NCLEX Questions 4th Rotation
7. When teaching a patient with renal failure about a low phosphate diet, it is a priority to teach the patient to restrict which of the following? a. ingestion of dairy products. b. intake of green, leafy vegetables. c. the amount of high-fat foods. d. the quantity of fruits.
a. ingestion of dairy products.
9. The nursing drug handbook states that the IV push administration time for furosemide (Lasix) should be slowed to 5 minutes when a patient has impaired renal function (stage3). At what eGFR should the nurse slow the IV push administration of furosemide? a. eGFR less than 30 mL/min b. eGFR less than 60 mL/min c. eGFR less than 90 mL/min d. eGFR less than 120 mL/min
b. eGFR less than 60 mL/min
10. A patient with a history of stage 3 renal failure is admitted with vomiting and diarrhea. Abnormal results of which laboratory test would be likely AND most likely to cause the greatest immediate harm? Explain why this is the best answer. a. Calcium b. Phosphorus c. Potassium d. Sodium
c. Potassium
27. The nurse is caring for a patient immediate post-op right BKA. There is a 7x 8 cm bright red area on the surgical dressing. Place these interventions in the appropriate order. a. Call the surgeon or rapid response team. b. Apply a tourniquet proximal to the surgical dressing. c. Reinforce the surgical dressing. d. Assess the blood pressure and pulse. e. Check the patient's most recent hemoglobin & hematocrit results.
1. Apply a tourniquet proximal to the surgical dressing. 2. Assess the blood pressure and pulse. 3. Call the surgeon or rapid response team. 4. Check the patient's most recent hemoglobin & hematocrit results. 5. Reinforce the surgical dressing.
2. In which order will the nurse take these actions when caring for a patient with a left leg fracture after a motor vehicle accident? a. Administer tetanus prophylaxis b. Apply splint to leg c. Assess lung sounds d. Check pedal pulses e. Obtain Xrays f. Take BP
1. Check pedal pulses 2. Apply splint to leg 3. Take BP 4. Assess lung sounds 5. Obtain xrays 6. Administer tetanus prophylaxis
15. A CKD patient presents with fatigue and peaked T waves on the STAT EKG. Place these interventions to be performed in the order of priority. a. Administer Kayexalate. b. Arrange for transfer to the telemetry floor. c. Ask about the presence of leg and other muscle cramps. d. Check the results of the basic metabolic panel (BMP). e. Notify the attending doctor in the ED.
1. d. Check the results of the basic metabolic panel (BMP). 2. c. Ask about the presence of leg and other muscle cramps. 3. e. Notify the attending doctor in the ED. 4. a. Administer Kayexalate. 5. b. Arrange for transfer to the telemetry floor.
5. A CKD patient is prescribed a drug that ends in (-pril) or (-sartan). Which of the following electrolytes may have an increased elevation due to the drug? a. Calcium b. Magnesium c. Potassium d. Sodium
c. Potassium
13. Which nursing diagnosis is a priority for a patient who has undergone a TURP? a. Potential for altered body image b. Potential for chronic infection c. Potential for hemorrhage d. Potential for sexual dysfunction
c. Potential for hemorrhage
7. The patient with CKD is placed on a fluid restriction of 1,500mL/day. On the 7A-7P shift she consumed two 5 ounce cups of coffee, 4 ounces of juice, one 12 ounce can of orange soda; and 5 ounces of water with medications. During shift report for the 7P-7A shift, the nurse would indicate that the patient may receive how much water on the next shift?
31 oz. X 30ml = 930 1500-930= 570 ml
28. The nurse should recognize the potential for early compartment syndrome when the orthopedic patient exhibits: a. deep pain on when the nurse is moving the extremity b. edema distal to the orthopedic injury c. sharp pain when the patient repositions himself d. tingling and weak pulse in the affected extremity
a. deep pain on when the nurse is moving the extremity
4. Which assessment finding is a priority to report to the healthcare provider when caring for a patient on bedrest for a fractured pelvis? a. Abdominal distention and absent bowel sounds - Suggests possible paralytic ileus. b. Ecchymosis on abdomen and hips c. Pelvic pain with palpation d. Sore back and pelvis feels unstable
a. Abdominal distention and absent bowel sounds - Suggests possible paralytic ileus.
14. A patient who is post-op open reduction & internal fixation (ORIF) of a left hip fracture has sudden onset of shortness of breath and tachypnea. The patient states "I think I am going to die". What action should the nurse take first? a. Administer oxygen per protocol. b. Check the patient's legs for swelling or tenderness. c. Notify the healthcare provider. d. Stay with the patient and offer reassurance.
a. Administer oxygen per protocol
6. A post-op TURP patient with continuous irrigation complains of bladder spasms. Which of the following is appropriate to relieve this discomfort? (Select all that apply) a. Administer prescribed flavoxate (Urispas) b. Administer prescribed morphine c. Apply a cold compress to the pubic area d. Consult with the urologist e. Hand irrigate the catheter with up to 50 mL of sterile NSS if ordered
a. Administer prescribed flavoxate (Urispas) e. Hand irrigate the catheter with up to 50 mL of sterile NSS if ordered
31. Which interventions should be implemented for a patient diagnosed with an open fracture of the left ankle? a. Administer tetanus toxoid in the left deltoid if not received in last 5-10 years. b. Apply an immobilizer snugly to prevent edema. c. Apply ice for intervals of 10 minutes on and 20 minutes off. d. Obtain an XRay of the ankle after applying an immobilizer. e. Place the extremity at the level of the heart.
a. Administer tetanus toxoid in the left deltoid if not received in last 5-10 years. e. Place the extremity at the level of the heart.
1. Which of the following would be least likely to increase creatinine levels? a. Age 75 years b. Atherosclerosis c. Crushing injury in farm accident d. Major surgery
a. Age 75 years
15. The nurse is providing discharge teaching to a 12-year-old girl (and parents) with a fractured humerus. What information should be included regarding cast care? a. Apply an ice pack over the cast if itching occurs. b. Explain that foul smells are expected due to trapping moisture under the cast. c. Keep the fractured arm at heart level. d. Us a wire hanger to scratch if itchy.
a. Apply an ice pack over the cast if itching occurs
2. Research regarding the prostate cancer journey suggests that wives and partners of men diagnosed with prostate cancer (Select all that apply) a. Are a key psychological support for the patient b. Are usually intrusive and hinder the patient discussing his feelings c. Limit obtaining information about the patient's true psychosocial issues d. May provide valuable insight into the patient's supportive care needs e. Usually underestimate the psychosocial stress experienced by the patient
a. Are a key psychological support for the patient d. May provide valuable insight into the patient's supportive care needs
29. The nurse is working on an orthopedic surgery unit. Which task is most appropriate to delegate to the unlicensed assistive personnel (UAP)? LPN? a. Ask the UAP to take a patient to PT. b. Change a dressing. c. Double check the unit of blood to be hung. d. Help a 2-day post-op patient put on a prosthesis.
a. Ask the UAP to take a patient to PT.
23. The nurse is providing pre-operative care for a T2 DM patient who is scheduled for a below-the-knee amputation. Which nursing intervention should the nurse implement? a. Asses the patient's current blood glucose with a glucose meter (EX: Accucheck). b. Determine if the patient is allergic to contrast dye. c. Request a referral to occupational therapy. d. Start an IV with a 22-gauge catheter.
a. Asses the patient's current blood glucose with a glucose meter (EX: Accucheck).
1. Which of the following is an example of a task that should be performed by the RN when an LPN/LVN is assigned to care for a stable post-op patient with continuous bladder irrigation per the Lewis text delegation decisions box? a. Assess catheter patency by measuring intake and output and presence of bladder spasms. b. Increase flow of irrigating solution c. Manually irrigate the catheter if bladder spasms or decreased outflow occurs.
a. Assess catheter patency by measuring intake and output and presence of bladder spasms. c. Manually irrigate the catheter if bladder spasms or decreased outflow occurs.
9. The patient comes to the ED with a significant injury to the left arm. What intervention should the nurse implement first? a. Assess the nailbeds for capillary refill b. Call radiology for a STAT XRay of the arm c. Prepare the patient for application of a cast d. Remove the patient's clothing from the arm
a. Assess the nailbeds for capillary refill
32. The UAP reports that a patient with a fractured femur has "globs" floating in the urine. What intervention should the nurse implement first? WHY????? a. Assess the patient for dyspnea & altered mental status. b. Call the health care provider (HCP) for a ventilation perfusion scan. c. Instruct the UAP to help keep the patient on bedrest. d. Obtain an arterial blood gas and portable chest XRay (CXR).
a. Assess the patient for dyspnea & altered mental status.
11. The nurse is caring for a patient diagnosed with rule out (R/O) nephrotic syndrome. Which intervention should be included in the plan of care? a. Assess the skin for sacral edema. b. Evaluate the diet for calories and grams of protein. c. Limit phosphate foods. d. Monitor the urine for bright red bleeding.
a. Assess the skin for sacral edema.
17. The patient returns from PACU after TURP or prostatectomy and has a BP 88/40, P110, R 24, and cool, clammy skin. Which interventions should the nurse implement? Select all that apply. a. Assess the urine in the drainage bag & tubing. b. Check the patient's postoperative BUN & creatinine. c. Contact the surgeon or hospitalist. d. Decrease the rate of continuous irrigation. e. Lower the head of the bed and raise the foot of the bed.
a. Assess the urine in the drainage bag & tubing. c. Contact the surgeon or hospitalist. e. Lower the head of the bed and raise the foot of the bed.
30. A traumatic above-the-elbow amputee is being discharged. Which of the following should be included in discharge instructions? Select all that apply. a. Be sure to attend all out-patient rehab appointments. b. Eat a well-balanced diet with an increase in fluids and protein. c. Encourage to stay at home as much as possible for the next 2-3 months to avoid infections. d. Keep the bandage wrapped as shown and elevate the limb to avoid swelling. e. Provide information regarding a local amputee support group. f. Report any pain not relieved by prescribed analgesics.
a. Be sure to attend all out-patient rehab appointments. b. Eat a well-balanced diet with an increase in fluids and protein. d. Keep the bandage wrapped as shown and elevate the limb to avoid swelling. e. Provide information regarding a local amputee support group. f. Report any pain not relieved by prescribed analgesics.
38. The nurse finds small fluid-filled lesions on the margins of the surgical dressing. Which is the most likely cause of these lesions? a. Blister reaction to tape used to anchor the dressing. b. Cautery in the operating room. c. Macular lesions from latex allergy. d. Papular wheals from herpes zoster.
a. Blister reaction to tape used to anchor the dressing.
15. The patient is 2nd day post-op TURP. Which task should the nurse delegate to UAP? LPN/LVN? a. Change the dressing b. Elevate the scrotum on a towel for support. c. Increase the irrigation fluid until it clears clots from the tubing d. Teach the patient anything.
a. Change the dressing ...LPN b. Elevate the scrotum on a towel for support...UAP
8. A patient is post-op resection of an intestinal tumor. He has an NG tube and an IV running at 150 mL/hour via an IV pump. What of the following should be reported to the HCP? a. Crackles and rhonchi in all lung fields. b. Intake is 1,800 mL; NG output 550 mL; foley output 950 mL. c. IV pump keeps sounding an alarm. d. Negative pedal edema & increasing LOC.
a. Crackles and rhonchi in all lung fields.
20. An 80-year-old patient has been diagnosed with prostate cancer. Which of the following treatments are most likely to be offered? Select all that apply a. Diesthylstilbeterol, a hormone therapy to slow progression of the disease b. Penile implants to maintain sexual functioning c. Radical prostatectomy with lymph node dissection d. Radiation therapy every four weeks e. Watchful waiting
a. Diesthylstilbeterol, a hormone therapy to slow progression of the disease e. Watchful waiting
8. On admission, a CKD patient admits to noncompliance with dietary restrictions. Which intervention would be most appropriate at this time? a. Explore reasons for the client not adhering to the diet. b. Explain the importance of eating the proper foods. c. Refer the patient and family to the dietician. d. Teach the person who cooks for the patient what the patient should eat.
a. Explore reasons for the client not adhering to the diet.
5. The nurse is caring for a patient who has CKD and is experiencing metabolic acidosis & Kussmaul breathing. Which of the following laboratory test results would the nurse expect to see? a. HCO3 19 mEq/L; PCO2 33 mm/Hg; pH 7.31 (metabolic acidosis w respiratory compensation) b. HCO3 19 mEq/L; PCO2 39 mm/Hg; pH 7.31 (combined metabolic & respiratory acidosis) c. HCO3 27 mEq/L; PCO2 33 mm/Hg; pH 7.31 (illogical - would be alkalosis) d. HCO3 27 mEq/L; PCO2 39 mm/Hg; pH 7.31 (respiratory acidosis with metabolic compensation)
a. HCO3 19 mEq/L; PCO2 33 mm/Hg; pH 7.31 (metabolic acidosis w respiratory compensation)
2. Which of these is normal and which suggests dehydration? a. Hb 12.7mg/dL; Hct 44.2%; BUN 23.9 mg/dL (10-20 mg/dL) b. Hb 13.5mg; Hct 41.1%; BUN 18 mg/dL
a. Hb 12.7mg/dL; Hct 44.2%; BUN 23.9 mg/dL (10-20 mg/dL)..... The Hct is 3x the Hb
24. A patient with prostate cancer is prescribed LHRH agonist drug therapy. Which statement suggests the patient's understanding of the treatment? a. I may have hot flashes while on this drug. b. I will be able to function normally. c. There are no significant adverse effects from this drug. d. This drug will cure my cancer.
a. I may have hot flashes while on this drug.
10. The nursing instructor is showing students in the skills lab how to apply traction. Which of the following should be included? a. Knots in the rope should not be resting against the pulleys. b. Skeletal traction can be removed for repositioning. c. The affected foot should be resting against a footboard. d. When turning a patient, place addition tension on the ropes
a. Knots in the rope should not be resting against the pulleys.
18. The nurse is caring for a 2nd day post-op prostatectomy. Which data suggests that the patient's condition is improving? a. The patient's bladder spasms are relieved by medication. b. The patient has passed a small, hard stool this morning. c. The patient is using the maximum allowed pain medication via the PCA pump. d. The patient's scrotum is swollen and tender when moved.
a. The patient's bladder spasms are relieved by medication.
25. A Jewish patient with PVD is scheduled for a left AKA. Which question is most important for the OR nurse to ask? a. "Do you have any special dietary needs?" b. "Have you made any special arrangements for your amputated leg?" c. "Would you like the rabbi to visit you in the post-anesthesia care unit (PACU)? d. "You will need to check your other foot at least once a day."
b. "Have you made any special arrangements for your amputated leg?"
41. The nurse is working on an orthopedic floor. Which assigned patient should the nurse assess 1st after change-of-shift report? a. 84-year-old female with a fractured femoral neck in Buck's traction b. 64-year-old female with a left TKA who has been confused c. 88year-old male post right THA with an abduction pillow in place d. 50-year-old post op right TKA who has a continuous passive motion device
b. 64-year-old female with a left TKA who has been confused
13. The nurse is caring for a patient with fluid volume excess. Which interventions should the nurse include in the plan of care? a. Administer mouth care when bathing the patient. b. Assess peripheral edema once a shift. c. Measure the patient's intake and output daily. d. Weigh the patient once a week at the same time, using the same scale.
b. Assess peripheral edema once a shift.
1. During hemodialysis, a patient complains of nausea and dizziness. Which action should the nurse take first? WHY??? a. Administer prn prescribed antiemetic b. Assess the patient's blood pressure c. Check most recent BUN and creatinine levels d. Slow down the rate of dialysis
b. Assess the patient's blood pressure
14. Which of the following laboratory test results for an elderly adult female most strongly suggests chronic kidney disease (CKD)? a. Blood urea nitrogen 10 mg/dL & creatinine 0.8mg/dL b. Blood urea nitrogen 15 mg/dL & creatinine 2.6mg/dL c. Blood urea nitrogen 20 mg/dL & creatinine 0.8 mg/dL d. Blood urea nitrogen 25 mg/dL & creatinine 1.0mg/dL
b. Blood urea nitrogen 15 mg/dL & creatinine 2.6mg/dL
8. On a very busy day, the nurse is assigned a patient who had an ORIF who needs to get out of bed for the 1st time. Which action should the nurse take? a. Avoid administration of pain medication to avoid fainting. b. Check post-operative orders for weight bearing status. c. Delegate the transfer to a LPN/LVN. d. Use a mechanical lift to transfer the patient from bed to chair.
b. Check post-operative orders for weight bearing status.
26. The patient is 8 hours post-op TURP for prostate cancer. Which intervention is a priority at this time? a. Assess the abdominal dressing. b. Control post-operative bleeding. c. Encourage early ambulation to prevent DVT. d. Monitor fluid & electrolyte balance.
b. Control post-operative bleeding.
13. The nurse is caring for a 60-year-old admitted with a femoral head fracture who is oriented x1. Which intervention should the nurse implement first? a. Check for a positive Homan's sign b. Determine the patient's normal orientation status c. Encourage the patient to deep breath & cough d. Monitor the Buck's traction
b. Determine the patient's normal orientation status
18. The patient in Buck's traction is complaining of severe pain. Which intervention should the nurse implement? a. Adjust the PCA dose for more frequent doses b. Ensure that the traction weights are aligned in the pulley & hanging freely c. Raise the HOB to 45° and the foot to 15° d. Turn the patient to the affected side and use pillows to support the other leg.
b. Ensure that the traction weights are aligned in the pulley & hanging freely
6. The nurse is creating a care plan for a patient with CKD. Which nursing problem is of greatest priority? a. Activity intolerance b. Excess fluid volume c. Knowledge deficit d. Low self esteem
b. Excess fluid volume
40. The nurse is caring for a patient who had a shoulder replacement. Which data would warrant immediate consultation with the surgeon or hospitalist? a. Creatinine 0.8 mg/dL b. Hemoglobin 8.1 g/dL c. Potassium 4.2 mEq/L d. WBC count 9,000/mm3
b. Hemoglobin 8.1 g/dL
16. Which statement by a patient with a fractured ulna suggests that the patient needs additional teaching? a. I need to eat a high-protein diet to promote healing. b. I need to keep the immobizer on when lying down only. c. I need to take the pain medication before the pain is too bad. d. I need to wiggle my fingers every hour to promote circulation.
b. I need to keep the immobizer on when lying down only.
30. A 76 year-old male is admitted with bladder distention related to prostatic hypertrophy. Which treatment should the nurse anticipate if pre-operative catheter insertion has been ordered? a. Administration of medication to relax the bladder deltrusor muscle. b. Insertion of a Caudé catheter. c. Scheduling of immediate surgery to relieve the bladder obstruction. d. Sitz bath to relax perineum and promote voiding.
b. Insertion of a Caudé catheter.
19. A patient's father died of metastatic prostate cancer. What symptoms is the patient most likely to exhibit if he has early prostate cancer? a. Low back pain b. None c. Retrograde ejaculation during intercourse d. Urinary urgency and frequency
b. None
8. Which data supports the diagnosis of chronic bacterial prostatitis? a. BUN 15 mg/dL b. PSA 10 ng/dL c. Urine pH 5.2 d. Urine specific gravity 1.020
b. PSA 10 ng/dL
16. The patient who is post-op TURP asks when he can resume sex. What response is most appropriate? a. Did you ask your doctor about your concern? b. Potency can return in 6-8 weeks. c. Tell me about your fears of impotence. d. You seem anxious about your surgery. What might be a better wording?
b. Potency can return in 6-8 weeks.
11. Which data supports the diagnosis of acute bacterial prostatitis? a. Stress incontinence b. Sudden fever and chills c. Terminal dribbling d. Urinary frequency What else could it be if the patient had BPH?
b. Sudden fever and chills
9. A 55 year-old patient who is scheduled for brachytherapy for prostate cancer is unsure about therapy because his daughter is 3 months pregnant. What should be included in teaching? a. The patient and his wife can have intercourse without restrictions. b. The patient should avoid close contact with his daughter for 2 months. c. The patient should not be in contact with the baby when it is born. d. The patient will be hospitalized until the seeds are no longer radioactive
b. The patient should avoid close contact with his daughter for 2 months.
3. The nurse in the dialysis unit has received report from the dialysis technicians. Which patient should the nurse assess first? a. The patient with a hemoglobin of 9.8g/dL and a hematocrit of 30%. b. The patient who does not having a palpable thrill or auscultated bruit. c. The patient who complains of being exhausted and is sleeping. d. The patient who did not take any antihypertensive medication this morning before dialysis.
b. The patient who does not having a palpable thrill or auscultated bruit.
3. After the patient had a cast applied to his arm in the ED, which statement by the patient suggests that the patient understood the nurse's teaching?" a. "I can get the cast wet as long as I dry it with a hair dryer right away." b. "I can use a Q-Tip if I get an itchy spot." c. "I should apply an ice pack on the cast over the fracture site for the next 24 hours." d. "I should avoid moving my fingers while the cast is on."
c. "I should apply an ice pack on the cast over the fracture site for the next 24 hours."
14. Which statement indicates discharge teaching has been effective for the patient who is post-op TURP? a. "I should continue to take my Proscar until I have my post-op visit with my surgeon". b. "I should not lift more than 20 pounds until I have my post-op visit with my surgeon". c. "I will call my surgeon if I experience any difficulty passing my water." d. "I will call my surgeon if I experience dribbling after I pee."
c. "I will call my surgeon if I experience any difficulty passing my water."
3. A patient asks "What does the PSA test result mean?" On which scientific rationale should the nurse base the response? a. An elevated PSA can be diagnostic for testicular cancer. b. An elevated PSA can only be because of prostate cancer. c. An elevated PSA can result from several different causes. d. An elevated PSA is the best test to diagnose BPH.
c. An elevated PSA can result from several different causes.
37. An 88-year-old is being admitted with a fractured pelvis. Which intervention should the nurse implement first? a. Administer a fleet's enema b. Apply Buck's traction c. Assess abdomen for bowel sounds - assess for internal injuries d. Insert an indwelling Foley catheter
c. Assess abdomen for bowel sounds - assess for internal injuries
7. The patient has returned to the nursing unit from PACU after undergoing a suprapubic prostatectomy. What should the nurse do if urine is leaking around the supra pubic tube? a. Administer a prescribed antibiotic b. Clamp the suprapubic tube c. Clean the tube and site using sterile technique d. Page the urologist STAT
c. Clean the tube and site using sterile technique
34. The nurse is caring for a patient with a fracture of the right distal humerus. Which data suggests a possible complication of the fracture? Select all that apply. a. 2+ radial pulses and 3 second capillary refill. b. Area tender to touch. c. Coldness of extremity and crepitus under skin. d. Crackles in all lobes with frothy sputum. e. Hardness and burning pain when the nurse moves the extremity. f. Numbness and mottled cyanosis.
c. Coldness of extremity and crepitus under skin. d. Crackles in all lobes with frothy sputum. e. Hardness and burning pain when the nurse moves the extremity. f. Numbness and mottled cyanosis.
6. Lab values for a patient with stage 5 chronic kidney disease (CKD) include an arterial blood pH of 7.31. Which of the following compensatory assessment findings would be expected? a. Bounding pulses c. Deep, rapid respirations c. Pale, clammy skin d. Poor skin turgor
c. Deep, rapid respirations (acidosis)
21. The nurse identifies the nursing problem of urinary retention for a patient diagnosed with stage IV prostate cancer. Which intervention should be implemented first? a. Catheterize to identify the amount of residual. b. Encourage the patient to stand when voiding. c. Determine the patient's normal voiding patterns. d. Teach the patient the Valsalva maneuver to empty the bladder.
c. Determine the patient's normal voiding patterns.
44. Which of the following would be appropriate nursing care when changing a post-operative amputation dressing? a. Apply the compression wrap from proximal to distal. b. Contact the surgeon if the suture, staple line looks as if it was sewn too tight the day after surgery. c. Discuss the prophylactic use of prescribed pain medication to be administered 15-30 minutes before the dressing change. d. Use aseptic technique when changing a post-op amputation dressing.
c. Discuss the prophylactic use of prescribed pain medication to be administered 15-30 minutes before the dressing change.
33. Which data R/T a patient with a left fractured tibia & fibula should be reported immediately to the HCP? a. Generalized weakness and increased sensitivity of the extremity to touch. b. Pain not completely relieved by prescribed hydrocodone/acetaminophen. c. Dorsalis pedis pulse not palpable or detectable by Doppler. d. Localized edema & bruising evident several hours after injury.
c. Dorsalis pedis pulse not palpable or detectable by Doppler.
5. The nurse reviews the patient's history which includes DM type 2, HTN, and BPH. Which of the following symptom, if experienced by the patient, would be of most concern? Why? a. Difficulty initiating urine flow b. Dribbling c. Dysuria. d. Frequent voiding
c. Dysuria.
6. A 28-year-old man who fell off a ladder is hospitalized with a compound fractured of the humerus. The next morning he is confused and tachycardic. Which of the following are most likely causes of these symptoms? a. Compartment syndrome or pain b. Deep vein thrombosis or fat emboli c. Fat emboli or increased intracranial pressure d. Increased intracranial pressure or compartment syndrome
c. Fat emboli or increased intracranial pressure
36. A patient who is 1 day post-op total hip arthroplasty (THA) complains of hearing a popping sound when turning. Which assessment should the nurse report to the surgeon immediately? Select all that apply. a. Bruising over the hip. b. Edema at the incision site. c. Groin pain of affected side. d. Serous-sanguinous drainage in the drain collection device. e. Surgical leg shortened and toe turned inward.
c. Groin pain of affected side. e. Surgical leg shortened and toe turned inward.
4. An 80 year-old male with a history of BPH has a markedly distended bladder and is agitated and confused. Which of the following prescribed interventions should the nurse implement first? WHY? a. Administer lorazepam (Ativan) 0.5 mg PO. b. Draw blood for BUN & creatinine testing. c. Insert a urinary retention catheter. d. Schedule an ordered intravenous pyelogram (IVP)
c. Insert a urinary retention catheter.
22. The post-anesthesia care unit (PACU) nurse is caring for a left below the knee amputation (BKA) patient. Which intervention should the nurse implement? a. Assess the surgical dressing every 2 hours. b. Do not allow the patient to see the residual limb. c. Keep a large tourniquet at the bedside. d. Perform passive range-of-motion (ROM) exercises to the right leg.
c. Keep a large tourniquet at the bedside.
2. A patient with severe heart failure develops elevated BUN & creatinine levels. What is the priority nursing goal? a. Correcting hyperphosphatemia b. Diluting needed nephrotoxic substances c. Maintaining cardiac output d. Preventing hypertension
c. Maintaining cardiac output
26. The patient who is 3 hours post-op BKA complains of severe pain in the amputated foot. What should the nurse do? a. Explain to the patient that the foot has been amputated. b. Instruct the patient on how to do guided imagery. c. Medicate the patient with the prescribed narcotic analgesic. d. Place the residual limb in the dependent position.
c. Medicate the patient with the prescribed narcotic analgesic.
4. The CKD patient has the following arterial blood gas results: pH 7.27; PaCO2 28; HCO3 11 mEq/L. What is your interpretation of these results? a. Metabolic acidosis with no compensation b. Metabolic and respiratory acidosis with no compensation c. Metabolic acidosis with respiratory compensation d. Metabolic alkalosis with respiratory compensation
c. Metabolic acidosis with respiratory compensation
11. When caring for a patient in traction, which of the following would be most appropriate to delegate to the LPN/LVN? a. Administer prescribed IV push morphine. b. Assess for symptoms of compartment syndrome. c. Monitor skin at pressure points. d. Teach caregiver how to perform ROM exercises
c. Monitor skin at pressure points.
7. A 77-year-old female is brought to the ED after falling in her home. Xrays confirm a fracture of the femur neck. What complication is most common in this situation? a. Avascular necrosis b. Nonadherence of bones c. Osteoporosis d. Septicemia
c. Osteoporosis
23. A patient is diagnosed with prostate cancer that has metastasized to the vertebrae and pelvis. What nursing intervention should the nurse implement? Why is this the best answer????? a. Discuss the patient's altered sexual functioning. b. Keep the foot of the bed elevated 15 at all times. c. Place the patient on a scheduled bowel regimen. d. Prepare for TURP surgery.
c. Place the patient on a scheduled bowel regimen.
19. A patient who underwent a total hip replacement is being repositioned. What should the nursing staff do to prevent dislocation of the prosthesis? a. Flex the hip by placing a pillow under the patient's knee b. Keep the affected leg in a position of adduction c. Prevent internal rotation of the affected leg d. Use methods other than turning to prevent pressure ulcers
c. Prevent internal rotation of the affected leg
42. While assessing a patient who has had knee replacement surgery, the nurse notes that the patient has developed a hematoma at the surgical site. What would be an appropriate nursing concern for this patient? a. Ineffective health maintenance b. Risk for infection c. Risk of peripheral neurovascular compromise d. Self-esteem disturbance
c. Risk of peripheral neurovascular compromise
24. The nurse is present when a person's right thumb is accidentally severed. Which action should the nurse take to preserve the severed thumb so that it can possibly be reattached? a. Place the thumb directly on some ice. b. Put the thumb in a container of warm water that has been boiled to kill germs. c. Secure the thumb in a clean plastic bag and place the bag on ice. d. Wrap the thumb in a piece of clean cloth.
c. Secure the thumb in a clean plastic bag and place the bag on ice.
35. Which interventions should be implemented for a post-op total hip arthroplasty (THA)? a. Cough and deep breathe every 4 hours. b. Keep an abduction pillow in place at all times. c. Sit in a high-seated chair for a hip flexion of less than 90 degrees. d. Turn from side to side every 2 hours to prevent skin breakdown.
c. Sit in a high-seated chair for a hip flexion of less than 90 degrees.
12. Which intervention should be included in the teaching for a patient with chronic prostatitis? a. Drink at least 3000 mL or fluid, especially tea or coffee, each day b. Elevate your feet for at least 2 hours every day c. Sit in a warm sitz bath for 10-20 minutes several times a day d. Void every hour
c. Sit in a warm sitz bath for 10-20 minutes several times a day
21. Which of the following is an appropriate nursing SMART outcome for a post-operative below-the-knee amputation (BKA)? a. Patient will not experience phantom limb pain or sensation post-operatively. b. Surgical site will be healed and non-tender within 7 days of surgery. c. Surgical site will be well approximated and without drainage within 48 hours of surgery. d. Surgical site will be without edema within 48 hours after surgery.
c. Surgical site will be well approximated and without drainage within 48 hours of surgery.
4. The nurse is caring for a patient who has CKD and is experiencing metabolic acidosis. Which statement best describes the scientific rationale a. A shortened lifespan of RBCs because of damage secondary to dialysis causes metabolic acidosis. b. An increase in nausea and vomiting causes loss of HCl and the respiratory system cannot adequately compensate for the loss. c. The kidneys cannot excrete increased levels of acid because they cannot effectively excrete ammonia and/or cannot reabsorb sodium bicarbonate. d. There is an increased excretion of phosphates and organic acids which leads to an increased arterial blood pH.
c. The kidneys cannot excrete increased levels of acid because they cannot effectively excrete ammonia and/or cannot reabsorb sodium bicarbonate.
28. The patient who is diagnosed with cancer of the prostate tells the nurse, "I caused this by being promiscuous when I was young and now I have to pay for my sins." Which statement is the most therapeutic response? a. Have you told your doctor and been checked for STIs & HIV? b. There is nothing that you can do about the past now. c. You feel guilty about some of your actions when you were younger? d. Why would you think that prostate cancer is caused by sex?
c. You feel guilty about some of your actions when you were younger?
43. The nurse would teach the patient that the primary purpose of elevating the extremity to the level of the heart with a newly applied cast is to: a. decrease irritation from rough edges b. improve comfort level c. increase venous return and prevent edema d. speed drying of cast
c. increase venous return and prevent edema
20. What can the nurse teach a patient with an above the knee amputation (AKA) to reduce the discomfort of phantom pain? a. Apply hot compresses to the area of amputation. b. Apply SCDs while in bed. c. Assess color, warmth, and pulses in the stump every 4 hours. d. Increase level of activity slowly.
d. Increase level of activity slowly.
27. The patient is 8 hours post-op TURP for prostate cancer. Which intervention is a priority at this time? a. Assess the abdominal dressing. b. Control post-operative pain. c. Encourage early ambulation to prevent DVT. d. Monitor fluid & electrolyte balance. Can absorb excess fluid - TURP syndrome
d. Monitor fluid & electrolyte balance. Can absorb excess fluid - TURP syndrome
5. A patient is placed in a long-arm cast after fracturing her humerus. Twelve hours after application of the cast the patient experience pain not relieved by prescribed analgesics. What would be the most appropriate nursing intervention? a. Encourage the patient to avoid wiggling her fingers. b. Obtain an order for a stronger pain medication. c. Petal the edges of the cast. d. Prepare the patient for possible bi-valving of the cast
d. Prepare the patient for possible bi-valving of the cast
2. A patient complains of leg cramps immediately after hemodialysis. Which of the following would be most appropriate? a. Administer acetaminophen (Tylenol) b. Massage the patient's legs c. Reposition the patient d. Request an order for serum electrolytes. i. Cramping is often due to rapid removal of water and sodium
d. Request an order for serum electrolytes. i. Cramping is often due to rapid removal of water and sodium
12. The nurse is caring for a patient who is 48 hours post-operative decompression fasciotomy (cutting into the fascia to relieve pressure) after experiencing compartment syndrome after an ulnar fracture. Which of the following would be a priority nursing concern in this? a. Cardiac output b. Fatigue c. Fluid balance d. Risk for infection
d. Risk for infection
29. What psychosocial and physiologic problems should be included in nursing care after radical prostatectomy? a. Altered coping b. High risk for hemorrhage c. Risk for electrolyte disturbance d. Sexual impotence
d. Sexual impotence
22. A patient has had a bilateral orchiectomy for cancer of the prostate. Which intervention would the nurse expect to implement? a. Administer testosterone supplement daily. b. Encourage the patient to place sperm in a sperm bank. c. Have the patient talk with another man about ejaculation problems. d. Support the scrotal sac on a rolled towel and apply ice.
d. Support the scrotal sac on a rolled towel and apply ice
12. The nurse is preparing a teaching plan for a patient with nephrotic syndrome. What teaching would the nurse expect to include? a. Increase the intake of sodium rich foods. b. Report a decrease in daily weight greater than 0.5 kg. c. Stop steroids if a moon face develops. d. Teach about the use of diuretics.
d. Teach about the use of diuretics.
9. The nurse identifies the problem of "fluid volume excess". Which intervention should be included in the plan of care? a. Change IV fluid from 0.9% NaCl (NSS) to 5% dextrose in water (D5W) b. Monitor blood glucose c. Prepare the patient for hemodialysis d. Teach the patient to avoid processed foods
d. Teach the patient to avoid processed foods
1. It is important for the nurse to teach a patient who has a cast on the lower leg to prevent muscle atrophy by: a. AROM of the ankle b. Avoiding adduction of the leg c. Bearing weight on the toes only d. Tensing & relaxing calf muscles
d. Tensing & relaxing calf muscles
3. What is the role of the kidneys when respiratory acidosis is occurring? a. The kidneys regulate the bicarbonate in the intracellular fluid (ICF). b. The kidneys respond rapidly to correct respiratory imbalances. c. The kidneys conserve hydrogen ions and excrete bicarbonate (HCO3) ions to help restore balance. d. The kidneys excrete hydrogen ions and conserve bicarbonate (HCO3) ions to help restore balance.
d. The kidneys excrete hydrogen ions and conserve bicarbonate (HCO3) ions to help restore balance.
17. What is an expected goal (outcome) for a patient with a fractured lower extremity? a. The patient will ambulate with assistance. b. The patient will be turned every 2 hours. c. The patient will have no infection. d. The patient will maintain function of the affected leg.
d. The patient will maintain function of the affected leg.
10. The nurse observes red urine and several large clots in the urine catheter tubing of a one day post-op prostatectomy patient receiving continuous bladder irrigation. Which intervention should the nurse implement? a. Administer protamine sulfate b. Administer vitamin K slowly c. Remove the indwelling catheter d. Titrate the irrigant to run faster
d. Titrate the irrigant to run faster
39. The nurse is assessing a patient 6-hours post-op right total knee arthroplasty (TKA). What data should be reported to the surgeon or hospitalist now? a. Distal pulses palpable, toes cool, and nailbeds pale bilaterally. b. Pain relief after using the PCA pump. c. Total of 100mL of sanguinous drainage in the auto-transfusion drainage system. d. Urinary output of 60 mL in the past 3 hours.
d. Urinary output of 60 mL in the past 3 hours.
25. Which would be a possible complication of cryotherapy for prostate cancer? a. Bone marrow suppression from the chemotherapy b. Chronic fluid & electrolyte imbalance from vomiting & diarrhea c. Ejaculation & erectile difficulties d. Urinary retention from urethral scarring.
d. Urinary retention from urethral scarring.
1. Which of the following symptoms, if a change, is not on the list of things that need to be reported STAT to the health care provider when a patient has CKD? a. Confusion b. Dyspnea c. Increase of >20 mm/Hg in systolic BP d. Weight gain greater than 2 pounds in 24 hours (greater than 4 pounds)
d. Weight gain greater than 2 pounds in 24 hours (greater than 4 pounds)