Nursing

A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

A. Metabolic acidosis

Which patient would the nurse identify as having anincreased risk for the development of respiratory acidosis? a. Chronic lung disease with increased carbon dioxide retention b. Acute anxiety, hyperventilation, and decreased carbon dioxide retention c. Decreased cardiac output with increased serum lactic acid production d. Gastric drainage with increased removal of gastric acid

a. Chronic lung disease with increased carbon dioxide retention

The nurse caring for a patient with type A hemophilia being admitted to the hospital with severe pain and swelling in the right knee will a. immobilize the joint. b. apply heat to the knee. c. assist the patient with light weight bearing. d. perform passive range of motion to the knee.

a. immobilize the joint.

Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a. Listen to a patients lung sounds for wheezes or rhonchi. b. Label specimens obtained during percutaneous lung biopsy. c. Instruct a patient about how to use home spirometry testing. d. Measure induration at the site of a patients intradermal skin test.

b. Label specimens obtained during percutaneous lung biopsy.

The nurse is caring for a patient with a descending aortic dissection. Which assessment finding is most important to report to the health care provider? a. Weak pedal pulses b. Absent bowel sounds c. Blood pressure 137/88 mm Hg d. 25 mL urine output over last hour Correct answer c. Blood pressure 137/88 mm Hg

Ans: C The blood pressure is typically kept at less than 120 mm Hg systolic to minimize extension of the dissection.The nurse will need to notify the health care provider so that b-blockers or other antihypertensive medications can be prescribed. The other findings are typical with aortic dissection and should also be reported but do not require immediate action.

Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown origin? a. Instruct the patient to call for assistance before getting out of bed. b. Explain the association between various dysrhythmias and syncope. c. Educate the patient about the need to avoid caffeine and other stimulants. d. Tell the patient about the benefits of implantable cardioverter-defibrillators.

Instruct the patient to call for assistance before getting out of bed.

After the nurse has received change-of-shift report, which patient should the nurse assess first?

b. A patient with possible lung cancer who has just returned after bronchoscopy

Which action should the nurse take when administering the initial dose of oral labetalol (Normodyne) to a patient with hypertension? a. Encourage the use of hard candy to prevent dry mouth. b. Instruct the patient to ask for help if heart palpitations occur. c. Ask the patient to request assistance when getting out of bed. d. Teach the patient that headaches may occur with this medication.

c. Ask the patient to request assistance when getting out of bed.

After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about a. cerebral aneurysm clipping. b. heparin intravenous infusion. c. oral low-dose aspirin therapy. d. tissue plasminogen activator (tPA).

c. oral low-dose aspirin therapy.

During the change of shift report a nurse is told that a patient has an occluded left posterior cerebral artery. The nurse will anticipate that the patient may have a. dysphasia. b. confusion. c. visual deficits. d. poor judgment

c. visual deficits

A 67-year-old patient is admitted to the hospital with a diagnosis of venous insufficiency. Which patientstatement is most supportive of the diagnosis? a. I cant get my shoes on at the end of the day. b. I cant seem to ever get my feet warm enough. c. I have burning leg pains after I walk two blocks. d. I wake up during the night because my legs hurt.

a. I cant get my shoes on at the end of the day.

A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most importantfor the nurse to monitor for while the patient is receiving this infusion? a. Lung sounds b. Urinary output c. Peripheral pulses d. Peripheral edema

a. Lung sounds

A 40-year-old patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan? a. Apply intermittent pneumatic compression stockings. b. Assist to dangle on edge of bed and assess for dizziness. c. Encourage patient to cough and deep breathe every 4 hours. d. Insert an oropharyngeal airway to prevent airway obstruction.

a. Apply intermittent pneumatic compression stockings.

Which finding in a patient hospitalized with bronchiectasis is most important to report to the health care provider? a. Cough productive of bloody, purulent mucus b. Scattered rhonchi and wheezes heard bilaterally c. Respiratory rate 28 breaths/minute while ambulating in hallway d. Complaint of sharp chest pain with deep breathing

a. Cough productive of bloody, purulent mucus

A 28-year-old man with von Willebrand disease is admitted to the hospital for minor knee surgery. The nurse will review the coagulation survey to check the a. platelet count. b. bleeding time. c. thrombin time. d. prothrombin time.

B. bleeding time The bleeding time is affected by von Willebrand disease. Platelet count, prothrombin time, and thrombin time are normal in von Willebrand disease

A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of: a. iron. b. folic acid. c. cobalamin (vitamin B12). d. ascorbic acid (vitamin C).

B. folic acid Methotrexate use can lead to folic acid deficiency. Supplementation with oral folic acid supplements is theusual treatment. The other nutrients would not correct folic acid deficiency, although they would be used totreat other types of anemia.

A patients cardiac monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious and pulseless. Which action should the nurse take first? a. Perform immediate defibrillation. b. Give epinephrine (Adrenalin) IV. c. Prepare for endotracheal intubation. d. Give ventilations with a bag-valve-mask device.

a. Perform immediate defibrillation.

The patient asks the nurse to explain the function of the sinoatrial node in the heart. What is the nurse's best response? a. "It stimulates the heart to beat in a normal rhythm." b. "It protects the heart from atherosclerotic changes." c. "It provides the heart with oxygenated blood." d. "It protects the heart from infection."

a. "It stimulates the heart to beat in a normal rhythm."

The nurse in the emergency department receives arterial blood gas results for four recently admittedpatients with obstructive pulmonary disease. Which patient will require the most rapid action by the nurse? a. 22-year-old with ABG results: pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg b. 34-year-old with ABG results: pH 7.48, PaCO2 30 mm Hg, and PaO2 65 mm Hg c. 45-year-old with ABG results: pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg d. 65-year-old with ABG results: pH 7.31, PaCO2 58 mm Hg, and PaO2 64 mm Hg

a. 22-year-old with ABG results: pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg The pH, PaCO2, and PaO2 indicate that the patient has severe uncompensated respiratory acidosis andhypoxemia. Rapid action will be required to prevent increasing hypoxemia and correct the acidosis. The otherpatients also should be assessed as quickly as possible but do not require interventions as quickly as the 22-year-old.

The nurse on the intermediate care unit received change-of-shift report on four patients with hypertension. Which patient should the nurse assess first? a. 43-year-old with a (blood pressure (BP) of 160/92 who is complaining of chest pain b. 52-year-old with a BP of 212/90 who has intermittent claudication c. 50-year-old with a BP of 190/104 who has a creatinine of 1.7 mg/dL d. 48-year-old with a BP of 172/98 whose urine shows microalbuminuria

a. 43-year-old with a (blood pressure (BP) of 160/92 who is complaining of chest pain The patient with chest pain may be experiencing acute myocardial infarction, and rapid assessment andintervention are needed. The symptoms of the other patients also show target organ damage but are notindicative of acute processes.

After receiving change-of-shift report on the following four patients, which patient should the nurse seefirst? a. A 60-year-old patient with right-sided weakness who has an infusion of tPA prescribed b. A 50-year-old patient who has atrial fibrillation and a new order for warfarin (Coumadin) c. A 40-year-old patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due d. A 30-year-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop) scheduled

a. A 60-year-old patient with right-sided weakness who has an infusion of tPA prescribed

The nurse has just finished teaching a hypertensive patient about the newly prescribed ramipril (Altace). Which patient statement indicates that more teaching is needed? a. A little swelling around my lips and face is okay. b. The medication may not work as well if I take any aspirin. c. The doctor may order a blood potassium level occasionally. d. I will call the doctor if I notice that I have a frequent cough.

a. A little swelling around my lips and face is okay.

Which patient should the nurse assign as the roommate for a patient who has aplastic anemia? a. A patient with chronic heart failure b. A patient who has viral pneumonia c. A patient who has right leg cellulitis d. A patient with multiple abdominal drains

a. A patient with chronic heart failure Patients with aplastic anemia are at risk for infection because of the low white blood cell production associated with this type of anemia, so the nurse should avoid assigning a roommate with any possible infectious process.

The nurse reviews the medication administration record (MAR) for a patient having an acute asthma attack. Which medication should the nurse administer first? a. Albuterol (Ventolin) 2.5 mg per nebulizer b. Methylprednisolone (Solu-Medrol) 60 mg IV c. Salmeterol (Serevent) 50 mcg per dry-powder inhaler (DPI) d. Triamcinolone (Azmacort) 2 puffs per metered-dose inhaler (MDI)

a. Albuterol (Ventolin) 2.5 mg per nebulizer

A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan. Which information obtained by the nurse is a priority to communicate to the health care provider before the CT? a. Allergy to shellfish b. Apical pulse of 104 c. Respiratory rate of 30 d. Oxygen saturation of 90%

a. Allergy to shellfish

A 20-year-old has a mandatory electrocardiogram (ECG) before participating on a college soccer team and is found to have sinus bradycardia, rate 52. Blood pressure (BP) is 114/54, and the student denies any health problems. What action by the nurse is most appropriate? a. Allow the student to participate on the soccer team. b. Refer the student to a cardiologist for further diagnostic testing. c. Tell the student to stop playing immediately if any dyspnea occurs. d. Obtain more detailed information about the students family health

a. Allow the student to participate on the soccer team.

The nurse is assessing a patient's differential white blood cell count. What implications would this test have on evaluating the adequacy of a patient's gas exchange? a. An elevation of the total white cell count indicates generalized inflammation. b. Eosinophil count will assist to identify the presence of a respiratory infection. c. White cell count will differentiate types of respiratory bacteria. d. Level of neutrophils provides guidelines to monitor a chronic infection.

a. An elevation of the total white cell count indicates generalized inflammation.

A newly admitted patient is diagnosed with hyponatremia. When making room assignments, the charge nurse should take which action? a. Assign the patient to a room near the nurses station. b. Place the patient in a room nearest to the water fountain. c. Place the patient on telemetry to monitor for peaked T waves. d. Assign the patient to a semi-private room and place an order for a low-salt diet.

a. Assign the patient to a room near the nurses station. The patient should be placed near the nurses station if confused in order for the staff to closely monitor the patient. To help improve serum sodium levels, water intake is restricted. Therefore a confused patient should not be placed near a water fountain. Peaked T waves are a sign of hyperkalemia, not hyponatremia. A confused patient could be distracting and disruptive for another patient in a semiprivate room. This patient needs sodium replacement, not restriction

The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse? a. Blood pressure is 90/40 mm Hg. b. Urine output is 30 mL over the last hour. c. Oral fluid intake is 100 mL for the last 8 hours. d. There is prolonged skin tenting over the sternum.

a. Blood pressure is 90/40 mm Hg. The blood pressure indicates that the patient may be developing hypovolemic shock as a result of intravascular fluid loss due to the burn injury. This finding will require immediate intervention to prevent the complications associated with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all indicate the need for increasing the patients fluid intake but not as urgently as the hypotension.

A 46-year-old is diagnosed with thromboangiitis obliterans (Buergers disease). When the nurse isdeveloping a discharge teaching plan for the patient, which outcome has the highest priority for this patient? a. Cessation of all tobacco use b. Control of serum lipid levels c. Maintenance of appropriate weight d. Demonstration of meticulous foot care

a. Cessation of all tobacco use

Which nursing action should the nurse take first in order to assist a patient with newly diagnosed stage 1 hypertension in making needed dietary changes? a. Collect a detailed diet history. b. Provide a list of low-sodium foods. c. Help the patient make an appointment with a dietitian. d. Teach the patient about foods that are high in potassium.

a. Collect a detailed diet history The initial nursing action should be assessment of the patients baseline dietary intake through a thorough diet history. The other actions may be appropriate, but assessment of the patients baseline should occur first.

A nurse in the outpatient clinic is caring for a patient who has a magnesium level of 1.3 mg/dL. Which assessment would be most important for the nurse to make? a. Daily alcohol intake b. Intake of dietary protein c. Multivitamin/mineral use d. Use of over-the-counter (OTC) laxatives

a. Daily alcohol intake Hypomagnesemia is associated with alcoholism. Protein intake would not have a significant effect onmagnesium level. OTC laxatives (such as milk of magnesia) and use of multivitamin/mineral supplements would tend to increase magnesium levels.

The nurse is reviewing the patient's arterial blood gas results. The PaO2 is 96 mm Hg, pH is 7.20, PaCO2 is 55 mm Hg, and HCO3is 25 mEq/L. What might the nurse expect to observe on assessment of this patient? a. Disorientation and tremors b. Tachycardia and decreased blood pressure c. Increased anxiety and irritability d. Hyperventilation and lethargy

a. Disorientation and tremors The patient is experiencing respiratory acidosis (↓pH and ↑PaCO2) which may be manifested by disorientation, tremors, possible seizures, and decreased level of consciousness. Tachycardia and decreased blood pressure are not characteristic of a problem of respiratory acidosis. Increased anxiety and hyperventilation will cause respiratory alkalosis, which is manifested by an increase in pH and a decrease in PaCO2.

The nurse is conducting a patient assessment. The patient tells the nurse that he has smoked two packs of cigarettes per day for 27 years. The nurse may find which data upon assessment? a. Elevated blood pressure b. Bounding pedal pulses c. Night blindness d. Reflux disease

a. Elevated blood pressure Smokers have a constriction of the blood vessels due to the tar and nicotine in cigarettes. This constriction may lead to hypertension. Bounding pulses, night blindness, and reflux disease do not have a direct link to smoking.

A patient in the clinic with cystic fibrosis (CF) reports increased sweating and weakness during the summer months. Which action by the nurse would be most appropriate? a. Have the patient add dietary salt to meals. b. Teach the patient about the signs of hypoglycemia. c. Suggest decreasing intake of dietary fat and calories. d. Instruct the patient about pancreatic enzyme replacements

a. Have the patient add dietary salt to meals. Added dietary salt is indicated whenever sweating is excessive, such as during hot weather, when fever is present, or from intense physical activity. The management of pancreatic insufficiency includes pancreatic enzyme replacement of lipase, protease, and amylase (e.g., Pancreaze, Creon, Ultresa, Zenpep) administeredbefore each meal and snack. This patient is at risk for hyponatremia based on reported symptoms. Adequate intake of fat, calories, protein, and vitamins is important. Fat-soluble vitamins (vitamins A, D, E, and K) mustbe supplemented because they are malabsorbed. Use of caloric supplements improves nutritional status.Hyperglycemia due to pancreatic insufficiency is more likely to occur than hypoglycemia.

Which patient finding would the nurse identify as being a risk factor for altered transport of oxygen? a. Hemoglobin level of 8.0 b. Bronchoconstriction and mucus c. Peripheral arterial disease d. Decreased thoracic expansion

a. Hemoglobin level of 8.0 Altered transportation of oxygen refers to patients with insufficient red blood cells to transport the oxygen present.Bronchoconstriction and decreased thoracic expansion (spinal cord injury) would result in impairment of ventilation. Peripheralvascular disease would result in inadequate perfusion

Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate? a. I will call my health care provider if my stools turn black. b. I will take a stool softener if I feel constipated occasionally. c. I should take the iron with orange juice about an hour before eating. d. I should increase my fluid and fiber intake while I am taking iron tablets

a. I will call my health care provider if my stools turn black.

The nurse is reviewing the care plan for a patient experiencing difficulty coping with stress. Which action should the nurse implement to assist the patient? a. Identifying the cause of fear b. Accessing a community support group c. Identifying relaxation methods d. Reviewing an educational pamphlet

a. Identifying the cause of fear

The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake? a. Increase fluids if your mouth feels dry. b. More fluids are needed if you feel thirsty. c. Drink more fluids in the late evening hours. d. If you feel lethargic or confused, you need more to drink.

a. Increase fluids if your mouth feels dry. An alert, older patient will be able to self-assess for signs of oral dryness such as thick oral secretions or dry appearing mucosa. The thirst mechanism decreases with age and is not an accurate indicator of volume depletion. Many older patients prefer to restrict fluids slightly in the evening to improve sleep quality. The patient will not be likely to notice and act appropriately when changes in level of consciousness occur.

After the nurse gives IV atropine to a patient with symptomatic type 1, second-degree atrioventricular (AV) block, which finding indicates that the medication has been effective? a. Increase in the patients heart rate b. Increase in strength of peripheral pulses c. Decrease in premature atrial contractions d. Decrease in premature ventricular contractions

a. Increase in the patients heart rate

A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question? a. Infuse 5% dextrose in water at 125 mL/hr. b. Administer IV morphine sulfate 4 mg every 2 hours PRN. c. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea. d. Administer 3% saline if serum sodium decreases to less than 128 mEq/L.

a. Infuse 5% dextrose in water at 125 mL/hr.

Which action by a new registered nurse (RN) who is orienting to the progressive care unit indicates a good understanding of the treatment of cardiac dysrhythmias? a. Injects IV adenosine (Adenocard) over 2 seconds to a patient with supraventricular tachycardia b. Obtains the defibrillator and quickly brings it to the bedside of a patient whose monitor shows asystole c. Turns the synchronizer switch to the on position before defibrillating a patient with ventricular fibrillation d. Gives the prescribed dose of diltiazem (Cardizem) to a patient with new-onset type II second degree AV block

a. Injects IV adenosine (Adenocard) over 2 seconds to a patient with supraventricular tachycardia

On auscultation of a patients lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding? a. Inspiratory crackles at the bases b. Expiratory wheezes in both lungs c. Abnormal lung sounds in the apices of both lungs d. Pleural friction rub in the right and left lower lobes

a. Inspiratory crackles at the bases Crackles are low-pitched, bubbling sounds usually heard on inspiration. Wheezes are high-pitched sounds.They can be heard during the expiratory or inspiratory phase of the respiratory cycle. The lower third of both lungs are the bases, not apices. Pleural friction rubs are grating sounds that are usually heard during both inspiration and expiration.

A patient who is experiencing an acute asthma attack is admitted to the emergency department. Which assessment should the nurse complete first? a. Listen to the patients breath sounds. b. Ask about inhaled corticosteroid use. c. Determine when the dyspnea started. d. Obtain the forced expiratory volume (FEV) flow rate.

a. Listen to the patients breath sounds.

Which action will the nurse include in the plan of care for a 72-year-old woman admitted with multiplemyeloma? a. Monitor fluid intake and output. b. Administer calcium supplements. c. Assess lymph nodes for enlargement. d. Limit weight bearing and ambulation

a. Monitor fluid intake and output.

The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Whichaction should the nurse take next? a. Monitor ionized calcium level. b. Give oral calcium citrate tablets. c. Check parathyroid hormone level. d. Administer vitamin D supplements

a. Monitor ionized calcium level.

The nurse would identify which body systems as directly involved in the process of normal gas exchange? (Select all that apply.) a. Neurologic system b. Endocrine system c. Pulmonary system d. Immune system e. Cardiovascular system f. Hepatic system

a. Neurologic system c. Pulmonary system e. Cardiovascular system

A patient who is experiencing an asthma attack develops bradycardia and a decrease in wheezing. Which action should the nurse take first? a. Notify the health care provider. b. Document changes in respiratory status. c. Encourage the patient to cough and deep breathe. d. Administer IV methylprednisolone (Solu-Medrol).

a. Notify the health care provider. The patients assessment indicates impending respiratory failure, and the nurse should prepare to assist withintubation and mechanical ventilation after notifying the health care provider. IV corticosteroids requireseveral hours before having any effect on respiratory status. The patient will not be able to cough or deepbreathe effectively. Documentation is not a priority at this time.

A patient with renal failure has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. The patient arrives for outpatient hemodialysis and is unresponsive to questions and has decreased deep tendon reflexes. Which action should the dialysis nurse take first? a. Notify the patients health care provider. b. Obtain an order to draw a potassium level. c. Review the magnesium level on the patients chart. d. Teach the patient about the risk of magnesium-containing antacids

a. Notify the patients health care provider. The health care provider should be notified immediately. The patient has a history and manifestations consistent with hypermagnesemia. The nurse should check the chart for a recent serum magnesium level and make sure that blood is sent to the laboratory for immediate electrolyte and chemistry determinations. Dialysis should correct the high magnesium levels. The patient needs teaching about the risks of taking magnesium containing antacids. Monitoring of potassium levels also is important for patients with renal failure, but the patients current symptoms are not consistent with hyperkalemia.

The nurse would identify which patient condition as a problem of impaired gas exchange secondary to a perfusion problem? a. Peripheral arterial disease of the lower extremities b. Chronic obstructive pulmonary disease (COPD) c. Chronic asthma d. Severe anemia secondary to chemotherapy

a. Peripheral arterial disease of the lower extremities Perfusion relates to the ability of the blood to deliver oxygen to the cellular level and return the carbon dioxide to the lung forremoval. COPD and asthma are examples of a ventilation problem. Severe anemia is an example of a transport problem of gasexchange.

The nurse is caring for a patient with cor pulmonale. The nurse should monitor the patient for whichexpected finding? a. Peripheral edema b. Elevated temperature c. Clubbing of the fingers d. Complaints of chest pain

a. Peripheral edema

The nurse is caring for a patient immediately after repair of an abdominal aortic aneurysm. On assessment, the patient has absent popliteal, posterior tibial, and dorsalis pedis pulses. The legs are cool and mottled. Which action should the nurse take first? a. Notify the surgeon and anesthesiologist. b. Wrap both the legs in a warming blanket. c. Document the findings and recheck in 15 minutes. d. Compare findings to the preoperative assessment of the pulses.

a. Notify the surgeon and anesthesiologist. Lower extremity pulses may be absent for a short time after surgery because of vasospasm and hypothermia.Decreased or absent pulses together with a cool and mottled extremity may indicate embolization or graftocclusion. These findings should be reported to the physician immediately because this is an emergency situation. Because pulses are marked prior to surgery, the nurse would know whether pulses were present priorto surgery before notifying the health care providers about the absent pulses. Because the patients symptoms may indicate graft occlusion or multiple emboli and a possible need to return to surgery, it is not appropriate to wait 15 minutes before taking action. A warming blanket will not improve the circulation to the patients legs.

Which nursing action for a patient with chronic obstructive pulmonary disease (COPD) could the nurse delegate to experienced unlicensed assistive personnel (UAP)? a. Obtain oxygen saturation using pulse oximetry. b. Monitor for increased oxygen need with exercise. c. Teach the patient about safe use of oxygen at home. d. Adjust oxygen to keep saturation in prescribed parameters.

a. Obtain oxygen saturation using pulse oximetry.

An 80-year-old patient with a history of an abdominal aortic aneurysm arrives at the emergency department (ED) with severe back pain and absent pedal pulses. Which actions should the nurse take first? a. Obtain the blood pressure. b. Obtain blood for laboratory testing. c. Assess for the presence of an abdominal bruit. d. Determine any family history of kidney disease

a. Obtain the blood pressure.

Which menu choice indicates that the patient understands the nurses teaching about best dietary choices for iron-deficiency anemia? a. Omelet and whole wheat toast b. Cantaloupe and cottage cheese c. Strawberry and banana fruit plate d. Cornmeal muffin and orange juice

a. Omelet and whole wheat toast

A patient who has been receiving diuretic therapy is admitted to the emergency department with a serumpotassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication? a. Oral digoxin (Lanoxin) 0.25 mg daily b. Ibuprofen (Motrin) 400 mg every 6 hours c. Metoprolol (Lopressor) 12.5 mg orally daily d. Lantus insulin 24 U subcutaneously every evening

a. Oral digoxin (Lanoxin) 0.25 mg daily Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse will alsoneed to do more assessment regarding the other medications, but they are not of as much concern with thepotassium level

To determine whether there is a delay in impulse conduction through the atria, the nurse will measure the duration of the patients a. P wave. b. Q wave. c. P-R interval. d. QRS complex.

a. P wave. The P wave represents the depolarization of the atria. The P-R interval represents depolarization of the atria,atrioventricular (AV) node, bundle of His, bundle branches, and the Purkinje fibers. The QRS represents ventricular depolarization. The Q wave is the first negative deflection following the P wave and should be narrow and short.

Following a thyroidectomy, a patient complains of a tingling feeling around my mouth. Which assessment should the nurse complete immediately? a. Presence of the Chvosteks sign b. Abnormal serum potassium level c. Decreased thyroid hormone level d. Bleeding on the patients dressing

a. Presence of the Chvosteks sign The patients symptoms indicate possible hypocalcemia, which can occur secondary to parathyroidinjury/removal during thyroidectomy. There is no indication of a need to check the potassium level, the thyroidhormone level, or for bleeding.

The nurse assesses a patient with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea over the last 3 days. Which finding is most important for the nurse to report to the health care provider? a. Respirations are 36 breaths/minute. b. Anterior-posterior chest ratio is 1:1. c. Lung expansion is decreased bilaterally. d. Hyperresonance to percussion is present

a. Respirations are 36 breaths/minute. The increase in respiratory rate indicates respiratory distress and a need for rapid interventions such as administration of oxygen or medications. The other findings are common chronic changes occurring in patients with COPD.

Which information obtained by the nurse assessing a patient admitted with multiple myeloma is most important to report to the health care provider? a. Serum calcium level is 15 mg/dL. b. Patient reports no stool for 5 days. c. Urine sample has Bence-Jones protein. d. Patient is complaining of severe back pain.

a. Serum calcium level is 15 mg/dL. Hypercalcemia may lead to complications such as dysrhythmias or seizures, and should be addressed quickly.The other patient findings will also be discussed with the health care provider, but are not life threatening.

A patient is admitted to the emergency department complaining of sudden onset shortness of breath and is diagnosed with a possible pulmonary embolus. How should the nurse prepare the patient for diagnostic testing to confirm the diagnosis? a. Start an IV so contrast media may be given. b. Ensure that the patient has been NPO for at least 6 hours. c. Inform radiology that radioactive glucose preparation is needed. d. Instruct the patient to undress to the waist and remove any metal objects

a. Start an IV so contrast media may be given.

A patient in the outpatient clinic has a new diagnosis of peripheral artery disease (PAD). Which group of medications will the nurse plan to include when providing patient teaching about PAD management? a. Statins b. Antibiotics c. Thrombolytics d. Anticoagulants

a. Statins

The nurse is planning to teach a patient how to use relaxation techniques to prevent elevation of blood pressure and heart rate. The nurse is teaching the patient to control which physiological function? a. Switch from the sympathetic mode of the autonomic nervous system to the parasympathetic mode. b. Alter the internal state by modifying electronic signals related to physiologic processes. c. Replace stress-producing thoughts and activities with daily stress-reducing thoughts and activities. d. Reduce catecholamine production and promote the production of additional

a. Switch from the sympathetic mode of the autonomic nervous system to the parasympathetic mode.

A patient tells the nurse "My doctor thinks my problems with stress relate to the negative way I think about things, and he wantsme to learn a new way of thinking." Which response would be in keeping with the doctor's recommendations? a. Teaching the patient to recognize, reconsider, and reframe irrational thoughts b. Encouraging the patient to imagine being in calming circumstances c. Teaching the patient to use instruments that give feedback about bodily functions d. Provide the patient with a blank journal and guidance about journaling

a. Teaching the patient to recognize, reconsider, and reframe irrational thoughts Feedback

A patient who is 2 days post-femoral-popliteal bypass graft to the right leg is being cared for on the vascular unit. Which action by a licensed practical/vocational nurse (LPN/LVN) caring for the patient requires the registered nurse (RN) to intervene? a. The LPN/LVN has the patient sit in a chair for 90 minutes. b. The LPN/LVN assists the patient to walk 40 feet in the hallway. c. The LPN/LVN gives the ordered aspirin 160 mg after breakfast. d. The LPN/LVN places the patient in a Fowlers position for meals.

a. The LPN/LVN has the patient sit in a chair for 90 minutes.

Which intervention by a new nurse who is caring for a patient who has just had an implantablecardioverter-defibrillator (ICD) inserted indicates a need for more education about care of patients with ICDs? a. The nurse assists the patient to do active range of motion exercises for all extremities. b. The nurse assists the patient to fill out the application for obtaining a Medic Alert ID. c. The nurse gives amiodarone (Cordarone) to the patient without first consulting with the health care provider. d. The nurse teaches the patient that sexual activity usually can be resumed once the surgical incision is healed

a. The nurse assists the patient to do active range of motion exercises for all extremities.

A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate? a. The obstructing plaque is surgically removed from an artery in the neck. b. The diseased portion of the artery in the brain is replaced with a synthetic graft. c. A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed. d. A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque

a. The obstructing plaque is surgically removed from an artery in the neck.

After teaching a patient with newly diagnosed Raynauds phenomenon about how to manage the condition, which action by the patient demonstrates that the teaching has been effective? a. The patient exercises indoors during the winter months. b. The patient places the hands in hot water when they turn pale. c. The patient takes pseudoephedrine (Sudafed) for cold symptoms. d. The patient avoids taking nonsteroidal antiinflammatory drugs (NSAIDs).

a. The patient exercises indoors during the winter months.

A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for thenurse to report to the health care provider? a. The patient is experiencing laryngeal stridor. b. The patient complains of generalized fatigue. c. The patients bowels have not moved for 4 days. d. The patient has numbness and tingling of the lips.

a. The patient is experiencing laryngeal stridor.

A 19-year-old woman with immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion. Which information indicates that the nurse should consult with the health care provider before obtaining and administering platelets? a. The platelet count is 42,000/mL. b. Petechiae are present on the chest. c. Blood pressure (BP) is 94/56 mm Hg. d. Blood is oozing from the venipuncture site.

a. The platelet count is 42,000/mL.

The nurse is making a home visit to a child who has a chronic disease. Which finding has the most implication for acid-base aspects of this patient's care? a. Urine output is very small today. b. Whites of the eyes appear more yellow. c. Skin around the mouth is very chapped. d. Skin is sweaty under three blankets.

a. Urine output is very small today.

A young adult patient who denies any history of smoking is seen in the clinic with a new diagnosis of chronic obstructive pulmonary disease (COPD). It is most appropriate for the nurse to teach the patient about a. a1-antitrypsin testing. b. use of the nicotine patch. c. continuous pulse oximetry. d. effects of leukotriene modifiers

a. a1-antitrypsin testing.

A patient with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. The priority teaching needed for this patient would include information about a. anticoagulant therapy. b. permanent pacemakers. c. electrical cardioversion. d. IV adenosine (Adenocard).

a. anticoagulant therapy. Atrial fibrillation therapy that has persisted for more than 48 hours requires anticoagulant treatment for 3weeks before attempting cardioversion. This is done to prevent embolization of clots from the atria.Cardioversion may be done after several weeks of anticoagulation therapy. Adenosine is not used to treat atrialfibrillation. Pacemakers are routinely used for patients with bradydysrhythmias. Information does not indicate that the patient has a slow heart rate.

A female patient who had a stroke 24 hours ago has expressive aphasia. The nurse identifies the nursingdiagnosis of impaired verbal communication. An appropriate nursing intervention to help the patientcommunicate is to a. ask questions that the patient can answer with yes or no. b. develop a list of words that the patient can read and practice reciting. c. have the patient practice her facial and tongue exercises with a mirror. d. prevent embarrassing the patient by answering for her if she does not respond.

a. ask questions that the patient can answer with yes or no. Communication will be facilitated and less frustrating to the patient when questions that require a yes or no response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond

Propranolol (Inderal) is prescribed for a patient diagnosed with hypertension. The nurse should consult with the health care provider before giving this medication when the patient reveals a history of a. asthma. b. daily alcohol use. c. peptic ulcer disease. d. myocardial infarction (MI)

a. asthma. Nonselective b-blockers block b1 and b2-adrenergic receptors and can cause bronchospasm, especially inpatients with a history of asthma. b-Blockers will have no effect on the patients peptic ulcer disease or alcoho luse. b-Blocker therapy is recommended after MI.

An appropriate nursing intervention for a patient with non-Hodgkins lymphoma whose platelet count drops to 18,000/L during chemotherapy is to a. check all stools for occult blood. b. encourage fluids to 3000 mL/day. c. provide oral hygiene every 2 hours. d. check the temperature every 4 hours

a. check all stools for occult blood.

The charge nurse observes a new registered nurse (RN) doing discharge teaching for a patient with hypertension who has a new prescription for enalapril (Vasotec). The charge nurse will need to intervene if the new RN tells the patient to a. increase the dietary intake of high-potassium foods. b. make an appointment with the dietitian for teaching. c. check the blood pressure (BP) with a home BP monitor at least once a day. d. move slowly when moving from lying to sitting to standing.

a. increase the dietary intake of high-potassium foods. The ACE inhibitors cause retention of potassium by the kidney, so hyperkalemia is a possible adverse effect.The other teaching by the new RN is appropriate for a patient with newly diagnosed hypertension who has just started therapy with enalapril.

For a patient who had a right hemisphere stroke the nurse establishes a nursing diagnosis of a. risk for injury related to denial of deficits and impulsiveness. b. impaired physical mobility related to right-sided hemiplegia. c. impaired verbal communication related to speech-language deficits. d. ineffective coping related to depression and distress about disability.

a. risk for injury related to denial of deficits and impulsiveness. The patient with right-sided brain damage typically denies any deficits and has poor impulse control, leading torisk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided braindamage is associated with depression and distress about the disability

A patient is admitted for hypovolemia associated with multiple draining wounds. Which assessment would be the most accurate way for the nurse to evaluate fluid balance? a. Skin turgor b. Daily weight c. Presence of edema d. Hourly urine output

b. Daily weight

Which statements said by patients indicate that the nurse's teaching regarding prevention of acid-base imbalances is successful?(Select all that apply.) a. "Baking soda is an effective and inexpensive antacid." b. "I should take my insulin on time every day." c. "My aspirin is on a high shelf away from children." d. "I have reliable transportation to dialysis sessions." e. "Fasting is a great way to lose weight rapidly

b. "I should take my insulin on time every day." c. "My aspirin is on a high shelf away from children." d. "I have reliable transportation to dialysis sessions."

The patient had diarrhea for 5 days and developed an acid-base imbalance. Which statement would indicate that the nurse's teaching about the acid-base imbalance has been effective? a. "To prevent another problem, I should eat less sodium during diarrhea." b. "My blood became too acid because I lost some base in the diarrhea fluid." c. "Diarrhea removes fluid from the body, so I should drink more ice water." d. "I should try to slow my breathing so my acids and bases will be balanced."

b. "My blood became too acid because I lost some base in the diarrhea fluid."

The nurse receives a change-of-shift report on the following patients with chronic obstructive pulmonary disease (COPD). Which patient should the nurse assess first? a. A patient with loud expiratory wheezes b. A patient with a respiratory rate of 38/minute c. A patient who has a cough productive of thick, green mucus d. A patient with jugular venous distention and peripheral edema

b. A patient with a respiratory rate of 38/minute

Which blood pressure (BP) finding by the nurse indicates that no changes in therapy are needed for a patient with stage 1 hypertension who has a history of diabetes mellitus? a. 102/60 mm Hg b. 128/76 mm Hg c. 139/90 mm Hg d. 136/82 mm Hg

b. 128/76 mm Hg The goal for antihypertensive therapy for a patient with hypertension and diabetes mellitus is a BP <130/80mm Hg. The BP of 102/60 may indicate overtreatment of the hypertension and an increased risk for adverse drug effects. The other two blood pressures indicate a need for modifications in the patients treatment

Several patients call the outpatient clinic and ask to make an appointment as soon as possible. Which patient should the nurse schedule to be seen first? a. 44-year-old with sickle cell anemia who says my eyes always look sort of yellow b. 23-year-old with no previous health problems who has a nontender lump in the axilla c. 50-year-old with early-stage chronic lymphocytic leukemia who reports chronic fatigue d. 19-year-old with hemophilia who wants to learn to self-administer factor VII replacement

b. 23-year-old with no previous health problems who has a nontender lump in the axilla

After receiving change-of-shift report for several patients with neutropenia, which patient should the nurse assess first? a. 56-year-old with frequent explosive diarrhea b. 33-year-old with a fever of 100.8 F (38.2 C) c. 66-year-old who has white pharyngeal lesions d. 23-year old who is complaining of severe fatigue

b. 33-year-old with a fever of 100.8 F (38.2 C)

A 19-year-old student comes to the student health center at the end of the semester complaining that, My heart is skipping beats. An electrocardiogram (ECG) shows occasional premature ventricular contractions (PVCs). What action should the nurse take next? a. Start supplemental O2 at 2 to 3 L/min via nasal cannula. b. Ask the patient about current stress level and caffeine use. c. Ask the patient about any history of coronary artery disease. d. Have the patient taken to the hospital emergency department (ED).

b. Ask the patient about current stress level and caffeine use. In a patient with a normal heart, occasional PVCs are a benign finding. The timing of the PVCs suggests stressor caffeine as possible etiologic factors. It is unlikely that the patient has coronary artery disease, and this should not be the first question the nurse asks. The patient is hemodynamically stable, so there is no indication that the patient needs to be seen in the ED or that oxygen needs to be administered.

Several weeks after a stroke, a 50-year-old male patient has impaired awareness of bladder fullness,resulting in urinary incontinence. Which nursing intervention will be best to include in the initial plan for an effective bladder training program? a. Limit fluid intake to 1200 mL daily to reduce urine volume. b. Assist the patient onto the bedside commode every 2 hours. c. Perform intermittent catheterization after each voiding to check for residual urine. d. Use an external condom catheter to protect the skin and prevent embarrassment

b. Assist the patient onto the bedside commode every 2 hours.

Which intervention will be included in the nursing care plan for a patient with immune thrombocytopenic purpura (ITP)? a. Assign the patient to a private room. b. Avoid intramuscular (IM) injections. c. Use rinses rather than a soft toothbrush for oral care. d. Restrict activity to passive and active range of motion.

b. Avoid intramuscular (IM) injections. IM or subcutaneous injections should be avoided because of the risk for bleeding. A soft toothbrush can be used for oral care. There is no need to restrict activity or place the patient in a private room.

A patient comes to the clinic complaining of frequent, watery stools for the last 2 days. Which action should the nurse take first? a. Obtain the baseline weight. b. Check the patients blood pressure. c. Draw blood for serum electrolyte levels. d. Ask about any extremity numbness or tingling.

b. Check the patients blood pressure.

A young adult female patient with cystic fibrosis (CF) tells the nurse that she is not sure about getting married and having children some day. Which initial response by the nurse is best? a. Are you aware of the normal lifespan for patients with CF? b. Do you need any information to help you with that decision? c. Many women with CF do not have difficulty conceiving children. d. You will need to have genetic counseling before making a decision.

b. Do you need any information to help you with that decision?

A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction and is complaining of anxiety and incisional pain. The patients respiratory rate is 32 breaths/minute and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first? a. Discontinue the nasogastric suction. b. Give the patient the PRN IV morphine sulfate 4 mg. c. Notify the health care provider about the ABG results. d. Teach the patient how to take slow, deep breaths when anxious.

b. Give the patient the PRN IV morphine sulfate 4 mg.

Which action will the nurse in the hypertension clinic take in order to obtain an accurate baseline blood pressure (BP) for a new patient? a. Deflate the BP cuff at a rate of 5 to 10 mm Hg per second. b. Have the patient sit in a chair with the feet flat on the floor. c. Assist the patient to the supine position for BP measurements. d. Obtain two BP readings in the dominant arm and average the results.

b. Have the patient sit in a chair with the feet flat on the floor.

The nurse provides dietary teaching for a patient with chronic obstructive pulmonary disease (COPD) who has a low body mass index (BMI). Which patient statement indicates that the teaching has been effective? a. I will drink lots of fluids with my meals. b. I can have ice cream as a snack every day. c. I will exercise for 15 minutes before meals. d. I will decrease my intake of meat and poultry.

b. I can have ice cream as a snack every day.

A patient has ST segment changes that support an acute inferior wall myocardial infarction. Which leadwould be best for monitoring the patient? a. I b. II c. V2 d. V6

b. II

The clinic nurse makes a follow-up telephone call to a patient with asthma. The patient reports having abaseline peak flow reading of 600 L/minute and the current peak flow is 420 L/minute. Which action should the nurse take first? a. Tell the patient to go to the hospital emergency department. b. Instruct the patient to use the prescribed albuterol (Proventil). c. Ask about recent exposure to any new allergens or asthma triggers. d. Question the patient about use of the prescribed inhaled corticosteroids.

b. Instruct the patient to use the prescribed albuterol (Proventil).

When developing a teaching plan for a 76-year-old patient newly diagnosed with peripheral artery disease (PAD), which instructions should the nurse include? a. Exercise only if you do not experience any pain. b. It is very important that you stop smoking cigarettes. c. Try to keep your legs elevated whenever you are sitting. d. Put elastic compression stockings on early in the morning.

b. It is very important that you stop smoking cigarettes.

The patient has severe hyperthyroidism and will have surgery tomorrow. What assessment is most important for the nurse to perform in order to detect development of the highest risk acid-base imbalance? a. Urine output and color b. Level of consciousness c. Heart rate and blood pressure d. Lung sounds in lung bases

b. Level of consciousness

The nurse is admitting a patient diagnosed with an acute exacerbation of chronic obstructive pulmonary disease (COPD). What is the best way for the nurse to determine the appropriate oxygen flow rate? a. Minimize oxygen use to avoid oxygen dependency. b. Maintain the pulse oximetry level at 90% or greater. c. Administer oxygen according to the patients level of dyspnea. d. Avoid administration of oxygen at a rate of more than 2 L/minute.

b. Maintain the pulse oximetry level at 90% or greater.

When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensedassistive personnel (UAP) to remove which food from the patients food tray? a. Grape juice b. Milk carton c. Mixed green salad d. Fried chicken breast

b. Milk carton

The nurse obtains the following information from a patient newly diagnosed with prehypertension. Which finding is most important to address with the patient? a. Low dietary fiber intake b. No regular aerobic exercise c. Weight 5 pounds above ideal weight d. Drinks a beer with dinner on most nights

b. No regular aerobic exercise

The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to unlicensed assistive personnel (UAP)? a. Verify the patient identification (ID) according to hospital policy. b. Obtain the temperature, blood pressure, and pulse before the transfusion. c. Double-check the product numbers on the PRBCs with the patient ID band. d. Monitor the patient for shortness of breath or chest pain during the transfusion

b. Obtain the temperature, blood pressure, and pulse before the transfusion.

The nurse is caring for a patient with critical limb ischemia who has just arrived on the nursing unit after having percutaneous transluminal balloon angioplasty. Which action should the nurse perform first? a. Begin oral intake. b. Obtain vital signs. c. Assess pedal pulses. d. Start discharge teaching.

b. Obtain vital signs.

The emergency department nurse is evaluating the effectiveness of therapy for a patient who has received treatment during an asthma attack. Which assessment finding is the best indicator that the therapy has been effective? a. No wheezes are audible. b. Oxygen saturation is >90%. c. Accessory muscle use has decreased. d. Respiratory rate is 16 breaths/minute.

b. Oxygen saturation is >90%.

The nurse is assessing a patient for the adequacy of ventilation. What assessment findings would indicate the patient has good ventilation? (Select all that apply.) a. Respiratory rate is 24 breaths/min. b. Oxygen saturation level is 98%. c. The right side of the thorax expands slightly more than the left. d. Trachea is just to the left of the sternal notch. e. Nail beds are pink with good capillary refill. f. There is presence of quiet, effortless breath sounds at lung base bilaterally

b. Oxygen saturation level is 98%. e. Nail beds are pink with good capillary refill. f. There is presence of quiet, effortless breath sounds at lung base bilaterally

A patient is scheduled for a computed tomography (CT) of the chest with contrast media. Which assessment findings should the nurse immediately report to the health care provider (select all that apply)? a. Patient is claustrophobic. b. Patient is allergic to shellfish. c. Patient recently used a bronchodilator inhaler. d. Patient is not able to remove a wedding band. e. Blood urea nitrogen (BUN) and serum creatinine levels are elevated.

b. Patient is allergic to shellfish. e. Blood urea nitrogen (BUN) and serum creatinine levels are elevated. Because the contrast media is iodine-based and may cause dehydration and decreased renal blood flow, asking about iodine allergies (such as allergy to shellfish) and monitoring renal function before the CT scan are necessary. The other actions are not contraindications for CT of the chest, although they may be for other diagnostic tests, such as magnetic resonance imaging (MRI) or pulmonary function testing (PFT).

he nurse who works in the vascular clinic has several patients with venous insufficiency scheduled today. Which patient should the nurse assign to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Patient who has been complaining of increased edema and skin changes in the legs b. Patient who needs wound care for a chronic venous stasis ulcer on the right lower leg c. Patient who has a history of venous thromboembolism and is complaining of some dyspnea d. Patient who needs teaching about the use of elastic compression stockings for venous insufficiency

b. Patient who needs wound care for a chronic venous stasis ulcer on the right lower leg

Which collaborative problem will the nurse include in a care plan for a patient admitted to the hospital with idiopathic aplastic anemia? a. Potential complication: seizures b. Potential complication: infection c. Potential complication: neurogenic shock d. Potential complication: pulmonary edema

b. Potential complication: infection

Which finding by the nurse for a patient with a nursing diagnosis of impaired gas exchange will be most useful in evaluating the effectiveness of treatment? a. Even, unlabored respirations b. Pulse oximetry reading of 92% c. Respiratory rate of 18 breaths/minute d. Absence of wheezes, rhonchi, or crackles

b. Pulse oximetry reading of 92%

A patient with hypertension who has just started taking atenolol (Tenormin) returns to the health clinic after 2 weeks for a follow-up visit. The blood pressure (BP) is unchanged from the previous visit. Which actionshould the nurse take first? a. Inform the patient about the reasons for a possible change in drug dosage. b. Question the patient about whether the medication is actually being taken. c. Inform the patient that multiple drugs are often needed to treat hypertension. d. Question the patient regarding any lifestyle changes made to help control BP.

b. Question the patient about whether the medication is actually being taken.

A patient whose heart monitor shows sinus tachycardia, rate 132, is apneic and has no palpable pulses. What is the first action that the nurse should take? a. Perform synchronized cardioversion. b. Start cardiopulmonary resuscitation (CPR). c. Administer atropine per agency dysrhythmia protocol. d. Provide supplemental oxygen via non-rebreather mask

b. Start cardiopulmonary resuscitation (CPR).

Which problem reported by a patient with hemophilia is most important for the nurse to communicate to the physician? a. Leg bruises b. Tarry stools c. Skin abrasions d. Bleeding gums

b. Tarry stools

A patient with cystic fibrosis (CF) has blood glucose levels that are consistently between 180 to 250mg/dL. Which nursing action will the nurse plan to implement? a. Discuss the role of diet in blood glucose control. b. Teach the patient about administration of insulin. c. Give oral hypoglycemic medications before meals. d. Evaluate the patients home use of pancreatic enzymes.

b. Teach the patient about administration of insulin.

The nurse notes that a patients cardiac monitor shows that every other beat is earlier than expected, has no visible P wave, and has a QRS complex that is wide and bizarre in shape. How will the nurse document the rhythm? a. Ventricular couplets b. Ventricular bigeminy c. Ventricular R-on-T phenomenon d. Multifocal premature ventricular contractions

b. Ventricular bigeminy

The nurse is assessing a patient who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider? a. Urine output over 8 hours is 250 mL less than the fluid intake. b. The patient cannot move the left arm and leg when asked to do so. c. Tremors are noted in the fingers when the patient extends the arms. d. The patient complains of a headache with pain at level 8/10 (0 to 10 scale).

b. The patient cannot move the left arm and leg when asked to do so. The patients inability to move the left arm and leg indicates that a hemorrhagic stroke may be occurring and will require immediate action to prevent further neurologic damage. The other clinical manifestations are also likely caused by the hypertension and will require rapid nursing actions, but they do not require action as urgently as the neurologic changes

Which information obtained by the nurse caring for a patient with thrombocytopenia should be immediately communicated to the health care provider? a. The platelet count is 52,000/L. b. The patient is difficult to arouse. c. There are purpura on the oral mucosa. d. There are large bruises on the patients back.

b. The patient is difficult to arouse.

Which patient requires the most rapid assessment and care by the emergency department nurse? a. The patient with hemochromatosis who reports abdominal pain b. The patient with neutropenia who has a temperature of 101.8 F c. The patient with sickle cell anemia who has had nausea and diarrhea for 24 hours d. The patient with thrombocytopenia who has oozing after having a tooth extracted

b. The patient with neutropenia who has a temperature of 101.8 F

Which information about the patient who has had a subarachnoid hemorrhage is most important to communicate to the health care provider? a. The patient complains of having a stiff neck. b. The patients blood pressure (BP) is 90/50 mm Hg. c. The patient reports a severe and unrelenting headache. d. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).

b. The patients blood pressure (BP) is 90/50 mm Hg.

A 68-year-old woman with acute myelogenous leukemia (AML) asks the nurse whether the plannedchemotherapy will be worth undergoing. Which response by the nurse is appropriate? a. If you do not want to have chemotherapy, other treatment options include stem cell transplantation. b. The side effects of chemotherapy are difficult, but AML frequently goes into remission with chemotherapy. c. The decision about treatment is one that you and the doctor need to make rather than asking what I would do. d. You dont need to make a decision about treatment right now because leukemias in adults tend to progress quite slowly

b. The side effects of chemotherapy are difficult, but AML frequently goes into remission with chemotherapy.

The patient is hyperventilating from anxiety and abdominal pain. Which assessment findings should the nurse attribute to respiratory alkalosis? (Select all that apply.) a. Skin pale and cold b. Tingling of fingertips c. Heart rate of 102 d. Numbness around mouth e. Cramping in feet

b. Tingling of fingertips d. Numbness around mouth e. Cramping in feet Hyperventilation is a risk factor for respiratory alkalosis. Respiratory alkalosis can cause perioral and digital paresthesia and pedal spasms. Pallor, cold skin, and tachycardia are characteristic of activation of the sympathetic nervous system, not respiratory alkalosis.

A patient with a history of a transfusion-related acute lung injury (TRALI) is to receive a transfusion of packed red blood cells (PRBCs). Which action by the nurse will decrease the risk for TRALI for this patient? a. Infuse the PRBCs slowly over 4 hours. b. Transfuse only leukocyte-reduced PRBCs. c. Administer the scheduled diuretic before the transfusion. d. Give the PRN dose of antihistamine before the transfusion.

b. Transfuse only leukocyte-reduced PRBCs.

Which instruction should the nurse include in an exercise teaching plan for a patient with chronic obstructive pulmonary disease (COPD)? a. Stop exercising if you start to feel short of breath. b. Use the bronchodilator before you start to exercise. c. Breathe in and out through the mouth while you exercise. d. Upper body exercise should be avoided to prevent dyspnea

b. Use the bronchodilator before you start to exercise. Use of a bronchodilator before exercise improves airflow for some patients and is recommended. Shortness of breath is normal with exercise and not a reason to stop. Patients should be taught to breathe in through the nose and out through the mouth (using a pursed lip technique). Upper-body exercise can improve the mechanics of breathing in patients with COPD.

An appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia is to a. provide a diet high in vitamin K. b. alternate periods of rest and activity. c. teach the patient how to avoid injury. d. place the patient on protective isolation.

b. alternate periods of rest and activity.

A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. The nurse will anticipate teaching the patient about a. alteplase (tPA). b. aspirin (Ecotrin). c. warfarin (Coumadin). d. nimodipine (Nimotop).

b. aspirin (Ecotrin).

A routine complete blood count indicates that an active 80-year-old man may have myelodysplasticsyndrome. The nurse will plan to teach the patient about a. blood transfusion b. bone marrow biopsy. c. filgrastim (Neupogen) administration. d. erythropoietin (Epogen) administration.

b. bone marrow biopsy.

It is important for the nurse providing care for a patient with sickle cell crisis to a. limit the patients intake of oral and IV fluids. b. evaluate the effectiveness of opioid analgesics. c. encourage the patient to ambulate as much as tolerated. d. teach the patient about high-protein, high-calorie foods.

b. evaluate the effectiveness of opioid analgesics.

A patient has a 6-cm thoracic aortic aneurysm that was discovered during a routine chest x-ray. Whenobtaining an admission history from the patient, it will be most important for the nurse to ask about a. low back pain. b. trouble swallowing. c. abdominal tenderness. d. changes in bowel habits.

b. trouble swallowing.

A patient diagnosed with hypertension asks the nurse how this disease could have happened to them. What is the nurse's best response? a. "Hypertension happens to everyone sooner or later. Don't be concerned about it." b. "Hypertension can happen from eating a poor diet, so change what you are eating." c. "Hypertension can happen from arterial changes that block the blood flow." d. "Hypertension happens when people do not exercise, so you should walk every day

c. "Hypertension can happen from arterial changes that block the blood flow."

A nurse is explaining the concept of perfusion to a student nurse. The nurse knows the student understands the concept of perfusion when the student makes which statement? a. "Perfusion is a normal function of the body, and I don't have to be concerned about it." b. "Perfusion is monitored by the physician." c. "Perfusion is monitored by vital signs and capillary refill." d. "Perfusion varies as a person ages, so I would expect changes in the body."

c. "Perfusion is monitored by vital signs and capillary refill."

A patient has a junctional escape rhythm on the monitor. The nurse will expect the patient to have a heart rate of _____ beats/minute. a. 15 to 20 b. 20 to 40 c. 40 to 60 d. 60 to 100

c. 40 to 60

After receiving report, which patient admitted to the emergency department should the nurse assess first? a. 67-year-old who has a gangrenous left foot ulcer with a weak pedal pulse b. 58-year-old who is taking anticoagulants for atrial fibrillation and has black stools c. 50-year-old who is complaining of sudden sharp and worst ever upper back pain d. 39-year-old who has right calf tenderness, redness, and swelling after a long plane ride

c. 50-year-old who is complaining of sudden sharp and worst ever upper back pain Feedback

A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take? a. Draw blood for a new crossmatch. b. Send a urine specimen to the laboratory. c. Administer PRN acetaminophen (Tylenol). d. Give the PRN diphenhydramine (Benadryl).

c. Administer PRN acetaminophen (Tylenol).

A patient seen in the asthma clinic has recorded daily peak flows that are 75% of the baseline. Which action will the nurse plan to take next? a. Increase the dose of the leukotriene inhibitor. b. Teach the patient about the use of oral corticosteroids. c. Administer a bronchodilator and recheck the peak flow. d. Instruct the patient to keep the next scheduled follow-up appointment.

c. Administer a bronchodilator and recheck the peak flow.

Which action will the nurse include in the plan of care for a patient who has thalassemia major? a. Teach the patient to use iron supplements. b. Avoid the use of intramuscular injections. c. Administer iron chelation therapy as needed. d. Notify health care provider of hemoglobin 11g/dL

c. Administer iron chelation therapy as needed.

While caring for a patient with respiratory disease, the nurse observes that the patients SpO2 drops from 93% to 88% while the patient is ambulating in the hallway. What is the priority action of the nurse? a. Notify the health care provider. b. Document the response to exercise. c. Administer the PRN supplemental O2. d. Encourage the patient to pace activity

c. Administer the PRN supplemental O2. The drop in SpO2 to 85% indicates that the patient is hypoxemic and needs supplemental oxygen when exercising. The other actions are also important, but the first action should be to correct the hypoxemia.

The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take? a. Give the prescribed PRN lorazepam (Ativan). b. Start the prescribed PRN oxygen at 2 to 4 L/min. c. Administer the prescribed normal saline bolus and insulin. d. Encourage the patient to take deep, slow breaths with guided imagery

c. Administer the prescribed normal saline bolus and insulin.

The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Assess the patients gag and cough reflexes. b. Determine when the stroke symptoms began. c. Administer the prescribed short-acting insulin. d. Infuse the prescribed IV metoprolol (Lopressor).

c. Administer the prescribed short-acting insulin.

Which action for a patient with neutropenia is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Assessing the patient for signs and symptoms of infection b. Teaching the patient the purpose of neutropenic precautions c. Administering subcutaneous filgrastim (Neupogen) injection d. Developing a discharge teaching plan for the patient and family

c. Administering subcutaneous filgrastim (Neupogen) injection

The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired self-feeding ability for a left-handed patient with left-sided hemiplegia. Which intervention should be included in the plan of care? a. Provide a wide variety of food choices. b. Provide oral care before and after meals. c. Assist the patient to eat with the right hand. d. Teach the patient the chin-tuck technique.

c. Assist the patient to eat with the right hand. Because the nursing diagnosis indicates that the patients imbalanced nutrition is related to the left-sided hemiplegia, the appropriate interventions will focus on teaching the patient to use the right hand for self feeding.The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition.

Which action should the nurse take first when a patient complains of acute chest pain and dyspnea soon after insertion of a centrally inserted IV catheter? a. Notify the health care provider. b. Offer reassurance to the patient. c. Auscultate the patients breath sounds. d. Give the prescribed PRN morphine sulfate IV.

c. Auscultate the patients breath sounds.

Which instruction will the nurse plan to include in discharge teaching for the patient admitted with a sickle cell crisis? a. Take a daily multivitamin with iron. b. Limit fluids to 2 to 3 quarts per day. c. Avoid exposure to crowds when possible. d. Drink only two caffeinated beverages daily.

c. Avoid exposure to crowds when possible.

Which finding about a patient with polycythemia vera is most important for the nurse to report to the health care provider? a. Hematocrit 55% b. Presence of plethora c. Calf swelling and pain d. Platelet count 450,000/mL

c. Calf swelling and pain The calf swelling and pain suggest that the patient may have developed a deep vein thrombosis, which will require diagnosis and treatment to avoid complications such as pulmonary embolus. The other findings will also be reported to the health care provider but are expected in a patient with this diagnosis.

A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergencydepartment. Which action should the nurse take first? a. Monitor the blood pressure. b. Send the patient for a computed tomography (CT) scan. c. Check the respiratory rate and effort. d. Assess the Glasgow Coma Scale score

c. Check the respiratory rate and effort.

The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patients condition has improved? a. Hematocrit 28% b. Absence of skin tenting c. Decreased peripheral edema d. Blood pressure 110/72 mm Hg

c. Decreased peripheral edema

A 3-month-old infant is at increased risk for developing anemia. The nurse would identify which principle contributing to thisrisk? a. The infant is becoming more active. b. There is an increase in intake of breast milk or formula. c. The infant is unable to maintain an adequate iron intake. d. A depletion of fetal hemoglobin occurs.

d. A depletion of fetal hemoglobin occurs.

A male patient who has right-sided weakness after a stroke is making progress in learning to use the lefthand for feeding and other activities. The nurse observes that when the patients wife is visiting, she feeds and dresses him. Which nursing diagnosis is most appropriate for the patient? a. Interrupted family processes related to effects of illness of a family member b. Situational low self-esteem related to increasing dependence on spouse for care c. Disabled family coping related to inadequate understanding by patients spouse d. Impaired nutrition: less than body requirements related to hemiplegia and aphasia

c. Disabled family coping related to inadequate understanding by patients spouse

The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. When auscultating the patients lungs, which finding would the nurse most likely hear? a. Continuous rumbling, snoring, or rattling sounds mainly on expiration b. Continuous high-pitched musical sounds on inspiration and expiration c. Discontinuous, high-pitched sounds of short duration heard on inspiration d. A series of long-duration, discontinuous, low-pitched sounds during inspiration

c. Discontinuous, high-pitched sounds of short duration heard on inspiration

A 46-year-old service-counter worker undergoes sclerotherapy for treatment of superficial varicose veins at an outpatient center. Which instructions should the nurse provide to the patient before discharge? a. Sitting at the work counter, rather than standing, is recommended. b. Exercise, such as walking or jogging, can cause recurrence of varicosities. c. Elastic compression stockings should be applied before getting out of bed. d. Taking an aspirin daily will help prevent clots from forming around venous valves.

c. Elastic compression stockings should be applied before getting out of bed.

A patient with chronic obstructive pulmonary disease (COPD) has poor gas exchange. Which action by the nurse would be most appropriate? a. Have the patient rest in bed with the head elevated to 15 to 20 degrees. b. Ask the patient to rest in bed in a high-Fowlers position with the knees flexed. c. Encourage the patient to sit up at the bedside in a chair and lean slightly forward. d. Place the patient in the Trendelenburg position with several pillows behind the head.

c. Encourage the patient to sit up at the bedside in a chair and lean slightly forward.

A 72-year-old patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, I dont need the aspirin today. I dont have a fever. Which action should the nurse take? a. Document that the aspirin was refused by the patient. b. Tell the patient that the aspirin is used to prevent a fever. c. Explain that the aspirin is ordered to decrease stroke risk. d. Call the health care provider to clarify the medication order.

c. Explain that the aspirin is ordered to decrease stroke risk.

A patient who is on the progressive care unit develops atrial flutter, rate 150, with associated dyspnea and chest pain. Which action that is included in the hospital dysrhythmia protocol should the nurse do first? a. Obtain a 12-lead electrocardiogram (ECG). b. Notify the health care provider of the change in rhythm. c. Give supplemental O2 at 2 to 3 L/min via nasal cannula. d. Assess the patients vital signs including oxygen saturation.

c. Give supplemental O2 at 2 to 3 L/min via nasal cannula. Because this patient has dyspnea and chest pain in association with the new rhythm, the nurses initial actions should be to address the patients airway, breathing, and circulation (ABC) by starting with oxygen administration. The other actions also are important and should be implemented rapidly.

The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider? a. Oral temperature of 100.1 F b. Serum sodium level of 138 mEq/L (138 mmol/L) c. Gradually decreasing level of consciousness (LOC) d. Weight gain of 2 pounds (1 kg) above the admission weight

c. Gradually decreasing level of consciousness (LOC)

The nurse is assigned a group of patients. Which patient finding would the nurse identify as a factor leading to increased risk forimpaired gas exchange a. Blood glucose of 350 mg/dL b. Anticoagulant therapy for 10 days c. Hemoglobin of 8.5 g/dL d. Heart rate of 100 beats/min and blood pressure of 100/60

c. Hemoglobin of 8.5 g/dL

A patient who had been complaining of intolerable stress at work has demonstrated the ability to use progressive muscle relaxation and deep breathing techniques. He will return to the clinic for follow-up evaluation in 2 weeks. Which data will bestsuggest that the patient is successfully using these techniques to cope more effectively with stress? a. The patient's wife reports that he spends more time sitting quietly at home. b. He reports that his appetite, mood, and energy levels are all good. c. His systolic blood pressure has gone from the 140s to the 120s (mm Hg). d. He reports that he feels better and that things are not bothering him as much.

c. His systolic blood pressure has gone from the 140s to the 120s (mm Hg).

The nurse teaches a patient about pulmonary function testing (PFT). Which statement, if made by the patient, indicates teaching was effective? a. I will use my inhaler right before the test. b. I wont eat or drink anything 8 hours before the test. c. I should inhale deeply and blow out as hard as I can during the test. d. My blood pressure and pulse will be checked every 15 minutes after the test.

c. I should inhale deeply and blow out as hard as I can during the test.

The nurse is developing a care plan for a patient with ineffective coping skills. Which intervention would be an example of a problem-focused coping strategy? a. Scheduling a regular exercise program b. Attending a seminar on treatment options c. Identifying a confidant to share feelings d. Attending a support group for families

c. Identifying a confidant to share feelings Problem-focused strategies are used to find solutions or improvement to the underlying stressor, such as accessing community resources or attending educational seminars. Exercise, emotional support, and support groups are emotion-based strategies that create a feeling of well-being.

The school nurse is assessing coping skills of high school students who attend an alternative school for students at high risk to not graduate. What is the priority concern that the nurse has for this student population? a. Altered vital sign readings b. Inaccurate perceptions of stressors c. Increased risk for suicide d. Decreased access to alcoholic beverages

c. Increased risk for suicide

A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature 102 F (38.9 C), and severe back pain. Which physician order will the nurse implement first? a. Administer morphine sulfate 4 mg IV. b. Give acetaminophen (Tylenol) 650 mg. c. Infuse normal saline 500 mL over 30 minutes. d. Schedule complete blood count and coagulation studies.

c. Infuse normal saline 500 mL over 30 minutes.

A patient with a venous thromboembolism (VTE) is started on enoxaparin (Lovenox) and warfarin(Coumadin). The patient asks the nurse why two medications are necessary. Which response by the nurse is most appropriate? a. Taking two blood thinners reduces the risk for another clot to form. b. Lovenox will start to dissolve the clot, and Coumadin will prevent any more clots from forming. c. Lovenox will work right away, but Coumadin takes several days to have an effect on preventing clots. d. Because of the risk for a blood clot in the lungs, it is important for you to take more than one blood thinner

c. Lovenox will work right away, but Coumadin takes several days to have an effect on preventing clots. Low molecular weight heparin (LMWH) is used because of the immediate effect on coagulation and discontinued once the international normalized ratio (INR) value indicates that the warfarin has reached a therapeutic level. LMWH has no thrombolytic properties. The use of two anticoagulants is not related to the risk for pulmonary embolism, and two are not necessary to reduce the risk for another VTE. Furthermore,anticoagulants should not be described as blood thinners.

A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient complains of just blowing up and has peripheral edema and shortness of breath. Which assessment should the nurse complete first? a. Skin turgor b. Heart sounds c. Mental status d. Capillary refill

c. Mental status Increases in extracellular fluid (ECF) can lead to swelling of cells in the central nervous system, initiallycausing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heartsounds also may be affected by increases in ECF, these are signs that do not have as immediate impact onpatient outcomes as cerebral edema.

An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, andweakness. Which laboratory result should the nurse report to the health care provider immediately? a. K+ 3.4 mEq/L (3.4 mmol/L) b. Ca+2 7.8 mg/dL (1.95 mmol/L) c. Na+ 154 mEq/L (154 mmol/L) d. PO4 -3 4.8 mg/dL (1.55 mmol/L)

c. Na+ 154 mEq/L (154 mmol/L) The elevated serum sodium level is consistent with the patients neurologic symptoms and indicates a need for immediate action to prevent further serious complications such as seizures. The potassium and calcium levels vary slightly from normal but do not require immediate action by the nurse. The phosphate level is normal

Which assessment finding for a patient who has been admitted with a right calf venous thromboembolism (VTE) requires immediate action by the nurse? a. Erythema of right lower leg b. Complaint of right calf pain c. New onset shortness of breath d. Temperature of 100.4 F (38 C)

c. New onset shortness of breath

Which nursing action can the registered nurse (RN) delegate to experienced unlicensed assistive personnel (UAP) working as a telemetry technician on the cardiac care unit? a. Decide whether a patients heart rate of 116 requires urgent treatment. b. Monitor a patients level of consciousness during synchronized cardioversion. c. Observe cardiac rhythms for multiple patients who have telemetry monitoring. d. Select the best lead for monitoring a patient admitted with acute coronary syndrome

c. Observe cardiac rhythms for multiple patients who have telemetry monitoring. Feedback UAP serving as telemetry technicians can monitor cardiac rhythms for individuals or groups of patients.Nursing actions such as assessment and choice of the most appropriate lead based on ST segment elevationlocation require RN-level education and scope of practice

A patient with chronic obstructive pulmonary disease (COPD) has a nursing diagnosis of imbalanced nutrition: less than body requirements. Which intervention would be most appropriate for the nurse to include in the plan of care? a. Encourage increased intake of whole grains. b. Increase the patients intake of fruits and fruit juices. c. Offer high-calorie snacks between meals and at bedtime. d. Assist the patient in choosing foods with high vegetable and mineral content.

c. Offer high-calorie snacks between meals and at bedtime.

After receiving change-of-shift report, which patient should the nurse assess first? a. Patient with serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping b. Patient with serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water c. Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes d. Patient with serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium-phosphate precipitates

c. Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes The low magnesium level and neuromuscular irritability suggest that the patient may be at risk for seizures.The other patients have mild electrolyte disturbances and/or symptoms that require action, but they are not at risk for life-threatening complications

When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care? a. Apply an eye patch to the right eye. b. Approach the patient from the right side. c. Place objects needed on the patients left side. d. Teach the patient that the left visual deficit will resolve

c. Place objects needed on the patients left side. During the acute period, the nurse should place objects on the patients unaffected side. Because there is a visual defect in the right half of each eye, an eye patch is not appropriate. The patient should be approached from the left side. The visual deficit may not resolve, although the patient can learn to compensate for the defect.

A patient in metabolic alkalosis is admitted to the emergency department, and pulse oximetry (SpO2)indicates that the O2 saturation is 94%. Which action should the nurse take next? a. Administer bicarbonate. b. Complete a head-to-toe assessment. c. Place the patient on high-flow oxygen. d. Obtain repeat arterial blood gases (ABGs).

c. Place the patient on high-flow oxygen.

The nurse observes a student who is listening to a patients lungs who is having no problems with breathing. Which action by the student indicates a need to review respiratory assessment skills? a. The student starts at the apices of the lungs and moves to the bases. b. The student compares breath sounds from side to side avoiding bony areas. c. The student places the stethoscope over the posterior chest and listens during inspiration. d. The student instructs the patient to breathe slowly and a little more deeply than normal through the mouth.

c. The student places the stethoscope over the posterior chest and listens during inspiration.

When a patient with splenomegaly is scheduled for splenectomy, which action will the nurse include in the preoperative plan of care? a. Discourage deep breathing to reduce risk for splenic rupture. b. Teach the patient to use ibuprofen (Advil) for left upper quadrant pain. c. Schedule immunization with the pneumococcal vaccine (Pneumovax). d. Avoid the use of acetaminophen (Tylenol) for 2 weeks prior to surgery.

c. Schedule immunization with the pneumococcal vaccine (Pneumovax).

A patient newly diagnosed with asthma is being discharged. The nurse anticipates including which topic in the discharge teaching? a. Use of long-acting b-adrenergic medications b. Side effects of sustained-release theophylline c. Self-administration of inhaled corticosteroids d. Complications associated with oxygen therapy

c. Self-administration of inhaled corticosteroids

A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretichormone (SIADH). The nurse should notify the health care provider about which assessment finding? a. Reported weight gain b. Serum hematocrit of 42% c. Serum sodium level of 120 mg/dL d. Total urinary output of 280 mL during past 8 hours

c. Serum sodium level of 120 mg/dL

The registered nurse (RN) is caring for a patient with a hypertensive crisis who is receiving sodium nitroprusside (Nipride). Which nursing action can the nurse delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Titrate nitroprusside to decrease mean arterial pressure (MAP) to 115 mm Hg. b. Evaluate effectiveness of nitroprusside therapy on blood pressure (BP). c. Set up the automatic blood pressure machine to take BP every 15 minutes. d. Assess the patients environment for adverse stimuli that might increase BP.

c. Set up the automatic blood pressure machine to take BP every 15 minutes.

A patient has not been sleeping well because he is worried about losing his job and not being able to support his family. The nurse takes the patient's vital signs and notes a pulse rate of 112 beats/min, respirations are 26 breaths/min, and his blood pressure is 166/88 instead his usual 110-120/76-84 range. Which nursing intervention or recommendation should be used first? a. Go to sleep 30-60 minutes earlier each night to increase rest. b. Relax by spending more time playing with his pet dog. c. Slow and deepen breathing via use of a positive, repeated word. d. Consider that a new job might be better than his present one.

c. Slow and deepen breathing via use of a positive, repeated word. The patient is responding to stress with increased arousal of the sympathetic nervous system, as evident in his elevated vital signs. These will have a negative effect on his health and increase his perception of being anxious and stressed. Stimulating the parasympathetic nervous system (i.e., Benson's relaxation response) will counter the sympathetic nervous system's arousal,normalizing these vital-sign changes and reducing the physiologic demands stress is placing on his body. Other options do not address his physiologic response pattern as directly or immediately.

An older patient has been diagnosed with possible white coat hypertension. Which action will the nurseplan to take next? a. Schedule the patient for regular blood pressure (BP) checks in the clinic. b. Instruct the patient about the need to decrease stress levels. c. Tell the patient how to self-monitor and record BPs at home. d. Inform the patient that ambulatory blood pressure monitoring will be needed.

c. Tell the patient how to self-monitor and record BPs at home.

A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why aperipherally inserted central catheter was inserted. Which response by the nurse is most appropriate? a. There is a decreased risk for infection when 25% dextrose is infused through a central line. b. The prescribed infusion can be given much more rapidly when the patient has a central line. c. The 25% dextrose is hypertonic and will be more rapidly diluted when given through a central line. d. The required blood glucose monitoring is more accurate when samples are obtained from a central line

c. The 25% dextrose is hypertonic and will be more rapidly diluted when given through a central line.

Which action by a nurse who is giving fondaparinux (Arixtra) to a patient with a lower leg venousthromboembolism (VTE) indicates that more education about the drug is needed? a. The nurse avoids rubbing the injection site after giving the drug. b. The nurse injects the drug into the abdominal subcutaneous tissue. c. The nurse ejects the air bubble in the syringe before giving the drug. d. The nurse fails to assess the partial thromboplastin time (PTT) before giving the drug.

c. The nurse ejects the air bubble in the syringe before giving the drug.

The nurse interviews a patient with a new diagnosis of chronic obstructive pulmonary disease (COPD).Which information is most helpful in confirming a diagnosis of chronic bronchitis? a. The patient tells the nurse about a family history of bronchitis. b. The patients history indicates a 30 pack-year cigarette history. c. The patient complains about a productive cough every winter for 3 months. d. The patient denies having any respiratory problems until the last 12 months.

c. The patient complains about a productive cough every winter for 3 months.

During change-of-shift report, the nurse obtains the following information about a hypertensive patient who received the first dose of nadolol (Corgard) during the previous shift. Which information indicates that the patient needs immediate intervention? a. The patients most recent blood pressure (BP) reading is 158/91 mm Hg. b. The patients pulse has dropped from 68 to 57 beats/minute. c. The patient has developed wheezes throughout the lung fields. d. The patient complains that the fingers and toes feel quite cold.

c. The patient has developed wheezes throughout the lung fields.

The nurse teaches a patient with chronic bronchitis about a new prescription for Advair Diskus (combined fluticasone and salmeterol). Which action by the patient would indicate to the nurse that teaching about medication administration has been successful? a. The patient shakes the device before use. b. The patient attaches a spacer to the Diskus. c. The patient rapidly inhales the medication. d. The patient performs huff coughing after inhalation

c. The patient rapidly inhales the medication.

A 68-year-old patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin? a. The patient has dysphasia. b. The patient has atrial fibrillation. c. The patient reports that symptoms began with a severe headache. d. The patient has a history of brief episodes of right-sided hemiplegia.

c. The patient reports that symptoms began with a severe headache.

The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). Which information obtained from the patient would prompt the nurse to consult with the health care provider before administering the prescribed theophylline? a. The patient reports a recent 15-pound weight gain. b. The patient denies any shortness of breath at present. c. The patient takes cimetidine (Tagamet) 150 mg daily. d. The patient complains about coughing up green mucus.

c. The patient takes cimetidine (Tagamet) 150 mg daily.

The nurse takes an admission history on a patient with possible asthma who has new-onset wheezing and shortness of breath. Which information may indicate a need for a change in therapy? a. The patient has chronic inflammatory bowel disease. b. The patient has a history of pneumonia 6 months ago. c. The patient takes propranolol (Inderal) for hypertension. d. The patient uses acetaminophen (Tylenol) for headaches

c. The patient takes propranolol (Inderal) for hypertension.

Which stroke risk factor for a 48-year-old male patient in the clinic is most important for the nurse to address? a. The patient is 25 pounds above the ideal weight. b. The patient drinks a glass of red wine with dinner daily. c. The patients usual blood pressure (BP) is 170/94 mm Hg. d. The patient works at a desk and relaxes by watching television.

c. The patients usual blood pressure (BP) is 170/94 mm Hg. Hypertension is the single most important modifiable risk factor. People who drink more than 1 (for women)or 2 (for men) alcoholic beverages a day may increase risk for hypertension. Physical inactivity and obesity contribute to stroke risk but not as much as hypertension.

Which information will the nurse include when teaching a patient who is scheduled for a radiofrequency catheter ablation for treatment of atrial flutter? a. The procedure will prevent or minimize the risk for sudden cardiac death. b. The procedure will use cold therapy to stop the formation of the flutter waves. c. The procedure will use electrical energy to destroy areas of the conduction system. d. The procedure will stimulate the growth of new conduction pathways between the atria.

c. The procedure will use electrical energy to destroy areas of the conduction system.

The nurse assesses a patient with a history of asthma. Which assessment finding indicates that the nurse should take immediate action? a. Pulse oximetry reading of 91% b. Respiratory rate of 26 breaths/minute c. Use of accessory muscles in breathing d. Peak expiratory flow rate of 240 L/minute

c. Use of accessory muscles in breathing Use of accessory muscle indicates that the patient is experiencing respiratory distress and rapid intervention is needed. The other data indicate the need for ongoing monitoring and assessment but do not suggest that immediate treatment is required.

A patient is scheduled for pulmonary function testing. Which action should the nurse take to prepare the patient for this procedure a. Give the rescue medication immediately before testing. b. Administer oral corticosteroids 2 hours before the procedure. c. Withhold bronchodilators for 6 to 12 hours before the examination. d. Ensure that the patient has been NPO for several hours before the test

c. Withhold bronchodilators for 6 to 12 hours before the examination.

A 54-year-old woman with acute myelogenous leukemia (AML) is considering treatment with a hematopoietic stem cell transplant (HSCT). The best approach for the nurse to assist the patient with a treatment decision is to a. emphasize the positive outcomes of a bone marrow transplant. b. discuss the need for adequate insurance to cover post-HSCT care. c. ask the patient whether there are any questions or concerns about HSCT. d. explain that a cure is not possible with any other treatment except HSCT.

c. ask the patient whether there are any questions or concerns about HSCT. Offering the patient an opportunity to ask questions or discuss concerns about HSCT will encourage the patient to voice concerns about this treatment and also will allow the nurse to assess whether the patient needs more information about the procedure. Treatment of AML using chemotherapy is another option for the patient. It is not appropriate for the nurse to ask the patient to consider insurance needs in making this decision.

A 47-year-old patient will attempt oral feedings for the first time since having a stroke. The nurse should assess the gag reflex and then a. order a varied pureed diet. b. assess the patients appetite. c. assist the patient into a chair. d. offer the patient a sip of juice.

c. assist the patient into a chair.

A 23-year-old patient tells the health care provider about experiencing cold, numb fingers when running during the winter and Raynauds phenomenon is suspected. The nurse will anticipate teaching the patient about tests for a. hyperglycemia. b. hyperlipidemia. c. autoimmune disorders. d. coronary artery disease.

c. autoimmune disorders.

A 52-year-old patient has a new diagnosis of pernicious anemia. The nurse determines that the patient understands the teaching about the disorder when the patient states, I a. need to start eating more red meat and liver. b. will stop having a glass of wine with dinner. c. could choose nasal spray rather than injections of vitamin B12. d. will need to take a proton pump inhibitor like omeprazole (Prilosec).

c. could choose nasal spray rather than injections of vitamin B12.

The patient has type B chronic obstructive pulmonary disease (COPD) exacerbated by an acute upper respiratory infection. Which blood gas values should the nurse expect to see? a. pH high, PaCO2 high, HCO3 - high b. pH low, PaCO2 low, HCO3 - low c. pH low, PaCO2 high, HCO3 - high d. pH low, PaCO2 high, HCO3 - normal

c. pH low, PaCO2 high, HCO3 - high

The nurse performing an assessment with a patient who has chronic peripheral artery disease (PAD) of the legs and an ulcer on the right second toe would expect to find a. dilated superficial veins. b. swollen, dry, scaly ankles. c. prolonged capillary refill in all the toes. d. a serosanguineous drainage from the ulcer.

c. prolonged capillary refill in all the toes.

A patient reports dizziness and shortness of breath for several days. During cardiac monitoring in theemergency department (ED), the nurse obtains the following electrocardiographic (ECG) tracing. The nurse interprets this heart rhythm as a. junctional escape rhythm. b. accelerated idioventricular rhythm. c. third-degree atrioventricular (AV) block. d. sinus rhythm with premature atrial contractions (PACs).

c. third-degree atrioventricular (AV) block.

The nurse has telephone messages from four patients who requested information and assistance. Which one should the nurse refer to a social worker or community agency first? a. "Is there a place that I can dispose of my unused morphine pills?" b. "I want to lose at least 20 pounds without getting sick this time." c. "I think I have asthma because I cough when dogs are near." d. "I ran out of money and am cutting my insulin dose in half."

d. "I ran out of money and am cutting my insulin dose in half." Decreasing an insulin dose by half creates high risk of diabetic ketoacidosis, and this patient has the highest priority. The other patients have less priority due to lower risk situations with longer time course before development of an acid-base imbalance. The coughing when dogs are near is not a sign of a severe asthma episode that causes respiratory acidosis, although this patient does need attention after the insulin situation is handled. Disposing of morphine properly helps prevent respiratory acidosis from opioid overdose. Guidance regarding weight loss helps prevent starvation ketoacidosis.

A patient tells the nurse, "I'm told that I should reduce the stress in my life, but I have no idea where to start." Which would bethe best initial nursing response? a. "Why not start by learning to meditate? That technique will cover everything." b. "In cases like yours, physical exercise works to elevate mood and reduce anxiety." c. "Reading about stress and how to manage it might be a good place to start." d. "Let's talk about what is going on in your life and then look at possible options."

d. "Let's talk about what is going on in your life and then look at possible options."

The nurse has received change-of-shift report about the following patients on the progressive care unit.Which patient should the nurse see first? a. A patient who is in a sinus rhythm, rate 98, after having electrical cardioversion 2 hours ago b. A patient with new onset atrial fibrillation, rate 88, who has a first dose of warfarin (Coumadin) due c. A patient with second-degree atrioventricular (AV) block, type 1, rate 60, who is dizzy when ambulating d. A patient whose implantable cardioverter-defibrillator (ICD) fired two times today who has a dose of amiodarone (Cordarone) due

d. A patient whose implantable cardioverter-defibrillator (ICD) fired two times today who has a dose of amiodarone (Cordarone) due

Which laboratory test will the nurse use to determine whether filgrastim (Neupogen) is effective for a patient with acute lymphocytic leukemia who is receiving chemotherapy? a. Platelet count b. Reticulocyte count c. Total lymphocyte count d. Absolute neutrophil count

d. Absolute neutrophil count Filgrastim increases the neutrophil count and function in neutropenic patients. Although total lymphocyte,platelet, and reticulocyte counts also are important to monitor in this patient, the absolute neutrophil count is used to evaluate the effects of filgrastim.

Which laboratory result will the nurse expect to show a decreased value if a patient develops heparin induced thrombocytopenia (HIT)? a. Prothrombin time b. Erythrocyte count c. Fibrinogen degradation products d. Activated partial thromboplastin time

d. Activated partial thromboplastin time Platelet aggregation in HIT causes neutralization of heparin, so that the activated partial thromboplastin timewill be shorter and more heparin will be needed to maintain therapeutic levels. The other data will not beaffected by HIT.

A patient admitted with possible stroke has been aphasic for 3 hours and his current blood pressure (BP) is 174/94 mm Hg. Which order by the health care provider should the nurse question? a. Keep head of bed elevated at least 30 degrees. b. Infuse normal saline intravenously at 75 mL/hr. c. Administer tissue plasminogen activator (tPA) per protocol. d. Administer a labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg.

d. Administer a labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg

Which topic should the nurse include in patient teaching for a patient with a venous stasis ulcer on the left lower leg? a. Need to increase carbohydrate intake b. Methods of keeping the wound area dry c. Purpose of prophylactic antibiotic therapy d. Application of elastic compression stockings

d. Application of elastic compression stockings

A patient develops sinus bradycardia at a rate of 32 beats/minute, has a blood pressure (BP) of 80/42 mmHg, and is complaining of feeling faint. Which actions should the nurse take next? a. Recheck the heart rhythm and BP in 5 minutes. b. Have the patient perform the Valsalva maneuver. c. Give the scheduled dose of diltiazem (Cardizem). d. Apply the transcutaneous pacemaker (TCP) pads

d. Apply the transcutaneous pacemaker (TCP) pads.

A patient who has a history of chronic obstructive pulmonary disease (COPD) was hospitalized for increasing shortness of breath and chronic hypoxemia (SaO2 levels of 89% to 90%). In planning for discharge, which action by the nurse will be most effective in improving compliance with discharge teaching? a. Start giving the patient discharge teaching on the day of admission. b. Have the patient repeat the instructions immediately after teaching. c. Accomplish the patient teaching just before the scheduled discharge. d. Arrange for the patients caregiver to be present during the teaching.

d. Arrange for the patients caregiver to be present during the teaching. Hypoxemia interferes with the patients ability to learn and retain information, so having the patients caregiver present will increase the likelihood that discharge instructions will be followed. Having the patient repeat the instructions will indicate that the information is understood at the time, but it does not guarantee retention of the information. Because the patient is likely to be distracted just before discharge, giving discharge instructions just before discharge is not ideal. The patient is likely to be anxious and even more hypoxemic than usual on the day of admission, so teaching about discharge should be postponed.

A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. It is most appropriate for the nurse to take which action? a. Assess for facial muscle spasms. b. Ask the patient about loose stools. c. Suggest that the patient avoid orange juice with meals. d. Ask the health care provider to order a basic metabolic panel.

d. Ask the health care provider to order a basic metabolic panel.

The nurse palpates the posterior chest while the patient says 99 and notes absent fremitus. Which action should the nurse take next? a. Palpate the anterior chest and observe for barrel chest. b. Encourage the patient to turn, cough, and deep breathe. c. Review the chest x-ray report for evidence of pneumonia. d. Auscultate anterior and posterior breath sounds bilaterally.

d. Auscultate anterior and posterior breath sounds bilaterally. Feedback To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration when the patient repeats a word or phrase such as 99. After noting absent fremitus, the nurse should then auscultate the lungs to assess for the presence or absence of breath sounds. Absent fremitus may be noted with pneumothoraxor atelectasis. The vibration is increased in conditions such as pneumonia, lung tumors, thick bronchialsecretions, and pleural effusion. Turning, coughing, and deep breathing is an appropriate intervention foratelectasis, but the nurse needs to first assess breath sounds. Fremitus is decreased if the hand is farther from the lung or the lung is hyperinflated (barrel chest).The anterior of the chest is more difficult to palpate for fremitus because of the presence of large muscles and breast tissue.

When assessing the respiratory system of an older patient, which finding indicates that the nurse should take immediate action? a. Weak cough effort b. Barrel-shaped chest c. Dry mucous membranes d. Bilateral crackles at lung bases

d. Bilateral crackles at lung bases

A patients cardiac monitor shows sinus rhythm, rate 64. The P-R interval is 0.18 seconds at 1:00 AM, 0.22seconds at 2:30 PM, and 0.28 seconds at 4:00 PM. Which action should the nurse take next? a. Place the transcutaneous pacemaker pads on the patient b. Administer atropine sulfate 1 mg IV per agency dysrhythmia protocol. c. Document the patients rhythm and assess the patients response to the rhythm. d. Call the health care provider before giving the next dose of metoprolol (Lopressor).

d. Call the health care provider before giving the next dose of metoprolol (Lopressor).

A patient's serum electrolytes are being monitored. The nurse notices that the potassium level is low. What should the nurse monitor for in this patient? a. Tissue ischemia b. Brain malformations c. Intestinal blockage d. Cardiac dysrhythmia

d. Cardiac dysrhythmia

A patient has just been diagnosed with hypertension and has been started on captopril (Capoten). Which information is important to include when teaching the patient about this medication? a. Check blood pressure (BP) in both arms before taking the medication. b. Increase fluid intake if dryness of the mouth is a problem. c. Include high-potassium foods such as bananas in the diet d. Change position slowly to help prevent dizziness and falls.

d. Change position slowly to help prevent dizziness and falls.

A patient is being evaluated for post-thrombotic syndrome. Which assessment will the nurse perform? a. Ask about leg pain with exercise. b. Determine the ankle-brachial index. c. Assess capillary refill in the patients toes. d. Check for presence of lipodermatosclerosis

d. Check for presence of lipodermatosclerosis

A patient with severe chronic obstructive pulmonary disease (COPD) tells the nurse, I wish I were dead! Im just a burden on everybody. Based on this information, which nursing diagnosis is most appropriate? a. Complicated grieving related to expectation of death b. Ineffective coping related to unknown outcome of illness c. Deficient knowledge related to lack of education about COPD d. Chronic low self-esteem related to increased physical dependence

d. Chronic low self-esteem related to increased physical dependence

A 73-year-old patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find? a. Impulsive behavior b. Right-sided neglect c. Hyperactive left-sided tendon reflexes d. Difficulty comprehending instructions Correct answer d. Difficulty comprehending instructions

d. Difficulty comprehending instructions

A patient who has been receiving a heparin infusion and warfarin (Coumadin) for a deep vein thrombosis(DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when her platelet level drops to 110,000/L. Which action will the nurse include in the plan of care? a. Use low-molecular-weight heparin (LMWH) only. b. Administer the warfarin (Coumadin) at the scheduled time. c. Teach the patient about the purpose of platelet transfusions. d. Discontinue heparin and flush intermittent IV lines using normal saline

d. Discontinue heparin and flush intermittent IV lines using normal saline

The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan? a. Maintain the patient on bed rest. b. Auscultate lung sounds every 4 hours. c. Monitor for Trousseaus and Chvosteks signs. d. Encourage fluid intake up to 4000 mL every day.

d. Encourage fluid intake up to 4000 mL every day.

Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective? a. I will try to drink at least 8 glasses of water every day. b. I will use a salt substitute to decrease my sodium intake. c. I will increase my intake of potassium-containing foods. d. I will drink apple juice instead of orange juice for breakfast.

d. I will drink apple juice instead of orange juice for breakfast.

Postural drainage with percussion and vibration is ordered twice daily for a patient with chronic bronchitis. Which intervention should the nurse include in the plan of care? a. Schedule the procedure 1 hour after the patient eats. b. Maintain the patient in the lateral position for 20 minutes. c. Perform percussion before assisting the patient to the drainage position. d. Give the ordered albuterol (Proventil) before the patient receives the therapy.

d. Give the ordered albuterol (Proventil) before the patient receives the therapy.

A 55-year-old patient with increasing dyspnea is being evaluated for a possible diagnosis of chronicobstructive pulmonary disease (COPD). When teaching a patient about pulmonary function testing (PFT) for this condition, what is the most important question the nurse should ask? a. Are you claustrophobic? b. Are you allergic to shellfish? c. Do you have any metal implants or prostheses? d. Have you taken any bronchodilators in the past 6 hours?

d. Have you taken any bronchodilators in the past 6 hours? Pulmonary function testing will help establish the COPD diagnosis. Bronchodilators should be avoided at least6 hours before the test. PFTs do not involve being placed in an enclosed area such as for magnetic resonance imaging (MRI). Contrast dye is not used for PFTs. The patient may still have PFTs done if metal implants or prostheses are present, as these are contraindications for an MRI.

Which nursing intervention for a patient who had an open repair of an abdominal aortic aneurysm 2 dayspreviously is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a. Monitor the quality and presence of the pedal pulses. b. Teach the patient the signs of possible wound infection. c. Check the lower extremities for strength and movement. d. Help the patient to use a pillow to splint while coughing.

d. Help the patient to use a pillow to splint while coughing.

Which information should the nurse include when teaching a patient with newly diagnosed hypertension? a. Increasing physical activity will control blood pressure (BP) for most patients. b. Most patients are able to control BP through dietary changes. c. Annual BP checks are needed to monitor treatment effectiveness. d. Hypertension is usually asymptomatic until target organ damage occurs

d. Hypertension is usually asymptomatic until target organ damage occurs

After providing a patient with discharge instructions on the management of a new permanent pacemaker,the nurse knows that teaching has been effective when the patient states a. I will avoid cooking with a microwave oven or being near one in use. b. It will be 1 month before I can take a bath or return to my usual activities. c. I will notify the airlines when I make a reservation that I have a pacemaker. d. I wont lift the arm on the pacemaker side up very high until I see the doctor.

d. I wont lift the arm on the pacemaker side up very high until I see the doctor. The patient is instructed to avoid lifting the arm on the pacemaker side above the shoulder to avoid displacing the pacemaker leads. The patient should notify airport security about the presence of a pacemaker before going through the metal detector, but there is no need to notify the airlines when making a reservation. Microwave oven use does not affect the pacemaker. The insertion procedure involves minor surgery that will have a short recovery period.

The nurse admits a patient who has a diagnosis of an acute asthma attack. Which statement indicates that the patient may need teaching regarding medication use? a. I have not had any acute asthma attacks during the last year. b. I became short of breath an hour before coming to the hospital. c. Ive been taking Tylenol 650 mg every 6 hours for chest-wall pain. d. Ive been using my albuterol inhaler more frequently over the last 4 days.

d. Ive been using my albuterol inhaler more frequently over the last 4 days. The increased need for a rapid-acting bronchodilator should alert the patient that an acute attack may beimminent and that a change in therapy may be needed. The patient should be taught to contact a health careprovider if this occurs. The other data do not indicate any need for additional teaching.

A patient who has non-Hodgkins lymphoma is receiving combination treatment with rituximab (Rituxan) and chemotherapy. Which patient assessment finding requires the most rapid action by the nurse? a. Anorexia b. Vomiting c. Oral ulcers d. Lip swelling

d. Lip swelling

While working in the outpatient clinic, the nurse notes that a patient has a history of intermittentclaudication. Which statement by the patient would support this information? a. When I stand too long, my feet start to swell. b. I get short of breath when I climb a lot of stairs. c. My fingers hurt when I go outside in cold weather. d. My legs cramp whenever I walk more than a block.

d. My legs cramp whenever I walk more than a block. Cramping that is precipitated by a consistent level of exercise is descriptive of intermittent claudication. Fingerpain associated with cold weather is typical of Raynauds phenomenon. Shortness of breath that occurs with exercise is not typical of intermittent claudication, which is reproducible. Swelling associated with prolonged standing is typical of venous disease.

Following successful treatment of Hodgkins lymphoma for a 55-year-old woman, which topic will the nurse include in patient teaching? a. Potential impact of chemotherapy treatment on fertility b. Application of soothing lotions to treat residual pruritus c. Use of maintenance chemotherapy to maintain remission d. Need for follow-up appointments to screen for malignancy

d. Need for follow-up appointments to screen for malignancy The chemotherapy used in treating Hodgkins lymphoma results in a high incidence of secondary malignancies;follow-up screening is needed. The fertility of a 55-year-old woman will not be impacted by chemotherapy.Maintenance chemotherapy is not used for Hodgkins lymphoma. Pruritus is a clinical manifestation of lymphoma, but should not be a concern after treatment.

A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first? a. Complete blood count (CBC) b. Chest radiograph (Chest x-ray) c. 12-Lead electrocardiogram (ECG) d. Noncontrast computed tomography (CT) scan

d. Noncontrast computed tomography (CT) scan

The health care provider has prescribed bed rest with the feet elevated for a patient admitted to the hospital with venous thromboembolism. Which action by the nurse to elevate the patients feet is best? a. The patient is placed in the Trendelenburg position. b. Two pillows are positioned under the affected leg. c. The bed is elevated at the knee and pillows are placed under the feet. d. One pillow is placed under the thighs and two pillows are placed under the lower legs.

d. One pillow is placed under the thighs and two pillows are placed under the lower legs. The purpose of elevating the feet is to enhance venous flow from the feet to the right atrium, which is best accomplished by placing two pillows under the feet and one under the thighs. Placing the patient in the Trendelenburg position will lower the head below heart level, which is not indicated for this patient. Placing pillows under the calf or elevating the bed at the knee may cause blood stasis at the calf level.

A patient hospitalized with chronic obstructive pulmonary disease (COPD) is being discharged home on oxygen therapy. Which instruction should the nurse include in the discharge teaching? a. Storage of oxygen tanks will require adequate space in the home. b. Travel opportunities will be limited because of the use of oxygen. c. Oxygen flow should be increased if the patient has more dyspnea. d. Oxygen use can improve the patients prognosis and quality of life.

d. Oxygen use can improve the patients prognosis and quality of life. Feedback The use of home oxygen improves quality of life and prognosis. Because increased dyspnea may be a symptom of an acute process such as pneumonia, the patient should notify the physician rather than increasing the oxygen flow rate if dyspnea becomes worse. Oxygen can be supplied using liquid, storage tanks, or concentrators, depending on individual patient circumstances. Travel is possible using portable oxygen concentrators

The nurse is caring for a 70-year-old who uses hydrochlorothiazide (HydroDIURIL) and enalapril(Norvasc), but whose self-monitored blood pressure (BP) continues to be elevated. Which patient information may indicate a need for a change? a. Patient takes a daily multivitamin tablet. b. Patient checks BP daily just after getting up. c. Patient drinks wine three to four times a week. d. Patient uses ibuprofen (Motrin) daily to treat osteoarthritis

d. Patient uses ibuprofen (Motrin) daily to treat osteoarthritis

A young adult patient with cystic fibrosis (CF) is admitted to the hospital with increased dyspnea. Which intervention should the nurse include in the plan of care? a. Schedule a sweat chloride test. b. Arrange for a hospice nurse visit. c. Place the patient on a low-sodium diet. d. Perform chest physiotherapy every 4 hours.

d. Perform chest physiotherapy every 4 hours.

A patient who was recently diagnosed with diabetes is having trouble concentrating. This patient is usually very organized and laid back. Which action should the nurse take? a. Ask the healthcare provider for a psychiatric referral. b. Administer the PRN sedative medication every 4 hours. c. Suggest the use of a home caregiver to the patient's family. d. Plan to reinforce and repeat teaching about diabetes management

d. Plan to reinforce and repeat teaching about diabetes management.

A patient who was admitted with a myocardial infarction experiences a 45-second episode of ventricular tachycardia, then converts to sinus rhythm with a heart rate of 98 beats/minute. Which of the following actions should the nurse take next? a. Immediately notify the health care provider. b. Document the rhythm and continue to monitor the patient. c. Perform synchronized cardioversion per agency dysrhythmia protocol. d. Prepare to give IV amiodarone (Cordarone) per agency dysrhythmia protocol.

d. Prepare to give IV amiodarone (Cordarone) per agency dysrhythmia protocol.

Which clinical management prevention concept would the nurse identify as representative of secondary prevention? a. Decreasing venous stasis and risk for pulmonary emboli b. Implementation of strict hand washing routines c. Maintaining current vaccination schedules d. Prevention of pneumonia in patients with chronic lung disease

d. Prevention of pneumonia in patients with chronic lung disease Prevention of and treatment of existing health problems to avoid further complications is an example of secondary prevention.Primary prevention includes infection control (hand washing), smoking cessation, immunizations, and prevention of postoperative complications

When analyzing the rhythm of a patients electrocardiogram (ECG), the nurse will need to investigate further upon finding a(n) a. isoelectric ST segment. b. P-R interval of 0.18 second. c. Q-T interval of 0.38 second. d. QRS interval of 0.14 second.

d. QRS interval of 0.14 second.

Using the illustrated technique, the nurse is assessing for which finding in a patient with chronicobstructive pulmonary disease (COPD)? a. Hyperresonance b. Tripod positioning c. Accessory muscle use d. Reduced chest expansion

d. Reduced chest expansion

A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

d. Respiratory alkalosis The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO3.

Which statement by a patient indicates good understanding of the nurses teaching about prevention of sickle cell crisis? a. Home oxygen therapy is frequently used to decrease sickling. b. There are no effective medications that can help prevent sickling. c. Routine continuous dosage narcotics are prescribed to prevent a crisis. d. Risk for a crisis is decreased by having an annual influenza vaccination.

d. Risk for a crisis is decreased by having an annual influenza vaccination.

Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness (LOC). Which nursing diagnosis do they determine has the highest priority for the patient? a. Impaired physical mobility related to weakness b. Disturbed sensory perception related to brain injury c. Risk for impaired skin integrity related to immobility d. Risk for aspiration related to inability to protect airway

d. Risk for aspiration related to inability to protect airway Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses are also appropriate, but interventions to prevent aspiration are the priority at this time.

Which patient information is most important for the nurse to monitor when evaluating the effectiveness of deferoxamine (Desferal) for a patient with hemochromatosis? a. Skin color b. Hematocrit c. Liver function d. Serum iron level

d. Serum iron level

Which laboratory result for a patient with multifocal premature ventricular contractions (PVCs) is mostimportant for the nurse to communicate to the health care provider? a. Blood glucose 243 mg/dL b. Serum chloride 92 mEq/L c. Serum sodium 134 mEq/L d. Serum potassium 2.9 mEq/L

d. Serum potassium 2.9 mEq/L

The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient? a. Supine with the head of the bed elevated 30 degrees b. In a high-Fowlers position with the left arm extended c. On the right side with the left arm extended above the head d. Sitting upright with the arms supported on an over bed table

d. Sitting upright with the arms supported on an over bed table

A patient with chronic obstructive pulmonary disease (COPD) has a nursing diagnosis of impaired breathing pattern related to anxiety. Which nursing action is most appropriate to include in the plan of care? a. Titrate oxygen to keep saturation at least 90%. b. Discuss a high-protein, high-calorie diet with the patient. c. Suggest the use of over-the-counter sedative medications. d. Teach the patient how to effectively use pursed lip breathing

d. Teach the patient how to effectively use pursed lip breathing Pursed lip breathing techniques assist in prolonging the expiratory phase of respiration and decrease air trapping. There is no indication that the patient requires oxygen therapy or an improved diet. Sedative medications should be avoided because they decrease respiratory drive.

The nurse analyzes the results of a patients arterial blood gases (ABGs). Which finding would requireimmediate action? a. The bicarbonate level (HCO3) is 31 mEq/L. b. The arterial oxygen saturation (SaO2) is 92%. c. The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg. d. The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.

d. The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.

After the nurse teaches the patient with stage 1 hypertension about diet modifications that should be implemented, which diet choice indicates that the teaching has been effective? a. The patient avoids eating nuts or nut butters. b. The patient restricts intake of chicken and fish. c. The patient has two cups of coffee in the morning. d. The patient has a glass of low-fat milk with each meal.

d. The patient has a glass of low-fat milk with each meal. For the prevention of hypertension, the Dietary Approaches to Stop Hypertension (DASH) recommendations include increasing the intake of calcium-rich foods. Caffeine restriction and decreased protein intake are not included in the recommendations. Nuts are high in beneficial nutrients and 4 to 5 servings weekly are recommended in the DASH diet.

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with anintracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a. The patients speech is difficult to understand. b. The patients blood pressure is 144/90 mm Hg. c. The patient takes a diuretic because of a history of hypertension. d. The patient has atrial fibrillation and takes warfarin (Coumadin).

d. The patient has atrial fibrillation and takes warfarin (Coumadin).

An older patient presents to the outpatient clinic with a chief complaint of headache and insomnia. In gathering the history, the nurse notes which factors as contributing to this patient's chief complaint? a. The patient is responsible for caring for two school-age grandchildren. b. The patient's daughter works to support the family. c. The patient is being treated for hypertension and is overweight. d. The patient has recently lost her spouse and needed to move in with her daughter.

d. The patient has recently lost her spouse and needed to move in with her daughter.

The nurse teaches a patient how to administer formoterol (Perforomist) through a nebulizer. Which action by the patient indicates good understanding of the teaching? a. The patient attaches a spacer before using the inhaler. b. The patient coughs vigorously after using the inhaler. c. The patient activates the inhaler at the onset of expiration. d. The patient removes the facial mask when misting has ceased

d. The patient removes the facial mask when misting has ceased. A nebulizer is used to administer aerosolized medication. A mist is seen when the medication is aerosolized,and when all of the medication has been used, the misting stops. The other options refer to inhaler use.Coughing vigorously after inhaling and activating the inhaler at the onset of expiration are both incorrecttechniques when using an inhaler

The nurse teaches a patient who has asthma about peak flow meter use. Which action by the patientindicates that teaching was successful? a. The patient inhales rapidly through the peak flow meter mouthpiece. b. The patient takes montelukast (Singulair) for peak flows in the red zone. c. The patient calls the health care provider when the peak flow is in the green zone. d. The patient uses albuterol (Proventil) metered dose inhaler (MDI) for peak flows in the yellow zone

d. The patient uses albuterol (Proventil) metered dose inhaler (MDI) for peak flows in the yellow zone

The nurse completes an admission assessment on a patient with asthma. Which information given bypatient is most indicative of a need for a change in therapy? a. The patient uses albuterol (Proventil) before any aerobic exercise. b. The patient says that the asthma symptoms are worse every spring. c. The patients heart rate increases after using the albuterol (Proventil) inhaler. d. The patients only medications are albuterol (Proventil) and salmeterol (Serevent).

d. The patients only medications are albuterol (Proventil) and salmeterol (Serevent).

A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse? a. The patients radial pulse is 105 beats/minute. b. There is sediment and blood in the patients urine. c. The blood pressure increases from 120/80 to 142/94. d. There are crackles audible throughout both lung fields

d. There are crackles audible throughout both lung fields.

Which information will the nurse include in the asthma teaching plan for a patient being discharged? a. Use the inhaled corticosteroid when shortness of breath occurs. b. Inhale slowly and deeply when using the dry powder inhaler (DPI). c. Hold your breath for 5 seconds after using the bronchodilator inhaler. d. Tremors are an expected side effect of rapidly acting bronchodilators.

d. Tremors are an expected side effect of rapidly acting bronchodilators.

When discussing risk factor modification for a 63-year-old patient who has a 5-cm abdominal aorticaneurysm, the nurse will focus discharge teaching on which patient risk factor? a. Male gender b. Turner syndrome c. Abdominal trauma history d. Uncontrolled hypertension

d. Uncontrolled hypertension

Which action will be included in the plan of care when the nurse is caring for a patient who is receiving nicardipine (Cardene) to treat a hypertensive emergency? a. Keep the patient NPO to prevent aspiration caused by nausea and possible vomiting. b. Organize nursing activities so that the patient has undisturbed sleep for 6 to 8 hours at night. c. Assist the patient up in the chair for meals to avoid complications associated with immobility. d. Use an automated noninvasive blood pressure machine to obtain frequent blood pressure (BP) measurements.

d. Use an automated noninvasive blood pressure machine to obtain frequent blood pressure (BP) measurements.

The nurse needs to quickly estimate the heart rate for a patient with a regular heart rhythm. Which method will be best to use? a. Count the number of large squares in the R-R interval and divide by 300. b. Print a 1-minute electrocardiogram (ECG) strip and count the number of QRS complexes. c. Calculate the number of small squares between one QRS complex and the next and divide into 1500. d. Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10.

d. Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10.

The nurse develops a teaching plan to help increase activity tolerance at home for an older adult with severe chronic obstructive pulmonary disease (COPD). Which instructions would be most appropriate for the nurse to include in the plan of care? a. Stop exercising when short of breath. b. Walk until pulse rate exceeds 130 beats/minute. c. Limit exercise to activities of daily living (ADLs). d. Walk 15 to 20 minutes daily at least 3 times/week.

d. Walk 15 to 20 minutes daily at least 3 times/week. Encourage the patient to walk 15 to 20 minutes a day at least three times a week with gradual increases.Shortness of breath is normal with exercise and not an indication that the patient should stop. Limiting exerciseto ADLs will not improve the patients exercise tolerance. A 70-year-old patient should have a pulse rate of 120or less with exercise (80% of the maximal heart rate of 150).

A 62-year old man with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patients laboratory findings to include a. a hematocrit (Hct) of 38%. b. an RBC count of 4,500,000/mL. c. normal red blood cell (RBC) indices. d. a hemoglobin (Hgb) of 8.6 g/dL (86 g/L).

d. a hemoglobin (Hgb) of 8.6 g/dL (86 g/L).

A patient at the clinic says, I have always taken a walk after dinner, but lately my leg cramps and hurts after just a few minutes of starting. The pain goes away after I stop walking, though. The nurse should a. check for the presence of tortuous veins bilaterally on the legs. b. ask about any skin color changes that occur in response to cold. c. assess for unilateral swelling, redness, and tenderness of either leg. d. assess for the presence of the dorsalis pedis and posterior tibial pulses

d. assess for the presence of the dorsalis pedis and posterior tibial pulses

Several hours after an open surgical repair of an abdominal aortic aneurysm, the UAP reports to the nurse that urinary output for the past 2 hours has been 40 mL. The nurse notifies the health care provider and anticipates an order for a(n) a. hemoglobin count. b. additional antibiotic. c. decrease in IV infusion rate. d. blood urea nitrogen (BUN) level

d. blood urea nitrogen (BUN) level

A 56-year-old patient who has no previous history of hypertension or other health problems suddenly develops a blood pressure (BP) of 198/110 mm Hg. After reconfirming the BP, it is appropriate for the nurse to tell the patient that a. a BP recheck should be scheduled in a few weeks. b. dietary sodium and fat content should be decreased. c. there is an immediate danger of a stroke and hospitalization will be required. d. diagnosis of a possible cause, treatment, and ongoing monitoring will be needed.

d. diagnosis of a possible cause, treatment, and ongoing monitoring will be needed. A sudden increase in BP in a patient over age 50 with no previous hypertension history or risk factors indicates that the hypertension may be secondary to some other problem. The BP will need treatment and ongoing monitoring. If the patient has no other risk factors, a stroke in the immediate future is unlikely. There is no indication that dietary salt or fat intake have contributed to this sudden increase in BP, and reducing intake of salt and fat alone will not be adequate to reduce this BP to an acceptable level.

A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after atransfusion of packed red blood cells is started. The nurses first action should be to a. administer oxygen therapy at a high flow rate. b. obtain a urine specimen to send to the laboratory. c. notify the health care provider about the symptoms. d. disconnect the transfusion and infuse normal saline.

d. disconnect the transfusion and infuse normal saline.

A patient has a normal cardiac rhythm and a heart rate of 72 beats/minute. The nurse determines that the P-R interval is 0.24 seconds. The most appropriate intervention by the nurse would be to a. notify the health care provider immediately. b. give atropine per agency dysrhythmia protocol. c. prepare the patient for temporary pacemaker insertion. d. document the finding and continue to monitor the patient.

d. document the finding and continue to monitor the patient.

A 73-year-old patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the right leg. The nurse should notify the health care provider and immediately a. apply a compression stocking to the leg. b. elevate the leg above the level of the heart. c. assist the patient in gently exercising the leg. d. keep the patient in bed in the supine position.

d. keep the patient in bed in the supine position.

A critical action by the nurse caring for a patient with an acute exacerbation of polycythemia vera is to: a. place the patient on bed rest. b. administer iron supplements. c. avoid use of aspirin products. d. monitor fluid intake and output.

d. monitor fluid intake and output. Monitoring hydration status is important during an acute exacerbation because the patient is at risk for fluid overload or underhydration. Aspirin therapy is used to decrease risk for thrombosis. The patient should be encouraged to ambulate to prevent deep vein thrombosis (DVT). Iron is contraindicated in patients with polycythemia vera

The laboratory has just called with the arterial blood gas (ABG) results on four patients. Which result ismost important for the nurse to report immediately to the health care provider? a. pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97% b. pH 7.35, PaO2 85 mm Hg, PaCO2 45 mm Hg, and O2 sat 95% c. pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98% d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%

d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%

A 58-year-old patient with a left-brain stroke suddenly bursts into tears when family members visit. The nurse should a. use a calm voice to ask the patient to stop the crying behavior. b. explain to the family that depression is normal following a stroke. c. have the family members leave the patient alone for a few minutes. d. teach the family that emotional outbursts are common after strokes.

d. teach the family that emotional outbursts are common after strokes. Feedback Patients who have left-sided brain stroke are prone to emotional outbursts that are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patients outburstsuggests that depression is not the major cause of the behavior. The family should stay with the patient. Thecrying is not within the patients control and asking the patient to stop will lead to embarrassment.

A 56-year-old patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for a. surgical endarterectomy. b. transluminal angioplasty. c. intravenous heparin administration. d. tissue plasminogen activator (tPA) infusion.

d. tissue plasminogen activator (tPA) infusion.

When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral atherosclerosis a. to monitor and record the blood pressure daily. b. that Plavix will dissolve clots in the cerebral arteries. c. that Plavix will reduce cerebral artery plaque formation. d. to call the health care provider if stools are bloody or tarry.

d. to call the health care provider if stools are bloody or tarry.

The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, P-R interval not measurable, ventricular rate 162, R-R interval regular, and QRS complex wide and distorted, QRS duration 0.18 second. The nurse interprets the patients cardiac rhythm as a. atrial flutter. b. sinus tachycardia. c. ventricular fibrillation. d. ventricular tachycardia

d. ventricular tachycardia The absence of P waves, wide QRS, rate >150 beats/minute, and the regularity of the rhythm indicate ventricular tachycardia. Atrial flutter is usually regular, has a narrow QRS configuration, and has flutter waves present representing atrial activity. Sinus tachycardia has P waves. Ventricular fibrillation is irregular and does not have a consistent QRS duration