hurts. The FACES scale may also be useful for adults who have difficulty with numerical or visual analog scales. Specific pain assessment scales have been tested for use in many patient populations from neonates to patients who have dementia. The Visual Analog Scale and Numerical Pain Scale are not the best choices for a 5-year-old because they depend on the patient being able to read and use numbers

The nurse needs to carefully monitor a patient with traumatic injuries. Which of the following actions by the nurse demonstrates understanding of the most essential component of the patient's pain assessment? a) The nurse administers ketorolac (Toradol) on admission to the unit. b) The nurse validates the patient's report of pain by assessing the patient's blood pressure. c) The nurse administers pain medication based on the patient's reported pain level. d) The nurse assesses the response to medication after every meal consumed by the patient.

c) The nurse administers pain medication based on the patient's reported pain level. Explanation: Patients quickly adapt physiologically despite pain and may have normal or below normal vital signs in the presence of severe pain. The overriding principle is that the absence of an elevated BP or heart rate does not mean the absence of pain. The ability of an individual to give a report, in the case of pain—especially its intensity—is the most essential component of pain assessment. Pain does not need to be assessed an hour after analgesics are administered or after every meal consumed by the patient. Pain medication should not routinely be administered to a patient on admission to the unit.

Which of the following may be a potential cause of hypoglycemia in the patient diagnosed with diabetes mellitus? a) The patient has not been compliant with the prescribed treatment regimen. b) The patient has not been exercising. c) The patient has not consumed food and continues to take insulin or oral antidiabetic medications. d) The patient has consumed food and has not taken or received insulin.

c) The patient has not consumed food and continues to take insulin or oral antidiabetic medications. Explanation: Hypoglycemia in patients is usually the result of too much insulin or delays in eating

The nurse understands that an overall goal of hypertension management includes which of the following? a) There is no complaint of postural hypotension. b) There are no complaints of sexual dysfunction. c) There is no indication of target organ damage. d) The patient maintains a normal blood pressure reading.

c) There is no indication of target organ damage. Explanation: Prolonged blood pressure elevation gradually damages blood vessels throughout the body, particularly in target organs such as the heart, kidneys, brain, and eyes. The overall goal of management is that the patient does not experience target organ damage. The desired effects of antihypertensives are to maintain a normal BP. Postural hypotension and sexual dysfunction are side effects of certain antihypertension medications.

Which of the following statements when made by a cancer patient with moderate-to-severe pain prescribed oxymorphone (Opana IR) indicates further instruction is required? a) "I can also have this medication in an extended release tablet." b) "The IR indicates I will get fast relief when I take the medication." c) "I will stop drinking beer while I'm on this medication." d) "I will take this medication with breakfast for the best results."

d) "I will take this medication with breakfast for the best results." Explanation: Oxymorphone (Opana IR) must be taken on an empty stomach (1 hour before or 2 hours after a meal). Co-ingestion of alcohol can increase the serum concentration of the drug. Oxymorphone has been available for many years in parenteral formulation and more recently in short-acting (Opana IR) and modified-release (Opana ER) oral tablets.

A patient with a history of alcoholism and scheduled for an urgent surgery asks the nurse, "Why is everyone so concerned about how much I drink?" What is the best response by the nurse? a) "It is a required screening question for all patients having surgery." b) "The amount of alcohol you drink will determine the amount of pain medication you will need postoperatively." c) "We can have counselors available after surgery; if it is determined you need help for your drinking." d) "It is important for us to know how much and how often you drink to help prevent surgical complications."

d) "It is important for us to know how much and how often you drink to help prevent surgical complications." Explanation: Alcohol use and alcoholism can contribute to serious postoperative complications. If the medical and nursing staff is aware of the use or abuse, measures can be implemented proactively to prevent complications. Although alcohol may interfere with a medication's effectiveness, it does not determine the amount of pain medications that are prescribed following surgery. Even though this is a required screening question and counselors can be made available for those who want help, those are not the best responses to answer the patient's question.

The advance practice nurse is treating a patient experiencing a neuropathic pain syndrome. Which of the following statements when made by the patient demonstrates an understanding of concepts related to neuropathic pain? a) "Neuropathic pain will only last a few days and is easily treated with COX-2 analgesic agents." b) "When the inflammation in my foot resolves I will no longer have pain from neuropathy." c) "Neuropathic pain is the body's normal response to tissue damage causing pain." d) "My phantom limb pain serves no purpose, and I may need to take antidepressants to help."

d) "My phantom limb pain serves no purpose, and I may need to take antidepressants to help." Explanation: Neuropathic pain is chronic and not treated with COX-2 analgesics. Neuropathic pain is an abnormal processing of sensory input by the peripheral or central nervous system or both. Neuropathic pain may occur in the absence of tissue damage and inflammation. Neuropathic pain serves no useful purpose. Evidence-based guidelines recommend the TCAs despiramine (Norpramin) and nortriptyline (Aventyl, Pamelor) and the SNRIs duloxetine (Cymbalta) and venlafaxine (Effexor) as first-line options for neuropathic pain treatment.

A 55-year-old man newly diagnosed with hypertension returns to his physician's office for a routine follow-up appointment after several months of treatment with Lopressor (metoprolol). During the nurse's initial assessment the patient's blood pressure (BP) is recorded as 180/90 mm Hg. The patient states he does not take his medication as prescribed. The best response by the nurse is which of the following? a) "Your hypertension must be treated with medications; you need to take your Lopressor every day." b) "Be certain to discuss your noncompliance with your medication regimen with the physician." c) "It is very important for you to take your medication as prescribed, or you could experience a stroke." d) "The medication you were prescribed may cause sexual dysfunction; are you experiencing this side effect?"

d) "The medication you were prescribed may cause sexual dysfunction; are you experiencing this side effect?" Explanation: The nurse needs to understand why the patient is not taking his medication. Lopressor is a beta-blocker. All patients should be informed that beta-blockers might cause sexual dysfunction and that other medications are available if problems with sexual function occur. The other statements, although true, are nontherapeutic and would not elicit why the patient was not taking his medications as prescribed.

A patient has been transported to the operating room for emergent surgery. Which statement by the nurse best supports the need for emergent surgery? a) "The patient was tachycardic, had progressive weight loss, and bouts of insomnia as a result of hyperthyroidism." b) "The patient had epigastric abdominal pain, an elevated white blood count, and vomiting for 1 day." c) "The patient had severe pain and a laceration to the face with minimal bleeding after being attacked by a dog 1 hour ago." d) "The patient was unresponsive, had a distended abdomen, and unstable vital signs following a motor vehicle accident."

d) "The patient was unresponsive, had a distended abdomen, and unstable vital signs following a motor vehicle accident." Explanation: Emergency surgery means that the patient requires immediate attention and the disorder may be life threatening. The patient with unstable vital signs and a distended abdomen following a motor vehicle accident requires immediate attention. The patient with left sided abdominal pain may not need surgery. Epigastric pain with vomiting for 1 day is usually not an indication for emergent surgery. Lacerations to the face require sutures, not emergent surgery. A thyroidectomy to treat hyperthyroidism is a required surgery, not an emergent one.

A patient is undergoing a lumbar puncture. The nurse educates the patient about surgical positioning. Which of the following statements by the nurse is appropriate? a) "You will be placed flat on the table, face down." b) "You will be flat on your back with the table slanted so your head is below your feet." c) "You will be on your back with the head of the bed at 30 degrees." d) "You will be lying on your side with your knees to your chest."

d) "You will be lying on your side with your knees to your chest." Explanation: For the lumbar puncture procedure, the patient usually lies on the side in a knee-chest position. Flat on the table, face down does not open the vertebral spaces to allow access for the lumbar puncture. Having the patient lie on their back does not allow for access to the surgical site.

Officially, hypertension is diagnosed when the patient demonstrates a systolic blood pressure greater than ______ mm Hg and a diastolic blood pressure greater than _____ mm Hg over a sustained period. a) 120, 70 b) 130, 80 c) 110, 60 d) 140, 90

d) 140, 90 Explanation: According to the categories of blood pressure levels established by the Joint National Committee (JNC) VI, stage 1 hypertension is demonstrated by a systolic pressure of 140 to 159, or a diastolic pressure of 90 to 99. Pressure of 130 systolic and 80 diastolic falls within the normal range for an adult. Pressure of 110 systolic and 60 diastolic falls within the normal range for an adult. Pressure of 120 systolic and 70 diastolic falls within the normal range for an adult

Which of the following is a true statement regarding placebos? a) A placebo effect is an indication that the person does not have pain. b) A positive response to a placebo indicates that the person's pain is not real. c) A placebo should be used as the first line of treatment for the patient. d) A placebo should never be used to test the person's truthfulness about pain.

d) A placebo should never be used to test the person's truthfulness about pain. Explanation: Perception of pain is highly individualized. A placebo effect is a true physiologic response. A placebo should never be used as a first line of treatment. The American Society for Pain Management Nurses contends that placebos should not be used to assess or manage pain in any patient, regardless of age or diagnosis. Reduction in pain as a response to placebo should never be interpreted as an indication that the person's pain is not real.

A patient is scheduled for an invasive procedure. What is the priority documentation needed regarding the procedure? a) The medication reconciliation form b) Prescriptions for postoperative medications c) A health history obtained by the primary physician d) A signed consent form from the patient

d) A signed consent form from the patient Explanation: A signed consent is required and is important for initiating invasive procedures. The nurse should therefore check for the patient's signed consent form. A health history, medication reconciliation, and postoperative prescriptions are good items to have, but are not required documentation before performing an invasive procedure.

A patient newly diagnosed with type 1 diabetes has an unusual increase in blood glucose from bedtime to morning. The physician suspects the patient is experiencing insulin waning. Based on this diagnosis, the nurse will expect which of the following changes to the patient's medication regimen? a) Changing the time of injection of evening intermediate-acting insulin from dinnertime to bedtime b) Increasing morning dose of long-acting insulin c) Decreasing evening bedtime dose of intermediate-acting insulin and administering a bedtime snack d) Administering a dose of intermediate-acting insulin before the evening meal

d) Administering a dose of intermediate-acting insulin before the evening meal Explanation: Insulin waning is a progressive rise in blood glucose form bedtime to morning. Treatment includes increasing the evening (predinner or bedtime) dose of intermediate-acting or long-acting insulin or instituting a dose of insulin before the evening meal if that is not already part of the treatment regimen.

A 75-year-old patient had surgery for her hip fracture yesterday. She is under stress due to the pain, the medications, sleep deprivation, and hospital surroundings. Which of the following nursing interventions to treat the patient's pain when ordered by the doctor should the nurse question? a) Acetaminophen for pain management b) Use of transelectrical nerve stimulator (TENS) c) Morphine rather than Advil for pain management d) Advil for pain management

d) Advil for pain management. Explanation: NSAIDs, such as Advil, increase the risk of GI toxicity in individuals older than 60 years and should be assessed further prior to administration. There are many risk factors for opioid-induced respiratory depression in individuals older than 65 years; a thorough respiratory assessment is indicated. Acetaminophen should be used for mild pain. Nonpharmacologic methods of pain management, such as TENS, are acceptable in this situation. Society has proposed that opioids are a safer choice than NSAIDs in many older adults because of the increased risk for NSAID-induced GI adverse effects in that population.

A patient is postoperative day 3 for surgical repair of an open abdominal wound and traumatic amputation of the right lower leg following a motorcycle crash. What is the highest priority nursing intervention? a) Administering pain medications within 1 hour of the patient's request b) Educating patient on safe bed-to-chair transfer procedures c) Obtaining dietary consultation for improved wound healing d) Assessing WBC count, temperature, and wound appearance

d) Assessing WBC count, temperature, and wound appearance Explanation: The patient has an increased risk for infection related to the surgical wound classification of dirty. Assessing the WBC count, temperature, and wound appearance will allow the nurse to intervene at the earliest sign of infection. The patient will have special nutritional needs for wound healing and need education on safe transfer procedures but the need to monitor for infection is a higher priority. The patient should receive pain medication as soon as possible after asking but the latest literature suggest that pain medication should be given on a schedule versus "as needed."

When administering a fentanyl patch, the last dose of sustained-release morphine should be administered at what point? a) Immediately following the morning shower b) There are no administration requirements c) Prior to respiratory assessment d) At the same time the first patch is applied

d) At the same time the first patch is applied Explanation: The skin must be clean and dry prior to patch application; no shower is required. Respiratory assessment must be conducted prior to applying the fentanyl patch. Because it takes 12 to 24 hours for the fentanyl levels to increase gradually from the first patch, the last dose of sustained-release morphine should be administered at the same time the first patch is applied. The other time frames are incorrect.

Which of the following clinical manifestations of type 2 diabetes occurs if glucose levels are very high? a) Oliguria b) Increased energy c) Hyperactivity d) Blurred vision

d) Blurred vision Explanation: Blurred vision occurs when the blood glucose levels are very high. The other clinical manifestations are not consistent with type 2 diabetes

The nurse is administering medications on a medical surgical unit. A patient is ordered to receive 40 mg of oral Corgard (nadolol) for the treatment of hypertension. Prior to administering the medication, the nurse should complete which of the following? a) Checking the patient's urine output b) Checking the patient's serum K+ level c) Weighing the patient d) Checking the patient's heart rate

d) Checking the patient's heart rate Explanation: Corgard is a beta-blocker. A desired effect of this medication is to reduce the pulse rate in patients with tachycardia and an elevated blood pressure (BP). The nurse should check the patient's heart rate (HR) prior to administering Corgard to ensure that the patient's pulse rate is not below 60 (beats per minute (bpm). The other interventions are not indicated prior to administering a beta-blocker medication.

The nurse is caring for a patient with a serum sodium level of 113 mEq/L. The nurse should monitor the patient for the development of which of the following? a) Nausea b) Headache c) Hallucinations d) Confusion

d) Confusion Explanation: Normal serum concentration level ranges from 135 to 145 mEq/L. Hyponatremia exists when the serum level decreases below 135 mEq/L, there is. When the serum sodium level decreases to less than 115 mEq/L (115 mmol/L), signs of increasing intracranial pressure, such as lethargy, confusion, muscle twitching, focal weakness, hemiparesis, papilledema, seizures, and death, may occur. General manifestations of hyponatremia include poor skin turgor, dry mucosa, headache, decreased saliva production, orthostatic fall in blood pressure, nausea, vomiting, and abdominal cramping. Neurologic changes, including altered mental status, status epilepticus, and coma, are probably related to cellular swelling and cerebral edema associated with hyponatremia. Hallucinations are associated with increased serum sodium levels.

Which of the following is an age-related change that may affect diabetes and its management? a) Increased thirst b) Increased bowel motility c) Hypotension d) Decreased renal function

d) Decreased renal function Explanation: Decreased renal function affects the management of diabetes. With decreasing renal function, it takes longer for oral hypoglycemic agents to be excreted by the kidneys and changes in insulin clearance occur with decreased renal function. Other age-related changes that may affect diabetes and its management include hypertension, decreased bowel motility, and decreased thirst

The nurse is caring for a patient with a serum potassium level of 6.0 mEq/L. The patient is ordered to receive oral sodium polystyrene sulfonate (Kayexelate) and furosemide (Lasix). What other orders should the nurse anticipate giving? a) Change the lactated Ringer's solution to 2.5% dextrose. b) Change the lactated Ringer's solution to 3% saline. c) Increase the rate of the IV lactated Ringer's solution. d) Discontinue the IV lactated Ringer's solution.

d) Discontinue the IV lactated Ringer's solution. Explanation: The lactated Ringer's IV fluid is contributing to both the fluid volume excess and the hyperkalemia. In addition to the volume of IV fluids contributing to the fluid volume excess, lactated Ringer's contains more sodium than daily requirements and excess sodium worsens fluid volume excess. Lactated Ringer's also contains potassium, which would worsen the hyperkalemia.

A medical student, scheduled to observe surgery, enters the unrestricted surgical zone wearing jeans, a t-shirt, and tennis shoes. What is the best action by the nurse? a) Provide the medical student a cap and mask. b) Immediately escort the medical student out of the area. c) No action is needed. d) Educate the medical student on required attire for each surgical zone

d) Educate the medical student on required attire for each surgical zone. Explanation: It would be best to educate the medical student on the required attire for each surgical zone. Since the student will be observing a surgery, the student will need to dress appropriately in each zone to decrease the risk of introducing pathogens. The unrestricted zone allows for street clothes; therefore, the student does not need to be removed. If no action is taken by the nurse, the student could enter the semirestricted or restricted zone without appropriate attire. Providing a cap and mask does not address the need to change out of the street clothes to observe the surgery.

A nurse assesses a postoperative patient to have the protrusion of abdominal organs through the surgical incision. Which term, documented by the nurse, best describes the assessment findings? a) Hernia b) Dehiscence c) Erythema d) Evisceration

d) Evisceration Explanation: Evisceration is a surgical emergency. A hernia is a weakness in the abdominal wall. Dehiscence refers to the partial or complete separation of wound edges. Erythema refers to the redness of tissue.

A patient with an abdominal surgical wound sneezes and states, "Something doesn't feel right with my wound." The nurse asses the upper half of the surgical wounds edges are no longer approximated and the lower half remains well approximated. What documentation by the nurse is most appropriate? a) Following a sneeze, the wound hemorrhaged. b) Following a sneeze, the wound eviscerated. c) Following a sneeze, the wound pustulated. d) Following a sneeze, the wound dehisced.

d) Following a sneeze, the wound dehisced. Explanation: Dehiscence is the partial or complete separation of wound edges. Evisceration is the protrusion of organs through the surgical incision. Pustulated refers to the formation of pustules Hemorrhage is excessive bleeding.

The advance nurse practitioner treating a patient diagnosed with neuropathic pain decides to start adjuvant analgesic agent therapy. Which of the following medications is appropriate for the nurse practitioner to prescribe? a) Hydromorphone (Dilaudid) b) Ketamine (Ketalar) c) Tramadol (Ultracet) d) Gabapentin (Neurontin)

d) Gabapentin (Neurontin) Explanation: The anticonvulsants gabapentin (Neurontin) is a first-line analgesic agent for neuropathic pain. Tramadol (Ultracet) is designated as a second-line analgesic agent for the treatment of neuropathic pain. Ketamine (Ketalar) is used as a third-line analgesic agent for refractory acute pain. Hydromorphone (Dilaudid) is a first-line opioid not used as an analgesic agent for neuropathic pain.

Target organ damage from untreated/undertreated hypertension includes which of the following? Select all that apply. a) Diabetes b) Hyperlipidemia c) Stroke d) Heart failure e) Retinal damage

d) Heart failure, e) Retinal damage, c) Stroke Explanation: Target organ systems include cardiac, cerebrovascular, peripheral vascular, renal, and the eye. Hyperlipidemia and diabetes are risk factors for development of hypertension.

A patient is being treated with loop diuretics; gastric suctioning has been initiated. The nurse understands the patient is at risk for developing which of the following electrolyte imbalances? a) Hyponatremia b) Hypocalcemia c) Hypomagnesium d) Hypokalemia

d) Hypokalemia Explanation: Potassium-losing diuretics, such as the thiazides and loop diuretics, can induce hypokalemia. Gastrointestinal (GI) loss of potassium is another common cause of potassium depletion. Vomiting and gastric suction frequently lead to hypokalemia

The nurse understands that patient education related to antihypertensive medication should include all of the following instructions except which of the following? a) Avoid over the counter (OTC) cold, weight reduction, and sinus medications. b) Do not stop antihypertensive medication abruptly. c) Avoid hot baths, exercise, and alcohol within 3 hours of taking vasodilators. d) If a dosage of medication is missed, double up on the next one to catch up

d) If a dosage of medication is missed, double up on the next one to catch up. Explanation: Doubling doses could cause serious hypotension (HTN) and is not recommended. Medications should be taken as prescribed. Hot baths, strenuous exercise, and excessive alcohol are all vasodilators and should be avoided. Many OTC preparations can precipitate HTN. Stopping antihypertensives abruptly can precipitate a severe hypertensive reaction and is not recommended

A 60-year-old patient comes to the ED with complaints of weakness, vision problems, increased thirst, increased urination, and frequent infections that do not seem to heal easily. The physician suspects that the patient has diabetes. Which of the following classic symptoms should the nurse watch for to confirm the diagnosis of diabetes? a) Fatigue b) Numbness c) Dizziness d) Increased hunger

d) Increased hunger Explanation: The classic symptoms of diabetes are the three Ps: polyuria (increased urination), polydipsia (increased thirst), and polyphagia (increased hunger). Some of the other symptoms include tingling, numbness, and loss of sensation in the extremities and fatigue.

A patient is admitted with diabetic ketoacidosis (DKA). The physician writes all of the following orders. Which order should the nurse implement first? a) Administer sodium bicarbonate 50 mEq IV push. b) Start an infusion of regular insulin at 50 U/hr. c) Administer regular insulin 30 U IV push. d) Infuse 0.9% normal saline solution 1 L/hr for 2 hours.

d) Infuse 0.9% normal saline solution 1 L/hr for 2 hours. Explanation: In addition to treating hyperglycemia, management of DKA is aimed at correcting dehydration, electrolyte loss, and acidosis before correcting the hyperglycemia with insulin. In dehydrated patients, rehydration is important for maintaining tissue perfusion. Initially, 0.9% sodium chloride (normal saline) solution is administered at a rapid rate, usually 0.5 to 1 L/hr for 2 to 3 hours

A patient asks about the purpose of withholding food and fluid before surgery. Which response by the nurse is appropriate? a) It prevents overhydration and hypertension. b) It decreases urine output so that a catheter would not be needed. c) It decreases the risk of elevated blood sugars and slow wound healing. d) It prevents aspiration and respiratory complications.

d) It prevents aspiration and respiratory complications. Explanation: The major purpose of withholding food and fluid before surgery is to prevent aspiration, which can lead to respiratory complications. Preventing overhydration, decreasing urine output, and decreasing blood sugar levels are not major purposes of withholding food and fluid before surgery.

The nurse is caring for a patient undergoing alcohol withdrawal. Which of the following serum laboratory values should the nurse monitor most closely? a) Potassium b) Phosphorus c) Calcium d) Magnesium

d) Magnesium Explanation: Chronic alcohol abuse is a major cause of symptomatic hypomagnesemia in the United States. The serum magnesium level should be measured at least every 2 or 3 days in patients undergoing alcohol withdrawal. The serum magnesium level may be normal on admission but may decrease as a result of metabolic changes, such as the intracellular shift of magnesium associated with IV glucose administration.

A patient with type 1 diabetes is experiencing polyphagia. The nurse knows to assess for which additional clinical manifestations associated with this classic symptom? a) Weight gain b) Dehydration c) Altered mental state d) Muscle wasting and tissue loss

d) Muscle wasting and tissue loss Explanation: Polyphagia results from the catabolic state induced by insulin deficiency and the breakdown of proteins and fats. Although people with type 1 diabetes may experience polyphagia (increased hunger), they may also exhibit muscle wasting, subcutaneous tissue loss, and weight loss due to impaired glucose and protein metabolism and impaired fatty acid storage.

A postoperative patient, with an open abdominal wound is currently taking corticosteroids. The physician orders a wound culture of the abdominal wound even though there are no signs and symptoms of infection. What action by the nurse is appropriate? a) Hold the order until purulent drainage is noted. b) Use an antibiotic cleaning agent before obtaining the specimen. c) Request the order be discontinued without obtaining the specimen. d) Obtain the wound culture specimen.

d) Obtain the wound culture specimen. Explanation: Corticosteroids may mask the presence of infection by impairing the normal inflammatory response. The culture should be obtained even though the patient is not demonstrating traditional signs and symptoms of infection. The order should not be discontinued or held until purulent drainage is noted because the infection could worsen and the patient will possibly develop sepsis. An antibiotic cleaning agent should not be used before obtaining the specimen because it will alter the growth of the organisms.

Postoperative day 2, a patient requires wound care for a surgical wound using second-intention healing. What type of dressing change should the nurse anticipate doing? a) Cleaning the wound with soap and water, then leaving open to air b) Cleaning the wound with sterile saline and applying cyanoacrylate tissue adhesive c) Covering the well approximated wound edges with a dry dressing d) Packing the wound bed with sterile saline-soaked dressing and covering with dry dressing

d) Packing the wound bed with sterile saline-soaked dressing and covering with dry dressing Explanation: Postoperative surgical wounds that are allowed to heal using second-intention healing are usually packed with a sterile saline dressing and covered with a dry dressing. The edges of a second-intention healing wound are not approximated. The wound may be cleaned using sterile saline but the nurse would not apply a cyanoacrylate tissue adhesive. The wound should not be left open to the air, as it could expose the wound to microorganisms and dry out the wound bed impairing healing.

A patient is being treated in the ICU 24 hours after having a radical neck dissection completed. The patient's serum calcium level is 7.6 mg/dL. Which of the following physical examination findings is consistent with this electrolyte imbalance? a) Muscle weakness b) Negative Chvostek's sign c) Slurred speech d) Presence of Trousseau's sign

d) Presence of Trousseau's sign Explanation: A patient status post radical neck resection is prone to developing hypocalcemia. Hypocalcemia is defined as a serum values lower than 8.6 mg/dL [2.15 mmol/L]. Signs and symptoms of hypocalcemia include: Chvostek's sign, which consists of muscle twitching enervated by the facial nerve when the region that is about 2 cm anterior to the earlobe, just below the zygomatic arch, is tapped, and a positive Trousseau's sign can be elicited by inflating a blood pressure cuff on the upper arm to about 20 mm Hg above systolic pressure; within 2 to 5 minutes, carpal spasm (an adducted thumb, flexed wrist and metacarpophalangeal joints, and extended interphalangeal joints with fingers together) will occur as ischemia of the ulnar nerve develops. Slurred speech and muscle weakness are signs of hypercalcemia.

When measuring the blood pressure in each of the patient's arms, the nurse recognizes that in the healthy adult, which of the following is true? a) Pressures may vary, with the higher pressure found in the left arm. b) Pressures must be equal in both arms. c) Pressures may vary 10 mm Hg or more between arms. d) Pressures should not differ more than 5 mm Hg between arms.

d) Pressures should not differ more than 5 mm Hg between arms. Explanation: Normally, in the absence of disease of the vasculature, there is a difference of no more than 5 mm Hg between arm pressures. The pressures in each arm do not have to be equal in order to be considered normal. Pressures that vary more than 10 mm Hg between arms indicate an abnormal finding. The left arm pressure is not anticipated to be higher than the right as a normal anatomic variant

The nurse is caring for a client newly diagnosed with secondary hypertension. Which of the following conditions contributes to the development of secondary hypertension? a) Hepatic function b) Calcium deficit c) Acid-based imbalance d) Renal disease

d) Renal disease Explanation: Secondary hypertension occurs when a cause for the high blood pressure can be identified. These causes include renal parenchymal disease, narrowing of the renal arteries, hyperaldosteronism (mineralocorticoid hypertension), pheochromocytoma, certain medications (e.g., prednisone, epoietin alfa [Epogen]), and coarctation of the aorta. High blood pressure can also occur with pregnancy; women who experience high blood pressure during pregnancy are at increased risk of ischemic heart disease, heart attacks, strokes, kidney disease, diabetes, and death from heart attack. Calcium deficiency or acid-based imbalance does not contribute to hypertension

A scrub nurse is diagnosed with a skin infection to the right forearm. What is the priority action by the nurse? a) Request role change to circulating nurse. b) Ensure the infection is covered with a dressing. c) Return to work after being on antibiotics for 24 hours. d) Report the infection to an immediate supervisor.

d) Report the infection to an immediate supervisor. Explanation: The infection needs to be reported immediately because of the asepsis environment of the operating room. The usual barriers may not protect the patient when an infection is present. The employee will need to follow the policy of the operating room regarding infections. Covering the infections with a dressing may be necessary but the infection must first be reported. The scrub nurse may still be able to work depending on the policy; therefore, returning to work after 24 hours is not the priority action. Even if the nurse requests a role change to circulating nurse, the policy for infections in the operating room must be followed; therefore, it must first be reported.

Which of the following findings indicates that hypertension is progressing to target organ damage? a) Urine output of 60 cc/mL over 2 hours b) Chest x-ray showing pneumonia c) Blood urea nitrogen (BUN) level of 12 mg/dL d) Retinal blood vessel damage

d) Retinal blood vessel damage Explanation: Symptoms suggesting that hypertension is progressing to the extent that target organ damage is occurring must be detected early so that appropriate treatment can be initiated. All body systems must be assessed to detect any evidence of vascular damage. An eye examination with an ophthalmoscope is important because retinal blood vessel damage indicates similar damage elsewhere in the vascular system. The patient is questioned about blurred vision, spots in front of the eyes, and diminished visual acuity. The heart, nervous system, and kidneys are also carefully assessed. A BUN level and 60 cc/mL over 2 hours are normal findings. The presence of pneumonia does not indicate target organ damage.

A postanesthesia care unit (PACU) nurse is preparing to discharge a patient home following ankle surgery. The patient keeps staring at the ceiling while being given discharge instructions. What action by the nurse is appropriate? a) Ask the patient, "Do you understand?" b) Continuously repeat the instructions until the patient restates them. c) Give the written instructions to the patient's 16-year-old child. d) Review the instructions with the patient and accompanying adult

d) Review the instructions with the patient and accompanying adult. Explanation: The effects of the anesthesia may impair the memory or concentration of the patient. It is important that the discharge instructions are covered with the patient and an accompanying adult. Giving the instructions to a 16-year-old is not appropriate. Repeating the instruction until the patient restates them does not ensure that the patient will remember them because of how anesthesia can impair the memory. Asking if the patient understands the instructions only elicits an yes or no answer but does not give insight on if the patient comprehending the instructions.

A patient with type 1 diabetes mellitus is being taught about self-injection of insulin. Which of the following facts about site rotation should the nurse include in the teaching? a) Avoid the abdomen because absorption there is irregular. b) Choose a different site at random for each injection. c) Rotate sites from area to area every other day. d) Use all available injection sites within one area

d) Use all available injection sites within one area. Explanation: Systematic rotation of injection sites within an anatomic area is recommended to prevent localized changes in fatty tissue. To promote consistency in insulin absorption, the patient should be encouraged to use all available injection sites within one area rather than randomly rotating sites from area to area

Which of the following statements are true when the nurse is measuring blood pressure (BP)? Select all that apply. a) Using a BP cuff that is too large will give a higher BP measurement. b) Ask the patient to sit quietly while the BP is being measured. c) The patient's arm should be positioned at the level of the heart. d) Using a BP cuff that is too small will give a higher BP measurement. e) The patient's BP should be taken 1 hour after the consumption of alcohol.

d) Using a BP cuff that is too small will give a higher BP measurement., c) The patient's arm should be positioned at the level of the heart., b) Ask the patient to sit quietly while the BP is being measured. Explanation: These statements are all true when measuring a BP. When using a BP cuff that is too large the reading will be lower than the actual BP. The patient should avoid smoking cigarettes or drinking caffeine for 30 minutes before BP is measured.

Which of the following factors is the focus of nutrition intervention for patients with type 2 diabetes? a) Protein metabolism b) Blood glucose level c) Carbohydrate intake d) Weight loss

d) Weight loss Explanation: In most instances, people with type 2 diabetes require weight reduction; therefore, weight loss is the focus of nutrition intervention for patients with type 2 diabetes. A low-calorie diet may reduce clinical symptoms, and even a mild to moderate weight loss, such as 10 to 20 pounds, may lower blood glucose levels and improve insulin action.

The nurse is teaching a patient about self-administration of insulin and mixing of regular and neutral protamine Hagedorn (NPH) insulin. Which of the following is important to include in the teaching plan? a) When mixing insulin, the NPH insulin is drawn up into the syringe first. b) If two different types of insulin are ordered, they need to be given in separate injections. c) There is no longer a need to inject air into the bottle of insulin before insulin is withdrawn. d) When mixing insulin, the regular insulin is drawn up into the syringe first.

d) When mixing insulin, the regular insulin is drawn up into the syringe first. Explanation: When rapid-acting or short-acting insulins are to be given simultaneously with longer-acting insulins, they are usually mixed together in the same syringe; the longer-acting insulins must be mixed thoroughly before drawing into the syringe. The American Diabetic Association (ADA) recommends that the regular insulin be drawn up first. The most important issues are (1) that patients are consistent in technique, so the wrong dose is not drawn in error or the wrong type of insulin, and (2) that patients not inject one type of insulin into the bottle containing a different type of insulin. Injecting cloudy insulin into a vial of clear insulin contaminates the entire vial of clear insulin and alters its action.

Which of the following arterial blood gas (ABG) results would the nurse anticipate for a patient with a 3-day history of vomiting? a) pH: 7.34, PaCO2: 60 mm Hg, HCO3: 34 b) pH: 7.45, PaCO2: 32 mm Hg, HCO3-: 21 c) pH: 7.28, PaCO2: 25 mm Hg, HCO3: 15 d) pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28

d) pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 Explanation: The patient's ABG would likely demonstrate metabolic alkalosis. Metabolic alkalosis is a clinical disturbance characterized by a high pH (decreased H+ concentration) and a high plasma bicarbonate concentration. It can be produced by a gain of bicarbonate or a loss of H+. A common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis where only gastric fluid is lost. The other results do not represent metabolic alkalosis

Choose the statements that correctly match the hypertensive medication with its side effect. Select all that apply. a) Beta-blockers may cause sedation. b) With ACE inhibitors, assess for bradycardia. c) With thiazide diuretics, monitor serum potassium levels. d) With adrenergic inhibitors, cough is a common side effect. e) Direct vasodilators may cause headache and tachycardia.

e) Direct vasodilators may cause headache and tachycardia., c) With thiazide diuretics, monitor serum potassium levels. Explanation: Thiazide diuretics may deplete potassium; many clients will need potassium supplementation. Angiotensin-converting enzyme (ACE) inhibitors can induce a mild to severe dry cough. Beta-blockers may induce decreased heart rate; pulse rate should be assessed before administration. Direct vasodilators may cause headache and increased heart rate. Adrenergic inhibitors can cause sedation and fatigue

A 76-year-old patient had surgery for an abdominal hernia. The PACU nurse assesses that the patient is confused and is trying to climb out of the bed and pull at the cardiac monitor lines. At this time, what interventions by the nurse are appropriate? Select all that apply. a) Administer opioid pain medication per orders. b) Assess for hypoxia. c) Assess for urine output. d) Apply wrist restraints. e) Reorient the patient. f) Ambulate the patient.

e) Reorient the patient., b) Assess for hypoxia., c) Assess for urine output. Explanation: The nurse should provide reassurance and reorient the patient as needed. Hypoxia and urinary retention may cause acute confusion in the older adult postoperative patient, so it would be appropriate for the nurse to assess for hypoxia and urine output. Opioid pain medications may cause further confusion; consultation with the physician about the type and dosage of the pain medication should occur. Ambulating the patient may be a safety issue, especially if the patient is bleeding or hypoxic. Applying wrist restraints should only be used as a last resort

For which of the following reasons are nonpharmacologic pain management techniques employed? Select all that apply. a) They can successfully replace pain medications. b) They allow patients to match the technique to their own individual and cultural preferences. c) They lower the risk of patients' becoming addicted to pain medications. d) They help decrease the distress the patient experiences from pain. e) They help decrease the sensation of pain.

e) They help decrease the sensation of pain., d) They help decrease the distress the patient experiences from pain., b) They allow patients to match the technique to their own individual and cultural preferences. Explanation: Nonpharmacologic pain management techniques are usually used in conjunction with medications and help to decrease the sensation of pain and the distress the patient experiences from pain. Nonpharmacologic methods are used to complement, not replace, pharmacologic methods. Many patients find that the use of nonpharmacologic methods helps them cope better with their pain and feel greater control over the pain. Nonpharmacologic methods do not have any relationship to a patient's risk of becoming addicted to pain medications. A variety of techniques allows them to match the technique to their own individual and cultural preferences.