Patho/Pharm 3 Week 1, 2, 3 Combined: Midterm
A patient is receiving dabigatran (Pradaxa) 150 mg twice daily as part of treatment for atrial fibrillation. Which condition, if present, would be a concern if the patient were to receive this dose? a. Asthma b. Elevated liver enzymes c. Renal impairment d. History of myocardial infarction
c. Renal impairment
A young patient is admitted to the pediatric unit with a diagnosis of cystic fibrosis (CF) exacerbation. The nurse monitors the patient closely for which potentially fatal complication of CF? a. Airway rigidity b. Pulmonary edema c. Respiratory failure d. Asthma-like bronchospasms
c. Respiratory failure
A 6-month-old presents with rhinorrhea, cough, poor feeding, lethargy, and fever and is diagnosed with bronchiolitis. Which of the following will the nurse most likely observe on the culture report? a. Parainfluenza virus b. Haemophilus influenzae type B c. Respiratory syncytial virus d. Group A beta-hemolytic streptococcus
c. Respiratory syncytial virus
Which assessment finding by the nurse characterizes a mild concussion? a. A brief loss of consciousness b. Significant behavioral changes c. Retrograde amnesia d. Permanent confusion
c. Retrograde amnesia
A patient presents with acute low back pain. There is no history of trauma. An MRI reveals that the vertebra at L5 has slipped forward relative to those below it. Which of the following conditions will be documented on the chart? a. Degenerative disk disease b. Spondylolysis c. Spondylolisthesis d. Spinal stenosis
c. Spondylolisthesis
A 2-week-old female presents with fever, productive cough, respiratory distress, and empyema. Which of the following is the most likely diagnosis the nurse will observe on the chart? a. Viral pneumonia b. Pneumococcal pneumonia c. Staphylococcal pneumonia d. Mycoplasma pneumonia
c. Staphylococcal pneumonia
2. A patient with fluctuating levels of awareness, confusion, and disturbed orientation shouts, Bugs are crawling on my legs. Get them off! Which problem is the patient experiencing? a. Aphasia c. Tactile hallucinations b. Dystonia d. Mnemonic disturbance
c. Tactile hallucinations The patient feels bugs crawling on both legs, even though no sensory stimulus is actually present. This description meets the definition of a hallucination, a false sensory perception. Tactile hallucinations may be part of the symptom constellation of delirium. Aphasia refers to a speech disorder. Dystonia refers to excessive muscle tonus. Mnemonic disturbance is associated with dementia rather than delirium. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 432-434 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
3. Which nursing diagnoses are most applicable for a patient diagnosed with severe Alzheimers disease? Select all that apply. a. Acute confusion b. Anticipatory grieving c. Urinary incontinence d. Disturbed sleep pattern e. Risk for caregiver role strain
c. Urinary incontinence d. Disturbed sleep pattern e. Risk for caregiver role strain The correct answers are consistent with problems frequently identified for patients with late-stage Alzheimers disease. Confusion is chronic, not acute. The patients cognition is too impaired to grieve.
A 13-year-old female is diagnosed with asthma. Which of the following should the nurse teach the patient to recognize as a part of an asthmatic attack? a. Headache b. Chest pain c. Wheezing d. Low heart rate
c. Wheezing
When a patient asks, "What is the cause of multiple sclerosis?" the nurse bases the answer on the interaction between: a. vascular and metabolic factors. b. bacterial infection and the inflammatory response. c. autoimmunity and genetic susceptibility. d. neurotransmitters and inherited genes.
c. autoimmunity and genetic susceptibility.
After birth, red blood cells are normally made only in the: a. liver. b. spleen. c. bone marrow. d. kidney.
c. bone marrow.
An unstable type of hemoglobin that cannot bind with oxygen is termed: a. deoxyhemoglobin. b. oxyhemoglobin. c. methemoglobin. d. glycosylated hemoglobin.
c. methemoglobin
Fibrinolysis is mediated by: a. heparin. b. fibrinogen. c. plasmin. d. albumin.
c. plasmin
During a respiratory assessment of an infant diagnosed with respiratory distress syndrome, a depression in the supraclavicular and intercostal areas of the thorax was noted with inspiration. This observation is documented as: a. grunting. b. tachypnea. c. retractions. d. nasal flaring.
c. retractions.
Patients diagnosed with myasthenia gravis often have tumors or pathologic changes in the: a. brain. b. pancreas. c. thymus. d. lungs.
c. thymus.
A 72-year-old patient demonstrates left-sided weakness of upper and lower extremities. The symptoms lasted less than an hour and resolved with no evidence of infarction. The patient most likely experienced a(n): a. stroke in evolution. b. arteriovenous malformation. c. transient ischemic attack. d. cerebral hemorrhage.
c. transient ischemic attack.
A patient has prescriptions for two inhalers. One inhaler is a bronchodilator, and the other is a corticosteroid. Which instruction regarding these inhalers will the nurse give to the patient? a. "Take the corticosteroid inhaler first." b. "Take the bronchodilator inhaler first." c. "Take these two drugs at least 2 hours apart." d. "It does not matter which inhaler you use first."
"Take the bronchodilator inhaler first." An inhaled bronchodilator is used before the inhaled corticosteroid to provide bronchodilation before administration of the antiinflammatory drug.
On average, _____% of renal plasma flow (RPF) to the glomerulus is filtered into the Bowman's capsule.
20
Cardiac cells can withstand ischemic conditions for _____ minutes before irreversible cell injury occurs.
20 minutes Cardiac cells can withstand ischemic conditions for about 20 minutes before irreversible hypoxic injury causes cellular death (apoptosis) and tissue necrosis.
A nurse would chart that a patient is experiencing oliguria when a 24-hour urine output is less than ________ milliliters per day.
400
A patient has a metered-dose inhaler that contains 200 actuations (puffs), and it does not have a dose counter. He is to take two puffs two times a day. If he does not take any extra doses, how many days will this inhaler last at the prescribed dose?
50 days
A client with heart disease has the left ventricular ejection fraction measured. What is the normal left ventricular ejection when determined by angiocardiography? 35% - 55% 45% - 65% 55% - 75% 65% - 85%
55% - 75% Explanation: The normal left ventricular ejection fraction is usually 55 percent to 75 percent when determined by angiocardiography.
A nurse recalls the superficial cortical nephrons account for ____% of all nephrons.
85
The nurse is developing a discharge teaching plan for the family of a child with Kawasaki's disease. Which of the following is the first priority? A. Teaching parents to administer aspirin and watch for side effects. B. Monitoring the child's temperature and notifying the doctor if it is over 98.6 degrees F. C. Recommending the child avoid contact sports. D. Establishing home schooling for 6 months.
A
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 crackles and wheezes heard bilaterally c. Complaint of sharp chest pain with deep breathing d. Respiratory rate 28 breaths/minute while ambulating
A Hemoptysis may indicate life-threatening hemorrhage, and should be reported immediately to the health care provider. The other findings are frequently noted in patients with bronchiectasis and may need further assessment but are not indicators of life-threatening complications.
A nurse is assessing a patient with hypoparathyroidism. Clinical manifestations of hypoparathyroidism include: (select all that apply) a. tetany. b. Chvostek sign. c. Trousseau sign. d. oily skin. e. hair loss.
A, B, C, E - Symptoms of hypoparathyroidism include tetany, Chvostek and Trousseau signs, dry (not oily) skin, and loss of body and scalp hair.
A young adult patient is being seen in the clinic with increased secretion of the anterior pituitary hormones. The nurse would expect the laboratory test results to show a. increased urinary cortisol. b. decreased serum thyroxine. c. elevated serum aldosterone levels. d. low urinary catecholamines excretion.
A. Increased secretion of adrenocorticotropic hormone (ACTH) by the anterior pituitary gland will lead to an increase in serum and urinary cortisol levels. An increase, rather than a decrease, in thyroxine level would be expected with increased secretion of thyroid-stimulating hormone (TSH) by the anterior pituitary. Aldosterone and catecholamine levels are not controlled by the anterior pituitary.
Monocytes are blood cells that mature (differentiate) into: a. macrophages. b. neutrophils. c. eosinophils. d. mast cells.
A. macrophages
At sea level, the partial pressure of oxygen is approximately ___% (round to the nearest whole number).
ANS: 21 At sea level, the air is made up of oxygen (20.9%).
Physiologic pH is maintained around 7.4 because carbonic acid and bicarbonate exist in a ratio of: a. 20:1 b. 1:20 c. 10:2 d. 2:10
ANS: A Normal carbonic acid to bicarbonate ratio is 20:1.
The organism that causes tuberculosis is a: a. bacterium. b. fungus. c. virus. d. parasite.
ANS: A The organism that causes tuberculosis is a bacterium. Tuberculosis is not a fungus, a virus, or a parasite.
The nurse is describing the slit-shaped space between the true vocal cords. What term should the nurse use? a. Glottis b. Epiglottis c. Larynx d. Carina
ANS: A The slit-shaped space between the true vocal cords forms the glottis. The slit-shaped space between the true vocal cords is not referred to as the epiglottis, the larynx, or the carina.
A patient is receiving thrombolytic therapy, and the nurse monitors the patient for adverse effects. What is the most common undesirable effect of thrombolytic therapy? a. Dysrhythmias b. Nausea and vomiting c. Anaphylactic reactions d. Internal and superficial bleeding
d. Internal and superficial bleeding
A 3-month-old infant is at increased risk for developing anemia. The nurse would identify which principle contributing to this risk? 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.
Following a parathyroidectomy, which electrolyte should the nurse most closely monitor? a. Potassium b. Sodium c. Magnesium d. Calcium
d. Calcium Because the parathyroids are located on the thyroid gland, similar concerns for postoperative monitoring apply. Additionally, calcium levels are monitored to avoid hypocalcemic crisis.
A nurse is preparing to teach staff about the most common type of traumatic brain injury. Which type of traumatic brain injury should the nurse discuss? a. Penetrating trauma b. Diffuse axonal injury c. Focal brain injury d. Concussion
d. Concussion
Which of the following would increase a patient's risk for thrombotic stroke? a. Hyperthyroidism b. Hypertension c. Anemia d. Dehydration
d. Dehydration
The coroner ruled sudden infant death syndrome (SIDS) as the cause of death of a 5-month-old-female. Which risk factor is most likely associated with SIDS? a. Congenital heart disease b. Female gender c. White race d. Frequent respiratory infections
d. Frequent respiratory infections
What is the most common early symptom of a brain abscess? a. Neck rigidity b. Vomiting c. Drowsiness d. Headache
d. Headache
After nearly drowning a 2-year-old developed acute respiratory distress syndrome (ARDS). Which of the following should the nurse assess the patient for? a. Decreased heart rate b. Increased lung compliance c. Increased surfactant production d. Hypoxemia
d. Hypoxemia
A nurse is reviewing urinalysis results and notices glucose is present in the urine. A nurse realizes glucose will be excreted in the urine when: a. The maximum rate of glucose filtration is achieved b. The carrier molecules have reached their maximum c. Glucose is consumed d. The ability of the kidneys to regulate blood glucose is lost
ANS: B When the carrier molecules for glucose become saturated (i.e., with the development of hyperglycemia), the excess will be excreted in the urine.
A nurse remembers the majority of total airway resistance occurs in the: a. bronchi. b. nose. c. oral pharynx. d. diaphragm.
ANS: B One half to two thirds of total airway resistance occurs in the nose, not the bronchi, the oral pharynx, or the diaphragm.
A young adult who has 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. c. thrombin time. b. bleeding time. d. prothrombin time.
ANS: B The bleeding time is affected by von Willebrand disease. Platelet count, prothrombin time, and thrombin time are normal in von Willebrand disease. DIF: Cognitive Level: Understand (comprehension) REF: 626 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
A nurse recalls the pleural membranes are examples of _____ membranes. a. mucous b. serous c. synovial d. peritoneal
ANS: B The pleural membranes are serous membranes. Mucous membranes are found in the mouth. Synovial membranes are found in joints. Peritoneal membranes would be found in the bowel.
A nurse is caring for a patient who cannot clot. Which end product of the clotting cascade is this patient unable to make? a. Collagen b. Fibrinogen c. Thrombin d. Fibrin
d. fibrin
A cardiovascular alteration seen in a newborn diagnosed with respiratory distress syndrome includes: a. left-to-right shunt. b. left ventricular dilation. c. pulmonary hypotension. d. opening of fetal shunt pathways.
d. opening of fetal shunt pathways.
Erythropoietin is produced in the:
kidneys
A 30 year old is diagnosed with emphysema. Changes in this patient's lungs are caused by: a. viral infections. b. destruction of alveolar macrophages. c. alpha1-antitrypsin deficiency. d. fibrotic lung disease.
ANS: C Alpha1-antitrypsin deficiency is suggested in individuals who develop emphysema before 40 years of age; it is not due to viral infections. Changes in the lungs are not associated with alveolar macrophage destruction or with fibrotic lung disease.
A 50-year-old male is diagnosed with pulmonary embolism (PE). Which of the following symptoms most likely occurred before treatment is initiated? a. Dry cough and inspiratory crackles b. Shallow respirations and wheezing c. Chest pain and shortness of breath d. Kussmaul respirations and back pain
ANS: C An individual with PE usually presents with the sudden onset of pleuritic chest pain, dyspnea, tachypnea, tachycardia, and unexplained anxiety. Individuals with PE do not experience a cough or wheezing. Kussmaul respirations are associated with acidosis.
When a 42-year-old is diagnosed with chronic renal failure, which dietary restriction will the nurse discuss with the patient? a. Fats b. Complex carbohydrates c. Proteins d. Sugars
ANS: C testbanks_and_xanax Low-protein diets are recommended. Management of chronic renal failure is not associated with diets that limit fats, carbohydrates, or sugars. REF: p. 767
13. After 2 months of tuberculosis (TB) treatment with isoniazid, rifampin (Rifadin), pyrazinamide, and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next? a. Teach about drug-resistant TB. b. Schedule directly observed therapy. c. Ask the patient whether medications have been taken as directed. d. Discuss the need for an injectable antibiotic with the health care provider.
ANS: C The first action should be to determine whether the patient has been compliant with drug therapy because negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. Assessment is the first step in the nursing process. Depending on whether the patient has been compliant or not, different medications or directly observed therapy may be indicated. The other options are interventions based on assumptions until an assessment has been completed.
A patient calls the clinic office saying that the cholestyramine (Questran) powder he started yesterday clumps and sticks to the glass when he tries to mix it. The nurse will suggest what method for mixing this medication for administration? a. Mix the powder in a carbonated soda drink to dissolve it faster. b. Add the powder to any liquid, and stir vigorously to dissolve it quickly. c. Mix the powder with food or fruit, or at least 4 to 6 ounces of fluid. d. Sprinkle the powder into a spoon and take it dry, followed by a glass of water
ANS: C Mix the powder with food or at least 4 to 6 ounces of fluid. The powder may not mix completely at first, but patients should be sure to mix the dose as much as possible and then dilute any undissolved portion with additional fluid. The powder should be dissolved for at least 1 full minute. Powder and granule dosages are never to be taken in dry form
A patient who had a total hip replacement had an intraoperative hemorrhage 14 hours ago. Which laboratory test result would the nurse expect? a. Hematocrit of 46% b. Hemoglobin of 13.8 g/dL c. Elevated reticulocyte count d. Decreased white blood cell (WBC) count
ANS: C. Elevated reticulocyte count Hemorrhage causes the release of reticulocytes (immature red blood cells) from the bone marrow into circulation. The hematocrit and hemoglobin levels are normal. The WBC count is not affected by bleeding.
The nurse assesses a patient with pernicious anemia. Which assessment finding would the nurse expect? a. Yellow-tinged sclerae b. Shiny, smooth tongue c. Numbness of the extremities d. Gum bleeding and tenderness
ANS: C. Numbness of the extremities Extremity numbness is associated with cobalamin (vitamin B12) deficiency or pernicious anemia. Loss of the papillae of the tongue occurs with chronic iron deficiency. Yellow-tinged sclera is associated with hemolytic anemia and the resulting jaundice. Gum bleeding and tenderness occur with thrombocytopenia or neutropenia.
A nurse is preparing to teach about the loop of Henle. Which information should be included? The descending segment of the loop of Henle primarily allows for: a. Sodium secretion b. Potassium secretion c. Hydrogen ion reabsorption d. Water reabsorption
ANS: D
35. The nurse reviews the admission orders shown in the accompanying figure for a patient newly diagnosed with peripheral artery disease. Which admission order should the nurse question? a. Use of treadmill for exercise b. Referral for dietary instruction c. Exercising to the point of discomfort d. Combined clopidogrel and omeprazole therapy
ANS: D Because the antiplatelet effect of clopidogrel is reduced when it is used with omeprazole, the nurse should clarify this prescription with the health care provider. The other interventions are appropriate for a patient with peripheral artery disease.
Which information is most important for the nurse to communicate rapidly to the health care provider about a patient admitted with possible syndrome of inappropriate antidiuretic hormone (SIADH)? a. The patient has a recent weight gain of 9 lb. b. The patient complains of dyspnea with activity. c. The patient has a urine specific gravity of 1.025. d. The patient has a serum sodium level of 118 mEq/L.
ANS: D A serum sodium of less than 120 mEq/L increases the risk for complications such as seizures and needs rapid correction. The other data are not unusual for a patient with SIADH and do not indicate the need for rapid action DIF: Cognitive Level: Analyze (analysis) REF: 1160 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
A 70 year old hospitalized for a pelvic fracture develops a pulmonary embolism. The nurse realizes this embolus is most commonly composed of: a. fat. b. air. c. tissue fragment. d. blood clot.
ANS: D A thromboembolism is most commonly composed of a blood clot. A thromboembolism is less commonly composed of fat, air, or tissue fragments.
Carbon dioxide (CO2) is mainly transported in the blood: a. attached to oxygen (O2). b. dissolved in red blood cells. c. combined with albumin. d. in the form of bicarbonate.
ANS: D CO2 is carried in the blood as bicarbonate and not attached to O2, dissolved in red blood cells, or combined with albumin.
An intravenous piggyback (IVPB) antibiotic needs to infuse over 90 minutes. The IVPB bag contains 150 mL. Calculate the setting for the infusion pump. _______
Answer: 100 mL/hr
A newborn with possible hypoplastic left heart disease is to be admitted to the nursing unit. Which drug should be available for use? A. Digitoxin (Crystodigin). B. Prostaglandin E1 (Prostin VR). C. Morphine Sulfate. D. Testosterone (Andro).
B
The laboratory finding that would be seen in the cyanotic heart disease client but not in the acyanotic heart disease client would be a(an): A. Elevated pO2. B. Elevated red blood cell count. C. Decreased hematocrit. D. Decreased pCO2.
B
An unresponsive patient w/ type 2 diabetes is brought to the ED and diagnosed w/ hyperosmolar hyperglycemia syndrome (HHS). The nurse will anticipate the need to a) give a bolus of 50% dextrose b) insert a large-bore IV catheter c) initiate oxygen by nasal cannula d) administer glargine (Lantus) insulin
B HHS is initially treated w/ large volumes of IV fluids to correct hypovolemia.
The nurse is caring for a 45-yr-old male patient during a water deprivation test. Which finding is most important for the nurse to communicate to the health care provider? a. The patient complains of intense thirst. b. The patient has a 5-lb (2.3-kg) weight loss. c. The patient's urine osmolality does not increase. d. The patient feels dizzy when sitting on the edge of the bed.
B A drop in the weight of more than 2 kg indicates severe dehydration, and the test should be discontinued. The other assessment data are not unusual with this test.
A registered nurse (RN) is caring for a patient with a goiter and possible hyperthyroidism. Which action by the RN indicates that the charge nurse needs to provide the RN with additional teaching? a. The RN checks the blood pressure in both arms. b. The RN palpates the neck to assess thyroid size. c. The RN orders saline eye drops to lubricate the patient's bulging eyes. d. The RN lowers the thermostat to decrease the temperature in the room.
B Palpation can cause the release of thyroid hormones in a patient with an enlarged thyroid and should be avoided. The other actions by the new RN are appropriate when caring for a patient with an enlarged thyroid.
Which additional information will the nurse need to consider when reviewing the laboratory results for a patient's total calcium level? a. The blood glucose b. The serum albumin c. The phosphate level d. The magnesium level
B Part of the total calcium is bound to albumin, so hypoalbuminemia can lead to misinterpretation of calcium levels. The other laboratory values will not affect total calcium interpretation.
The nurse will teach a patient who is scheduled to complete a 24-hour urine collection for 17-ketosteroids to a. insert and maintain a retention catheter. b. keep the specimen refrigerated or on ice. c. drink at least 3 L of fluid during the 24 hours. d. void and save that specimen to start the collection.
B The specimen must be kept on ice or refrigerated until the collection is finished. Voided or catheterized specimens are acceptable for the test. The initial voided specimen is discarded. There is no fluid intake requirement for the 24-hour collection.
Which hypothyroid diagnosis is supported by low levels of TSH? a. Primary b. Secondary c. Autoimmune d. Atypical
B - Causes of secondary hypothyroidism are related to either pituitary or hypothalamic failure, which would be evident by low levels of TSH. Primary and autoimmune hypothyroidism would be evident by elevated levels of TSH. Atypical hypothyroidism would be evident by normal or elevated TSH.
While checking the lab results for a patient diagnosed with Graves disease, the nurse would expect the T3 level to be abnormally: a. low. b. high. c. variable. d. absent.
B - T3 levels are elevated in Graves disease.
Visual disturbances are a common occurrence in patients with untreated Graves disease. The endocrinologist explains to the patient that the main cause of these complications is: a. decreased blood flow to the eye. b. orbital edema and protrusion of the eyeball. c. TSH neurotoxicity to retinal cells. d. local lactic acidosis.
B - Visual disturbances with Graves disease include orbital fat accumulation, inflammation, and edema of the orbital contents resulting in exophthalmos (protrusion of the eyeball), periorbital edema, and extraocular muscle weakness leading to diplopia (double vision). Blood flow to the eye is not an effect, but visual changes occur. Functional abilities of the eye result from hyperactivity of the sympathetic system. Lactic acid is not involved with visual changes in the eye.
1. A nurse working in a pediatric clinic recognizes that which child is most at risk for cognitive impairment? A. An infant who is being fed reconstituted powdered formula. B. A toddler living in an older home that is being remodeled. C. A preschooler who attends a play group 3 days a week. D. A school-age child who rides a school bus 5 days a week
B. A toddler living in an older home that is being remodeled.
A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse? a. Arterial blood pH is 7.32. b. Serum calcium is 18 mg/dL. c. Serum potassium is 5.1 mEq/L. d. Arterial oxygen saturation is 91%.
B. Serum calcium is 18 mg/dL. The serum calcium is well above the normal level and puts the patient at risk for cardiac dysrhythmias.
To ensure accurate results of a fasting blood glucose analysis, the nurse instructs the patient to fast for at least how long? a. 2 hours b. 4 hours c. 8 hours d. 12 hours
C
Which endocrine gland secretes cortisol in a diurnal pattern? a. Ovaries b. Thyroid c. Adrenal cortex d. Adrenal medulla
C
The nurse is assessing a 22 y/o patient experiencing the onset of symptoms of type 1 diabetes. Which question is most appropriate for the nurse to ask? a) Are you anorexic? b) Is your urine dark colored? c) Have you lost weight daily? d) Do you crave sugary drinks?
C Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy.
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 removes the facial mask when misting stops. d. The patient activates the inhaler at the onset of expiration.
C 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 incorrect techniques when using an inhaler.
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. Give the prescribed albuterol (Ventolin HFA) before the therapy. d. Perform percussion before assisting the patient to the drainage position.
C Bronchodilators are administered before chest physiotherapy. Postural drainage, percussion, and vibration should be done 1 hour before or 3 hours after meals. Patients remain in each postural drainage position for 5 minutes. Percussion is done while the patient is in the postural drainage position.
The nurse will plan to teach a patient to minimize physical and emotional stress while the patient is undergoing a. a water deprivation test. b. testing for serum T3 and T4 levels. c. a 24-hour urine test for free cortisol. d. a radioactive iodine (I-131) uptake test.
C Physical and emotional stress can affect the results of the free cortisol test. The other tests are not impacted by stress.
A patient is admitted with tetany. Which laboratory value should the nurse plan to monitor? a. Total protein b. Blood glucose c. Ionized calcium d. Serum phosphate
C Tetany is associated with hypocalcemia. The other values would not be useful for this patient.
Which instruction should the nurse include in an exercise teaching plan for a patient with chronic obstructive pulmonary disease (COPD)? a. "Avoid upper body exercise to prevent dyspnea." b. "Stop exercising if you start to feel short of breath." c. "Use the bronchodilator before you start to exercise." d. "Breathe in and out through the mouth while you exercise."
C 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.
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/min c. Use of accessory muscles in breathing d. Peak expiratory flow rate of 240 L/min
C 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.
6. The nurse is sitting with the family of a patient who has just received the diagnosis of dementia. The family asks for information on what treatment will be needed to cure the condition. What is the nurse's best response? a. "Hormone therapy will reverse the condition." b. "Vitamin C and zinc will reverse the condition." c. "There is no treatment that reverses dementia." d. "Dementia can be reversed with diet, exercise, and medications."
C. "There is no treatment that reverses dementia"
Which action by a patient indicates that the home health nurse's teaching about glargine and regular insulin has been successful? a) The patient administers the glargine 30 minutes before each meal b) The patient's family prefills the syringes w/ the mix of insulins weekly c) The patient draws up the regular insulin then the glargine in the same syringe d) The patient disposes of the open vials of glargine and regular insulin after 4 weeks
D Insulin can be stored at room temperature for 4 weeks.
A patient w/ type 2 diabetes is schedules for a follow-up visit in the clinic several months from now. Which test will the nurse schedule to evaluate the effectiveness of treatment for the patient? a) Urine dipstick for glucose b) Oral glucose tolerance test c) Fasting blood glucose level d) Glycosylated Hgb level
D The A1C test shows the overall control of glucose over 90-120 days.
Which finding indicates a need to contact the HCP before the nurse administers metformin (Glucophage)? a) The patient's blood glucose level is 174 mg/dL b) The patient has gained 2lb (0.6 kg) since yesterday c) The patient is scheduled for a chest x-ray in an hour d) The patient's BUN is 52 mg/dL
D The BUN indicates possible renal failure, and metformin should not be used in patients w/ renal failure.
A 61-yr-old female patient admitted with pneumonia has a total serum calcium level of 13.3 mg/dL (3.3 mmol/L). The nurse will anticipate the need to teach the patient about testing for _____ levels. a. calcitonin b. catecholamine c. thyroid hormone d. parathyroid hormone
D Parathyroid hormone (PTH) is the major controller of blood calcium levels. Although calcitonin secretion is a countermechanism to PTH, it does not play a major role in calcium balance. Catecholamine and thyroid hormone levels do not affect serum calcium level.
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 a common side effect of short-acting b2-adrenergic (SABA) medications and not a reason to avoid using the SABA inhaler. Inhaled corticosteroids do not act rapidly to reduce dyspnea. Rapid inhalation is needed when using a DPI. The patient should hold the breath for 10 seconds after using inhalers.
Palpation of the neck of a patient diagnosed with Graves disease would most likely reveal: a. a normal-sized thyroid. b. a small discrete thyroid nodule. c. multiple discrete thyroid nodules. d. diffuse thyroid enlargement.
D - A patient with Graves disease would reveal stimulation of the gland causing diffuse thyroid enlargement. In Graves disease, the thyroid will not have nodules present.
While reviewing lab results, the nurse recalls that the most abundant cells in the blood are...
Erythrocytes
Which of the following assessment findings is most likely to occur following a splenectomy? a. Leukocytosis b. Hypoglycemia c. Decreased red blood cell count d. Decreased platelets
Leukocytosis
When evaluating a patient's use of a metered-dose inhaler (MDI), the nurse notes that the patient is unable to coordinate the activation of the inhaler with her breathing. What intervention is most appropriate at this time? a. Notify the doctor that the patient is unable to use the MDI. b. Obtain an order for a peak flow meter. c. Obtain an order for a spacer device. d. Ask the prescriber if the medication can be given orally.
Obtain an order for a spacer device. The use of a spacer may be indicated with metered-dose inhalers, especially if success with inhalation is limited. The other options are not appropriate interventions.
an underlying symptom of ischemia is
Pain Ischemia is associated with pain.
A patient has a new order for an ipratropium (Atrovent) inhaler, an anticholinergic drug. The nurse knows to assess for an allergy to which food before giving this drug? a. Shellfish b. Soy products c. Peanuts d. Eggs
Peanuts There have been reported cases of severe anaphylactic reactions to ipratropium inhalers in patients with allergies to peanuts, and such use must be avoided.
an underlying symptom of Peptic ulcer disease is
Peptic ulcer disease is associated with pain and intestinal discomfort.
an underlying symptom of pneumonia is
Pneumonia is associated with pain and shortness of breath.
Which factor represents the amount of blood that the heart must pump with each beat and is determined by the stretch of the cardiac muscle fibers and the actions of the heart prior to cardiac contraction? Cardiac contractility Preload Heart rate Afterload
Preload Explanation: Preload is the distending force that stretches the heart muscle just prior to the work of the onset of ventricular contraction. It represents the volume of blood stretching the ventricular muscle fibers at the end of diastole (i.e., end-diastolic volume) and is the sum of the blood remaining in the heart at the end of systole (end-systolic volume) and the venous return to the heart.
The heart consists of four valves. Which are the semilunar valves? Select all that apply. Pulmonary Tricuspid Aortic Mitral
Pulmonary Aortic Explanation: The heart's semilunar valves are the pulmonary and aortic values. The heart's atrioventricular valves are the tricupsid and the mitral.
The heart is a four-chambered pump. What is the function of the right ventricle? Receives blood returning to the heart from the systemic circulation Pumps blood into the systemic circulation Receives oxygenated blood from the lungs Pumps blood to the lungs
Pumps blood to the lungs Explanation: The right ventricle pumps blood to the lungs. The right atrium receives blood returning to the heart from the system circulation. The left atrium receives oxygenated blood from the lungs. The left ventricle pumps blood into the systemic circulation.
A client has prominent jugular veins. What type of medical problem is associated with prominent jugular veins? Cerebrovascular accident (stroke) Shock Right-sided heart failure Left-sided heart failure
Right-sided heart failure Explanation: Right-sided heart failure is seen with prominent jugular veins.
The heart consists of four valves. Which are the heart's atrioventricular valves? Select all that apply. Mitral Aortic Tricuspid Pulmonary
Tricuspid Mitral Explanation: The heart's atrioventricular valves are the tricupsid and the mitral. The semilunar valves are the pulmonary and aortic.
Hypoplastic left heart syndrome consists of hypoplasia (i.e., underdevelopment or incomplete development) of the left ventricle and ascending aorta, maldevelopment and hypoplasia of the aortic and mitral valves (frequently aortic atresia is present), an atrial septal defect, and a large patent ductus arteriosus. Unless normal closure of the patent ductus arteriosus is prevented with prostaglandin infusion, cardiogenic shock and death ensue. The only cure is heart transplantation. This condition can be palliated through three-stage open-heart surgical procedures. This is not a cure, as the child's circulation is made to work with only two of the heart's four chambers. True or false?
True
The cardiac cycle describes the pumping action of the heart. Which statement is correct about systole? Ventricles contract and blood is ejected from the heart. Ventricles relax and blood fills the heart. Atria contract and blood is ejected from the heart. Atria relax and blood fills the heart.
Ventricles contract and blood is ejected from the heart. Explanation: Systole occurs when the ventricles contract and blood is ejected from the heart. Diastole occurs when the ventricles are relaxed and blood fills the heart.
There are three main atrial pressure waves that occur during the cardiac cycle. What are the three main atrial pressure waves? Select all that apply. c a b v
a c v Explanation: There are three main atrial pressure waves that occur during the cardiac cycle: the a, c, and v waves.
A patient will be taking dabigatran (Pradaxa) as part of treatment for chronic atrial fibrillation. Which statements about dabigatran are true? (Select all that apply.) a. The dose of dabigatran is reduced in patients with decreased renal function. b. Bleeding is the most common adverse effect. c. Idarucizumab (Praxbind) is given as an antidote in cases of uncontrolled bleeding. d. Dabigatran levels are monitored by measuring prothrombin time/international normalized ratio (PT/INR) results. e. This drug is a prodrug and becomes activated in the liver.
a. The dose of dabigatran is reduced in patients with decreased renal function. b. Bleeding is the most common adverse effect. c. Idarucizumab (Praxbind) is given as an antidote in cases of uncontrolled bleeding. e. This drug is a prodrug and becomes activated in the liver.
28. An elderly person presents with symptoms of delirium. The family reports, Everything was fine until yesterday. What is the most important assessment information for the nurse to gather? a. A list of all medications the person currently takes b. Whether the person has experienced any recent losses c. Whether the person has ingested aged or fermented foods d. The persons recent personality characteristics and changes
a. A list of all medications the person currently takes Delirium is often the result of medication interactions or toxicity. The distracters relate to MAOI therapy and depression. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 433-434 | Page 439 (Table 23-2) TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
A patient is scheduled for a computed tomography (CT) scan of the chest with contrast media. Which assessment findings should the nurse report to the health care provider before the patient goes for the CT.(Select all that apply.)? a. Allergy to shellfish b. patient reports claustrophobia c. elevated serum creatinine level d. recent bronchodilator inhaler use e. inability to remove wedding band
a. Allergy to shellfish c. elevated serum creatinine level
SATA: When a staff member asks how erythrocytes can carry oxygen, the nurse should describe which of the following properties that allow erythrocytes to function as gas carriers? (select all that apply) a. Biconcavity b. Reversible deformability c. Undergoes mitotic division d. Presence of many mitochondria e. Presence of a nucleus
a. Biconcavity b. Reversible deformability
Of the following groups, who are at highest risk for a cerebrovascular accident (CVA)? a. Blacks over 65 years of age b. Whites over 65 years of age c. Blacks under 65 years of age d. Whites under 65 years of age
a. Blacks over 65 years of age
The acid-base status of a patient is dependent on normal gas exchange. Which patient would the nurse identify as having an increased 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 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 HCO3 is 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
A 15-month-old child from Pennsylvania was brought to the ER with symptomology that includes fever, seizure activity, cranial palsies, and paralysis. Which form of encephalitis is best supported by the available assessment data? a. Eastern equine encephalitis b. Venezuelan encephalitis c. St. Louis encephalitis d. West Nile encephalitis
a. Eastern equine encephalitis
A coup injury resulting from a blow to the frontal portion of the skull would occur in which region of the brain? a. Frontal b. Temporal c. Parietal d. Occipital
a. Frontal
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
The nurse is assessing a patient who has a new prescription for vorapaxar (Zontivity). Which of these conditions are considered contraindications to the use of vorapaxar? (Select all that apply.) a. Impaired renal function b. Impaired liver function c. History of myocardial infarction d. Peripheral artery disease e. History of intracranial hemorrhage
a. Impaired renal function b. Impaired liver function e. History of intracranial hemorrhage
6. A patient diagnosed with delirium is experiencing perceptual alterations. Which environmental adjustment should the nurse make for this patient? a. Provide a well-lit room without glare or shadows. Limit noise and stimulation. b. Maintain soft lighting day and night. Keep a radio on low volume continuously. c. Light the room brightly day and night. Awaken the patient hourly to assess mental status. d. Keep the patient by the nurses desk while awake. Provide rest periods in a room with a television on.
a. Provide a well-lit room without glare or shadows. Limit noise and stimulation. A quiet, shadow-free room offers an environment that produces the fewest sensory perceptual distortions for a patient with cognitive impairment associated with delirium. The other options have the potential to produce increased perceptual alterations. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 445 (Table 23-6) | Page 436 (Box 23-1) | Page 445 (Box 23-3) | Page 452 (Nursing Care Plan 23-1) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment
Which cytokines participate in hematopoiesis? a. Stimulating factors (CSFs) b. Eosinophils c. Basophils d. Neutrophils
a. Stimulating factors (CSFs)
SATA: A nurse is caring for an elderly patient. Which of the following are true regarding the hematological system and aging? (select all that apply) a. Total serum iron is decreased. b. Total iron-binding capacity is decreased. c. Intestinal iron absorption is decreased. d. Lymphocyte function is unchanged. e. Platelet aggregation is unchanged.
a. Total serum iron is decreased. b. Total iron-binding capacity is decreased. c. Intestinal iron absorption is decreased.
A newborn diagnosed with respiratory distress syndrome is monitored for atelectasis because of: a. a lack of surfactant. b. pulmonary edema. c. airway obstruction. d. pulmonary fibrosis.
a. a lack of surfactant.
A patient presents with seizures. An MRI reveals a meningioma most likely originating from the: a. dura mater and arachnoid membrane. b. astrocytes. c. pia mater. d. CNS neurons.
a. dura mater and arachnoid membrane.
During an infection, lymph nodes enlarge and become tender because: a. lymphocytes are rapidly dividing. b. edema accumulates within the fibrous capsule. c. microorganisms are accumulating. d. the nodes are not functioning properly.
a. lymphocytes are rapidly dividing.
The nurse is monitoring drug levels for a patient who is receiving theophylline. The most recent theophylline level was 13 mcg/mL, and the nurse evaluates this level to be a. below the therapeutic level. b. at a therapeutic level. c. above the therapeutic level. d. at a toxic level.
at a therapeutic level Although the optimal level may vary from patient to patient, most standard references have suggested that the therapeutic range for theophylline blood level is 10 to 20 mcg/mL. However, most clinicians now advise levels between 5 and 15 mcg/mL.
A patient has had recent mechanical heart valve surgery and is receiving anticoagulant therapy. While monitoring the patient's laboratory work, the nurse interprets that the patient's international normalized ratio (INR) level of 3 indicates: which of these? a. The patient is not receiving enough warfarin to have a therapeutic effect. b. The patient's warfarin dose is at therapeutic levels. c. The patient's intravenous heparin dose is dangerously high. d. The patient's intravenous heparin dose is at therapeutic levels.
b. The patient's warfarin dose is at therapeutic levels.
The nurse is teaching a patient about the self-administration of enoxaparin (Lovenox). Which statement will be included in this teaching session? a. "We will need to teach a family member how to give this drug in your arm." b. "This drug is given in the folds of your abdomen, but at least 2 inches away from your navel." c. "This drug needs to be taken at the same time every day with a full glass of water." d. "Be sure to massage the injection site thoroughly after administering the drug."
b. "This drug is given in the folds of your abdomen, but at least 2 inches away from your navel."
Sudden infant death syndrome (SIDS) peaks between _____ and ____months of age. a. 1; 2 b. 2; 4 c. 6; 8 d. 10; 12
b. 2; 4
While checking lab results, the nurse remembers that the normal leukocyte count is: a. 1000-2000 per cubic millimeter. b. 5000-10,000 per cubic millimeter. c. 4.2-6.2 million per cubic millimeter. d. 1.2-2.2 million per cubic millimeter.
b. 5000-10,000 per cubic millimeter.
A patient is starting warfarin (Coumadin) therapy as part of treatment for atrial fibrillation. The nurse will follow which principles of warfarin therapy? (Select all that apply.) a. Teach proper subcutaneous administration. b. Administer the oral dose at the same time every day. c. Assess carefully for excessive bruising or unusual bleeding. d. Monitor laboratory results for a target INR of 2 to 3. e. Monitor laboratory results for a therapeutic aPTT value of 1.5 to 2.5 times the control value.
b. Administer the oral dose at the same time every day. c. Assess carefully for excessive bruising or unusual bleeding. d. Monitor laboratory results for a target INR of 2 to 3.
12. Consider these diagnostic findings: apolipoprotein E (apoE) malfunction, neurofibrillary tangles, neuronal degeneration in the hippocampus, and brain atrophy. Which health problem corresponds to these diagnostic findings? a. Huntingtons disease c. Parkinsons disease b. Alzheimers disease d. Vascular dementia
b. Alzheimers disease All of the options relate to dementias however, the pathophysiological phenomena described apply to Alzheimers disease. Parkinsons disease is associated with dopamine dysregulation. Huntingtons disease is genetic. Vascular dementia is the consequence of circulatory changes. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 437-438 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
A 9-year-old contracted influenza. Which of the following complications is of greatest concern to the nurse? a. Chronic bronchitis b. Bronchiolitis obliterans c. Emphysema d. Respiratory distress syndrome (RDS)
b. Bronchiolitis obliterans
An infant was born 10 weeks premature and requires mechanical ventilation. Two months later the infant presents with hypoxemia and hypercapnia. Which of the following is the most likely diagnosis the nurse will observe documented on the chart? a. Respiratory distress syndrome of the newborn b. Bronchopulmonary dysplasia (BPD) c. Bronchiolitis d. Pneumonia
b. Bronchopulmonary dysplasia (BPD)
To help confirm a diagnosis of cystic fibrosis in a 1-year-old child which substance will be monitored for in the child's sweat? a. Potassium b. Chloride c. Magnesium d. Carbonic acid
b. Chloride
A 69-year-old patient with a history of alcohol abuse presents to the emergency room (ER) after a month-long episode of headaches and confusion. The patient's history and symptomology support which medical diagnosis? a. Concussion b. Chronic subdural hematoma c. Epidural hematoma d. Subacute subdural hematoma
b. Chronic subdural hematoma
18. During morning care, a nurse asks a patient diagnosed with dementia, How was your night? The patient replies, It was lovely. I went out to dinner and a movie with my friend. Which term applies to the patients response? a. Sundown syndrome c. Perseveration b. Confabulation d. Delirium
b. Confabulation Confabulation refers to making up of stories or answers to questions by a person who does not remember. It is a defensive tactic to protect self-esteem and prevent others from noticing memory loss. The patients response was not sundown syndrome. Perseveration refers to repeating a word or phrase over and over. Delirium is not present in this scenario. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 438 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
A patient is newly diagnosed with multiple sclerosis (MS). What physiological change is causing the patient's symptoms? a. Depletion of dopamine in the central nervous system (CNS) b. Demyelination of nerve fibers in the CNS c. The development of neurofibril webs in the CNS d. Reduced amounts of acetylcholine at the neuromuscular junction
b. Demyelination of nerve fibers in the CNS
Which pathology is characteristic of asthma? a. Increased lung volumes b. Expiratory wheezing c. Air trapping d. Dead space
b. Expiratory wheezing
23. A patient with severe dementia no longer recognizes family members and becomes anxious and agitated when they attempt reorientation. Which alternative could the nurse suggest to the family members? a. Wear large name tags. b. Focus interaction on familiar topics. c. Frequently repeat the reorientation strategies. d. Place large clocks and calendars strategically.
b. Focus interaction on familiar topics. Reorientation may seem like arguing to a patient with cognitive deficit and increases the patients anxiety. Validating, talking with the patient about familiar, meaningful things, and reminiscing give meaning to existence both for the patient and family members. The option that suggests using validating techniques when communicating is the only option that addresses an interactional strategy. Wearing large name tags and placing large clocks and calendars strategically are reorientation strategies. Frequently repeating the reorientation strategies is inadvisable because patients with dementia sometimes become more agitated with reorientation. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 445 (Table 23-6) | Page 445 (Box 23-3) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
A patient received a double dose of heparin during surgery and is bleeding through the incision site. While the surgeons are working to stop the bleeding at the incision site, the nurse will prepare to take what action? a. Give IV vitamin K as an antidote. b. Give IV protamine sulfate as an antidote. c. Call the blood bank for an immediate platelet transfusion. d. Obtain an order for packed red blood cells.
b. Give IV protamine sulfate as an antidote.
A CT scan reveals that a patient has an open basilar skull fracture. Which major complication should the nurse observe for in this patient? a. Hematoma formation b. Meningeal infection c. Increased intracranial pressure (ICP) d. Cognitive deficits
b. Meningeal infection
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.
19. A nurse counsels the family of a patient diagnosed with Alzheimers disease who lives at home and wanders at night. Which action is most important for the nurse to recommend to enhance safety? a. Apply a medical alert bracelet to the patient. b. Place locks at the tops of doors. c. Discourage daytime napping. d. Obtain a bed with side rails.
b. Place locks at the tops of doors. Placing door locks at the top of the door makes it more difficult for the patient with dementia to unlock the door because the ability to look up and reach upward is diminished. The patient will try to climb over side rails, increasing the risk for injury and falls. Avoiding daytime naps may improve the patients sleep pattern but does not assure safety. A medical alert bracelet will be helpful if the patient leaves the home, but it does not prevent wandering or assure the patients safety. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 449 (Table 23-9) TOP: Nursing Process: Planning MSC: Client Needs: Safe, Effective Care Environment
Upon autopsy of a 25-year-old, abnormalities in the media of the arterial wall and degenerative changes were detected. Which of the following would most likely accompany this finding? a. Fusiform aneurysm b. Saccular aneurysm c. Arteriovenous malformation d. Thrombotic stroke
b. Saccular aneurysm
A 48-year-old patient presents at the ER reporting an acute severe headache, nausea, photophobia, and nuchal rigidity. Which medical diagnosis is supported by these signs and symptoms? a. Diffuse brain injury b. Subarachnoid hemorrhage c. Epidural hematoma d. Classic concussion
b. Subarachnoid hemorrhage
Which information is basic to the assessment findings associated with a patient diagnosed with an aneurysm? a. A headache is the most common symptom. b. The majority are asymptomatic. c. Nosebleeds are an early symptom. d. Epidural hemorrhage occurs in over 80% of patients.
b. The majority are asymptomatic.
A 7-month-old presents with cystic fibrosis (CF) accompanied by failure to thrive and frequent, loose, and oily stools. Sweat testing confirms the diagnosis. Which of the following is characteristic of CF? a. Autoantibodies that target the lungs and pancreas b. Thick mucous sputum c. Enzymes that degrade surfactant in the alveoli d. A toxic amount of electrolytes from secretory glands
b. Thick mucous sputum
Most causes of encephalitis are which of the following? a. Bacterial b. Viral c. Fungal d. Toxoid
b. Viral
A 2-year-old presents with fever and cough and is diagnosed with pneumonia. While planning treatment for this patient, the nurse recognizes that which of the following is the most likely cause? a. Bacteria b. Viruses c. Mycoplasma species d. Toxic inhalations
b. Viruses
To prevent sudden infant death syndrome, the nurse should instruct parents to: a. place infants on a soft mattress for sleeping. b. always lay infants down on their backs to sleep. c. breast-feed their infants. d. keep the infant's room very warm.
b. always lay infants down on their backs to sleep.
The patient reports generalized muscle weakness. The health care provider orders administration of the medication edrophonium chloride (Tensilon). This medication is used in the diagnosis of: a. amyotrophic lateral sclerosis (ALS). b. myasthenia gravis. c. multiple sclerosis (MS). d. autonomic hyperreflexia.
b. myasthenia gravis.
The nurse notes in the patient's medication orders that the patient will be starting anticoagulant therapy. What is the primary goal of anticoagulant therapy? a. Stabilizing an existing thrombus b. Dissolving an existing thrombus c. Preventing thrombus formation d. Dilating the vessel around a clot
c. Preventing thrombus formation
A patient has received an overdose of intravenous heparin, and is showing signs of excessive bleeding. Which substance is the antidote for heparin overdose? a. Vitamin E b. Vitamin K c. Protamine sulfate d. Potassium chloride
c. Protamine sulfate
A patient has been instructed to take one enteric-coated low-dose aspirin a day as part of therapy to prevent strokes. The nurse will provide which instruction when providing patient teaching about this medication? a. Aspirin needs to be taken on an empty stomach to ensure maximal absorption. b. Low-dose aspirin therapy rarely causes problems with bleeding. c. Take the medication with 6 to 8 ounces of water and with food. d. Coated tablets may be crushed if necessary for easier swallowing.
c. Take the medication with 6 to 8 ounces of water and with food.
A patient diagnosed with a spinal cord injury experienced spinal shock lasting 15 days. The patient is now experiencing an uncompensated cardiovascular response to sympathetic stimulation. What does the nurse suspect caused this condition? a. Toxic accumulation of free radicals below the level of the injury b. Pain stimulation above the level of the spinal cord lesion c. A distended bladder or rectum d. An abnormal vagal response
c. A distended bladder or rectum
A patient diagnosed with a diffuse brain injury (DBI) is at increased risk for which complication? a. Complete loss of vision b. Arrhythmia c. Acute brain swelling d. Meningitis infection
c. Acute brain swelling
10. An older adult was stopped by police for driving through a red light. When asked for a drivers license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident? a. Aphasia c. Agnosia b. Apraxia d. Anhedonia
c. Agnosia Agnosia refers to the loss of sensory ability to recognize objects. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movement. Anhedonia refers to a loss of joy in life. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 438 | Page 452 (Nursing Care Plan 23-1) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
A 60-year-old patient with a recent history of head trauma and a long-term history of hypertension presents to the ER for changes in mental status. MRI reveals that the patient has experienced a subarachnoid hemorrhage. What does the nurse suspect caused this type of stroke? a. Rheumatic heart disease b. Thrombi c. Aneurysm d. Hypotension
c. Aneurysm
What are the most common primary central nervous system (CNS) tumors in adults? a. Meningiomas b. Oligodendrogliomas c. Astrocytomas d. Ependymomas
c. Astrocytomas
Six weeks ago a patient suffered a T6 spinal cord injury. What complication does the nurse suspect when the patient develops a blood pressure of 200/120, a severe headache, blurred vision, and bradycardia? a. Extreme spinal shock b. Acute anxiety c. Autonomic hyperreflexia d. Parasympathetic areflexia
c. Autonomic hyperreflexi
29. A nurse gives anticipatory guidance to the family of a patient diagnosed with stage 3, mild cognitive decline Alzheimers disease. Which problem common to that stage should the nurse address? a. Violent outbursts c. Communication deficits b. Emotional disinhibition d. Inability to feed or bathe self
c. Communication deficits Families should be made aware that the patient will have difficulty concentrating and following or carrying on in-depth or lengthy conversations. The other symptoms are usually seen at later stages of the disease. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 440 (Table 23-3) | Page 443 (Table 23-4) | Page 452 (Nursing Care Plan 23-1) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
A 30-year-old white male recently suffered a cerebrovascular accident. Which of the following is the most likely factor that contributed to his stroke? a. Age b. Gender c. Diabetes d. Race
c. Diabetes
Immediately after being struck by a motor vehicle, a patient is unconscious, but the patient regains consciousness before arriving at the hospital and appears alert and oriented. The next morning the patient is confused and demonstrates impaired responsiveness. The patient's history and symptoms support which medical diagnosis? a. Mild concussion b. Subdural hematoma c. Extradural (epidural) hematoma d. Mild diffuse axonal injury
c. Extradural (epidural) hematoma
The nurse is assigned a group of patients. Which patient finding would the nurse identify as a factor leading to increased risk for impaired 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
c. Hemoglobin of 8.5 g/dL
An 11-year-old presents with a low-grade fever and cough and is diagnosed with atypical pneumonia. What type of pneumonia does the nurse suspect the patient is experiencing? a. Pneumococcal pneumonia b. Viral pneumonia c. Mycoplasma pneumonia d. Streptococcal pneumonia
c. Mycoplasma pneumonia
A newborn is diagnosed with respiratory distress syndrome. When obtaining the patient's history, which of the following is the most important predisposing factor for this condition? a. Low birth weight b. Alcohol consumption by the mother during pregnancy c. Premature birth d. Smoking by the mother during pregnancy
c. Premature birth
After receiving a nebulizer treatment with a beta agonist, the patient complains of feeling slightly nervous and wonders if her asthma is getting worse. What is the nurse's best response? a. "This is an expected adverse effect. Let me take your pulse." b. "The next scheduled nebulizer treatment will be skipped." c. "I will notify the physician about this adverse effect." d. "We will hold the treatment for 24 hours."
"This is an expected adverse effect. Let me take your pulse." Nervousness, tremors, and cardiac stimulation are possible and expected adverse effects of beta agonists. The other options are incorrect responses.
A 22 year old presents with chronic bronchitis. Tests reveal closure of the airway during expiration. This condition is most likely caused by: a. thick mucus from hypertrophied glands. b. ventilation-perfusion mismatch. c. hyperventilation. d. thinning smooth muscle in the bronchioles.
ANS: A Chronic bronchitis is defined by hypersecretion of thick mucus. Ventilation-perfusion mismatch may occur, but chronic bronchitis is defined as hypersecretion of mucus. Neither hyperventilation nor thinning of smooth muscle occurs.
28. A 46-year-old is diagnosed with thromboangiitis obliterans (Buerger's disease). When the nurse is developing 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
ANS: A Absolute cessation of nicotine use is needed to reduce the risk for amputation in patients with Buerger's disease. Other therapies have limited success in treatment of this disease.
4. A 74-year-old professional golfer has chest pain that occurs toward the end of his golfing games. He says the pain usually goes away after one or two sublingual nitroglycerin tablets and rest. What type of angina is he experiencing? a. Classic b. Variant c. Unstable d. Prinzmetal's
ANS: A Classic, or chronic stable, angina is triggered by either exertion or stress and usually subsides within 15 minutes with either rest or drug therapy. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 363 TOP: NURSING PROCESS: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation
Which finding indicates to the nurse that the current therapies are effective for a patient with acute adrenal insufficiency? a. Increasing serum sodium levels b. Decreasing blood glucose levels c. Decreasing serum chloride levels d. Increasing serum potassium levels
ANS: A Clinical manifestations of Addison's disease include hyponatremia and an increase in sodium level indicates improvement. The other values indicate that treatment has not been effective DIF: Cognitive Level: Apply (application) REF: 1178 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
2. The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect? a. Increased tactile fremitus b. Dry, nonproductive cough c. Hyperresonance to percussion d. A grating sound on auscultation
ANS: A Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal pneumonia typically presents with a loose, productive cough. Adventitious breath sounds such as crackles and wheezes are typical. A grating sound is more representative of a pleural friction rub rather than pneumonia.
A patient with elevated lipid levels has a new prescription for nicotinic acid (niacin). The nurse informs the patient that which adverse effects may occur with this medication? a. Pruritus, cutaneous flushing b. Tinnitus, urine with a burnt odor c. Myalgia, fatigue d. Blurred vision, headaches
ANS: A Possible adverse effects of nicotinic acid include pruritus, cutaneous flushing, and gastrointestinal distress. Tinnitus, urine with a burnt odor, and headaches are possible adverse effects of bile acid sequestrants. Headaches are also possible adverse effects of HMG-CoA reductase inhibitors, as are myalgia and fatigue
A patient tells the nurse that he likes to eat large amounts of garlic "to help lower his cholesterol levels naturally." The nurse reviews his medication history and notes that which drug has a potential interaction with the garlic? a. acetaminophen (Tylenol) b. warfarin (Coumadin) c. digoxin (Lanoxin) d. phenytoin (Dilantin)
ANS: B When using garlic, it is recommended to avoid any other drugs that may interfere with platelet and clotting function. These drugs include antiplatelet drugs, anticoagulants, nonsteroidal antiinflammatory drugs, and aspirin. The other drugs listed do not have known interactions with garlic.
The nurse is reviewing therapy with glucocorticoid drugs. Which conditions are indications for glucocorticoid drugs? (Select all that apply.)" a Glaucoma b Cerebral edema c Chronic obstructive pulmonary disease and asthma d Organ transplantation e Varicella f Septicemia
ANS: B, C, D Cerebral edema, chronic obstructive pulmonary disease, asthma, and organ transplantation are indications for glucocorticoid therapy. Glaucoma, varicella, and septicemia are all contraindications to glucocorticoid therapy.
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 inexpensive antacid." b. "I shall 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."
ANS: B, C, D Taking insulin as prescribed helps prevent diabetic ketoacidosis. Safeguarding aspirin from children prevents metabolic acidosis from increased acid intake. Regular dialysis reduces the risk of metabolic acidosis from decreased renal excretion of metabolic acid. Baking soda is sodium bicarbonate and should not be used as an antacid due to the risk of metabolic alkalosis. Fasting without carbohydrate intake is a risk factor for starvation ketoacidosis.
A nurse is describing the trigone. Which information should be included? The trigone is defined as: a. The orifice of the ureter b. The inner area of the kidney c. A triangular area between the openings of the two ureters and the urethra d. The three divisions of the loop of Henle
ANS: C The trigone is a smooth triangular area between the openings of the two ureters and the urethra.
A 10 year old develops pneumonia. Physical exam reveals subcostal and intercostal retractions. The child reports that breathing is difficult with feelings that, "I cannot get enough air." What term should the nurse use to document this condition? a. Cyanosis b. Dyspnea c. Hyperpnea d. Orthopnea
ANS: B Dyspnea is defined as "a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity." Cyanosis is a bluish discoloration to the skin. Hyperpnea is an increased ventilatory rate and orthopnea is dyspnea that occurs when an individual lies flat
The nurse reviews the laboratory test results of a patient admitted with abdominal pain. Which information will be most important for the nurse to communicate to the health care provider? a. Monocytes 4% b. Hemoglobin 13.6 g/dL c. Platelet count 168,000/µL d. White blood cell (WBC) count 15,500/µL
ANS: D. White blood cell (WBC) count 15,500/µL The elevation in WBCs indicates that the patient has an inflammatory or infectious process ongoing, which may be the cause of the patient's pain, and that further diagnostic testing is needed. The monocytes are at a normal level. The hemoglobin and platelet counts are normal.
A 62-year old man with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patient's laboratory test findings to include a. an RBC count of 4,500,000/L. b. a hematocrit (Hct) value of 38%. c. normal red blood cell (RBC) indices. d. a hemoglobin (Hgb) of 8.6 g/dL (86 g/L).
ANS: D The patient's clinical manifestations indicate moderate anemia, which is consistent with a Hgb of 6 to 10 g/dL. The other values are all within the range of normal. DIF: Cognitive Level: Understand (comprehension) REF: 607 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
Which laboratory value should the nurse review to determine whether a patient's hypothyroidism is caused by a problem with the anterior pituitary gland or with the thyroid gland? a. Thyroxine (T4) level b. Triiodothyronine (T3) level c. Thyroid-stimulating hormone (TSH) level d. Thyrotropin-releasing hormone (TRH) level
C A low TSH level indicates that the patient's hypothyroidism is caused by decreased anterior pituitary secretion of TSH. Low T3and T4 levels are not diagnostic of the primary cause of the hypothyroidism. TRH levels indicate the function of the hypothalamus.
Which question from a nurse during a patient interview will provide focused information about a possible thyroid disorder? a. "What methods do you use to help cope with stress?" b. "Have you experienced any blurring or double vision?" c. "Have you had a recent unplanned weight gain or loss?" d. "Do you have to get up at night to empty your bladder?"
C Because thyroid function affects metabolic rate, changes in weight may indicate hyperfunction or hypofunction of the thyroid gland. Nocturia, visual difficulty, and changes in stress level are associated with other endocrine disorders.
A 52 year old is diagnosed with primary hypertension but has no other health problems. Present treatment would cause the nurse to anticipate administering which drug to the patient? a. a beta- adrenergic agonist b. an alpha- adrenergic agonist c. a diuretic d. a calcium channel agonist
C. A Diuretic Diuretics have been shown to be the safest and most effective medications for lowering blood pressure and preventing the cardiovascular complications of hypertension. A beta-adrenergic, an alpha-adrenergic, or a calcium channel agonist drug would be used for patients with other concurrent health problems.
To monitor for complications in a patient w/ type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually (select all that apply)? a) Chest x-ray b) BP c) Serum creatinine d) Urine for microalbuminuria e) CBC f) Monofilament testing of the foot
B, C, D, F BP, serum creatinine, urine testing for microalbuminuria, and monofilament testing of the foot are recommended at least annually to screen for possible miscrovascular and macrovascular complications of diabetes.
A patient was admitted to the intensive care unit with a diagnosis of acute myocardial infarction (MI) and is being treated for shock. The primary cause of shock is most likely: a. rapid heart rate. b. decreased cardiac contractility. c. increased capillary permeability. d. decreased afterload due to vasodilation.
B. decreased cardiac contractility. MI leads to decreased cardiac contractility due to a damaged myocardium and would lead to shock. A rapid heart rate would not cause shock. Increased capillary permeability would not lead to shock. Decreased afterload will not lead to shock associated with MI.
A 42 year old is diagnosed with constrictive pericarditis. The nurse assesses the blood pressure for decreased cardiac output because of: a. pericardial effusions. b. fibrosis and calcification of the pericardial layers. c. cardiomyopathy. d. hemorrhage in the pericardial cavity.
B. fibrosis and calcification of the pericardial layers. In constrictive pericarditis, fibrous scarring compresses the heart and eventually reduces cardiac output. Pericardial effusion is manifested by chest pain. Cardiomyopathy is a general term for pathophysiologic changes in the heart. Hemorrhage in the pericardial cavity will lead to tamponade.
A 68-year-old male presents to the ER reporting chest pain. He has a history of stable angina that now appears to be unstable. He most likely has: a. mild to moderate atherosclerosis. b. impending myocardial infarction (MI). c. electrical conduction problems in the heart. d. decreased myocardial oxygen demand.
B. impending myocardial infarction (MI). Unstable angina is an indication of impending MI. Unstable angina could be caused by moderate atherosclerosis, altered electrical conduction, or a decrease in myocardial oxygen, but it is an indication of impending MI.
A 73 year old has increased pulmonary pressure resulting in right heart failure. A potential cause for the right heart to fail is: a. hypertension. b. left heart failure. c. acute pneumonia. d. pericarditis.
B. left heart failure. Right-sided failure often follows left-sided failure when pulmonary congestion forces backward flow of blood into the left ventricle. It is not due to hypertension, pneumonia, or pericarditis.
What is the most common cause of hypoparathyroidism? a. Pituitary hyposecretion b. Parathyroid adenoma c. Parathyroid gland injury d. Hypothalamic inactivity
C - Hypoparathyroidism is most commonly caused by damage to the parathyroid glands, not pituitary hyposecretion, parathyroid adenoma, or inactivity of the hypothalamus.
A patient diagnosed with thyroid carcinoma would be expected to have T3 and T4 levels that are: a. high. b. low. c. normal. d. variable.
C - Most individuals with thyroid carcinoma have normal T3 and T4 levels and are therefore euthyroid.
What is the earliest manifestation of diabetes-induced kidney dysfunction? a. Polyuria b. Glycosuria c. Microalbuminuria d. Decreased glomerular filtration
C - Polyuria occurs due to increased fluid in the vascular space, and microalbuminuria is the earliest manifestation. While glycosuria occurs due to hyperglycemia, it is not the first sign of kidney dysfunction. Decreased glomerular filtration and polyuria can occur due to changes, but neither are initial manifestations.
A patient diagnosed with Graves disease is admitted to a medical-surgical unit. Which of the following symptoms would the nurse expect to find before treatment? a. Weight gain, cold intolerance b. Slow heart rate, rash c. Skin hot and moist, rapid heart rate d. Constipation, confusion
C - Symptoms of Graves disease include heat intolerance and increased tissue sensitivity to stimulation by the sympathetic division of the autonomic nervous system. Weight loss, rather than weight gain, and heat intolerance would result. Tachycardia, not slow heart rate, would occur. Diarrhea would occur as opposed to constipation.
What is the cause of type 1 diabetes mellitus (DM)? a. A familial, autosomal dominant gene defect b. Obesity and lack of exercise c. Immune destruction of the pancreas d. Hyperglycemia from eating too many sweets
C - The most common cause of type 1 DM is a slowly progressive autoimmune T-cell-mediated disease that destroys the beta cells of the pancreas; it is not due to a gene defect. Although obesity can contribute to diabetes, it doesn't cause type 1 DM. Eating too many sweets may contribute to the development of obesity.
The nurse determines a need for additional instruction when the patient w/ newly diagnosed type 1 diabetes says which of the following? a) I can have an occasional alcoholic drink if I include it in my meal plan b) I will need a bedtime snack because I take an evening dose of NPH insulin c) I can choose any foods, as long as I use enough insulin to cover the calories d) I will eat something at meal times to prevent hypoglycemia, even if I'm not hungry
C Most patients w/ type 1 diabetes need to plan diet choices very carefully.
A few weeks after an 82 y/o w/ a new diagnosis of type 2 diabetes has been placed on metformin (Glucophage) therapy and taught about appropriate diet and exercise, the home health nurse makes a visit. Which finding by the nurse is most important to discuss w/ the HCP? a) A1C is 7.9% b) Last eye exam was 18 months ago c) GFR rate is decreased d) Patient has questions about the prescribed diet
C The decrease in renal function may indicate a need to adjust the dose of metformin or change to a different medication.
A patient who was admitted w/ DKA secondary to a UTI has been weaned off an insulin drip 30 minutes ago. The patient reports feeling lightheaded and sweaty. Which action should the nurse take first? a) Infuse dextrose 50% by slow IV push b) Administer 1 mg glucagon SW c) Obtain a glucose reading using a finger stick d) Have the patient drink 4oz of orange juice
C The patient's clinical manifestations are consistent w/ hypoglycemia and the initial action should be to check the patient's glucose w/ a finger stick or order a stat blood glucose.
Many valvular stenosis and regurgitation disorders in adults have a common etiology. Which of the following conditions should alert the nurse that the patient may have both types of valve dysfunctions? a. Heart failure b. Connective tissue disorders c. Rheumatic fever or heart disease d. Syphilis infection
C. Rheumatic fever or heart disease Valvular dysfunction is often related to rheumatic fever. Heart failure decreases cardiac output but does not affect valvular function. It is not due to connective tissue disorders. Syphilis infection could affect valves, but it is not the most common cause.
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 patient's breath sounds. d. Give the prescribed PRN morphine sulfate IV.
C. The initial action should be to assess the patient further because the history and symptoms are consistent with several possible complications of central line insertion, including embolism and pneumothorax.
What term should the nurse use to document a detached blood clot? a. Thrombus b. Embolus c. Thromboembolus d. Infarction
C. Thromboembolus A thrombus is a clot that remains attached to a vessel wall; a detached thrombus is a thromboembolus. An embolus is a bolus of material floating in the bloodstream. An infarction is death of tissue.
The nurse is checking peripheral perfusion to a child's extremity following a cardiac catheterization. If there is adequate peripheral circulation, the nurse should find that the extremity A. Has a capillary refill of greater than three seconds. B. Has a palpable dorsalis pedis pulse but a weak posterior tibial pulse. C. Has decreased sensation with a weakened dorsalis pedis pulse. D. Is warm, with a capillary refill of two seconds or less.
D
The patient asks the nurse, "What is the difference between dalteparin (Fragmin) and heparin?" What is the nurse's best response? a. "There is really no difference, but dalteparin is preferred because it is less expensive." b. "I'm not really sure why some health care providers choose dalteparin and some heparin." c. "The only difference is that the heparin dosage calculation is based on the patient's weight." d. "Dalteparin is a low-molecular-weight heparin that has a more predictable anticoagulant effect."
D
The patient with type 1 diabetes mellitus is in the clinic to check his long-term glycemic control. Which test should be used? a. Water deprivation test b. Fasting blood glucose test c. Oral glucose tolerance test d. Glycosylated hemoglobin (A1C)
D
When the semilunar valves open it signals the onset of the ejection period. The aortic pressure reflects changes in the ejection of blood from which part of the heart? Right atrium Left ventricle Right ventricle Left atrium
Left ventricle Explanation: The aortic pressure reflects changes in the ejection of blood from the left ventricle, not the right ventricle or atrium.
The nurse is reviewing the anatomy and physiology of the heart. What is the function of the right atrium? Receives oxygenated blood from the lungs Pumps blood to the lungs Pumps blood into the systemic circulation Receives blood returning to the heart from the systemic circulation
Receives blood returning to the heart from the systemic circulation Explanation: The right atrium receives blood returning to the heart from the system circulation. The left atrium receives oxygenated blood from the lungs. The right ventricle pumps blood to the lungs. The left ventricle pumps blood into the systemic circulation.
The electrical activity of the heart is recorded on the ECG. What does the T wave on the ECG represent? Depolarization of the ventricular conduction system Repolarization of the atrium Repolarization of the ventricles Depolarization of the sinoatrial node
Repolarization of the ventricles Explanation: The P wave represents the depolarization of the sinoatrial node. The QRS complex represents the depolarization of the ventricles. The T wave represents repolarization of the ventricles, not the atrium.
The electrical activity of the heart is recorded on the ECG. What does the T wave on the ECG represent? Repolarization of the ventricles Repolarization of the atrium Depolarization of the ventricular conduction system Depolarization of the sinoatrial node
Repolarization of the ventricles Explanation: The P wave represents the depolarization of the sinoatrial node. The QRS complex represents the depolarization of the ventricles. The T wave represents repolarization of the ventricles, not the atrium.
Downstream peripheral pulses have a higher pulse pressure because the pressure wave travels faster than the blood itself. What occurs in peripheral arterial disease? Downstream peripheral pulses are greater than upstream pulses. The reflected wave is transmitted more rapidly through the aorta. Downstream peripheral pulses are increased even more than normal. The pulse decreases, rather than increases, in amplitude.
The pulse decreases, rather than increases, in amplitude. Explanation: With peripheral arterial disease, there is a delay in the transmission of the reflected wave so that the pulse decreases, rather than increases, in amplitude.
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.
What is the main source of bleeding in extradural (epidural) hematomas? a. Arterial b. Venous c. Capillary d. Sinus
a. Arterial
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
Which medication is an antiplatelet drug? a. Clopidogrel (Plavix) b. Alteplase (Activase) c. Heparin (Hemochron) d. Enoxaparin (Lovenox)
A
Which of the following should the nurse expect to note as a frequent complication for a child with congenital heart disease? A. Susceptibility to respiratory infection B. Bleeding tendencies C. Frequent vomiting and diarrhea D. Seizure disorder
A
The female patient is admitted with a new diagnosis of Cushing syndrome with elevated serum and urine cortisol levels. Which assessment findings should the nurse expect to see in this patient? a. Hair loss and moon face b. Decreased weight and hirsutism c. Decreased muscle mass and thick skin d. Elevated blood pressure and blood glucose
D
The nurse finds that an infant has stronger pulses in the upper extremities than in the lower extremities. The next assessment the nurse should perform is to check: A. Pedal pulses. B. Pulse oximetry level. C. Hemoglobin and hematocrit values. D. Blood pressure of the four extremities.
D
The patient with which diagnosis should have the highest priority for teaching regarding foods that are high in magnesium? a. Severe hemorrhage b. Diabetes insipidus c. Oliguric renal disease d. Adrenal insufficiency
(C) When renal excretion is decreased, magnesium intake must be decreased also, to prevent hypermagnesemia. The other conditions are not likely to require adjustment of magnesium intake.
*Stephanie is a 70-year-old retired schoolteacher who is interested in nondrug, mind-body therapies, self-management, and alternative strategies to deal with joint discomfort from rheumatoid arthritis. Which of the following options should you suggest for her plan of care, considering her expressed wishes?* A. Using a stationary exercise bicycle and free weights and attending a spinning class B. Using mind-body therapies such as music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy C. Drinking chamomile tea and applying icy/hot gel D. Receiving acupuncture and attending church services
*Answer: B* Rationale: Mind-body therapies are designed to enhance the mind's capacity to affect bodily functions and symptoms and include music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy, among many others. Although getting exercise, drinking chamomile tea and applying gels, and receiving acupuncture and attending church services may be beneficial, they are not classified as mind-body therapies in combination as specified in these answer choices.
*A 65-year-old woman has fallen while sweeping her driveway, sustaining a tissue injury. She describes her condition as an aching, throbbing back. Which type of pain are these complaints most indicative of?* A. Neuropathic pain B. Nociceptive pain C. Chronic pain D. Mixed pain syndrome
*Answer: B* Rationale: Nociceptive pain refers to the normal functioning of physiological systems that leads to the perception of noxious stimuli (tissue injury) as being painful. Patients describe this type of pain as dull or aching, and it is poorly localized. Neuropathic pain is described as shooting, tingling, burning, or numbness that is constant in the extremities, as in diabetic neuropathy. Chronic pain lasts longer than 30 days and is characterized by a disease affecting brain structure and function, such as chronic headaches or open wounds. Mixed pain syndromes are caused by different pathophysiological mechanisms such as a combination of neuropathic and nociceptive pain; this occurs in syndromes such as sciatica, spinal cord injuries, and cervical or lumbar spinal stenosis.
In which order will the nurse prepare NPH 20 units and regular insulin 2 units using the same syringe?
1) Rotate NPH vial 2) Inject 20 units of air into NPH vial 3) Inject 2 units of air into regular insulin vial 4) Withdraw regular insulin 5) Withdraw 20 units of NPH
A patient will be receiving oral theophylline (Theo-Dur), 600 mg/day, in three divided doses. How many milligrams will the patient receive per dose?
200 mg
A patient with a viral infection is to receive ganciclovir (Cytovene) 5 mg/kg/day IVPB every morning. The patient weighs 110 pounds. Identify how many milligrams will this patient receive for this dose. _______
250 mg
A patient with asthma has a personal best peak expiratory flow rate (PEFR) of 400 L/min. When explaining the asthma action plan, the nurse will teach the patient that a change in therapy is needed when the PEFR is less than ___ L/minute
320 A PEFR less than 80% of the personal best indicates that the patient is in the yellow zone where changes in therapy are needed to prevent progression of the airway narrowing.
Which assessment findings will the nurse observe in a patient diagnosed with severe pulmonary edema? a. Thick mucous secretions b. Pink, frothy sputum c. Hypocapnia d. Wheezing
ANS: B In severe edema, pink, frothy sputum is expectorated, not thick mucous secretions. Neither hypocapnia nor wheezing is an expected assessment finding associated with pulmonary edema
The nurse has admitted a child with a ventricular septal defect (VSD) to the unit. An appropriate nursing diagnosis for this child is A. Impaired Gas Exchange Related to Pulmonary Congestion Secondary to the Increased Pulmonary Blood Flow. B. Deficient Fluid Volume Related to Hyperthermia Secondary to the Congenital Heart Defect. C. Acute Pain Related to the Effects of a Congenital Heart Defect. D. Hypothermia Related to Decreased Metabolic State.
A
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
The patient asks the nurse to explain the function of the sinoatrial node in the heart. What is the nurse's best response? a. "The sinoatrial node stimulates the heart to beat in a normal rhythm." b. "The sinoatrial node protects the heart from atherosclerotic changes." c. "The sinoatrial node provides the heart with oxygenated blood." d. "The sinoatrial node protects the heart from infection."
A
A 2-year-old child is being discharged home and will have palliative surgery for tetralogy of Fallot at a later date. The mother wants to know about how much physical activity she can allow for the child. The nurse's best answer is: A. "Allow the child to regulate her activity." B. "Keep her on complete bedrest." C. "Limit her activities to a few hours." D. "Keep the child from crying."
A
A 54-year-old patient with pulmonary tuberculosis is evaluated for syndrome of inappropriate ADH secretion (SIADH). Which electrolyte imbalance would be expected in this patient? a. Hyponatremia b. Hyperkalemia c. Hypernatremia d. Hypokalemia
A - Hyponatremia occurs due to increased water reabsorption by kidneys. Hyperkalemia does not occur due to increased water reabsorption. Sodium levels are lowered with hyponatremia; they are not elevated. Hypokalemia does not occur; SIADH is a problem of sodium.
A 35-year-old hypertensive male begins taking a diuretic. Which of the following common side effects of this medication should the nurse monitor? a. Hypokalemia b. Hyponatremia c. Increased uric acid secretion d. Hypermagnesemia
A. Hypokalemia is a side effect of diuretics. Hypokalemia, not hyponatremia, is a side effect of diuretic therapy. Diuretics promote uric acid retention, not excretion. Hypokalemia is a side effect of diuretics. Hypermagnesemia is not.
One consequence of switching from aerobic to anaerobic cellular metabolism during shock states is: a. decreased adenosine triphosphate (ATP) production. b. cellular dehydration. c. cellular alkalosis. d. free radical formation.
A. decreased adenosine triphosphate (ATP) production. Anaerobic metabolism leads to decreased ATP production, not cellular dehydration, cellular alkalosis, and free radical formation.
An adult patient's blood sample is analyzed in a laboratory. Assuming a normal sample, which type of white blood cell accounts for the highest percentage? a. Neutrophil b. Eosinophil c. Basophil d. Lymphocyte
A. neutrophil
A patient has paralysis of both legs. What type of paralysis does the patient have? a. Paraplegia b. Quadriplegia c. Infraparaplegia d. Paresthesia
ANS: A Paraplegia is the paralysis of both legs. Quadriplegia is the paralysis of all four extremities. Infraparaplegia is not a description of paralysis. Paresthesia is a loss of sensation, not paralysis. REF: p. 382, Box 15-6
What is the most common type of renal stone composed of? testbanks_and_xanax a. Struvite b. Cystine c. Calcium d. Uric acid
ANS: C The most common stone types are calcium oxalate or phosphate (70-80%). Struvite (magnesium-ammonium-phosphate) occurs 15% of the time. Cystine stoes are rare (less than 1%). Uric acid stones occur 7% of the time. REF: p. 748
C Nocturia occurs as a result of the polyuria caused by diabetes insipidus. Edema, excess fluid volume, and fluid retention are not expected DIF: Cognitive Level: Apply (application) REF: 1161 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
An expected nursing diagnosis for a 30-year-old patient admitted to the hospital with symptoms of diabetes insipidus is a. excess fluid volume related to intake greater than output. b. impaired gas exchange related to fluid retention in lungs. c. sleep pattern disturbance related to frequent waking to void. d. risk for impaired skin integrity related to generalized edema.
A patient has been admitted for an exacerbation of chronic obstructive pulmonary disease and will be receiving methylprednisolone (Solu-Medrol) 30 mg intravenously every 6 hours. The medication is available in 40-mg/mL vials. Identify how many milliliters will the nurse draw up for this dose. _______
Answer: 0.75
The insulin order reads, "Check blood glucose levels before meals and at bedtime. For every 5 mg/dL over 150, give 1 unit of regular Humulin insulin, subcutaneously." The patient's blood glucose level at 11:30 ., before lunch, was 233 mg/dL. In units, identify how much insulin will the nurse give. _______
Answer: 20 units
The order reads, "Give 1500 mL of normal saline over 12 hours. The tubing drop factor is 15 gtt/mL." The nurse will set the gravity drip infusion at how many drops per minute (gtt/min). ______
Answer: 31 gtt/min
Which symptom would the nurse expect in a patient diagnosed with hyperaldosteronism? a. Hypovolemia b. Hypotension c. Hypokalemia d. Hyponatremia
C - Hypertension, hypokalemia, and neuromuscular manifestations are the hallmarks of primary hyperaldosteronism. Neither hypovolemia nor hyponatremia is associated with hyperaldosteronism.
A client is diagnosed with an abdominal aortic aneurysm that the physician just wants to "watch" for now. When teaching the client about signs/symptoms to watch for, the nurse will base the teaching on which physiologic principle? The larger the aneurysm, the less tension placed on the vessel. The primary cause for rupture relates to increase in abdominal pressure, such as straining to have a bowel movement. Small diameter of this vessel will cause it to rupture more readily. As the aneurysm grows, more tension is placed on the vessel wall, which increases the risk for rupture.
As the aneurysm grows, more tension is placed on the vessel wall, which increases the risk for rupture. Explanation: Because the pressure is equal throughout, the tension in the part of the balloon with the smaller radius is less than the tension in the section with the larger radius. The same holds true for an arterial aneurysm in which the tension and risk of rupture increase as the aneurysm grows in size. Wall tension is inversely related to wall thickness, such that the thicker the vessel wall, the lower the tension, and vice versa. Although arteries have a thicker muscular wall than veins, their distensibility allows them to store some of the blood that is ejected from the heart during systole, providing for continuous flow through the capillaries as the heart relaxes during diastole.
The nurse determines the patient has a good understanding of the discharge instructions regarding warfarin (Coumadin) with which patient statement? a. "I should keep taking ibuprofen for my arthritis." b. "I should use a soft toothbrush for dental hygiene." c. "I should decrease the dose if I start bruising easily." d. "I will double my dose if I forget to take it the day before."
B
When considering hypothyroidism, the basal metabolic rate is unusually: a. high. b. low. c. steady. d. variable.
B - The metabolic rate with hypothyroidism is low.
When a patient is diagnosed with coronary artery disease, the nurse assesses for myocardial: a. hypertrophy b. ischemia c. necrosis d. inflammation
B. Ischemia Coronary artery disease leads to myocardial ischemia. Coronary artery disease would not lead to hypertrophy but not to ischemia, necrosis, or inflammation.
The onset of anaphylactic shock is usually: a. mild. b. sudden and life threatening. c. delayed by several hours. d. delayed by 24 hours.
B. sudden and life threatening. The onset of anaphylactic shock is usually sudden and life threatening, not mild or delayed.
Neurogenic shock can be caused by any factor that inhibits the: a. parasympathetic nervous system. b. sympathetic nervous system. c. somatic nervous system. d. thalamus.
B. sympathetic nervous system. Neurogenic shock is caused by any factor that inhibits the sympathetic nervous system or overstimulates the parasympathetic nervous system. Neurogenic shock is not caused by inhibition of the somatic system or of the thalamus.
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 rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the need for correction of the acidosis with a saline bolus to prevent hypovolemia followed by insulin administration to allow glucose to reenter the cells. Oxygen therapy is not indicated because there is no indication that the increased respiratory rate is related to hypoxemia. The respiratory pattern is compensatory, and the patient will not be able to slow the respiratory rate. Lorazepam administration will slow the respiratory rate and increase the level of acidosis.
A 72 year old has a history of hypertension and atherosclerosis. An echocardiogram reveals backflow of blood into the left ventricle. Which of the following is the most likely diagnosis documented on the chart? a. Mitral regurgitation b. Mitral stenosis c. Aortic regurgitation d. Aortic stenosis
C. Aortic Regurgitation Aortic regurgitation would allow backward flow of blood into the left ventricle. Mitral regurgitation would allow backward flow of blood into the left atrium. Mitral stenosis would impede blood flow from the right atrium into the right ventricle. Aortic stenosis would impede blood flow into the aorta.
During shock states, glucose uptake is usually: a. enhanced. b. normal. c. impaired. d. energy intensive.
C. Impaired Some compensatory mechanisms activated by shock contribute to decreased glucose uptake by the cells, not enhanced uptake, normal uptake, not energy-intensive uptake.
When a person is in shock, a nurse remembers impairment in cellular metabolism is caused by: a. release of toxic substances. b. free radical formation. c. inadequate tissue perfusion. d. lack of nervous or endocrine stimulation.
C. inadequate tissue perfusion. In shock, impaired cellular metabolism is caused by inadequate tissue perfusion.Impairment of cellular metabolism is the result of inadequate tissue perfusion; toxic substances could develop, but it would be secondary to the inadequate perfusion. Free radicals are not the cause of impaired cellular metabolism. The lack of nervous control would lead to vasodilation, but perfusion still occurs.
A 27-year-old male is admitted to a neurologic unit with a complete C-5 spinal cord transection. On initial assessment, he is bradycardic, hypotensive, and hyperventilating. He appears to be going into shock. The most likely mechanism of his shock is: a. hypovolemia caused by blood loss. b. hypovolemia caused by evaporative fluid losses. c. vasodilation caused by gram-negative bacterial infection. d. vasodilation caused by a decrease in sympathetic stimulation.
D. vasodilation caused by a decrease in sympathetic stimulation. The patient is experiencing neurogenic shock in which blood volume has not changed, but SVR decreases drastically so that the amount of space containing the blood has increased, leading to hypotension. In this type of shock, blood loss has not occurred. In this type of shock, fluid loss has not occurred. Vasodilation due to infection would be septic shock; the type of shock described in the patient is due to loss of sympathetic stimulation.
Humoral control of blood flow involves the effect of vasodilator and vasoconstrictor substances in the blood. Select the factor that has a powerful vasodilator effect on arterioles and increases capillary permeability. Norepinephrine Serotonin Histamine Prostaglandins
Histamine Explanation: Histamine has a powerful vasodilator effect on arterioles and has the ability to increase capillary permeability, allowing leakage of both fluid and plasma proteins into the tissues. Norepinephrine is a powerful vasoconstrictor. Serotonin causes vasoconstriction and plays a major role in control of bleeding. Prostaglandins produce either vasoconstriction or vasodilation.
Which condition will cause a patient to secrete erythropoietin? a. Low blood pressure b. Hypercarbia c. Inflammation d. Hypoxia
d. hypoxia
Which of the following is true regarding pulmonary circulation? It consists of the left side of the heart, the aorta, and its branches. It is the larger of the two circulatory systems. The system functions with an increased arterial pressure to circulate through the distal parts of the body. It is a low-pressure system that allows for improved gas exchange.
It is a low-pressure system that allows for improved gas exchange. Explanation: The pulmonary circulation consists of the right heart and the pulmonary artery, capillaries, and veins. It is the smaller of the systems and functions at a lower pressure to assist with gas exchange.
When educating a patient recently placed on inhaled corticosteroids, the nurse will discuss which potential adverse effects? a. Fatigue and depression b. Anxiety and palpitations c. Headache and rapid heart rate d. Oral candidiasis and dry mouth
Oral candidiasis and dry mouth Oral candidiasis and dry mouth are two possible adverse effects of inhaled corticosteroids. The other responses are incorrect.
The nurse is reviewing the anatomy and physiology of the heart. What is the function of the right atrium? Pumps blood to the lungs Receives blood returning to the heart from the systemic circulation Pumps blood into the systemic circulation Receives oxygenated blood from the lungs
Receives blood returning to the heart from the systemic circulation Explanation: The right atrium receives blood returning to the heart from the system circulation. The left atrium receives oxygenated blood from the lungs. The right ventricle pumps blood to the lungs. The left ventricle pumps blood into the systemic circulation.
If the parasympathetic neurotransmitter releases acetylcholine, the nurse should anticipate observing what changes in the ECG pattern? Slowing of heart rate to below 60 beats/minute Complete cardiac standstill Disorganized ventricular fibrillation Heart rate 150 beats/minute, labeled as supraventricular tachycardia
Slowing of heart rate to below 60 beats/minute Explanation: Acetylcholine, the parasympathetic neurotransmitter released during vagal stimulation of the heart, slows down the heart rate by decreasing the slope of phase 4. The catecholamines, the sympathetic nervous system neurotransmitters epinephrine and norepinephrine, increase the heart rate by increasing the slope or rate of phase 4 depolarization. Fibrillation is the result of disorganized current flow within the ventricle (ventricular fibrillation). Fibrillation interrupts the normal contraction of the atria or ventricles. In ventricular fibrillation, the ventricles quiver but do not contract. Thus, there is no cardiac output, and there are no palpable or audible pulses (i.e., cardiac standstill).
During an assessment of a client with ankle swelling, the nurse observes jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. What is the correct interpretation of this finding? The client has increased pressure related to right-sided heart failure. The client has stenosis of the jugular veins. The client has decreased fluid volume. The client has an increased cardiac output.
The client has increased pressure related to right-sided heart failure. Explanation: The jugular veins are normally flat or collapsed. Since there are no valves at the atrial sites (i.e., venae cavae and pulmonary veins) where blood enters the heart, they can become prominent in severe right-sided heart failure. This means that excess blood is pushed back into the veins when the atria become distended.
16. An older adult patient in the intensive care unit has visual and auditory illusions. Which intervention will be most helpful? a. Using the patients glasses and hearing aids b. Placing personally meaningful objects in view c. Placing large clocks and calendars on the wall d. Assuring that the room is brightly lit but very quiet at all times
a. Using the patients glasses and hearing aids Illusions are sensory misperceptions. Glasses and hearing aids help clarify sensory perceptions. Without glasses, clocks, calendars, and personal objects are meaningless. Round-the-clock lighting promotes sensory overload and sensory perceptual alterations. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 434-436 (Box 23-1) | Page 445 (Box 23-3) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
The nurse is reviewing medications for the treatment of asthma. Which drugs are used for acute asthma attacks? (Select all that apply.) a. salmeterol (Serevent) inhaler b. albuterol (Proventil) nebulizer solution c. epinephrine d. montelukast (Singulair) e. fluticasone (Flovent) Rotadisk inhaler f. aminophylline IV infusion
albuterol (Proventil) nebulizer solution epinephrine aminophylline IV infusion Albuterol (a short-acting beta2 agonist) and epinephrine (a beta1 and beta2 agonist) are used for acute bronchospasms. Aminophylline can be used for mild to moderate cases of acute asthma. Salmeterol is a long-acting beta2 agonist that is indicated for maintenance treatment, not acute episodes. Fluticasone is an inhaled corticosteroid; montelukast is a leukotriene receptor antagonist (LTRA). These types of medications are used for asthma prophylaxis.
A patient is receiving heparin therapy as part of the treatment for a pulmonary embolism. The nurse monitors the results of which laboratory test to check the drug's effectiveness? a. Bleeding times b. Activated partial thromboplastin time (aPTT) c. Prothrombin time/international normalized ratio (PT/INR) d. Vitamin K levels
b. Activated partial thromboplastin time (aPTT)
A major contributing process in CVAs is the development of atheromatous plaques in cerebral circulation. Where do these plaques most commonly form? a. In the larger veins b. Near capillary sphincters c. In cerebral arteries d. In the venous sinuses
c. In cerebral arteries
A patient is taking a xanthine derivative as part of treatment for chronic obstructive pulmonary disease. The nurse will monitor for adverse effects associated with the use of xanthine derivatives, such as a. diarrhea. b. palpitations. c. bradycardia. d. drowsiness.
palpitations The common adverse effects of the xanthine derivatives include nausea, vomiting, and anorexia. In addition, gastroesophageal reflux has been observed to occur during sleep in patients taking these drugs. Cardiac adverse effects include sinus tachycardia, extrasystole, palpitations, and ventricular dysrhythmias. Transient increased urination and hyperglycemia are other possible adverse effects.
Which sequence is the correct pathway for blood flow through the heart? left atrium - bicuspid valve - left ventricle - pulmonary artery - lungs - pulmonary vein - right atrium - tricuspid valve - right ventricle - aorta right atrium - tricuspid valve - right ventricle - pulmonary artery - lungs - pulmonary vein - left atrium - mitral valve - left ventricle - aorta right atrium - bicuspid valve - right ventricle - pulmonary artery - lungs - pulmonary vein - left atrium - tricuspid valve - left ventricle - aorta left atrium - tricuspid valve - left ventricle - pulmonary artery - lungs - pulmonary vein - right atrium - mitral valve - right ventricle - aorta
right atrium - tricuspid valve - right ventricle - pulmonary artery - lungs - pulmonary vein - left atrium - mitral valve - left ventricle - aorta Explanation: The correct pathway for blood flow through the heart is the right atrium - tricuspid valve - right ventricle - pulmonary artery - lungs - pulmonary vein - left atrium - mitral valve - left ventricle - aorta.
What is the most likely cause of croup? a. Bacteria b. Acute hyperventilation c. Allergy d. Viral infection
d. Viral infection
Patient teaching is considered successful regarding myasthenia gravis when the patient identifies its cause as being: a. viral infection of skeletal muscle. b. atrophy of motor neurons in the spinal cord. c. demyelination of skeletal motor neurons. d. autoimmune injury at the neuromuscular junction.
d. autoimmune injury at the neuromuscular junction.
Which electrolyte will the nurse check to ensure normal platelet functioning? a. Sodium b. Potassium c. Magnesium d. Calcium
d. calcium
While planning care for a newborn, the pediatric nurse recalls that the site of hematopoiesis in the fetus is the: a. bone marrow. b. kidney. c. lymph nodes. d. spleen.
d. spleen
The nurse is providing instructions to a patient who has a new prescription for a corticosteroid metered-dose inhaler. Which statement by the patient indicates that further instruction is needed? (Select all that apply.) a. "I will rinse my mouth with water after using the inhaler and then spit out the water." b. "I will gargle after using the inhaler and then swallow." c. "I will clean the plastic inhaler casing weekly by removing the canister and then washing the casing in warm soapy water. I will then let it dry before reassembling." d. "I will use this inhaler for asthma attacks." e. "I will continue to use this inhaler, even if I am feeling better." f. "I will use a peak flow meter to measure my response to therapy."
"I will gargle after using the inhaler and then swallow." "I will use this inhaler for asthma attacks." The inhaled corticosteroid is a maintenance drug used to prevent asthma attacks; it is not indicated for acute asthma attacks. Rinsing the mouth with water is appropriate and necessary to prevent oral fungal infections; the water is not to be swallowed after rinsing. The patient needs to be given instructions about keeping the inhaler clean, including removing the canister from the plastic casing weekly and washing the casing in warm soapy water. Once the casing is dry, the canister and mouthpiece may be put back together and the cap applied. The glucocorticoid may predispose the patient to oral fungal overgrowth, thus the need for implicit instructions about cleaning inhaling devices. Use of a peak flow meter assists in monitoring the patient's response to therapy. The medication needs to be taken as ordered every day, regardless of whether the patient is feeling better.
The nurse is admitting an older adult with decompensated congestive heart failure. The nursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea. The nurse should question which doctor's order? a.Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr b.Furosemide (Lasix) 20 mg PO now c.Oxygen via face mask at 8 L/min d.KCl 20 mEq PO two times per day
(A) A patient with decompensated heart failure has extracellular fluid volume (ECV) excess. The IV of 0.9% NaCl is normal saline, which should be questioned because it would expand ECV and place an additional load on the failing heart. Diuretics such as furosemide are appropriate to decrease the ECV during heart failure. Increasing the potassium intake with KCl is appropriate, because furosemide increases potassium excretion. Oxygen administration is appropriate in this situation of near pulmonary edema from ECV excess.
The patient has recent bilateral, above-the-knee amputations and has developed C. difficile diarrhea. What assessments should the nurse use to detect ECV deficit in this patient? (Select all that apply.) a. Test for skin tenting. b. Measure rate and character of pulse. c. Measure postural blood pressure and heart rate. d. Check Trousseau's sign. e. Observe for flatness of neck veins when upright. f. Observe for flatness of neck veins when supine.
(A, B, F) ECV deficit is characterized by skin tenting; rapid, thready pulse; and flat neck veins when supine, which can be assessed in this patient. Although ECV deficit also causes postural blood pressure drop with tachycardia, this assessment is not appropriate for a patient with recent bilateral, above-the-knee amputations. Trousseau's sign is a test for increased neuromuscular excitability, which is not characteristic of ECV deficit. Flat neck veins when upright is a normal finding.
At change-of-shift report, the nurse learns the medical diagnoses for four patients. Which patient should the nurse assess most carefully for development of hyponatremia? a. Vomiting all day and not replacing any fluid b. Tumor that secretes excessive antidiuretic hormone (ADH) c. Tumor that secretes excessive aldosterone d. Tumor that destroyed the posterior pituitary gland
(B) ADH causes renal reabsorption of water, which dilutes the body fluids. Excessive ADH thus causes hyponatremia. Excessive aldosterone causes ECV excess rather than hyponatremia. The posterior pituitary gland releases ADH; lack of ADH causes hypernatremia. Vomiting without fluid replacement causes ECV deficit and hypernatremia.
The nurse assessed four patients at the beginning of the shift. Which finding should the nurse report most urgently to the physician? a.Swollen ankles in patient with compensated heart failure b.Positive Chvostek's sign in patient with acute pancreatitis c.Dry mucous membranes in patient taking a new diuretic d.Constipation in patient who has advanced breast cancer
(B) Positive Chvostek's sign indicates increased neuromuscular excitability, which can progress to dangerous laryngospasm or seizures and thus needs to be reported first. The other assessment findings are less urgent and need further assessment. Bilateral ankle edema is a sign of ECV excess, and follow-up is needed, but the situation is not immediately life-threatening. Dry mucous membranes in a patient taking a diuretic may be associated with ECV deficit; however, additional assessments of ECV deficit are required before reporting to the physician. Constipation has many causes, including hypercalcemia and opioid analgesics, and it needs action, but not as urgently as a positive Chvostek's sign.
The home health nurse has an acute immunodeficiency syndrome (AIDS) patient who has chronic diarrhea. Which assessments should the nurse use to detect the fluid and electrolyte imbalances for which the patient has high risk? (Select all that apply.) a. Bilateral ankle edema b. Weaker leg muscles than usual c. Postural blood pressure and heart rate d. Positive Trousseau's sign e. Flat neck veins when upright f. Decreased patellar reflexes
(B, C, D) Chronic diarrhea has high risk of causing ECV deficit, hypokalemia, hypocalcemia, and hypomagnesemia because it increases fecal excretion of sodium-containing fluid, potassium, calcium, and magnesium. Appropriate assessments include postural blood pressure and heart rate for ECV deficit; weaker leg muscles than usual for hypokalemia; and positive Trousseau's sign for hypocalcemia and hypomagnesemia. Bilateral ankle edema is a sign of ECV excess, which is not likely with chronic diarrhea. Flat neck veins when upright is a normal finding. Decreased patellar reflexes is associated with hypermagnesemia, which is not likely with chronic diarrhea.
The nurse is assessing a patient before hanging an IV solution of 0.9% NaCl with KCl in it. Which assessment finding should cause the nurse to hold the IV solution and contact the physician? a. Weight gain of 2 pounds since last week b. Dry mucous membranes and skin tenting c. Urine output 8 mL/hr d. Blood pressure 98/58
(C) Administering IV potassium to a patient who has oliguria is not safe, because potassium intake faster than potassium output can cause hyperkalemia with dangerous cardiac dysrhythmias. Dry mucous membranes, skin tenting, and blood pressure 98/58 are consistent with the need for IV 0.9% NaCl. Weight gain of 2 pounds in a week does not necessarily indicate fluid overload, because it can be from increased nutritional intake. Only an overnight weight gain indicates a fluid gain.
The patient's laboratory report today indicates severe hypokalemia, and the nurse has notified the physician. Nursing assessment indicates that heart rhythm is regular. What is the most important nursing intervention for this patient now? a. Raise bed side rails due to potential decreased level of consciousness and confusion. b. Examine sacral area and patient's heels for skin breakdown due to potential edema. c. Establish seizure precautions due to potential muscle twitching, cramps, and seizures. d. Institute fall precautions due to potential postural hypotension and weak leg muscles.
(D) Hypokalemia can cause postural hypotension and bilateral muscle weakness, especially in the lower extremities. Both of these increase the risk of falls. Hypokalemia does not cause edema, decreased level of consciousness, or seizures.
The patient is receiving tube feedings due to a jaw surgery. What change in assessment findings should prompt the nurse to request an order for serum sodium concentration? a. Development of ankle or sacral edema b. Increased skin tenting and dry mouth c. Postural hypotension and tachycardia d. Decreased level of consciousness
(D) Tube feedings pose a risk for hypernatremia unless adequate water is administered between tube feedings. Hypernatremia causes the level of consciousness to decrease. The serum sodium concentration is a laboratory measure for osmolality imbalances, not ECV imbalances. Edema is a sign of ECV excess, not hypernatremia. Skin tenting, dry mouth, postural hypotension, and tachycardia all can be signs of ECV deficit.
*Following the initiation of a pain management plan, pain should be reassessed and documented on a regular basis as a way to evaluate the effectiveness of treatments. Pain should be reassessed at which minimum interval?* A. With each new report of pain B. Before and after administration of narcotic analgesics C. Every 10 minutes D. Every shift
*Answer: A & B* Rationale: Following the initiation of a pain management plan, pain should be reassessed and documented on a regular basis as a way to evaluate the effectiveness of treatments. At a minimum, pain should be reassessed with each new report of pain and before and after administration of analgesics.
*Which of the following is a priority for a nurse to include in a teaching plan for a patient who desires self-management and alternative strategies?* A. Body alignment and superficial heat and cooling B. Patient-controlled analgesia (PCA) pump C. Neurostimulation D. Peripheral nerve blocks
*Answer: A* Rationale: Body alignment and thermal management are examples of nonpharmacological measures to manage pain. They can be used individually or in combination with other nondrug therapies. Proper body alignment achieved through proper positioning can help prevent or relieve pain. Thermal measures such as the application of localized, superficial heat and cooling may relieve pain and provide comfort. PCA, neurostimulation, and peripheral nerve blocks are not totally self-managed or alternative therapies, because they are used under the direction of medical professionals.
*Postoperative surgical patients should be given alternating doses of acetaminophen and which medication throughout the postoperative course, unless contraindicated?* A. Antihistamine B. Local anesthetic C. Opioids D. Nonsteroidal anti-inflammatory drug (NSAID)
*Answer: D* Rationale: Unless contraindicated, all surgical patients should routinely be given acetaminophen and an NSAID in scheduled doses throughout the postoperative course. Opioid analgesics are added to the treatment plan to manage moderate-to-severe postoperative pain. A local anesthetic is sometimes administered epidurally or by continuous peripheral nerve block.
Match the following congenital heart defects with the correct descriptor. There is only one descriptor per each defect. 1. Tetralogy of Fallot (TOF) 2. Atrial Septal Defect (ASD) 3. Truncus Arteriosus (TA) 4. Coarctation of the Aorta (COA) 5. Atrioventricular Septal Defect 6. Transposition of the Great Arteries (TGA) 7. Patent Ductus Arteriosus (PDA) A. Aorta is lined up just over the hole between the bottom two chambers of the heart. B. There is a hole between the top two chambers of the heart. C. One large blood vessel with a single valve leaves the heart. D. There is a narrowing of the major artery from the heart to the body. E. There is a hole between the top two chambers and the bottom two chambers of the heart. Common with Down syndrome. F. The pulmonary artery and the aorta are in opposite position of where they should be. Two noncommunicating circulatory systems—a condition incompatible with life. G. There is an open connection between the aorta and the pulmonary artery.
1 - A 2 - B 3 - C 4 - D 5 - E 6 - F 7 - G
A 7-year-old client is diagnosed with rheumatic fever. The physician orders throat cultures of all family members. The nurse explains that: A. "Family members can carry streptococcus and be asymptomatic." B. The child must have infected others." C. "Rheumatic fever is familial." D. "Family members can carry the virus for rheumatic fever."
A
A baby is observed at birth to be noncyanotic. On physical examination the patient is found to have a continuous "machinery-type" murmur that is present in both systole and diastole. A nonsteroidal anti-inflammatory drug is prescribed, and on follow-up the murmur has disappeared. Which of the following is the most likely congenital lesion? A. Patent ductus arteriosus B. Tetralogy of Fallot C. Transposition of the great arteries D. Truncus arteriosus
A
A child is being seen in the ambulatory clinic for a sore throat diagnosed as caused by group A beta hemolytic streptococcus. The nurse provides care with the understanding that the risk of developing rheumatic fever is greatest: A. Two weeks later. B. Prior to the administration of an antibiotic. C. Once the child has begun antibiotic therapy. D. With the onset of the strep infection.
A
A patient has a low serum T3 level. The HCP orders measurement of the TSH level. If the TSH level is elevated, what does this indicate? a. The cause of the low T3 level is most likely primary hypothyroidism. b. The negative feedback system is failing to stimulate the anterior pituitary gland. c. The patient has an underactive thyroid gland that is not receiving TSH stimulation. d. A tumor on the anterior pituitary gland that is causing increased production of TSH.
A
A patient who is prescribed an anticoagulant requests an aspirin (acetylsalicylic acid) for headache relief. What is the nurse's best action? a. Inform the patient of potential drug interactions with anticoagulants. b. Explain that a common initial adverse effect is a headache for this drug. c. Explain that acetylsalicylic acid is contraindicated and administer ibuprofen. d. Administer 650 mg of acetylsalicylic acid and reassess pain in 30 minutes.
A
A school-age child is admitted with a suspected acyanotic heart disease. After learning that the heart defect is a congenital disorder, the parents ask the nurse how they could have missed the problem all these years. The nurse's response should include the information that: A. Acyanotic heart disease may be asymptomatic. B. The child would only be cyanotic with great exertion. C. The parents should have recognized the symptoms associated with an acyanotic heart defect. D. The parents were probably ignoring the symptoms and hoping they would go away.
A
In a patient with an elevated serum cortisol, what should the nurse expect other laboratory findings to reveal? a. Hypokalemia b. Hyponatremia c. Hypoglycemia d. Decreased serum triglycerides
A
In assessing children with congenital heart defects, the nurse would expect to see clubbing of the fingers and toes in the child diagnosed with: A. Tetralogy of Fallot. B. Atrial septal defect. C. Coarctation of the aorta. D. Patent ductus arteriosus.
A
On initial exam of a child with newly diagnosed Kawasaki disease, the nurse should expect to document: A. Dry, swollen, fissured lips. B. Non-palpable lymph nodes. C. Conjunctivitis with exudates. D. Cyanosis of the hands and feet.
A
The mother of a child with a heart defect is questioning the nurse about the child's medication. When discussing the diuretic the child is on, the nurse should place an emphasis on teaching about: A. Close monitoring of output. B. The digitalization process. C. The possibility that pulses in the child might be weak. D. The child's increased appetite.
A
What are two effects of hypokalemia on the endocrine system? a. Decreased insulin and aldosterone release b. Decreased glucagon and increased cortisol release c. Decreased release of ANP and increased ADH release d. Decreased release of parathyroid hormone and increased calcitonin release
A
Which question during the assessment of a diabetic patient will help the nurse identify autonomic neuropathy? a) Do you feel bloated after eating? b) Have you seen any skin changes? c) Do you need to increase your insulin dosage when you are stressed? d) Have you noticed any painful new ulcerations or sores on your feet?
A Autonomic neuropathy can cause delayed gastric emptying, which results in a bloated feeling for the patient.
In order to assist an older diabetic patient to engage in moderate daily exercise, which action is most important for the nurse to take? a) Determine what type of activities the patient enjoys b) Remind the patient that exercise will improve self-esteem c) Teach the patient about the effects of exercise on glucose level d) Give the patient a list of activities that are moderate in intensity
A Because consistency w/ exercise is important, assessment for the types of exercise that the patient finds enjoyable is the most important action by the nurse in ensuring adherence to an exercise program.
Which nursing action can the nurse delegate to UAP who are working in the diabetic clinic? a) Measure the ankle-brachial index b) Check for changes in skin pigmentation c) Assess for unilateral or bilateral foot drop d) Ask the patient about symptoms of depression
A Checking systolic pressure at the ankle and brachial areas and calculating the ankle-brachial index is a procedure that can be done by UAP who have been trained in the procedure.
A 27 y/o patient admitted w/ DKA has a serum glucose level of 732 mg/dL and serum potassium level of 3.1 mEq/L. Which action prescribed by the HCP should the nurse take first? a) Place the patient on a cardiac monitor b) Administer IV potassium supplements c) Obtain urine glucose and ketone levels d) Start an insulin infusion at 0.1 units/kg/hr
A Hypokalemia can lead to potentially fatal dysrhythmias such as v-tach and v-fib, which would be detected w/ ECG monitoring.
Which patient action indicates a good understanding of the nurse's teaching about the use of an insulin pump? a) The patient programs the pump for an insulin bolus after eating b) The patient changes the location of the insertion site every week c) The patient takes the pump off at bedtime and starts it again each morning d) The patient plans for a diet that is less flexible when using the insulin pump
A In addition to the basal rate of insulin infusion, the patient will adjust the pump to administer a bolus after each meal, w/ the dosage depending on the oral intake.
A female patient is scheduled for an oral glucose tolerance test. Which information from the patient's health history is most important for the nurse to communicate to the HCP? a) The patient uses oral contraceptives b) The patient runs several days a week c) The patient has been pregnant three times d) The patient has a family history of diabetes
A Oral contraceptive use may falsely elevate oral glucose tolerance test values.
A 32 y/o patient w/ diabetes is starting on intensive insulin therapy. Which type of insulin will the nurse discuss using for mealtime coverage? a) Lispro (Humalog) b) Glargine (Lantus) c) Detemir (Levemir) d) NPH (Humulin N)
A Rapid or short-acting insulin is used for mealtime coverage for patients receiving intensive insulin therapy.
Which statement by the patient indicates a need for additional instruction in administering insulin? a) I need to rotate injection sites among my arms, legs, and abdomen each day b) I can by the 0.5 mL syringes because the line markings will be easier to see c) I should draw up the regular insulin first after injecting air into the NPH bottle d) I do not need to aspirate the plunger to check for blood before injecting insulin
A Rotating sites is no longer recommended because there is more consistent insulin absorption when the same site is used consistently.
A 38 y/o patient who has type 1 diabetes plans to swim laps daily at 1:00 PM. The clinic nurse will plan to teach the patient to a) check glucose level before, during, and after swimming b) delay eating the noon meal until after the swimming class c) increase the morning dose of NPH insulin d) time the morning insulin injection so that the peak occurs while swimming
A The change in exercise will affect blood glucose, and the patient will need to monitor glucose carefully to determine the need for changes in diet and insulin administration.
A 55 y/o female patient w/ type 2 diabetes has a nursing diagnosis of imbalanced nutrition: more than body requirements. Which goal is most important for this patient? a) The patient will reach an A1C level of less than 7% b) The patient will follow a diet and exercise plan that results in weight loss c) The patient will choose a diet that distributes calories throughout the day d) The patient will state the reasons for eliminating simple sugars in the diet
A The complications of diabetes are related to elevated blood glucose, and the most important patient outcome is the reduction of glucose to near-normal levels.
A 54 y/o patient is admitted w/ DKA. Which admission order should the nurse implement first? a) Infuse 1 L of normal saline per hour b) Give sodium bicarbonate 50 mEq IV push c) Administer regular insulin 10 U by IV push d) Start a regular insulin infusion at 0.1 units/kg/hr
A The most urgent problem is the hypovolemia associated w/ DKA, and the priority is to infuse IV fluids.
Which information will the nurse include in teaching a female patient who has peripheral arterial disease, type 2 diabetes, and sensory neuropathy of the feet and legs? a) Choose flat-soled leather shoes b) Set heating pads on a low temperature c) Use callus remover for corns or calluses d) Soak feet in warm water for an hour each day
A The patient is taught to avoid high heels and that leather shoes are preferred.
A patient receives aspart (NovoLog) insulin at 8:00 AM. Which time will it be most important for the nurse to monitor for symptoms of hypoglycemia? a) 10:00 AM b) 12:00 AM c) 2:00 PM d) 4:00 PM
A The rapid-acting insulins peak in 1-3 hours.
The nurse has administered 4oz of orange juice to an alert patient whose blood glucose was 62 mg/dL. 15 minutes later, the blood glucose is 67 mg/dL. Which action should the nurse take next? a) Give the patient 4-6 oz more orange juice b) Administer the PRN glucagon 1 mg IM c) Have the patient eat some peanut butter w/ crackers d) Notify the HCP about the hypoglycemia
A The rule of 15 indicates that administration of quickly acting carbs should be done 2-3 times for a conscious patient whose glucose remains less than 70 mg/dL before notifying the HCP.
Which nursing action for a patient with chronic obstructive pulmonary disease (COPD)could the nurse delegate to experienced unlicensed assistive personnel (UAP)? a. Obtain O2 saturation using pulse oximetry. b. Monitor for increased O2 need with exercise. c. Teach the patient about safe use of O2 at home. d. Adjust O2 to keep saturation in prescribed parameters.
A UAP can obtain O2 saturation (after being trained and evaluated in the skill). The other actions require more education and a scope of practice that licensed practical/vocational nurses (LPN/LVNs) or registered nurses (RNs) would have.
A patient who is experiencing an acute asthma attack is admitted to the emergency department. Which assessment should the nurse complete first? a. Listen to the patient's breath sounds. b. Ask about inhaled corticosteroid use. c. Determine when the dyspnea started. d. Obtain the forced expiratory volume (FEV) flow rate.
A Assessment of the patient's breath sounds will help determine how effectively the patient is ventilating and whether rapid intubation may be necessary. The length of time the attack has persisted is not as important as determining the patient's status at present. Most patients having an acute attack will be unable to cooperate with an FEV measurement. It is important to know about the medications the patient is using but not as important as assessing the breath sounds.
The nurse is caring for a 63-yr-old with a possible pituitary tumor who is scheduled for a computed tomography scan with contrast. Which information about the patient is important to discuss with the health care provider before the test? a. History of renal insufficiency b. Complains of chronic headache c. Recent bilateral visual field loss d. Blood glucose level of 134 mg/dL
A Because contrast media may cause acute kidney injury in patients with poor renal function, the health care provider will need to prescribe therapies such as IV fluids to prevent this complication. The other findings are consistent with the patient's diagnosis of a pituitary tumor.
A 30-year-old female presents to her primary care provider with fever, cardiac murmur, and petechial skin lesions and is diagnosed with infective endocarditis. The most likely cause of the disease is: a. bacteria. b. viruses. c. fungi. d. parasites.
A. Bacteria Infective endocarditis is due to a bacterial infection, not a viral, fungal, or parasitic infection.
The nurse in the emergency department receives arterial blood gas results for four recently admitted patients with obstructive pulmonary disease. The results for which patient will require the most rapid action by the nurse? a. pH 7.28, PaCO2 50 mm Hg, and PaO2 58 mm Hg b. pH 7.48, PaCO2 30 mm Hg, and PaO2 65 mm Hg c. pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg d. pH 7.31, PaCO2 58 mm Hg, and PaO2 64 mm Hg
A The pH, PaCO2, and PaO2 indicate that the patient has severe uncompensated respiratory acidosis and hypoxemia. Rapid action will be required to prevent increasing hypoxemia and correct the acidosis.
A patient who has been 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 The patient's assessment indicates impending respiratory failure, and the nurse should prepare to assist with intubation and mechanical ventilation after notifying the health care provider. IV corticosteroids require several hours before having any effect on respiratory status. The patient will not be able to cough or deep breathe effectively. Documentation is not a priority at this time.
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). The nurse should plan to teach the patient about a. a1-antitrypsin testing. b. leukotriene modifiers. c. use of the nicotine patch. d. continuous pulse oximetry.
A When COPD occurs in young patients, especially without a smoking history, a genetic deficiency in a1-antitrypsin should be suspected. Because the patient does not smoke, a nicotine patch would not be ordered. There is no indication that the patient requires continuous pulse oximetry. Leukotriene modifiers would be used in patients with asthma, not with COPD.
What is the most common cause of Addison disease? a. An autoimmune reaction b. Dietary deficiency of sodium and potassium c. Cancer d. Viral infection of the pituitary gland
A - Addison disease is caused by autoimmune mechanisms that destroy adrenal cortical cells and is more common in women. Addison disease is not due to dietary deficiency, to cancer, or to a viral infection.
A patient presents reporting visual disturbances. When CT reveals a pituitary tumor and lab tests reveal elevated prolactin, the diagnosis of prolactinoma is made. Which intervention is the treatment of choice for this condition? a. Dopaminergic agonists b. Calcium c. Insulin d. Radiation
A - Dopaminergic agonists (bromocriptine and cabergoline) are the treatment of choice for prolactinomas. Calcium is used to treat parathyroid disease. Insulin is used to treat diabetes. Radiation is not used to treat prolactionomas.
Besides hyposecretion and hypersecretion, endocrine system dysfunction can result from: a. abnormal receptor activity. b. abnormal hormone levels. c. increased synthesis of second messengers. d. extracellular electrolyte alterations.
A - Dysfunction may result from abnormal cell receptor function or from altered intracellular response to the hormone-receptor complex. Abnormal hormone levels can occur but are not the cause of endocrine dysfunction. Intracellular storage of second-messenger hormones would not lead to dysfunction; receptor function does. Extracellular electrolyte alterations may result from dysfunction, but they are not a cause.
Which assessment result would the nurse expect to find associated with a patient diagnosed with Graves disease? a. High levels of circulating thyroid-stimulating autoantibodies b. Ectopic secretion of thyroid-stimulating hormone (TSH) c. Low circulating levels of thyroid hormones d. Increased circulation of iodine
A - Graves disease results from a form of type II hypersensitivity in which there is stimulation of the thyroid by autoantibodies directed against the TSH receptor. The thyroid-stimulating antibodies stimulate TSH receptors; it is not an ectopic secretion. Graves disease is manifested by elevated levels of thyroid hormones. Iodine deficiency leads to goiter but not Graves disease.
A patient presents with breast discharge, dysmenorrhea, and excessive excitability. Tests reveal that all pituitary hormones are elevated. What does the nurse suspect as the most likely cause for these assessment findings? a. A pituitary adenoma b. Hypothalamic hyposecretion c. Hypothalamic inflammation d. Pheochromocytoma
A - Hormonal effects of pituitary adenomas include hypersecretion from the adenoma itself and hyposecretion from surrounding pituitary cells; in this case, prolactin would be elevated with the manifestation of menstrual irregularities and secretion from the breast. These symptoms are not indicative of hypothalamic inflammation, which would lead to hyposecretion. Pheochromocytoma is a tumor of the adrenal gland and would be manifested by elevated blood pressure.
A patient is admitted to the medical unit for complications of long-term, poorly controlled type 2 DM. Which of the following would the nurse expect to find in addition to elevated glucose? a. Atherosclerosis b. Metabolic alkalosis c. Elevated liver enzymes d. Anemia
A - Macrovascular disease (lesions in large and medium-sized arteries) increases morbidity and mortality and increases risk for accelerated atherosclerosis. Acidosis, rather than alkalosis, would occur in this patient. Neither elevated liver enzymes nor anemia would be expected.
A patient presents with polyuria and extreme thirst and is given exogenous ADH. For which of the following conditions would this treatment be effective? a. Neurogenic diabetes insipidus b. Psychogenic diabetes insipidus c. Nephrogenic diabetes insipidus d. SIADH
A - Neurogenic diabetes insipidus is caused by the insufficient secretion of ADH; thus, exogenous ADH would be useful in the treatment of this disorder. Psychogenic diabetes insipidus is due to increased intake of water and would not respond to exogenous ADH. ADH is high in nephrogenic diabetes insipidus; thus, exogenous ADH would be contraindicated. SIADH is manifested by high levels of ADH; thus, exogenous administration of ADH would be contraindicated.
A client with high blood pressure has swollen ankles. Which physiologic factor could relieve this condition? An increase in the colloidal pressure in tissue that drives the fluid into the tissue An increase in the colloidal pressure in circulation that drives fluid into the tissue A decrease in the hydrostatic pressure that drives fluid into the tissue An increase in the hydrostatic pressure that drives fluid into circulation
A decrease in the hydrostatic pressure that drives fluid into the tissue Explanation: The mean arterial pressure is the driving hydrostatic force and results in an increase of fluid in tissues. The colloidal pressure does influence fluid distribution but is not related to hypertension.
A client is admitted to the cardiac unit with a diagnosis of pericarditis. The nurse is teaching th client about the anatomical location of the infection. The nurse evaluates the effectiveness of the teaching when the client correctly identifies which of the following as the location of the pericardium? A membranous sac that encloses the heart The innermost lining of the heart chambers The electrical conduction system of the heart The outer muscular layer of the heart
A membranous sac that encloses the heart Explanation: The pericardium forms a fibrous covering around the heart, holding it in a fixed position in the thorax and providing physical protection and a barrier to infection. The pericardium is a tri-layer sac consisting of a tough, outer fibrous layer and a thin, inner serous layer.
A patient is in an urgent-care center with an acute asthma attack. The nurse expects that which medication will be used for initial treatment? a. An anticholinergic such as ipratropium (Atrovent) b. A short-acting beta2 agonist such as albuterol (Proventil) c. A long-acting beta2 agonist such as salmeterol (Serevent) d. A corticosteroid such as fluticasone (Flovent)
A short-acting beta2 agonist such as albuterol (Proventil) The short-acting beta2 agonists are commonly used during the acute phase of an asthmatic attack to reduce airway constriction quickly and to restore airflow to normal levels. The other drugs listed are not appropriate for acute asthma attacks. Anticholinergic drugs and long-acting beta2 agonists are used to prevent attacks; corticosteroids are used to reduce airway inflammation.
A nurse recalls acute orthostatic hypotension can be caused by: (Select all that apply.) a. prolonged immobility. b. drug action. c. starvation. d. volume depletion. e. exercise.
A, B, C, D Acute orthostatic hypotension occurs as a result of drug action, prolonged immobility, starvation, and volume depletion. Physical exhaustion, rather than exercise, could cause orthostatic hypotension.
The pediatric nurse understands that furosemide (Lasix): (select all that apply) A. Decreases preload B. Decreases afterload C. Increases contractility of the heart D. Has side effects of nausea, vomiting, anorexia, and bradycardia E. Has side effects of hypokalemia, metabolic alkalosis, and hypotension F. Has side effects of hyperkalemia and hypotension G. Promotes rapid diuresis by blocking reabsorption of sodium and water in the renal tubules.
AEG
The nurse recognizes that the patient understands the teaching about warfarin (Coumadin) when the patient verbalizes an increased risk of bleeding with concurrent use of which herbal product? (Select all that apply.) a. Garlic b. Ginkgo c. Dong quai d. Glucosamine e. St. John's wort
A,B,C,E
For a patient receiving an IV infusion of alteplase (Activase), which nursing actions should be taken? (Select all that apply.) a. Assess for cardiac dysrhythmias. b. Administer injections intramuscularly. c. Record vital signs and report changes. d. Monitor for an increase in liver enzymes. e. Observe for signs and symptoms of bleeding.
A,C,E
Which statements will the nurse include when teaching a patient who is scheduled for oral glucose tolerance testing in the outpatient clinic (select all that apply)? a. "You will need to avoid smoking before the test." b. "Exercise should be avoided until the testing is complete." c. "Several blood samples will be obtained during the testing." d. "You should follow a low-calorie diet the day before the test." e. "The test requires that you fast for at least 8 hours before testing."
A,C,E Smoking may affect the results of oral glucose tolerance tests. Blood samples are obtained at baseline and at 30, 60, and 120 minutes. Accuracy requires that the patient be fasting before the test. The patient should consume at least 1500 calories/day for 3 days before the test. The patient should be ambulatory and active for accurate test results.
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 nurse's 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 nurse's station. The patient should be placed near the nurse's 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 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.
3. A patient is experiencing periods of confusion, and the family is concerned. The patient's son asks the nurse for an explanation and recommendation. What is the nurse's best response? A. "Your father may be having mini-strokes; I will notify his physician." B. "Your father is just confused about some things since he is in the hospital." C. "The confusion will pass. Your father just has to get up and move around." D. "Talk with your father about past events, and that will help with the confusion."
A. "Your father may be having mini-strokes; I will notify his physician." Periods of confusion may be related to mini-strokes, or transient ischemic attacks (TIAs). Confusion during hospitalization does not occur with every patient. Talking with the patient or thinking the confusion may pass is not a viable solution. The patient should be assessed and the reason for the confusion identified. Awarded 1.0 points out of 1.0 possible points.
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. Elevation of total white cell count is indicative of inflammation that is often due to an infection. Upper respiratory infections are common problems in altering a patient's gas exchange. Eosinophil cells are increased in an allergic response. Neutrophils are more indicative of an acute inflammatory response. White cells do not assist to differentiate types of respiratory bacteria. Monocytes are an indicator of progress of a chronic infection.
The acid-base status of a patient is dependent on normal gas exchange. Which patient would the nurse identify as having an increased 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 Respiratory acidosis is caused by an increase in retention of carbon dioxide, regardless of the underlying disease. A decrease in carbon dioxide retention may lead to respiratory alkalosis. An increase in production of lactic acid leads to metabolic acidosis. Removal of an acid (gastric secretions) will lead to a metabolic alkalosis.
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 on magnesium level.
A 90-year-old patient is admitted to the hospital. Shortly after admission, the family notices that the patient is exhibiting disorientation and agitation. When questioned about the behavior by the family, the nurse states that the patient is at risk for developing which common complication of hospitalization in older adults? A. Delirium B. Dementia C. Alzheimer's disease D. Sundowner syndrome
A. Delirium
A patient recently admitted to the hospital has been diagnosed with delirium. The family of the patient asks the nurse to explain what delirium is. How should the nurse respond? A. Delirium is reversible with treatment of the underlying cause. B. Delirium is progressive and has no known cure. C. Delirium affects a specific area of cognitive functioning. D. Delirium indicates the onset of a cerebrovascular accident.
A. Delirium is reversible with treatment of the underlying cause. Delirium can be reversible with treatment of the precipitating problem and control of predisposing factors. Dementia is progressive and irreversible. Focal cognitive disorders affect a single area of cognitive functioning. Memory and orientation may be affected by a cerebrovascular accident (stroke), but delirium is not a sign of a stroke.
A patient recently admitted to the hospital has been diagnosed with delirium. The family of the patient asks the nurse to explain what delirium is. How should the nurse respond? A. Delirium is reversible with treatment of the underlying cause. B. Delirium is progressive and has no known cure. C. Delirium affects a specific area of cognitive functioning. D. Delirium indicates the onset of a cerebrovascular accident.
A. Delirium is reversible with treatment of the underlying causes.
A 90-year-old patient is admitted to the hospital. Shortly after admission, the family notices that the patient is exhibiting disorientation and agitation. When questioned about the behavior by the family, the nurse states that the patient is at risk for developing which common complication of hospitalization in older adults? A. Delirium B. Dementia C. Alzheimer's disease D. Sundowner syndrome
A. Delirium. Delirium, which occurs over hours to a few days, is the most frequent complication of hospitalization in the elderly population. Dementia occurs over a period of months. Alzheimer's disease develops over months to years. Sundowner syndrome is most prominent in dementia and becomes worse in the evenings.
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 HCO3 is 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 Correct 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.
1. The nurse is teaching primary prevention of cognitive impairment at a community health fair. Which topics would be included in the presentation? (Select all that apply.) a. Do not use substances such as cannabis and alcohol. b. Wear helmets when riding bicycles and motorcycles. c. Complete a Mini Mental Status Exam (MMSE) yearly. d. Correct acid-base imbalances related to underlying disease processes. e. Wear a seat belt whenever riding in a motorized vehicle. f. Complete a Confusion Assessment Method (CAM) scale yearly.
A. Do not use substances such as cannabis and alcohol B. Wear helmets when riding bicycles and motorcycles E. Wear a seat belt whenever riding in a motorized vehicle
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. Peripheral vascular disease would result in inadequate perfusion.
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.; Because the patient's gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringer's solution would usually be ordered for this patient. The other orders are appropriate for a postoperative patient with gastric suction
7. A cognitively impaired patient newly admitted to the hospital is experiencing signs of sundown syndrome. Which intervention is best for the nurse to implement? a. Leave a night light on in the room at all times. b. Leave the television on at night with the volume up. c. Restrain the patient to maintain safety during the confusion. d. Administer a sleeping medication to help the patient sleep.
A. Leave a night light on in the living room at all times.
A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for 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 Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are a serious manifestation of fluid excess.
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 The pH and HCO3 indicate that the patient has a metabolic acidosis. The ABGs are inconsistent with the other responses.
The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action 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. This patient with chronic malnutrition is likely to have a low serum albumin level, which will affect the total serum calcium. This patient with chronic malnutrition is likely to have a low serum albumin level, which will affect the total serum calcium. A more accurate reflection of calcium balance is the ionized calcium level. Most of the calcium in the blood is bound to protein (primarily albumin). Alterations in serum albumin levels affect the interpretation of total calcium levels. Low albumin levels result in a drop in the total calcium level, although the level of ionized calcium is not affected. The other actions may be needed if the ionized calcium is also decreased.
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 The neurologic system controls respiratory drive; the respiratory system controls delivery of oxygen to the lung capillaries; and the cardiac system is responsible for the perfusion of vital organs. These systems are primarily responsible for the adequacy of gas exchange in the body. The endocrine and hepatic systems are not directly involved with gas exchange. The immune system primarily protects the body against infection.
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 patient's health care provider. b. Obtain an order to draw a potassium level. c. Review the magnesium level on the patient's chart. d. Teach the patient about the risk of magnesium-containing antacids
A. Notify the patient's health care provider. The health care provider should be notified immediately. The patient has a history and manifestations consistent with hypermagnesemia.
A community health nurse is preparing a course on protecting cognitive function. Which population group should the nurse target for teaching? A. Older male adults with diabetes B. Older female adults who are overweight C. Young adults living in school dormitories D. Adolescents attending summer camps
A. Older male adults with diabetes
A community health nurse is preparing a course on protecting cognitive function. Which population group should the nurse target for teaching? A.Older male adults with diabetes B.Older female adults who are overweight C. Young adults living in school dormitories D. Adolescents attending summer camps
A. Older male adults with diabetes
A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium 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.
8. An 82-year-old patient who is in the hospital awakens from sleep and is disoriented to where she is at the present time. The nurse reorients the patient to her surroundings and helps the patient return to sleep. What data does the nurse consider as a probable cause of the patient's confusion? a. Pain medication received earlier in the night b. The death of the patient's spouse 2 years ago c. The patient's history of diabetes d. The age of the patient
A. Pain medication received earlier in the night
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 for removal. COPD and asthma are examples of a ventilation problem. Severe anemia is an example of a transport problem of gas exchange.
Following a thyroidectomy, a patient complains of "a tingling feeling around my mouth." Which assessment should the nurse complete immediately? a. Presence of the Chvostek's sign b. Abnormal serum potassium level c. Decreased thyroid hormone level d. Bleeding on the patient's dressing
A. Presence of the Chvostek's sign The patient's symptoms indicate possible hypocalcemia, which can occur secondary to parathyroid injury/removal during thyroidectomy.
Most cases of combined systolic and diastolic hypertension have no known cause and are documented on the chart as _____ hypertension. a. primary b. secondary c. congenital d, acquired
A. Primary Most cases of hypertension are diagnosed as primary hypertension, not secondary, which is due to a known cause. Most cases of hypertension are not a result of congenital or acquired causes.
A 65-year-old male is diagnosed with chronic pulmonary disease and elevated pulmonary vascular resistance. Which of the following heart failures should the nurse assess for in this patient? a. Right heart b. Left heart c. Low-output d. High-output
A. Right heart Right-sided failure occurs when the patient experiences chronic pulmonary disease and elevated pulmonary vascular resistance because the blood has difficulty overcoming the pressure and blood builds up in the right side of the heart. Pulmonary congestion leads to right-sided failure, not left, low-output failure, and high-output failure.
A 72-year-old female has a history of right heart failure caused by a right ventricular myocardial infarction. Which of the following symptoms are specifically related to her right heart failure? a. Significant edema to both lower legs and feet b. Hypertension c. Decreased urine output d. Dyspnea upon exertion
A. Significant edema to both lower legs and feet Right-sided failure allows blood to back up into the systemic circulation, leading to peripheral edema. Since it is backed up into the venous system, hypertension is less likely. Right-sided failure leads to edema and a greater venous blood volume, which would lead to increased urinary output. Dyspnea upon exertion is more indicating of left-sided failure.
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. 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 patient's fluid intake but not as urgently as the hypotension
When teaching about sodium reabsorption, which information should the nurse include? The majority of sodium reabsorption takes place in the: a. Proximal tubule b. Loop of Henle c. Distal tubule d. Collecting duct
ANS: A The majority of sodium reabsorption takes place in the proximal tubule.
A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider? a. The patient is experiencing laryngeal stridor. b. The patient complains of generalized fatigue. c. The patient's bowels have not moved for 4 days. d. The patient has numbness and tingling of the lips.
A. The patient is experiencing laryngeal stridor. Hypocalcemia can cause laryngeal stridor, which may lead to respiratory arrest. Rapid action is required to correct the patient's calcium level.
A 28 year old presents to the ER reporting severe chest pain that worsens with respirations or lying down. Other signs include a fever, tachycardia, and a friction rub. Assessment findings support which medical diagnosis? a. Acute pericarditis b. Myocardial infarction (MI) c. Stable angina d. Pericardial effusion
A. acute pericarditis Severe chest pain that worsens with respirations or lying down in a patient with fever, tachycardia, and a friction rub is characteristic of acute pericarditis. MI pain does not worsen with respirations. Stable angina does not worsen with respiration or lying down. Pericardial effusion is not manifested by these symptoms.
Which characteristic changes should the nurse keep in mind while caring for a patient with left heart failure? As left heart failure progresses: a. left ventricular preload increases. b. systemic vascular resistance decreases. c. left end-diastolic volume decreases. d. pulmonary vascular resistance decreases.
A. left ventricular preload increases. Left ventricular preload increases in left heart failure because less blood is ejected from the left ventricle. Left heart failure does not lead to a decrease in systemic resistance; it leads to an increase in resistance. Left end-diastolic volume will increase. Pulmonary vascular resistance will increase.
A nurse recalls the most common cardiac valve disease in the United States is: a. mitral valve prolapse. b. pulmonary stenosis. c. tricuspid valve prolapse. d. aortic stenosis.
A. mitral valve prolapse. Mitral valve prolapse is the most common valve disorder in the United States. Neither pulmonary stenosis, tricuspid valve prolapse, nor aortic stenosis is the most common valve disorder in the United States.
A 51-year-old male is at the health clinic for an annual physical exam. After walking from the car to the clinic, he developed substernal pain. He also reported discomfort in his left shoulder and his jaw, lasting 2-3 minutes and then subsiding with rest. He indicates that this has occurred frequently over the past few months with similar exertion. The nurse suspects he is most likely experiencing: a. stable angina. b. unstable angina. c. Prinzmetal angina. d. myocardial infarction (MI).
A. stable angina Stable angina is associated with activity and subsides with rest. Unstable angina is a form of acute coronary syndrome that results from reversible myocardial ischemia and occurs at rest. Chest pain that occurs at rest and at night is descriptive of Prinzmetal angina. MI pain does not subside with rest.
A patient presents to the emergency room complaining of vomiting with severe back and leg pain. The patient's home medications include daily oral corticosteroids. Vital signs reveal a low blood pressure and there are peaked T waves on the electrocardiogram. What is the nurse's priority intervention? a. Start an intravenous line b. Collect urine specimen c. Administer antiemetic d. Administer narcotic analgesia
A. start an intravenous line The patient is exhibiting signs of adrenal insufficiency (Addison's disease) given the regular use of corticosteroids. Cortisone, hydrocortisone (Cortef), prednisone, and fludrocortisone (Florinef) are used for the treatment of adrenocorticoid deficiency. Treatment of Addisonian crisis includes administration of hydrocortisone, saline solution, and sugar (dextrose) to correct the insufficiency. The priority intervention is to start an intravenous line so that appropriate treatments may be administered. A urine specimen may be collected but is not the priority intervention. Since the patient is vomiting, administration of antiemetics or analgesia would be given through an intravenous line. The nurse should also assess for changes in the level of consciousness; so administration of analgesia may be contraindicated if any decrease in level of consciousness occurs.
A 56 year old presents to his primary care provider for a checkup. Physical exam reveals edema, hepatomegaly, and muffled heart sounds. Which of the following is of greatest concern to the nurse? a. Tamponade b. Exudate c. Aneurysm d. Pulsus paradoxus
A. tamponade Muffled heart sounds are an indication of tamponade, and with tamponade the blood backs up into the venous system, leading to hepatomegaly. Muffled heart sounds with hepatomegaly are symptoms of tamponade, not exudates. An aneurysm would present without symptoms. Pulsus paradoxus is manifested by a change in blood pressure during inspiration and expiration.
An infant with tetralogy of Fallot is having a hypercyanotic episode ("tet" spell). Appropriate management of a tet spell in these children include: (Select all that apply). A. Place the child in knee-chest position. B. Draw blood for a serum hemoglobin. C. Administer oxygen. D. Administer morphine and propranolol intravenously as ordered. E. Administer Benadryl as ordered.
ACD
Signs and symptoms of congenital heart disease in infants include (Select all that apply) A. Dyspnea with crying or eating B. Pink blood-tinged phlegm C. Pallor D. Poor feeding E. Sweating F. Elevated blood pressure G. Murmur H. Cyanosis with crying or eating I. Fatigue J. No weight gain K. Irritable L. Vomiting
ACDEGHIJK
The pediatric nurse understands that characteristics of pulmonary hypertension include (select all that apply): A. The causes are lung disease and some congenital heart diseases. B. Characterized by mean pulmonary arterial pressure (PAP) less than 25 mmHg. C. Caused by narrowing of the pulmonary arterioles within the lung; the narrowing of the arteries creates resistance and an increased work load for the heart. D. Symptoms include chest pain, weakness, shortness of breath, and fatigue. E. Untreated, the disease usually develops into cyanotic heart defect and right-to-left shunting. F. Must treat this condition early while still reversible to prevent permanent destructive pulmonary vascular remodeling. G. Treatments include sildenafil, calcium channel blockers, diuretics, nitric oxide, and lung transplantation.
ACDFG
Tetrology of Fallot is characterized by which cardiac defects? (Select all that apply) A. Overriding aorta B. Patent ductus arteriosus C. Right ventricular hypertrophy D. Ventricular septal defect E. Coarctation of the Aorta F. Tricuspid atresia (TA) G. Pulmonary stenosis
ACDG
The pediatric nurse understands that spironolactone (aldactone): (select all that apply) A. Decreases preload B. Decreases afterload C. Increases contractility of the heart D. Has side effects of nausea, vomiting, anorexia, and bradycardia E. Has side effects of hypokalemia, metabolic alkalosis, and hypotension F. Has side effects of hyperkalemia and hypotension G. Is a potassium-sparing maintenance diuretic
AFG
1. When assessing a patient with possible peripheral artery disease (PAD), the nurse obtains a brachial BP of 147/82 and an ankle pressure of 112/74. The nurse calculates the patient's ankle-brachial index (ABI) as ________ (round up to the nearest hundredth).
ANS: 0.76 The ABI is calculated by dividing the ankle systolic BP by the brachial systolic BP.
A patient is to receive an infusion of 250 mL of platelets over 2 hours through tubing that is labeled: 1 mL equals 10 drops. How many drops per minute will the nurse infuse?
ANS: 21 To infuse 250 mL over 2 hours, the calculated drip rate is 20.8 drops/min or 21 drops/min. DIF: Cognitive Level: Apply (application) REF: 649 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
A patient is to receive methylprednisolone (Solu-Medrol) 100 mg. The label on the medication states: methylprednisolone 125 mg in 2 mL. How many milliliters will the nurse administer?
ANS: 1.6 A concentration of 125 mg in 2 mL will result in 100 mg in 1.6 mL. DIF: Cognitive Level: Apply (application) REF: 1179 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
Asthma affects ____% of children between birth and 17 years of age.
ANS: 10
1. A patient will be receiving metoprolol (Lopressor) 5 mg IV push for angina. The medication is available in a strength of 1 mg/mL. Identify how much medication will the nurse draw up for each dose. _______
ANS: 5 mL DIF: COGNITIVE LEVEL: Applying (Application) REF: N/A TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
A patient's blood pressure in the postanesthesia care unit (PACU) has dropped from an admission blood pressure of 140/86 to 102/60 with a pulse change of 70 to 96. SpO2 is 92% on 3 L of oxygen. In which order should the nurse take these actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Increase the IV infusion rate. b. Assess the patient's dressing. c. Increase the oxygen flow rate. d. Check the patient's temperature
ANS: A, C, B, D The first nursing action should be to increase the IV infusion rate. Because the most common cause of hypotension is volume loss, the IV rate should be increased. The next action should be to increase the oxygen flow rate to maximize oxygenation of hypoperfused organs. Because hemorrhage is a common cause of postoperative volume loss, the nurse should check the dressing. Finally, the patient's temperature should be assessed to determine the effects of vasodilation caused by rewarming.
While ambulating in the room, a patient complains of feeling dizzy. In what order will the nurse accomplish the following activities? (Put a comma and a space between each answer choice [A, B, C, D].) a. Have the patient sit down in a chair. b. Give the patient something to drink. c. Take the patient's blood pressure (BP). d. Notify the patient's health care provider
ANS: A, C, B, D The first priority for the patient with syncope is to prevent a fall, so the patient should be assisted to a chair. Assessment of the BP will determine whether the dizziness is due to orthostatic hypotension, which occurs because of hypovolemia. Increasing the fluid intake will help prevent orthostatic dizziness. Because this is a common postoperative problem that is usually resolved through nursing measures such as increasing fluid intake and making position changes more slowly, there is no urgent need to notify the health care provider
_____ seconds is required for oxygen (O2) concentration to equilibrate (equalize) across the alveolocapillary membrane.
ANS: 0.25
____% of oxygen (O2) enters the bloodstream bound to hemoglobin.
ANS: 97
If a nurse wants to obtain the best estimate of renal function, which test should the nurse monitor? a. Glomerular filtration rate (GFR) b. Circulating antidiuretic hormone (ADH) levels c. Volume of urine output d. Urine-specific gravity
ANS: A
A kidney has a glomerular capillary hydrostatic pressure of 50 mm Hg, a Bowman capsule hydrostatic pressure of 15 mm Hg, and a glomerular capillary oncotic pressure of 12 mm Hg. The net filtration pressure is ____ mm Hg. a. 23 b. 27 c. 35 d. 38
ANS: A /aAdd the opposing factors: a Bowman capsule hydrostatic pressure of 15 mm Hg, and a glomerular capillary oncotic pressure of 12 mm Hg equals 27 and subtract it from the promoting factor of 50 mm Hg, for a total of 23.
A nurse is preparing to teach about the collecting ducts. Reabsorption of water in the collecting ducts requires which of these hormones? a. Antidiuretic hormone (ADH) b. Atrial natriuretic factor (ANP) c. Renin d. Aldosterone
ANS: A ADH increases water permeability and reabsorption in the last segment of the distal tubule and along the entire length of the collecting ducts.
16. A 67-year-old patient is admitted to the hospital with a diagnosis of venous insufficiency. Which patient statement is most supportive of the diagnosis? a. "I can't get my shoes on at the end of the day." b. "I can't 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."
ANS: A Because the edema associated with venous insufficiency increases when the patient has been standing, shoes will feel tighter at the end of the day. The other patient statements are characteristic of peripheral artery disease (PAD).
22. 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.
ANS: A Because the patient appears to be experiencing aortic dissection, the nurse's first action should be to determine the hemodynamic status by assessing blood pressure. The other actions also may be done, but they will not provide information that will determine what interventions are needed immediately for this patient.
26. The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment could be used to evaluate the effectiveness of the therapies? a. Observe for distended neck veins. b. Auscultate for crackles in the lungs. c. Palpate for heaves or thrills over the heart. d. Monitor for elevated white blood cell count.
ANS: A Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations of right ventricular failure such as peripheral edema, jugular venous distention, and right upper-quadrant abdominal tenderness would be expected. Crackles in the lungs are likely to be heard with left-sided heart failure. Findings in cor pulmonale include evidence of right ventricular hypertrophy on electrocardiography and an increase in intensity of the second heart sound. Heaves or thrills are not common with cor pulmonale. White blood count elevation might indicate infection but is not expected with cor pulmonale.
4. 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
ANS: A Current research indicates that statin use by patients with PAD improves multiple outcomes. There is no research that supports the use of the other medication categories in PAD.
24. 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.
ANS: A 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 graft occlusion. 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 prior to surgery before notifying the health care providers about the absent pulses. Because the patient's 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 patient's legs.
9. After teaching a patient with newly diagnosed Raynaud's 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).
ANS: A Patients should avoid temperature extremes by exercising indoors when it is cold. To avoid burn injuries, the patient should use warm, rather than hot, water to warm the hands. Pseudoephedrine is a vasoconstrictor, and should be avoided. There is no reason to avoid taking NSAIDs with Raynaud's phenomenon.
A patient 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. Platelet count is 42,000/L. b. Petechiae are present on the chest. c. Blood pressure (BP) is 94/56 mm Hg. d. Blood is oozing from the venipuncture site.
ANS: A Platelet transfusions are not usually indicated until the platelet count is below 10,000 to 20,000/L unless the patient is actively bleeding. Therefore the nurse should clarify the order with the health care provider before giving the transfusion. The other data all indicate that bleeding caused by ITP may be occurring and that the platelet transfusion is appropriate. DIF: Cognitive Level: Apply (application) REF: 622 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
When a patient's renal system secretes rennin, what effect will that cause in the body? It causes the direct activation of: a. Angiotensin I b. Angiotensin II c. Antidiuretic hormone d. Aldosterone
ANS: A Renin secretion activates angiotensin I.
While reviewing urine lab results, the nurse remembers the glomerular filtration rate (GFR) is directly related to the: a. Perfusion pressure in the glomerular capillaries b. Oncotic pressure in the glomerular capillaries c. Vascular resistance in the glomerular arterioles d. Hydrostatic pressure in the Bowman capsule
ANS: A The filtration of the plasma per unit of time is known as the GFR, which is directly related to the perfusion pressure of the glomerular capillaries.
The urologist is teaching about the nephrons that determine the concentration of the urine. The urologist is discussing the _____ nephrons. a. Juxtamedullary b. Midcortical c. Cortical d. Medullary
ANS: A The juxtamedullary nephrons lie close to and extend deep into the medulla and are important for the concentration of urine.
27. 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 Fowler's position for meals.
ANS: A The patient should avoid sitting for long periods because of the increased stress on the suture line caused by leg edema and because of the risk for venous thromboembolism (VTE). The other actions by the LPN/LVN are appropriate.
When the nurse discusses the glomerulus and Bowman capsule together, it is referred to as the renal: a. Corpuscle b. Capsule c. Medulla d. Pyramid
ANS: A Together, the glomerulus and Bowman capsule are called the renal corpuscle.
Which action will the nurse include in the plan of care for a patient admitted with multiple myeloma? a. Monitor fluid intake and output. b. Administer calcium supplements. c. Assess lymph nodes for enlargement. d. Limit weight bearing and ambulation.
ANS: A A high fluid intake and urine output helps prevent the complications of kidney stones caused by hypercalcemia and renal failure caused by deposition of Bence-Jones protein in the renal tubules. Weight bearing and ambulation are encouraged to help bone retain calcium. Lymph nodes are not enlarged with multiple myeloma. Calcium supplements will further increase the patient's calcium level and are not used. DIF: Cognitive Level: Apply (application) REF: 646 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
When caring for a patient the second postoperative day after abdominal surgery for removal of a large pancreatic cyst, the nurse obtains an oral temperature of 100.8° F. Which action should the nurse take first? a. Have the patient use the incentive spirometer. b. Assess the surgical incision for redness and swelling. c. Administer the ordered PRN acetaminophen (Tylenol). d. Ask the health care provider to prescribe a different antibiotic.
ANS: A A temperature of 100.8° F in the first 48 hours is usually caused by atelectasis, and the nurse should have the patient cough and deep breathe. This problem may be resolved by nursing intervention, and therefore notifying the health care provider is not necessary. Acetaminophen will reduce the temperature, but it will not resolve the underlying respiratory congestion. Because a wound infection does not usually occur before the third postoperative day, a wound infection is not a likely source of the elevated temperature
Alan is a 30-year-old male admitted to the hospital with acute pancreatitis. He is in acute pain described as a 10/10, which is localized to the abdomen, periumbilical area, and some radiation to his back. The abdomen is grossly distended so it is difficult to assess. He is restless and agitated, with elevated pulse and blood pressure. An appropriate pain management plan of care may include a. IV Dilaudid q 4 hours prn, hydrocodone 5/500 PO q 6 hours prn, and acetaminophen. b. Norco 5/500 q 4 hours PO and Benadryl 25 mg PO q 6 hours. c. Phenergan 25 mg IM q 6 hours. d. Tylenol 325 mg q 6 hours.
ANS: A A variety of routes of administration are used to deliver analgesics. A principle of pain management is to use the oral route of administration whenever feasible. All of the first-line analgesics used to manage pain are available in short-acting and long-acting formulations. For patients who have continuous pain, a long-acting analgesic, such as modified-release oral morphine, oxycodone, or hydromorphone, or transdermal fentanyl, is used to treat the persistent baseline pain. A fast-onset, short-acting analgesic (usually the same drug as the long-acting) is used to treat breakthrough pain if it occurs. When the oral route is not possible, such as in patients who cannot swallow or are NPO or nauseated, other routes of administration are used, including intravenous (IV), subcutaneous, transdermal, and rectal. Norco, Benadryl, Phenergan, and Tylenol are not appropriate solo choices for acute pancreatitis with pain reported as 10/10.
A 65 year old diagnosed with emphysema presents to the ER for difficulty breathing. Physical exam reveals both bluish skin and mucous membranes. What term will the nurse use to document these observations? a. Cyanosis b. Hemoptysis c. Hematemesis d. Ischemia
ANS: A Cyanosis is a blue color to the skin. Hemoptysis is the coughing up of blood or bloody secretions, and hematemesis is blood in the vomitus. Ischemia is a lack of blood supply to tissues.
When caring for a patient who has just arrived on the telemetry unit after having cardiac catheterization, which nursing intervention should the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Give the scheduled aspirin and lipid-lowering medication. b. Perform the initial assessment of the catheter insertion site. c. Teach the patient about the usual postprocedure plan of care. d. Titrate the heparin infusion according to the agency protocol.
ANS: A Administration of oral medications is within the scope of practice for LPNs/LVNs. The initial assessment of the patient, patient teaching, and titration of IV anticoagulant medications should be done by the registered nurse (RN). DIF: Cognitive Level: Apply (application)
A 60 year old with a 25-year history of smoking is diagnosed with emphysema. Assessment shows an increased anterior-posterior chest diameter. The nurse attributes this finding to: a. air trapping. b. decreased inspiratory reserve volumes. c. increased flow rates. d. alveolar destruction.
ANS: A Air trapping, not increased flow rates, expands the thorax, putting the respiratory muscles at a mechanical disadvantage. Neither decreased inspiratory reserve volumes nor alveolar destruction is associated with an increased anterior-posterior chest diameter.
Which finding for a patient who has hypothyroidism and hypertension indicates that the nurse should contact the health care provider before administering levothyroxine (Synthroid)? a. Increased thyroxine (T4) level b. Blood pressure 112/62 mm Hg c. Distant and difficult to hear heart sounds d. Elevated thyroid stimulating hormone level
ANS: A An increased thyroxine level indicates the levothyroxine dose needs to be decreased. The other data are consistent with hypothyroidism and the nurse should administer the levothyroxine DIF: Cognitive Level: Apply (application) REF: 1169 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
A nurse notes that a patient walks with the leg extended and held stiff, causing a scraping over the floor surface. What type of gait is the patient experiencing? a. Spastic gait b. Cerebellar gait c. Basal ganglion gait d. Scissors gait
ANS: A An individual who walks with the leg extended and held stiff, causing a scraping over the floor surface, is experiencing a spastic gait. A cerebellar gait is wide based with the feet apart and often turned outward or inward for greater stability. A basal ganglion gait occurs when the person walks with small steps and a decreased arm swing. A scissors gait is associated with bilateral injury and spasticity. The legs are abducted so they touch each other. REF: p. 385
7. When applying transdermal nitroglycerin patches, which instruction by the nurse is correct? a. "Rotate application sites with each dose." b. "Use only the chest area for application sites." c. "Temporarily remove the patch if you go swimming." d. "Apply the patch to the same site each time."
ANS: A Application sites for transdermal nitroglycerin patches need to be rotated. Apply the transdermal patch to any nonhairy area of the body; the old patch should first be removed. The patch may be worn while swimming, but if it does come off, it should be replaced after the old site is cleansed. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 374 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
Aspiration of oral secretions increases a patient's risk for which complication? a. Pneumonia b. Bronchiectasis c. Pneumothorax d. Emphysema
ANS: A Aspiration could lead to pneumonia; bronchiectasis is related to dilation and is not associated with aspiration. Neither pneumothorax nor emphysema is associated with aspiration.
Which of the following terms should the nurse use when there is a balance between outward recoil of the chest wall and inward recoil of lungs at rest? a. Functional residual capacity (FRC) is reached. b. Vital capacity (VC) is reached. c. Total lung capacity (TLC) is reached. d. Residual volume (RV) is reached.
ANS: A Balance between the outward recoil of the chest wall and inward recoil of the lungs occurs at the resting level, the end of expiration, where the FRC is reached. VC is the amount of air that can be forcibly expired after a maximal inspiration. TLC is not reflected by outward and inward recoil. RV is the air that remains trapped in the alveoli.
When admitting a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI) to the intensive care unit, which action should the nurse perform first? a. Attach the heart monitor. c. Assess the peripheral pulses. b. Obtain the blood pressure. d. Auscultate the breath sounds.
ANS: A Because dysrhythmias are the most common complication of myocardial infarction (MI), the first action should be to place the patient on a heart monitor. The other actions are also important and should be accomplished as quickly as possible. DIF: Cognitive Level: Analyze (analysis)
14. 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
ANS: A Because iodine-based contrast media is used during a spiral CT, the patient may need to have the CT scan without contrast or be premedicated before injection of the contrast media. The increased pulse, low oxygen saturation, and tachypnea all indicate a need for further assessment or intervention but do not indicate a need to modify the CT procedure. DIF: Cognitive Level: Apply (application) REF: 492 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
Which is the most beneficial medication treatment for a patient experiencing detrusor sphincter dyssynergia? a. Alpha-blocker b. Beta-blocker c. Vasodilator d. Diuretic
ANS: A Because the bladder neck consists of circular smooth muscle with adrenergic innervation, detrusor sphincter dyssynergia may be managed by alpha-adrenergic blocking (antimuscarinic) medications. Treatment for detrusor sphincter dyssynergia is not associated with beta-blockers, vasodilators, or diuretics. REF: p. 751
An appropriate nursing intervention for a patient with non-Hodgkin's lymphoma whose platelet count drops to 18,000/μL 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.
ANS: A Because the patient is at risk for spontaneous bleeding, the nurse should check stools for occult blood. A low platelet count does not require an increased fluid intake. Oral hygiene is important, but it is not necessary to provide oral care every 2 hours. The low platelet count does not increase risk for infection, so frequent temperature monitoring is not indicated. DIF: Cognitive Level: Apply (application) REF: 644 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
For legal purposes, brain death is defined as: a. cessation of entire brain function. b. lack of cortical function. c. a consistent vegetative state (VS). d. death of the brainstem.
ANS: A Brain death occurs when there is cessation of function of the entire brain, including the brainstem and cerebellum. Lack of cortical function or brainstem death is not enough to define brain death. A VS is complete unawareness of the self or surrounding environment and complete loss of cognitive function. REF: p. 364
The patient is experiencing an increase in intracranial pressure. This increase results in: a. brain tissue hypoxia. b. intracranial hypotension. c. ventricular swelling. d. expansion of the cranial vault.
ANS: A Brain tissue hypoxia occurs as a result of increased intracranial pressure as it places pressure on the brain. Increased intracranial pressure leads to intracranial hypertension. Ventricular swelling may lead to increased intracranial pressure, but increased pressure does not lead to either ventricular swelling or the expansion of the cranial vault. REF: p. 374
A patient with an addiction to alcohol checked into a rehabilitation center as a result of experiencing delirium, inability to concentrate, and being easily distracted. What term would be used to document this state? a. Acute confusional state b. Echolalia c. Dementia d. Dysphagia
ANS: A Delirium and the inability to concentrate are characteristics of acute confusional state. Echolalia is the repeating of words and phrases. Dementia is characterized by loss of recent and remote memory. Dysphagia is difficulty speaking. REF: p. 367, Box 15-3
9. A 10-year-old male is brought to the emergency room (ER) because he is incoherent and semiconscious. CT scan reveals that he is suffering from cerebral edema. This type of edema is referred to as: a. Localized edema b. Generalized edema c. Pitting edema d. Lymphedema
ANS: A Cerebral edema is a form of localized edema. Generalized edema is manifested by a more uniform distribution of fluid in interstitial spaces. Pitting edema is due to a pit left in the skin. Lymphedema is due to swelling in interstitial spaces, primarily in the extremities.
Which finding by the nurse when assessing a patient with Hashimoto's thyroiditis and a goiter will require the most immediate action? a. New-onset changes in the patient's voice b. Apical pulse rate at rest 112 beats/minute c. Elevation in the patient's T3 and T4 levels d. Bruit audible bilaterally over the thyroid gland
ANS: A Changes in the patient's voice indicate that the goiter is compressing the laryngeal nerve and may lead to airway compression. The other findings will also be reported but are expected with Hashimoto's thyroiditis and do not require immediate action DIF: Cognitive Level: Analyze (analysis) REF: 1163 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
As a result of a severe head injury, a patient is now experiencing respiratory abnormalities characterized by alternating periods of deep and shallow breathing with periods of apnea. What term should the nurse use when charting this condition? a. Cheyne-Stokes b. Frank-Starling c. Apnea d. Orthopnea
ANS: A Cheyne-Stokes respirations are characterized by alternating periods of deep and shallow breathing, with periods of apnea lasting from 15 to 60 seconds. Frank-Starling is related to the stretch of fibers. Apnea is cessation of respirations. Orthopnea is dyspnea that occurs when an individual lies flat.
The breathing pattern that reflects respirations based primarily on carbon dioxide (CO2) levels in the blood is: a. Cheyne-Stokes. b. ataxic. c. central neurogenic. d. normal.
ANS: A Cheyne-Stokes respirations occur as a result of CO2 levels in the blood. Ataxic breathing occurs as a result of dysfunction of the medullary neurons. Central neurogenic patterns occur as a result of uncal herniation. Normal respirations are based on the levels of oxygen (O2) in the blood. REF: p. 361
4. 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
ANS: A 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. DIF: Cognitive Level: Understand (comprehension) REF: 487 | 489 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
When a nurse is preparing to teach about urine, which information should the nurse include? Just before entering the ureter, urine passes through the: a. Collecting duct b. Renal pelvis c. Urethra d. Major calyx
ANS: B Urine is collected in the renal pelvis and then funneled into the ureters.
Diffusion of respiratory gases takes place at the: a. alveolocapillary membrane. b. visceral pleurae. c. parietal pleurae. d. respiratory center.
ANS: A Diffusion of respiratory gases takes place across the alveolocapillary membrane. The visceral and parietal pleurae are the linings of the lung; gas exchange does not occur here. The respiratory center is where impulses to the respiratory muscles are generated.
The nurse is caring for a patient who was admitted to the coronary care unit following an acute myocardial infarction (AMI) and percutaneous coronary intervention the previous day. Teaching for this patient would include a. when cardiac rehabilitation will begin. b. the typical emotional responses to AMI. c. information regarding discharge medications. d. the pathophysiology of coronary artery disease.
ANS: A Early after an AMI, the patient will want to know when resumption of usual activities can be expected. At this time, the patient's anxiety level or denial will interfere with good understanding of complex information such as the pathophysiology of coronary artery disease. Teaching about discharge medications should be done closer to discharge. The nurse should support the patient by decreasing anxiety rather than discussing the typical emotional responses to myocardial infarction. DIF: Cognitive Level: Apply (application)
Which menu choice indicates that the patient understands the nurse's teaching about recommended dietary choices for iron-deficiency anemia? a. Omelet and whole wheat toast c. Strawberry and banana fruit plate b. Cantaloupe and cottage cheese d. Cornmeal muffin and orange juice
ANS: A Eggs and whole grain breads are high in iron. The other choices are appropriate for other nutritional deficiencies but are not the best choice for a patient with iron-deficiency anemia. DIF: Cognitive Level: Apply (application) REF: 610 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
What is the nurse's best response about developing diabetes to the patient whose father has type 1 diabetes mellitus? a. "You have a greater susceptibility for development of the disease because of your family history." b. "Your risk is the same as the general population, because there is no genetic risk for development of type 1 diabetes." c. "Type 1 diabetes is inherited in an autosomal dominant pattern. Therefore the risk for becoming diabetic is 50%." d. "Because you are a woman and your father is the parent with diabetes, your risk is not increased for eventual development of the disease. However, your brothers will become diabetic."
ANS: A Even though type 1 diabetes does not follow a specific genetic pattern of inheritance, those with one parent with type 1 diabetes are at an increased risk for development of the disease.
The nurse instructs a patient with type 1 diabetes mellitus to avoid which of the following drugs while taking insulin? a. Furosemide (Lasix) b. Dicumarol (Bishydroxycoumarin) c. Reserpine (Serpasil) d. Cimetidine (Tagamet)
ANS: A Furosemide is a loop diuretic and can increase serum glucose levels; its use is contraindicated with insulin. Dicumarol, an anticoagulant; reserpine, an anti-hypertensive; and cimetidine, an H2 receptor antagonist, do not affect blood glucose levels.
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.
ANS: A 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. DIF: Cognitive Level: Analyze (analysis) REF: 645 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
When taking care of a patient with hyperkalemia, which principle is priority? Hyperkalemia causes a(n) _____ in resting membrane potential with _____ excitability of cardiac muscle. a. Increase; increased b. Decrease; increased c. Increase; decreased d. Decrease; decreased
ANS: A Hyperkalemia causes an increase in resting membrane potential and increased excitability of cardiac muscle. Hyperkalemia does cause an increased excitability of cardiac muscle, but the result is an increase in resting membrane potential. Hyperkalemia does cause an increase in resting membrane potential, but the result is an increase in excitability of cardiac muscle. Hyperkalemia causes an increase in resting membrane potential and increased excitability of cardiac muscle.
A 56-year-old female patient has an adrenocortical adenoma, causing hyperaldosteronism. The nurse providing care should a. monitor the blood pressure every 4 hours. b. elevate the patient's legs to relieve edema. c. monitor blood glucose level every 4 hours. d. order the patient a potassium-restricted diet.
ANS: A Hypertension caused by sodium retention is a common complication of hyperaldosteronism. Hyperaldosteronism does not cause an elevation in blood glucose. The patient will be hypokalemic and require potassium supplementation before surgery. Edema does not usually occur with hyperaldosteronism DIF: Cognitive Level: Apply (application) REF: 1180 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
5. A patient arrives in the emergency department with severe chest pain. The patient reports that the pain has been occurring off and on for a week now. Which assessment finding would indicate the need for cautious use of nitrates and nitrites? a. Blood pressure of 88/62 mm Hg b. Apical pulse rate of 110 beats/min c. History of renal disease d. History of a myocardial infarction 2 years ago
ANS: A Hypotension is a possible contraindication to the use of nitrates because the medications may cause the blood pressure to decrease. The other options are incorrect. DIF: COGNITIVE LEVEL: Analyzing (Analysis) REF: p. 364 TOP: NURSING PROCESS: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
A patient's arterial blood gas reveals decreased carbon dioxide (CO2) levels. What is the most likely cause of this situation? a. Hyperventilation b. Hypoventilation c. Apnea d. Cyanosi
ANS: A Individuals with hyperventilation blow off CO2 while individuals with hypoventilation retain CO2. Apnea is cessation of breathing. Cyanosis is a blue color to the skin.
The nurse is administering intravenous acyclovir (Zovirax) to a patient with a viral infection. Which administration technique is correct? a. Infuse intravenous acyclovir slowly, over at least 1 hour. b. Infuse intravenous acyclovir by rapid bolus. c. Refrigerate intravenous acyclovir. d. Restrict oral fluids during intravenous acyclovir therapy.
ANS: A Intravenous acyclovir is stable for 12 hours at room temperature and often precipitates when refrigerated. Intravenous infusions must be diluted as recommended (e.g., with 5% dextrose in water or normal saline) and infused with caution. Infusion over longer than 1 hour is suggested to avoid the renal tubular damage seen with more rapid infusions. Adequate hydration should be encouraged (unless contraindicated) during the infusion and for several hours afterward to prevent drug-related crystalluria.
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."
ANS: A It is normal for the stools to appear black when a patient is taking iron, and the patient should not call the health care provider about this. The other patient statements are correct. DIF: Cognitive Level: Apply (application) REF: 609 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
A patient who has recently started taking pravastatin (Pravachol) and niacin reports several symptoms to the nurse. Which information is most important to communicate to the health care provider? a. Generalized muscle aches and pains b. Dizziness with rapid position changes c. Nausea when taking the drugs before meals d. Flushing and pruritus after taking the drugs
ANS: A Muscle aches and pains may indicate myopathy and rhabdomyolysis, which have caused acute kidney injury and death in some patients who have taken the statin medications. These symptoms indicate that the pravastatin may need to be discontinued. The other symptoms are common side effects when taking niacin, and although the nurse should follow-up with the health care provider, they do not indicate that a change in medication is needed. DIF: Cognitive Level: Analyze (analysis)
A 54-year-old female is diagnosed with nephritic syndrome. Which of the following is a common symptom of this disease? a. Hematuria b. Dysuria c. Oliguria d. Proteinuria
ANS: A Nephritic syndrome is hematuria and red blood cell casts in the urine. Proteinuria is usually less severe than in nephrotic syndrome. The patient with nephritic syndrome does not experience dysuria or oliguria. REF: p. 759
A 19-year-old male has sustained a transaction of C-7 in an MVA rendering him a quadriplegic. He describes his pain as burning, sharp, and shooting. This is characteristic of a. neuropathic pain. b. ghost pain. c. mixed pain syndrome. d. nociceptive pain.
ANS: A Neuropathic pain results from the abnormal processing of sensory input by the nervous system as a result of damage to the brain, spinal cord, or peripheral nerves. Simply put, neuropathic pain is pathologic. Examples of neuropathic pain include postherpetic neuralgia, diabetic neuropathy, phantom pain, and post stroke pain syndrome. Patients with neuropathic pain use very distinctive words to describe their pain, such as "burning," "sharp," and "shooting." Ghost pain is pain associated with loss of a limb or digit. Mixed pain syndrome is not easily recognized, is unique with multiple underlying and poorly understood mechanisms like fibromyalgia and low back pain. Nociceptive pain refers to the normal functioning of physiological systems that leads to the perception of noxious stimuli (tissue injury) as being painful. Patients describe this type of pain as aching, cramping, or throbbing. Neuropathic pain is pathologic and results from abnormal processing of sensory input by the nervous system as a result of damage to the brain, spinal cord, or peripheral nerves. Patients describe this type of pain as burning, sharp, and shooting.
A patient is admitted to the neurological critical care unit with a severe closed head injury. When an intraventricular catheter is inserted, the intracranial pressure (ICP) is recorded at 24 mm Hg. How should the nurse interpret this reading? a. Higher than normal b. Lower than normal c. Normal d. Borderline
ANS: A Normal ICP is 1-15 mm Hg; at 24 mm Hg, the patient's ICP is higher than normal. REF: p. 374, Box, 15-4
The nurse is making a home visit to a child who has a chronic disease. Which finding has the greatest 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.
ANS: A Oliguria decreases the excretion of metabolic acids and is a risk factor for metabolic acidosis. Jaundice requires follow-up but is not an acid-base problem. Perioral chapped skin needs intervention but is not an acid-base issue. With three blankets, diaphoresis is not unusual.
5. Water movement between the ICF and ECF compartments is determined by: a. Osmotic forces b. Plasma oncotic pressure c. Antidiuretic hormone d. Buffer systems
ANS: A Osmotic forces determine water movement between the ECF and ICF compartments. Oncotic pressure pulls water at the end of the capillary, which makes it move between intra and extra as interstitial is considered extra. The antidiuretic hormone regulates water balance which would make water move between the intra and extra. Buffer systems help regulate acid balance.
Controlling pain is important to promoting wellness. Unrelieved pain has been associated with a. prolonged stress response and a cascade of harmful effects system-wide. b. large tidal volumes and decreased lung capacity. c. decreased tumor growth and longevity. d. decreased carbohydrate, protein, and fat destruction.
ANS: A Pain triggers a number of physiologic stress responses in the human body. Unrelieved pain can prolong the stress response and produce a cascade of harmful effects in all body systems. The stress response causes the endocrine system to release excessive amounts of hormones, such as cortisol, catecholamines, and glucagon. Insulin and testosterone levels decrease. Increased endocrine activity in turn initiates a number of metabolic processes, in particular, accelerated carbohydrate, protein, and fat destruction, which can result in weight loss, tachycardia, increased respiratory rate, shock, and even death. The immune system is also affected by pain as demonstrated by research showing a link between unrelieved pain and a higher incidence of nosocomial infections and increased tumor growth. Large tidal volumes are not associated with pain while decreased lung capacity is associated with unrelieved pain. Decreased tumor growth and longevity are not associated with unrelieved pain. Decreased carbohydrate, protein, and fat are not associated with pain or stress response.
What nerve provides the lungs with parasympathetic innervation? a. Vagus b. Phrenic c. Brachial d. Pectoral
ANS: A Parasympathetic innervations for the lung are via the vagus nerve. Parasympathetic innervations of the lung are not associated with the phrenic, brachial, or pectoral nerves.
The nurse determines that additional instruction is needed for a 60-year-old patient with chronic syndrome of inappropriate antidiuretic hormone (SIADH) when the patient says which of the following? a. "I need to shop for foods low in sodium and avoid adding salt to food." b. "I should weigh myself daily and report any sudden weight loss or gain." c. "I need to limit my fluid intake to no more than 1 quart of liquids a day." d. "I will eat foods high in potassium because diuretics cause potassium loss."
ANS: A Patients with SIADH are at risk for hyponatremia, and a sodium supplement may be prescribed. The other patient statements are correct and indicate successful teaching has occurred DIF: Cognitive Level: Apply (application) REF: 1160 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
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
ANS: A 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. DIF: Cognitive Level: Apply (application) REF: 614 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
The nurse is describing the movement of blood into and out of the capillary beds of the lungs to the body organs and tissues. What term should the nurse use to describe this process? a. Perfusion b. Ventilation c. Diffusion d. Circulation
ANS: A Perfusion is the movement of blood into and out of the capillary beds of the lungs to body organs and tissues. Ventilation is the movement of air into and out of the lungs. Diffusion is the movement of gases between air spaces in the lungs and the bloodstream. Circulation is the movement of blood throughout the bloodstream.
A patient who has undergone a lung transplant has contracted cytomegalovirus (CMV) retinitis. The nurse expects which drug to be ordered for this patient? a. Acyclovir (Zovirax) b. Ganciclovir (Cytovene) c. Ribavirin (Virazole) d. Amantadine (Symmetrel)
ANS: B Ganciclovir is indicated for the treatment of cytomegalovirus retinitis. Acyclovir is used for herpes simplex types 1 and 2, herpes zoster, and chickenpox; amantadine is used for influenza type A; and zanamivir is used for influenza types A and B.
Asthma is thought to be caused by: a. an autosomal recessive trait. b. autoimmunity. c. excessive use of antibiotics as a young child. d. interactions between genetic and environmental factors.
ANS: D Asthma is an interaction between genetic and environmental factors. Asthma is not a recessive trait or an autoimmune response. Asthma is not due to excessive antibiotic use in childhood.
12. 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.
ANS: A Spiral computed tomography (CT) scans are the most commonly used test to diagnose pulmonary emboli, and contrast media may be given IV. A chest x-ray may be ordered but will not be diagnostic for a pulmonary embolus. Preparation for a chest x-ray includes undressing and removing any metal. Bronchoscopy is used to detect changes in the bronchial tree, not to assess for vascular changes, and the patient should be NPO 6 to 12 hours before the procedure. Positron emission tomography (PET) scans are most useful in determining the presence of malignancy, and a radioactive glucose preparation is used. DIF: Cognitive Level: Apply (application) REF: 492 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
While auscultating a patient's lungs, a nurse recalls the alveoli in the apices of the lungs are _____ than alveoli in the bases. a. larger b. more numerous c. more compliant d. less perfused
ANS: A The alveoli in the upper portions, or apices, of the lungs contain a greater residual volume of gas and are larger and less numerous, not more numerous, than those in the lower portions. The apices are less compliant but better perfused.
The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider? a. The right calf is swollen, warm, and painful. b. The patient's temperature is 100.3° F (37.9° C). c. The 24-hour oral intake is 600 mL greater than the total output. d. The patient complains of abdominal pain at level 6 (0 to 10 scale) when ambulating.
ANS: A The calf pain, swelling, and warmth suggest that the patient has a deep vein thrombosis, which will require the health care provider to order diagnostic tests and/or anticoagulants. Because the stress response causes fluid retention for the first 2 to 5 days postoperatively, the difference between intake and output is expected. A temperature elevation to 100.3° F on the second postoperative day suggests atelectasis, and the nurse should have the patient deep breathe and cough. Pain with ambulation is normal, and the nurse should administer the ordered analgesic before patient activities
A 57 year old presents with cough, sputum production, dyspnea, and decreased lung volume and is diagnosed with pneumoconiosis. When taking the patient's history, which finding is the most probable cause of the illness? a. Inhalation of silica b. Autoimmune disease c. Allergic reactions d. Flail chest
ANS: A The dusts of silica, asbestos, and coal are the most common causes of pneumoconiosis. Pneumoconiosis is neither an autoimmune nor an allergic disorder; it is not due to flail chest.
While reviewing the results of the pulmonary functions test, the nurse is aware that the maximum amount of gas that can be displaced (expired) from the lung is called: a. vital capacity (VC). b. total lung capacity. c. functional capacity. d. residual volume.
ANS: A VC is the amount of air that can be forcibly expired after a maximal inspiration. Total lung capacity is the volume of lung capacity at full inhalation. Functional capacity is not a term used to describe function tests. Residual volume is the amount of air remaining after exhalation.
20. 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.
ANS: A 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. DIF: Cognitive Level: Apply (application) REF: 482 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
A postoperative patient has not voided for 8 hours after return to the clinical unit. Which action should the nurse take first? a. Perform a bladder scan. b. Encourage increased oral fluid intake. c. Assist the patient to ambulate to the bathroom. d. Insert a straight catheter as indicated on the PRN order.
ANS: A The initial action should be to assess the bladder for distention. If the bladder is distended, providing the patient with privacy (by walking with them to the bathroom) will be helpful. Because of the risk for urinary tract infection, catheterization should only be done after other measures have been tried without success. There is no indication to notify the surgeon about this common postoperative problem unless all measures to empty the bladder are unsuccessful
For a patient with respiratory acidosis, chronic compensation by the body will include: a. Kidney excretion of H+ b. Kidney excretion of HCO3 c. Prolonged exhalations to blow off CO2 d. Protein buffering
ANS: A The kidneys excrete H+ to compensate for respiratory acidosis. The kidneys do not excrete HCO3 to compensate; this would increase acidosis. Prolonged exhalations would not be effective for compensation, especially in a chronic state. Protein buffering is intracellular and will not be effective enough to compensate for respiratory acidosis.
16. The most common cause of pure water deficit is: a. Renal water loss b. Hyperventilation c. Sodium loss d. Insufficient water intake
ANS: A The most common cause of water loss is increased renal clearance of free water as a result of impaired tubular function. Hyperventilation can cause water loss, but it is not the most common cause. Sodium loss leads to hyponatremia, not pure water deficit. Insufficient water intake causes hypernatremia, not water deficit.
While planning care for a patient with renal calculi, the nurse remembers the most important factor in renal calculus formation is: a. urine pH. b. body temperature. c. gender. d. serum mineral concentrations.
ANS: A The most important factor in renal calculus formation is urine pH, not gender, although calculi form more often in men. Neither body temperature nor serum mineral concentrations are as important as urine pH. REF: p. 749
In a patient with acidosis, the nurse would expect the oxyhemoglobin dissociation curve to shift: a. to the right, causing more O2 to be released to the cells. b. to the left, allowing less O2 to be released to the cells. c. downward, allowing less O2 to dissolve in the plasma. d. upward, allowing more O2 to dissolve in the plasma.
ANS: A The oxyhemoglobin dissociation curve is shifted to the right, not the left, by acidosis (low pH) and hypercapnia (increased PaCO2); more, not less, O2 is released to cells. The oxyhemoglobin dissociation curve is not downward or upward, by acidosis.
The nurse working in the postanesthesia care unit (PACU) notes that a patient who has just been transported from the operating room is shivering and has a temperature of 96.5° F (35.8° C). Which action should the nurse take? a. Cover the patient with a warm blanket and put on socks. b. Notify the anesthesia care provider about the temperature. c. Avoid the use of opioid analgesics until the patient is warmer. d. Administer acetaminophen (Tylenol) 650 mg suppository rectally.
ANS: A The patient assessment indicates the need for active rewarming. There is no indication of a need for acetaminophen. Opioid analgesics may help reduce shivering. Because hypothermia is common in the immediate postoperative period, there is no need to notify the anesthesia care provider, unless the patient continues to be hypothermic after active rewarming
A 42 year old presents with dyspnea; rapid, shallow breathing; inspiratory crackles; decreased lung compliance; and hypoxemia. Tests reveal a fulminant form of respiratory failure characterized by acute lung inflammation and diffuse alveolocapillary injury. What is the most likely diagnosis supported by the patient's condition? a. Acute respiratory distress syndrome (ARDS) b. Sarcoidosis c. Postoperative respiratory failure d. Malignant respiratory failure
ANS: A The patient is experiencing ARDS. The patient's symptoms do not support a diagnosis of sarcoidosis or either postoperative or malignant respiratory failure.
Pulmonary function tests reveal that an 80-year-old dyspneic patient has an increase in residual volume. A nurse suspects the most likely cause of the increased residual volume is _____ in lung compliance. a. an increase b. a decrease c. no change d. an absence
ANS: A The patient is experiencing an increase in lung compliance. Increased compliance indicates that the lungs or chest wall is abnormally easy to inflate and has lost some elastic recoil. Decreased compliance is seen in acute breathing disorders.
The nurse is caring for a patient admitted with diabetes insipidus (DI). Which information is most important to report to the health care provider? a. The patient is confused and lethargic. b. The patient reports a recent head injury. c. The patient has a urine output of 400 mL/hr. d. The patient's urine specific gravity is 1.003.
ANS: A The patient's confusion and lethargy may indicate hypernatremia and should be addressed quickly. In addition, patients with DI compensate for fluid losses by drinking copious amounts of fluids, but a patient who is lethargic will be unable to drink enough fluids and will become hypovolemic. A high urine output, low urine specific gravity, and history of a recent head injury are consistent with diabetes insipidus, but they do not require immediate nursing action to avoid life-threatening complications DIF: Cognitive Level: Analyze (analysis) REF: 1161 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
After receiving change-of-shift report about these postoperative patients, which patient should the nurse assess first? a. Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating b. Patient who has 30 mL of sanguineous drainage in the wound drain 10 hours after hip replacement surgery c. Patient who has bibasilar crackles and a temperature of 100°F (37.8°C) on the first postoperative day after chest surgery d. Patient who continues to have incisional pain 15 minutes after hydrocodone and acetaminophen (Vicodin) administration
ANS: A The patient's history and assessment suggests possible wound dehiscence, which should be reported immediately to the surgeon. Although the information about the other patients indicates a need for ongoing assessment and/or possible intervention, the data do not suggest any acute complications. Small amounts of red drainage are common in the first postoperative hours. Bibasilar crackles and a slightly elevated temperature are common after surgery, although the nurse will need to have the patient cough and deep breathe. Oral medications typically take more than 15 minutes for effective pain relief
An 80 year old develops pneumonia in the hospital. An assessment identifies that the patient is cyanotic and tachycardic and has developed a fever and a cough. Chest x-ray reveals pus in the pleural space. This symptomology supports which medical diagnosis? a. Empyema b. Emphysema c. Pleurisy d. Chyle
ANS: A The presence of pus in the pleural space is termed empyema; emphysema is a total lung disorder. Pleurisy causes pain with inspiration. Chyle is milky fluid with lymph and fat
A patient who had knee surgery received intramuscular ketorolac (Toradol) 30 minutes ago and continues to complain of pain at a level of 7 (0 to 10 scale). Which action is best for the nurse to take at this time? a. Administer the prescribed PRN IV morphine sulfate. b. Notify the health care provider about the ongoing knee pain. c. Reassure the patient that postoperative pain is expected after knee surgery. d. Teach the patient that the effects of ketorolac typically last about 6 to 8 hours.
ANS: A The priority at this time is pain relief. Concomitant use of opioids and nonsteroidal antiinflammatory drugs (NSAIDs) improves pain control in postoperative patients. Patient teaching and reassurance are appropriate, but should be done after the patient's pain is relieved. If the patient continues to have pain after the morphine is administered, the health care provider should be notified
A patient will be starting therapy with a corticosteroid. The nurse reviews the patient's orders and notes that an interaction may occur if the corticosteroid is taken with which of these drug classes?" a Nonsteroidal anti-inflammatory drugs b Antibiotics c Opioid analgesics d Antidepressants
ANS: A The use of corticosteroids with aspirin, other NSAIDs, and other ulcerogenic drugs produces additive gastrointestinal effects and an increased chance for the development of gastric ulcers. The other options are incorrect.
If an individual with respiratory difficulty were retaining too much carbon dioxide, which of the following compensatory responses would the nurse expect to be initiated? a. Increase in respiratory rate b. Decrease in ventilation rate c. Increase in tidal volume d. Vasodilation of the pulmonary arterioles
ANS: A To rid the body of excess carbon dioxide, the rate and depth of respiration are increased. A decrease in ventilation rate would increase carbon dioxide. An increase in tidal volume would not decrease carbon dioxide. Vasodilation of the pulmonary arterioles will not rid the body of carbon dioxide.
A few days after experiencing a myocardial infarction (MI) and successful percutaneous coronary intervention, the patient states, "It was just a little chest pain. As soon as I get out of here, I'm going for my vacation as planned." Which reply would be most appropriate for the nurse to make? a. "What do you think caused your chest pain?" b. "Where are you planning to go for your vacation?" c. "Sometimes plans need to change after a heart attack." d. "Recovery from a heart attack takes at least a few weeks."
ANS: A When the patient is experiencing denial, the nurse should assist the patient in testing reality until the patient has progressed beyond this step of the emotional adjustment to MI. Asking the patient about vacation plans reinforces the patient's plan, which is not appropriate in the immediate post-MI period. Reminding the patient in denial about the MI is likely to make the patient angry and lead to distrust of the nursing staff. DIF: Cognitive Level: Apply (application)
A 55-year-old female presents to her primary care provider and reports dizziness, confusion, and tingling in the extremities. Blood tests reveal an elevated pH, decreased PCO2, and slightly decreased HCO3. Which of the following is the most likely diagnosis? a. Respiratory alkalosis with renal compensation b. Respiratory acidosis with renal compensation c. Metabolic alkalosis with respiratory compensation d. Metabolic acidosis with respiratory compensation
ANS: A With an elevated pH, the diagnosis must be alkalosis. Since the PCO2 is low, it is likely respiratory with a slight decrease in HCO3 indicating renal compensation. With an elevated pH, the diagnosis must be alkalosis, not acidosis. With an elevated pH, the diagnosis must be alkalosis. Since the PCO2 is low, it is likely respiratory since the HCO3 is decreased. With an elevated pH, the diagnosis must be alkalosis.
A patient who was admitted with myxedema coma and diagnosed with hypothyroidism is improving and expected to be discharged in 2 days. Which teaching strategy will be best for the nurse to use? a. Provide written reminders of self-care information. b. Offer multiple options for management of therapies. c. Ensure privacy for teaching by asking visitors to leave. d. Delay teaching until patient discharge date is confirmed.
ANS: A Written instructions will be helpful to the patient because initially the hypothyroid patient may be unable to remember to take medications and other aspects of self-care. Because the treatment regimen is somewhat complex, teaching should be initiated well before discharge. Family members or friends should be included in teaching because the hypothyroid patient is likely to forget some aspects of the treatment plan. A simpler regimen will be easier to understand until the patient is euthyroid DIF: Cognitive Level: Apply (application) REF: 1170 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
Which prescribed medication should the nurse administer first to a 60-year-old patient admitted to the emergency department in thyroid storm? a. Propranolol (Inderal) b. Propylthiouracil (PTU) c. Methimazole (Tapazole) d. Iodine (Lugol's solution)
ANS: A b-Adrenergic blockers work rapidly to decrease the cardiovascular manifestations of thyroid storm. The other medications take days to weeks to have an impact on thyroid function DIF: Cognitive Level: Apply (application) REF: 1165 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
A 29-year-old female presents with cloudy urine, flank pain, and hematuria. These signs and symptoms support which diagnosis? a. Acute cystitis b. Renal calculi c. Chronic renal failure d. Postrenal renal failure
ANS: A testbanks_and_xanax The patient is demonstrating symptoms of acute cystitis. Although renal calculi can cause pain and hematuria, they are not manifested by fever and cloudy urine. Chronic renal failure is not manifested by cloudy urine. Postrenal renal failure is not manifested by hematuria and cloudy urine. REF: p. 754
11. An older adult is receiving standard multidrug therapy for tuberculosis (TB). Which finding should the nurse report to the health care provider? a. Yellow-tinged sclera b. Orange-colored sputum c. Thickening of the fingernails d. Difficulty hearing high-pitched voices
ANS: A Noninfectious hepatitis is a toxic effect of isoniazid, rifampin, and pyrazinamide, and patients who develop hepatotoxicity will need to use other medications. Changes in hearing and nail thickening are not expected with the four medications used for initial TB drug therapy. Presbycusis is an expected finding in the older adult patient. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider.
31. The nurse is caring for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider? a. O2 saturation is 88%. b. Blood pressure is 155/90 mm Hg. c. Respiratory rate is 24 breaths/min when lying flat. d. Pain level is 5 (on 0 to 10 scale) with a deep breath.
ANS: A O2 saturation should improve after a thoracentesis. A saturation of 88% indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low O2 saturation is the priority.
14. Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has no symptoms of TB and has never had a positive TB skin test before. Which information should the occupational health nurse plan to teach the staff nurse? a. Use and side effects of isoniazid b. Standard four-drug therapy for TB c. Need for annual repeat TB skin testing d. Bacille Calmette-Guérin (BCG) vaccine
ANS: A The nurse is considered to have a latent TB infection and should be treated with INH daily for 6 to 9 months. The four-drug therapy would be appropriate if the nurse had active TB. TB skin testing is not done for those who have already had a positive skin test result. BCG vaccine is not used in the United States for TB and would not be helpful for this individual, who already has a TB infection.
42. A patient who was admitted the previous day with pneumonia reports a sharp pain of 7 (on 0 to 10 scale) "whenever I take a deep breath." Which action will the nurse take next? a. Auscultate for breath sounds. b. Administer as-needed morphine. c. Have the patient cough forcefully. d. Notify the patient's health care provider.
ANS: A The patient's statement indicates that pleurisy or a pleural effusion may have developed, and the nurse will need to listen for a pleural friction rub and decreased breath sounds. Assessment should occur before administration of pain medications. The patient is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provider.
1. Which finding by the nurse most specifically indicates that a patient is not able to effectively clear the airway? a. Weak cough effort b. Profuse green sputum c. Respiratory rate of 28 breaths/min d. Resting pulse oximetry (SpO2) of 85%
ANS: A The weak cough effort indicates that the patient is unable to clear the airway effectively. The other data suggest problems with gas exchange and breathing pattern.
48. The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Document the amount of drainage every 8 hours. b. Obtain samples of drainage for culture from the system. c. Assess patient pain level associated with the chest tube. d. Check the water-seal chamber for the correct fluid level.
ANS: A UAP education includes documentation of intake and output. The other actions are within the scope of practice and education of licensed nursing personnel.
19. The nurse is teaching a group of patients about management of diabetes. Which statement about basal dosing is correct? a. "Basal dosing delivers a constant dose of insulin." b. "With basal dosing, you can eat what you want and then give yourself a dose of insulin." c. "Glargine insulin is given as a bolus with meals." d. "Basal-bolus dosing is the traditional method of managing blood glucose levels."
ANS: A Basal-bolus therapy is the attempt to mimic a healthy pancreas by delivering basal insulin constantly as a basal, and then as needed as a bolus. Glargine insulin is used as a basal dose, not as a bolus with meals. Basal-bolus therapy is a newer therapy; historically, sliding-scale coverage was implemented. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 519 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
5. A 75-year-old woman with type 2 diabetes has recently been placed on glyburide (Diabeta), 10 mg daily. She asks the nurse when the best time would be to take this medication. What is the nurse's best response? a. "Take this medication in the morning, 30 minutes before breakfast." b. "Take this medication in the evening with a snack." c. "This medication needs to be taken after the midday meal." d. "It does not matter what time of day you take this medication."
ANS: A Glyburide is taken in the morning, 30 minutes before breakfast. When taken at this time, it has a longer duration of action, causing a constant amount of insulin to be released. This may be beneficial in controlling blood glucose levels throughout the day. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 528 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
9. Which action is most appropriate regarding the nurse's administration of a rapid-acting insulin to a hospitalized patient? a. Give it within 15 minutes of mealtime. b. Give it after the meal has been completed. c. Administer it once daily at the time of the midday meal. d. Administer it with a snack before bedtime.
ANS: A Rapid-acting insulins, such as insulin lispro and insulin aspart, are able to mimic closely the body's natural rapid insulin output after eating a meal; for this reason, both insulins are usually administered within 15 minutes of the patient's mealtime. The other options are incorrect. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 518 TOP: NURSING PROCESS: Planning MSC: NCLEX: Safe and Effective Care Environment: Management of Care
1. The nurse is administering lispro (Humalog) insulin and will keep in mind that this insulin will start to have an effect within which time frame? a. 15 minutes b. 1 to 2 hours c. 80 minutes d. 3 to 5 hours
ANS: A The onset of action for lispro insulin is 15 minutes. The peak plasma concentration is 1 to 2 hours; the elimination half-life is 80 minutes; and the duration of action is 3 to 5 hours. DIF: COGNITIVE LEVEL: Remembering (Knowledge) REF: p. 518 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
When a staff member asks how the urine gets from the nephrons to the calyces, what is the nurse's best response? The renal structure that drains directly into the calyces is (are) the (select all that apply): a. Distal tubule b. Collecting duct c. Pyramid d. Renal pelvis e. Loop of Henle
ANS: A, B
A 1-year-old female is diagnosed with croup. Which of the following symptoms is most likely to be present when the nurse performs an assessment? (select all that apply) a. Barking cough b. Stridor c. Hoarseness d. Drooling e. Truncal rash
ANS: A, B, C
MULTIPLE RESPONSE 1. A nurse recalls that neural systems basic to cognitive functions include _____ systems. (select all that apply) a. attentional b. memory and language c. affective d. sensory and motor e. tactile
ANS: A, B, C The neural systems that are essential to cognitive function are: (i) attentional systems that provide arousal and maintenance of attention over time; (ii) memory and language systems by which information is communicated; and (iii) affective or emotive systems that mediate mood, emotion, and intention. The sensory, motor, and somatic systems are not involved. The tactile system is not involved in cognitive functioning. REF: p. 359
When a student asks what the components of the nephron are, how should the nurse respond? The components of the nephron include (select all that apply): a. Loop of Henle b. Renal corpuscle c. Proximal tubule d. Renal pelvis e. Convoluted tubule
ANS: A, B, C, E
1. Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia? (Select all that apply.) a. Age b. Blood pressure c. Respiratory rate d. O2 saturation e. Presence of confusion f. Blood urea nitrogen (BUN) level
ANS: A, B, C, E, F Data collected for the CURB-65 are mental status (confusion), BUN (elevated), blood pressure (decreased), respiratory rate (increased), and age (65 years and older). The other information is also essential to assess but are not used for CURB-65 scoring
1. A patient is taking a sulfonylurea medication for new-onset type 2 diabetes mellitus. When reviewing potential adverse effects during patient teaching, the nurse will include information about which of these effects? (Select all that apply.) a. Hypoglycemia b. Nausea c. Diarrhea d. Weight gain e. Peripheral edema
ANS: A, B, D The most common adverse effect of the sulfonylureas is hypoglycemia, the degree to which depends on the dose, eating habits, and presence of hepatic or renal disease. Another predictable adverse effect is weight gain because of the stimulation of insulin secretion. Other adverse effects include skin rash, nausea, epigastric fullness, and heartburn. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 521 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
A patient is in the HIV clinic for a follow-up appointment. He has been on antiretroviral therapy for HIV for more than 3 years. The nurse will assess for which potential adverse effects of long-term antiretroviral therapy? (Select all that apply.) a. Lipodystrophy b. Liver damage c. Kaposi's sarcoma d. Osteoporosis e. Type 2 diabetes
ANS: A, B, D, E Anti-HIV drugs produce strain on the liver and may result in liver disease. A major adverse effect of protease inhibitors is lipid abnormalities, including lipodystrophy, or redistribution of fat stores under the skin. In addition, dyslipidemias such as hypertriglyceridemia can occur, and insulin resistance and type 2 diabetes symptoms can result. The increase in long-term antiretroviral drug therapy due to prolonged disease survival has led to the emergence of another long-term adverse effect associated with these medications—bone demineralization and possible osteoporosis. Kaposi's sarcoma is an opportunistic disease associated with HIV, not a result of long-term drug therapy.
MULTIPLE RESPONSE The nurse is explaining clinical manifestations of alterations in the extrapyramidal system. The nurse would correctly include: (select all that apply) a. little or no paralysis of voluntary movement. b. normal or slightly increased tendon reflexes. c. positive (present) Babinski. d. presence of tremor. e. rigidity in muscle tone.
ANS: A, B, D, E The patient will experience little or no paralysis of voluntary movement. The patient will experience normal or slightly increased deep tendon reflexes. Babinski will be negative (absent). Tremor will be present. Rigidity of muscle tone occurs intermittently. REF: p. 386, Table 15-19
The nurse expects that a patient is experiencing undersecretion of adrenocortical hormones when which conditions are found upon assessment? (Select all that apply.)" a Dehydration b Weight loss c Steroid psychosis d Increased potassium levels e Increased blood glucose levels f Decreased serum sodium levels
ANS: A, B, D, F The undersecretion (hyposecretion) of adrenocortical hormones causes a condition known as Addison's disease, which is associated with decreased blood sodium and glucose levels, increased potassium levels, dehydration, and weight loss. Steroid psychosis is an effect of glucocorticoid excess.
A patient will be taking dabigatran (Pradaxa) as part of treatment for chronic atrial fibrillation. Which statements about dabigatran are true? (Select all that apply.) a. The dose of dabigatran is reduced in patients with decreased renal function. b. Bleeding is the most common adverse effect. c. Potassium chloride is given as an antidote in cases of overdose. d. Dabigatran levels are monitored by measuring prothrombin time/international normalized ratio (PT/INR) results. e. This drug is a prodrug and becomes activated in the liver.
ANS: A, B, E Dabigatran is excreted extensively in the kidneys, and the dose is dependent upon renal function. The normal dose is 150 mg twice daily, but it must be reduced to 75 mg twice daily if creatinine clearance is less than 30 mL/min. The most common and serious side effect is bleeding. Dabigatran is a prodrug that becomes activated in the liver. There is no antidote to dabigatran. The other options are incorrect. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 417 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
Which of the following would be included in the assessment of a patient with diabetes mellitus who is experiencing a hypoglycemic reaction? (Select all that apply.) a. Tremors b. Nervousness c. Extreme thirst d. Flushed skin e. Profuse perspiration f. Constricted pupils
ANS: A, B, E When hypoglycemia occurs, blood glucose levels fall, resulting in sympathetic nervous system responses such as tremors, nervousness, and profuse perspiration. Dilated pupils would also occur, not constricted pupils. Extreme thirst, flushed skin, and constricted pupils are consistent with hyperglycemia.
A patient who is diagnosed with genital herpes is taking topical acyclovir. The nurse will provide which teaching for this patient? (Select all that apply.) a. "Be sure to wash your hands thoroughly before and after applying this medicine." b. "Apply this ointment until the lesion stops hurting." c. "Use a clean glove when applying this ointment." d. "If your partner develops these lesions, then he can also use the medication." e. "You will need to avoid touching the area around your eyes." f. "You will have to practice abstinence when these lesions are active."
ANS: A, C, E, F This medication needs to be applied as long as prescribed, and the medication needs to be applied with clean gloves. Prescriptions should not be shared; if the partner develops these lesions, the partner will have to be evaluated before medication is prescribed, if needed. Eye contact should be avoided. The presence of active genital herpes lesions requires sexual abstinence.
1. The nurse is providing education about the use of sublingual nitroglycerin tablets. She asks the patient, "What would you do if you experienced chest pain while mowing your yard? You have your bottle of sublingual nitroglycerin with you." Which actions by the patient are appropriate in this situation? (Select all that apply.) a. Stop the activity, and lie down or sit down. b. Call 911 immediately. c. Call 911 if the pain is not relieved after taking one sublingual tablet. d. Call 911 if the pain is not relieved after taking three sublingual tablets in 15 minutes. e. Place a tablet under the tongue. f. Place a tablet in the space between the gum and cheek. g. Take another sublingual tablet if chest pain is not relieved after 5 minutes, up to three total.
ANS: A, C, E, G With sublingual forms, the medication is taken at the first sign of chest pain, not delayed until the pain is severe. The patient needs to sit down or lie down and take one sublingual tablet. According to current guidelines, if the chest pain or discomfort is not relieved in 5 minutes, after 1 dose, the patient (or family member) must call 911 immediately. The patient can take one more tablet while awaiting emergency care and may take a third tablet 5 minutes later, but no more than a total of three tablets. These guidelines reflect the fact that angina pain that does not respond to nitroglycerin may indicate a myocardial infarction. The sublingual dose is placed under the tongue, and the patient needs to avoid swallowing until the tablet has dissolved. Placing a tablet between the gum and cheek is the buccal route. DIF: COGNITIVE LEVEL: Analyzing (Analysis) REF: p. 372 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
Mechanisms for defense against urinary pathogens in men include: (select all that apply) a. the long length of the urethra. b. the alkaline pH of urine. c. the secretion of mucus that traps bacteria. d. the antimicrobial secretions from the prostate. e. the implantation of the ureters in the bladder.
ANS: A, D Both the longer urethra and prostatic secretions decrease the risk of infection in men. The urine is not more alkaline, and they do not secrete mucus that traps bacteria. The ureters in men and women are implanted in similar positions and in their normal position; it is not a factor in the development of cystitis. REF: p. 753
2. Which health promotion information should the nurse include when teaching a patient with a 42 pack-year history of cigarette smoking? (Select all that apply.) a. Resources for support in smoking cessation b. Reasons for annual sputum cytology testing c. Erlotinib (Tarceva) therapy to prevent tumor risk d. Computed tomography (CT) screening for cancer e. Importance of obtaining a yearly influenza vaccination
ANS: A, D, E Because smoking is the major cause of lung cancer, an important role for the nurse is teaching patients about the benefits of and means of smoking cessation. Screening for using low-dose CT is recommended for high-risk patients Encourage those at risk for pneumonia (e.g., those who smoke) to obtain both influenza and pneumococcal vaccines. Sputum cytology is a diagnostic test but does not prevent cancer or disease. Erlotinib may be used in patients who have lung cancer, but it is not used to reduce the risk of developing cancer.
Which of these characteristics are considered to be risk factors for coronary heart disease? (Select all that apply . ) a. Being male, 45 years of age or older b. Being female, 45 years of age or older c. Having a family history that includes a mother who died of a myocardial infarction at 71 years of age d. Having a high-density lipoprotein (HDL) level of 65 mg/dL e. Having an HDL level of 30 mg/dL f. Having a history of diabetes mellitus
ANS: A, E, F Risk factors include being male, 45 years of age or older, and being female, 55 years of age or older; having a family history of premature congenital heart disease (e.g., myocardial infarction or sudden death before 55 years of age in a father or other male first-degree relative, or before 65 years of age in a mother or other female first-degree relative); currently smoking cigarettes; having hypertension (blood pressure higher than 140/90 mm Hg or current antihypertensive drug therapy); having a low HDL level (lower than 40 mg/dL); and having diabetes mellitus
The nurse examines the lymph nodes of a patient during a physical assessment. Which assessment finding would be of most concern to the nurse? a. A 2-cm nontender supraclavicular node b. A 1-cm mobile and nontender axillary node c. An inability to palpate any superficial lymph nodes d. Firm inguinal nodes in a patient with an infected foot
ANS: A. A 2-cm nontender supraclavicular node Enlarged and nontender nodes are suggestive of malignancies such as lymphoma. Firm nodes are an expected finding in an area of infection. The superficial lymph nodes are usually not palpable in adults, but if they are palpable, they are normally 0.5 to 1 cm and nontender.
The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action should the nurse include in the plan of care? a. Avoid intramuscular injections. b. Encourage increased oral fluids. c. Check temperature every 4 hours. d. Increase intake of iron-rich foods.
ANS: A. Avoid intramuscular injections. Thrombocytopenia is a decreased number of platelets, which places the patient at high risk for bleeding. Neutropenic patients are at high risk for infection and sepsis and should be monitored frequently for signs of infection. Encouraging fluid intake and iron-rich food intake is not indicated in a patient with thrombocytopenia.
A patient with pancytopenia of unknown origin is scheduled for the following diagnostic tests. The nurse will provide a consent form to sign for which test? a. Bone marrow biopsy b. Abdominal ultrasound c. Complete blood count (CBC) d. Activated partial thromboplastin time (aPTT)
ANS: A. Bone marrow biopsy A bone marrow biopsy is a minor surgical procedure that requires the patient or guardian to sign a surgical consent form. The other procedures do not require a signed consent.
15. The nurse supervises a student nurse who is assigned to take care of a patient with active tuberculosis (TB). Which action, if performed by the student nurse, would require an intervention by the nurse? a. The patient is offered a tissue from the box at the bedside. b. A surgical face mask is applied before visiting the patient. c. A snack is brought to the patient from the unit refrigerator. d. Hand washing is performed before entering the patient's room.
ANS: B A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the patient's room because the HEPA mask can filter out 100% of small airborne particles. Hand washing before entering the patient's room is appropriate. Because anorexia and weight loss are frequent problems in patients with TB, bringing food to the patient is appropriate. The student nurse should perform hand washing after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue.
After receiving change-of-shift report for several patients with neutropenia, which patient should the nurse assess first? a. A 56-yr-old with frequent explosive diarrhea b. A 33-yr-old with a fever of 100.8° F (38.2° C) c. A 66-yr-old who has white pharyngeal lesions d. A 23-yr-old who is complaining of severe fatigue
ANS: B Any fever in a neutropenic patient indicates infection and can quickly lead to sepsis and septic shock. Rapid assessment and (if prescribed) initiation of antibiotic therapy within 1 hour are needed. The other patients also need to be assessed but do not exhibit symptoms of potentially life-threatening problems. DIF: Cognitive Level: Analyze (analysis) REF: 632 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
17. Which nursing action should be included in the plan of care after endovascular repair of an abdominal aortic aneurysm? a. Record hourly chest tube drainage. b. Monitor fluid intake and urine output. c. Check the abdominal incision for any redness. d. Teach the reason for a prolonged recovery period.
ANS: B Because renal artery occlusion can occur after endovascular repair, the nurse should monitor parameters of renal function such as intake and output. Chest tubes will not be needed for endovascular surgery, the recovery period will be short, and there will not be an abdominal wound.
8. When evaluating the discharge teaching for a patient with chronic peripheral artery disease (PAD), the nurse determines a need for further instruction when the patient says, "I will a. have to buy some loose clothes that do not bind across my legs or waist." b. use a heating pad on my feet at night to increase the circulation and warmth in my feet." c. change my position every hour and avoid long periods of sitting with my legs crossed." d. walk to the point of pain, rest, and walk again until the pain returns for at least 30 minutes 3 times a week."
ANS: B Because the patient has impaired circulation and sensation to the feet, the use of a heating pad could lead to burns. The other patient statements are correct and indicate that teaching has been successful.
26. 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.
ANS: B Bleeding is a possible complication after catheterization of the femoral artery, so the nurse's first action should be to assess for changes in vital signs that might indicate hemorrhage. The other actions are also appropriate but can be done after determining that bleeding is not occurring.
2. A patient has a 6-cm thoracic aortic aneurysm that was discovered during a routine chest x-ray. When obtaining 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.
ANS: B Difficulty swallowing may occur with a thoracic aneurysm because of pressure on the esophagus. The other symptoms will be important to assess for in patients with abdominal aortic aneurysms.
11. The health care provider prescribes an infusion of heparin (Hep-Lock) and daily partial thromboplastin time (PTT) testing for a patient with venous thromboembolism (VTE). The nurse will plan to a. decrease the infusion when the PTT value is 65 seconds. b. avoid giving any IM medications to prevent localized bleeding. c. monitor posterior tibial and dorsalis pedis pulses with the Doppler. d. have vitamin K available in case reversal of the heparin is needed.
ANS: B IM injections are avoided in patients receiving anticoagulation. A PTT of 65 seconds is within the therapeutic range. Vitamin K is used to reverse warfarin. Pulse quality is not affected by VTE.
Which intervention will be included in the nursing care plan for a patient with immune thrombocytopenic purpura? 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.
ANS: B 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. DIF: Cognitive Level: Apply (application) REF: 622 TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
When describing the male urinary anatomy, which information should the nurse include? The portion of the male urethra that is closest to the bladder is the _____ portion. a. Membranous b. Prostatic c. Cavernous d. Vas deferens
ANS: B In the male, the prostatic urethra is closest to the bladder.
34. The 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
ANS: B LPN education and scope of practice includes wound care. The other patients, which require more complex assessments or education, should be managed by the RN.
25. When caring for a patient on the first postoperative day after an abdominal aortic aneurysm repair, which assessment finding is most important for the nurse to communicate to the health care provider? a. Presence of flatus b. Loose, bloody stools c. Hypoactive bowel sounds d. Abdominal pain with palpation
ANS: B Loose, bloody stools at this time may indicate intestinal ischemia or infarction, and should be reported immediately because the patient may need an emergency bowel resection. The other findings are normal on the first postoperative day after abdominal surgery.
13. The nurse has started discharge teaching for a patient who is to continue warfarin (Coumadin) following hospitalization for venous thromboembolism (VTE). The nurse determines that additional teaching is needed when the patient says which of the following? a. "I should get a Medic Alert device stating that I take Coumadin." b. "I should reduce the amount of green, leafy vegetables that I eat." c. "I will need routine blood tests to monitor the effects of the Coumadin." d. "I will check with my health care provider before I begin any new medications."
ANS: B Patients taking warfarin are taught to follow a consistent diet with regard to foods that are high in vitamin K, such as green, leafy vegetables. The other patient statements are accurate.
21. 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." .
ANS: B Smoking cessation is essential for slowing the progression of PAD to critical limb ischemia and reducing the risk of myocardial infarction and death. Circulation to the legs will decrease if the legs are elevated. Patients with PAD are taught to exercise to the point of feeling pain, rest, and then resume walking. Support hose are not used for patients with PAD.
A nurse recalls the blood vessels of the kidneys are innervated by the: a. Vagus nerve b. Sympathetic nervous system c. Somatic nervous system d. Parasympathetic nervous system
ANS: B The blood vessels of the kidney are innervated by the autonomic nervous system through sympathetic fibers.
When the nurse is discussing the functional unit of the kidney, what other term should the nurse use? a. Calyx b. Nephron c. Collecting duct d. Pyramid
ANS: B The functional unit of the kidney is the nephron.
When a patient asks what role the kidneys play in vitamin D function, how should the nurse reply? a. Synthesizes vitamin D from cholesterol b. Activates intestinally absorbed vitamin D c. Metabolizes and breaks down vitamin D d. Excretes excess vitamin D
ANS: B The kidneys play a role in activating intestinally absorbed vitamin D.
When the nurse is discussing the sodium-sensing cells of the glomerulus, what term should the nurse use? a. Podocytes b. Macula densa c. Mesangial cells d. Loop of Henle
ANS: B The macula densa are sodium-sensing cells.
A nurse is teaching the staff about the kidneys. Which information should the nurse include? The region of the kidneys that contains the glomeruli is the: a. Medulla b. Cortex c. Pyramids d. Columns
ANS: B The outer layer of the kidney is called the cortex and it contains all of the glomeruli, most of the proximal tubules, and some segments of the distal tubule. The cortex, not the medulla, contains the glomeruli. The cortex, not the pyramids, contains the glomeruli. The cortex, not the columns, contains the glomeruli.
33. Which actions could the nurse delegate to unlicensed assistive personnel (UAP) who are providing care for a patient who is at risk for venous thromboembolism? a. Monitor for any bleeding after anticoagulation therapy is started. b. Apply sequential compression device whenever the patient is in bed. c. Ask the patient about use of herbal medicines or dietary supplements. d. Instruct the patient to call immediately if any shortness of breath occurs.
ANS: B UAP training includes the use of equipment that requires minimal nursing judgment, such as sequential compression devices. Patient assessment and teaching require more education and critical thinking and should be done by the registered nurse (RN).
After an acute myocardial infarction (AMI), a patient ambulates in the hospital hallway. When the nurse evaluates the patient's response to the activity, which data would indicate that the exercise level should be decreased? a. O2 saturation drops from 99% to 95%. b. Heart rate increases from 66 to 98 beats/min. c. Respiratory rate goes from 14 to 20 breaths/min. d. Blood pressure (BP) changes from 118/60 to 126/68 mm Hg.
ANS: B A change in heart rate of more than 20 beats over the resting heart rate indicates that the patient should stop and rest. The increases in BP and respiratory rate, and the slight decrease in O2 saturation, are normal responses to exercise. DIF: Cognitive Level: Apply (application)
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 thrombocytopenia who has oozing gums after a tooth extraction d. The patient with sickle cell anemia who has had nausea and diarrhea for 24 hours
ANS: B A neutropenic patient with a fever is assumed to have an infection and is at risk for rapidly developing sepsis. Rapid assessment, cultures, and initiation of antibiotic therapy are needed. The other patients also require rapid assessment and care but not as urgently as the neutropenic patient. DIF: Cognitive Level: Analyze (analysis) REF: 632 OBJ: Special Questions: Multiple Patients | Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
A patient has had recent mechanical heart valve surgery and is receiving anticoagulant therapy. While monitoring the patient's laboratory work, the nurse interprets that the patient's international normalized ratio (INR) level of 3 indicates that: a. the patient is not receiving enough warfarin to have a therapeutic effect. b. the patient's warfarin dose is at therapeutic levels. c. the patient's intravenous heparin dose is dangerously high. d. the patient's intravenous heparin dose is at therapeutic levels.
ANS: B A normal INR (without warfarin) is 1.0. A therapeutic INR for patients who have had mechanical heart valve surgery ranges from 2.5 to 3.5, with a middle value of 3. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 419 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
After a severe auto accident, a patient has been taken to the trauma unit and has an estimated blood loss of more than 30% of his blood volume. The nurse prepares to administer which product?" a Albumin b Whole blood c Packed red blood cells d Fresh frozen plasma
ANS: B A patient who has lost a massive amount (over 25%) of blood volume would receive whole blood. PRBCs are given to increase the oxygen-carrying capacity in patients with anemia, in patients with substantial hemoglobin deficits, and in patients who have lost up to 25% of their total blood volume. A patient with a coagulation disorder or a clotting-factor deficiency would receive fresh frozen plasma; albumin is used to expand fluid volume.
On admission of a patient to the postanesthesia care unit (PACU), the blood pressure (BP) is 122/72. Thirty minutes after admission, the BP falls to 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate? a. Increase the IV fluid rate. b. Continue to take vital signs every 15 minutes. c. Administer oxygen therapy at 100% per mask. d. Notify the anesthesia care provider (ACP) immediately.
ANS: B A slight drop in postoperative BP with a normal pulse and warm, dry skin indicates normal response to the residual effects of anesthesia and requires only ongoing monitoring. Hypotension with tachycardia and/or cool, clammy skin would suggest hypovolemic or hemorrhagic shock and the need for notification of the ACP, increased fluids, and high-concentration oxygen administration
10. A nurse is teaching the staff about antidiuretic hormone (ADH). Which information should the nurse include? Secretion of ADH is stimulated by: a. Increased serum potassium b. Increased plasma osmolality c. Decreased renal blood flow d. Generalized edema
ANS: B ADH is secreted when plasma osmolality increases or circulating blood volume decreases and blood pressure drops. ADH is secreted when plasma osmolality increases, not by an increase in potassium. ADH is secreted when plasma osmolality increases; it is not affected by decreased renal blood flow. Edema does not affect the secretion of ADH.
A 45-year-old male patient with suspected acromegaly is seen at the clinic. To assist in making the diagnosis, which question should the nurse ask? a. "Have you had a recent head injury?" b. "Do you have to wear larger shoes now?" c. "Is there a family history of acromegaly?" d. "Are you experiencing tremors or anxiety?"
ANS: B Acromegaly causes an enlargement of the hands and feet. Head injury and family history are not risk factors for acromegaly. Tremors and anxiety are not clinical manifestations of acromegaly DIF: Cognitive Level: Apply (application) REF: 1157 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
Acute poststreptococcal glomerulonephritis is primarily caused by: a. swelling of mesangial cells in the Bowman space in response to the presence of bacteria. b. immune complex deposition in the glomerular capillaries and inflammatory damage. c. inflammatory factors that stimulate cellular proliferation of epithelial cells. d. accumulation of antiglomerular basement membrane antibodies.
ANS: B Acute poststreptococcal glomerulonephritis is caused by an antigen-antibody complex. Acute poststreptococcal glomerulonephritis is not due to swelling of the Bowman space. It is not an inflammatory process nor is it caused by an accumulation of antiglomerular basement membrane antibodies. REF: p. 758, Table 30-6
The nurse is planning postoperative care for a patient who is being admitted to the surgical unit form the recovery room after transsphenoidal resection of a pituitary tumor. Which nursing action should be included? a. Palpate extremities for edema. b. Measure urine volume every hour. c. Check hematocrit every 2 hours for 8 hours. d. Monitor continuous pulse oximetry for 24 hours.
ANS: B After pituitary surgery, the patient is at risk for diabetes insipidus caused by cerebral edema. Monitoring of urine output and urine specific gravity is essential. Hemorrhage is not a common problem. There is no need to check the hematocrit hourly. The patient is at risk for dehydration, not volume overload. The patient is not at high risk for problems with oxygenation, and continuous pulse oximetry is not needed DIF: Cognitive Level: Apply (application) REF: 1159 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
The nurse is administering adrenal drugs to a patient. Which action by the nurse is appropriate for this patient?" a Administering oral drugs on an empty stomach to maximize absorption b Rinsing the oral cavity after using corticosteroid inhalers c Administering the corticosteroids before bedtime to minimize adrenal suppression d Discontinuing the medication immediately if weight gain of 5 pounds or more in 1 week occurs
ANS: B After the patient has used the corticosteroid inhalers, cleaning the oral cavity helps to prevent possible oral fungal infections from developing. Adrenal drugs need be taken with meals to minimize gastrointestinal upset and in the mornings to minimize adrenal suppression, and they need to be discontinued by weaning, not abruptly.
A 65-year-old patient who recently suffered a cerebral vascular accident is now unable to recognize and identify objects by touch because of injury to the sensory cortex. How should the nurse document this finding? a. Hypomimesis b. Agnosia c. Dysphasia d. Echolalia
ANS: B Agnosia is the failure to recognize the form and nature of objects. Hypomimesis is a disorder of communication. Dysphasia is an impairment of comprehension of language. Echolalia is the ability to repeat. REF: p. 367
12. A 25-year-old male is diagnosed with a hormone-secreting tumor of the adrenal cortex. Which finding would the nurse expect to see in the lab results? a. Decreased blood volume b. Decreased blood K+ levels c. Increased urine Na+ levels d. Increased white blood cells
ANS: B Aldosterone is secreted from the adrenal cortex. It promotes renal sodium and water reabsorption and excretion of potassium, leading to decreased potassium levels. Blood volume actually increases with aldosterone secretion. Aldosterone promotes sodium reabsorption, leading to normal or decreased Na+ levels. Aldosterone is not associated with white blood cells.
Outcomes of laboratory tests include an elevated level of natriuretic peptides. Which organ is the priority assessment? a. Lungs b. Heart c. Liver d. Brain
ANS: B Elevated natriuretic peptides indicate problems with the heart or the vasculature. Elevated natriuretic peptides indicate problems with the heart or the vasculature, not the lungs. Elevated natriuretic peptides indicate problems with the heart or the vasculature, not the liver. Elevated natriuretic peptides indicate problems with the heart or the vasculature, not the brain.
A patient who has been receiving IV heparin infusion and oral warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when the platelet level drops to 110,000/μL. Which action will the nurse include in the plan of care? a. Prepare for platelet transfusion. b. Discontinue the heparin infusion. c. Administer prescribed warfarin (Coumadin). d. Use low-molecular-weight heparin (LMWH).
ANS: B All heparin is discontinued when HIT is diagnosed. The patient should be instructed to never receive heparin or LMWH. Warfarin is usually not given until the platelet count has returned to 150,000/μL. The platelet count does not drop low enough in HIT for a platelet transfusion, and platelet transfusions increase the risk for thrombosis. DIF: Cognitive Level: Apply (application) REF: 622 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
What term is used to describe an explosive, disorderly discharge of cortical neurons? a. Reflex b. Seizure c. Inattentiveness d. Brain death
ANS: B An explosive, disorderly discharge of cortical neurons is a seizure. A reflex is an expected response. Inattentiveness is a form of neglect. Brain death is a cessation of function. REF: p. 372
An infant is diagnosed with noncommunicating hydrocephalus. What is an immediate priority concern for this patient? a. Metabolic edema b. Interstitial edema c. Vasogenic edema d. Ischemic edema
ANS: B An immediate concern for the infant with noncommunicating hydrocephalus is interstitial edema. Neither metabolic, vasogenic, nor ischemic edema is observed as a result of noncommunicating hydrocephalus.
A nurse assists a patient on the first postoperative day to ambulate, cough, deep breathe, and turn. Which action by the nurse is most helpful? a. Teach the patient to fully exhale into the incentive spirometer. b. Administer ordered analgesic medications before these activities. c. Ask the patient to state two possible complications of immobility. d. Encourage the patient to state the purpose of splinting the incision.
ANS: B An important nursing action to encourage these postoperative activities is administration of adequate analgesia to allow the patient to accomplish the activities with minimal pain. Even with motivation provided by proper teaching, positive reinforcement, and concern about complications, patients will have difficulty if there is a great deal of pain involved with these activities. When using an incentive spirometer, the patient should be taught to inhale deeply, rather than exhale into the spirometer to promote lung expansion and prevent atelectasis
Under most circumstances, increased work of breathing results in: a. increased partial pressure of O2 in the lungs. b. increased oxygen consumption. c. decreased PaCO2. d. alterations in alveolar perfusion.
ANS: B An increase in the work of breathing can result in a marked increase in oxygen consumption. A marked increase in oxygen consumption is not associated with an increase in partial pressure, lower CO2, or altered alveolar perfusion
When developing a teaching plan for a 61-yr-old patient with multiple risk factors for coronary artery disease (CAD), the nurse should focus primarily on the a. family history of coronary artery disease. b. elevated low-density lipoprotein (LDL) level. c. increased risk associated with the patient's gender. d. increased risk of cardiovascular disease as people age.
ANS: B Because family history, gender, and age are nonmodifiable risk factors, the nurse should focus on the patient's LDL level. Decreases in LDL will help reduce the patient's risk for developing CAD. DIF: Cognitive Level: Apply (application)
To improve the physical activity level for a mildly obese 71-yr-old patient, which action should the nurse plan to take? a. Stress that weight loss is a major benefit of increased exercise. b. Determine what kind of physical activities the patient usually enjoys. c. Tell the patient that older adults should exercise for no more than 20 minutes at a time. d. Teach the patient to include a short warm-up period at the beginning of physical activity.
ANS: B Because patients are more likely to continue physical activities that they already enjoy, the nurse will plan to ask the patient about preferred activities. The goal for older adults is 30 minutes of moderate activity on most days. Older adults should plan for a longer warm-up period. Benefits of exercises, such as improved activity tolerance, should be emphasized rather than aiming for significant weight loss in older mildly obese adults. DIF: Cognitive Level: Apply (application)
The nurse reviews the laboratory results for a patient on the first postoperative day after a hiatal hernia repair. Which finding would indicate to the nurse that the patient is at increased risk for poor wound healing? a. Potassium 3.5 mEq/L b. Albumin level 2.2 g/dL c. Hemoglobin 11.2 g/dL d. White blood cells 11,900/µL
ANS: B Because proteins are needed for an appropriate inflammatory response and wound healing, the low serum albumin level (normal level 3.5 to 5.0 g/dL) indicates a risk for poor wound healing. The potassium level is normal. Because a small amount of blood loss is expected with surgery, the hemoglobin level is not indicative of an increased risk for wound healing. WBC count is expected to increase after surgery as a part of the normal inflammatory response
18. After the nurse has received change-of-shift report, which patient should the nurse assess first? a. A patient with pneumonia who has crackles in the right lung base b. A patient with possible lung cancer who has just returned after bronchoscopy c. A patient with hemoptysis and a 16-mm induration with tuberculin skin testing d. A patient with chronic obstructive pulmonary disease (COPD) and pulmonary function testing (PFT) that indicates low forced vital capacity
ANS: B Because the cough and gag are decreased after bronchoscopy, this patient should be assessed for airway patency. The other patients do not have clinical manifestations or procedures that require immediate assessment by the nurse. DIF: Cognitive Level: Apply (application) REF: 492 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
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
ANS: B Because the patient with aplastic anemia has pancytopenia, the patient is at risk for infection and bleeding. There is no increased risk for seizures, neurogenic shock, or pulmonary edema. DIF: Cognitive Level: Apply (application) REF: 614 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
A patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU) is restless and shouting at the nurse. The patient's oxygen saturation is 96%, and recent laboratory results are all normal. Which action by the nurse is most appropriate? a. Increase the IV fluid rate. b. Assess for bladder distention. c. Notify the anesthesia care provider (ACP). d. Demonstrate the use of the nurse call bell button.
ANS: B Because the patient's assessment indicates physiologic stability, the most likely cause of the patient's agitation is emergence delirium, which will resolve as the patient wakes up more fully. The nurse should look for a cause such as bladder distention. Although hypoxemia is the most common cause, the patient's oxygen saturation is 96%. Emergence delirium is common in patients recovering from anesthesia, so there is no need to notify the ACP. Orientation of the patient to bed controls is needed, but is not likely to be effective until the effects of anesthesia have resolved more completely
The nurse is preparing to transfuse a patient with a unit of packed red blood cells (PRBCs). Which intravenous solution is correct for use with the PRBC transfusion?" a 5% dextrose in water (D5W) b 0.9% sodium chloride (NS) c 5% dextrose in 0.45% sodium chloride (D5NS) d 5% dextrose in lactated Ringer's solution (D5LR)
ANS: B Blood products should be given only with normal saline 0.9% because D5W will also cause hemolysis of the blood product.
A routine complete blood count for an active older man indicates possible myelodysplastic syndrome. The nurse will plan to teach the patient about a. blood transfusion. b. bone marrow biopsy. c. filgrastim (Neupogen) administration. d. erythropoietin (Epogen) administration.
ANS: B Bone marrow biopsy is needed to make the diagnosis and determine the specific type of myelodysplastic syndrome. The other treatments may be necessary if there is progression of the myelodysplastic syndrome, but the initial action for this asymptomatic patient will be a bone marrow biopsy. DIF: Cognitive Level: Apply (application) REF: 634 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
A patient is being discharged on anticoagulant therapy. The nurse will include in the patient-education conversation that it is important to avoid herbal products that contain which substance? a. Valerian b. Ginkgo c. Soy d. Saw palmetto
ANS: B Capsicum pepper, feverfew, garlic, ginger, ginkgo, St. John's wort, and ginseng are some herbals that have potential interactions with anticoagulants, especially with warfarin. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 417 TOP: NURSING PROCESS: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
The nurse is assessing a 41-year-old African American male patient diagnosed with a pituitary tumor causing panhypopituitarism. Assessment findings consistent with panhypopituitarism include a. high blood pressure. b. decreased facial hair. c. elevated blood glucose. d. tachycardia and cardiac palpitations.
ANS: B Changes in male secondary sex characteristics such as decreased facial hair, testicular atrophy, diminished spermatogenesis, loss of libido, impotence, and decreased muscle mass are associated with decreases in follicle stimulating hormone (FSH) and luteinizing hormone (LH). Fasting hypoglycemia and hypotension occur in panhypopituitarism as a result of decreases in adrenocorticotropic hormone (ACTH) and cortisol. Bradycardia is likely due to the decrease in thyroid stimulating hormone (TSH) and thyroid hormones associated with panhypopituitarism DIF: Cognitive Level: Apply (application) REF: 1158 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
The nurse is admitting a patient who has chest pain. Which assessment data suggest that the pain is caused by an acute myocardial infarction (AMI)? a. The pain increases with deep breathing. b. The pain has lasted longer than 30 minutes. c. The pain is relieved after the patient takes nitroglycerin. d. The pain is reproducible when the patient raises the arms.
ANS: B Chest pain that lasts for 20 minutes or more is characteristic of AMI. Changes in pain that occur with raising the arms or with deep breathing are more typical of musculoskeletal pain or pericarditis. Stable angina is usually relieved when the patient takes nitroglycerin. DIF: Cognitive Level: Apply (application)
The nurse is preparing to give a potassium supplement. Which laboratory test should be checked before the patient receives a dose of potassium?" a Complete blood count b Serum potassium level c Serum sodium level d Liver function studies
ANS: B Contraindications to potassium replacement products include hyperkalemia from any cause. It is important to know the patient's electrolyte levels before beginning electrolyte replacement therapy. Giving potassium supplements to a patient whose serum potassium levels are already high may cause worsening of the hyperkalemia. The other options are incorrect.
A glucocorticoid is prescribed for a patient. The nurse checks the patient's medical history knowing that glucocorticoid therapy is contraindicated in which disorder?" a Cerebral edema b Peptic ulcer disease c Tuberculous meningitis d Chronic obstructive pulmonary disease
ANS: B Contraindications to the administration of glucocorticoids include drug allergy and may include cataracts, glaucoma, peptic ulcer disease, mental health problems, and diabetes mellitus. The other options are indications for glucocorticoids.
The nurse determines that demeclocycline (Declomycin) is effective for a patient with syndrome of inappropriate antidiuretic hormone (SIADH) based on finding that the patient's a. weight has increased. b. urinary output is increased. c. peripheral edema is decreased. d. urine specific gravity is increased.
ANS: B Demeclocycline blocks the action of antidiuretic hormone (ADH) on the renal tubules and increases urine output. An increase in weight or an increase in urine specific gravity indicates that the SIADH is not corrected. Peripheral edema does not occur with SIADH. A sudden weight gain without edema is a common clinical manifestation of this disorder DIF: Cognitive Level: Apply (application) REF: 1160 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action should the nurse take first? a. Administer the ordered opioid. b. Check the oxygen (O2) saturation. c. Take the blood pressure and pulse. d. Apply wrist restraints to secure IV lines.
ANS: B Emergence delirium may be caused by a variety of factors. However, the nurse should first assess for hypoxemia. The other actions also may be appropriate, but are not the best initial action
When caring for a patient who is recovering from a sudden cardiac death (SCD) event and has no evidence of an acute myocardial infarction (AMI), the nurse will anticipate teaching the patient that a. sudden cardiac death events rarely reoccur. b. additional diagnostic testing will be required. c. long-term anticoagulation therapy will be needed. d. limiting physical activity will prevent future SCD events.
ANS: B Diagnostic testing (e.g., stress test, Holter monitor, electrophysiologic studies, cardiac catheterization) is used to determine the possible cause of the SCD and treatment options. SCD is likely to recur. Anticoagulation therapy will not have any effect on the incidence of SCD, and SCD can occur even when the patient is resting. DIF: Cognitive Level: Apply (application)
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."
ANS: B Diarrhea causes metabolic acidosis through loss of bicarbonate, which is a base. Eating less sodium during diarrhea increases the risk of ECV deficit. Although diarrhea does remove fluid from the body, it also removes sodium and bicarbonate which need to be replaced. Rapid deep respirations are the compensatory mechanism for metabolic acidosis and should be encouraged rather than stopped.
Which assessment finding should the nurse caring for a patient with thrombocytopenia communicate immediately to the health care provider? a. The platelet count is 52,000/μL. b. The patient is difficult to arouse. c. There are purpura on the oral mucosa. d. There are large bruises on the patient's back.
ANS: B Difficulty in arousing the patient may indicate a cerebral hemorrhage, which is life threatening and requires immediate action. The other information should be documented and reported but would not be unusual in a patient with thrombocytopenia. DIF: Cognitive Level: Analyze (analysis) REF: 623 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
A 19-year-old male presents to his primary care provider reporting restlessness, muscle cramping, and diarrhea. Lab tests reveal that he is hyperkalemic. Which of the following could have caused his condition? a. Primary hyperaldosteronism b. Acidosis c. Insulin secretion d. Diuretic use
ANS: B During acute acidosis, hydrogen ions accumulate in the ICF and potassium shifts out of the cell to the ECF, causing hyperkalemia. Primary hyperaldosteronism is associated with hypokalemia, not hyperkalemia. Insulin secretion helps reduce potassium levels in the cell, not cause it. Diuretics would cause hypokalemia, not hyperkalemia.
The cardiac telemetry unit charge nurse receives status reports from other nursing units about four patients who need cardiac monitoring. Which patient should be transferred to the cardiac unit first? a. Patient with Hashimoto's thyroiditis and a heart rate of 102 b. Patient with tetany who has a new order for IV calcium chloride c. Patient with Cushing syndrome and a blood glucose of 140 mg/dL d. Patient with Addison's disease who takes hydrocortisone twice daily
ANS: B Emergency treatment of tetany requires IV administration of calcium; ECG monitoring will be required because cardiac arrest may occur if high calcium levels result from too-rapid administration. The information about the other patients indicates that they are more stable than the patient with tetany DIF: Cognitive Level: Analyze (analysis) REF: 1168 OBJ: Special Questions: Multiple Patients | Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
A patient is concerned about the body changes that have resulted from long-term prednisone therapy for the treatment of asthma. Which effect of this drug therapy would be present to support the nursing diagnosis of disturbed body image?" a Weight loss b Weight gain c Pale skin color d Hair loss
ANS: B Facial erythema, weight gain, hirsutism, and "moon face" (characteristic of Cushing's syndrome) are possible body changes that may occur with long-term prednisone therapy.
A 40-year-old male complains of uncontrolled excessive movement and progressive dysfunction of intellectual and thought processes. He is experiencing movement problems that begin in the face and arms and eventually affect the entire body. The most likely diagnosis is: a. tardive dyskinesia. b. Huntington disease. c. hypokinesia. d. Alzheimer disease.
ANS: B Huntington disease is manifested by chorea, abnormal movement that begins in the face and arms and eventually affects the entire body. There is progressive dysfunction of intellectual and thought processes. Tardive dyskinesia is manifested by rapid, repetitive, and stereotypic movements. Most characteristic is continual chewing with intermittent protrusions of the tongue, lip smacking, and facial grimacing. Hypokinesia is a loss of voluntary movement despite preserved consciousness and normal peripheral nerve and muscle function. Alzheimer disease is manifested by cognitive deficits and not movement problems; motor impairments will occur in the later stages. REF: p. 378 | p. 380
A 52-year-old diabetic male presents to the ER with lethargy, confusion, and depressed reflexes. His wife indicates that he does not follow the prescribed diet and takes his medication sporadically. Lab results indicate hyperglycemia. Which assessment finding is most likely to occur? a. Clammy skin b. Decreased sodium c. Decreased urine formation d. Metabolic alkalosis
ANS: B Hypertonic hyponatremia develops with hyperglycemia. Increases in plasma lipids displace water volume and decrease sodium concentration, leading to the symptoms described. The patient is experiencing symptoms of hyponatremia and hyperglycemia, not hypernatremia and hypoglycemia. The patient will have increased ECF and would have increased urine formation. Metabolic acidosis would occur, not alkalosis.
17. Hyperlipidemia and hyperglycemia are associated with: a. Hypernatremia b. Hypertonic hyponatremia c. Hypokalemia d. Acidosis
ANS: B Hypertonic hyponatremia develops with hyperlipidemia, hyperproteinemia, and hyperglycemia. Increases in plasma lipids displace water volume and decrease sodium concentration. Hyperlipidemia and hyperglycemia are associated with hyponatremia, not hypernatremia. Hyperlipidemia and hyperglycemia are associated with hyponatremia, not hypokalemia. Hyperlipidemia and hyperglycemia are associated with hyponatremia, not acidosis.
A low ventilation-perfusion ratio of the lung will result in: a. increased dead space. b. shunting. c. alveolar collapse. d. bronchoconstriction
ANS: B Hypoxemia caused by inadequate ventilation of well-perfused areas of the lung is a form of mismatching called shunting, not bronchoconstriction. Inadequate ventilation of well-perfused areas of the lung is not referred to as dead space. Alveolar collapse is called atelectasis.
Which of the following conditions would cause the nurse to monitor for hyperkalemia? a. Excess aldosterone b. Acute acidosis c. Insulin usage d. Metabolic alkalosis
ANS: B In acidosis, ECF hydrogen ions shift into the cells in exchange for ICF potassium and sodium; hyperkalemia and acidosis therefore often occur together. Acidosis causes hyperkalemia, not excess aldosterone. Insulin would help treat hyperkalemia, not cause it. It is acidosis, not alkalosis, that leads to hyperkalemia.
For a patient experiencing metabolic acidosis, the body will compensate by: a. Excreting H+ through the kidneys b. Hyperventilating c. Retaining CO2 in the lungs d. Secreting aldosterone
ANS: B In an attempt to compensate for metabolic acidosis, the lungs hyperventilate to blow off CO2. It is the lungs hyperventilating that would compensate for metabolic acidosis, not the kidneys. CO2 retention would increase the acidotic state. Aldosterone would conserve water, but does not help compensate for acidosis.
Which nursing assessment of a 69-year-old patient is most important to make during initiation of thyroid replacement with levothyroxine (Synthroid)? a. Fluid balance b. Apical pulse rate c. Nutritional intake d. Orientation and alertness
ANS: B In older patients, initiation of levothyroxine therapy can increase myocardial oxygen demand and cause angina or dysrhythmias. The medication also is expected to improve mental status and fluid balance and will increase metabolic rate and nutritional needs, but these changes will not result in potentially life-threatening complications DIF: Cognitive Level: Analyze (analysis) REF: 1169 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
Which of the following lab values would the nurse expect in a patient who has sustained trauma to the lungs and chest wall and is experiencing respiratory failure? a. Electrolyte imbalances b. Elevated PaCO2 c. Low hematocrit d. Elevated p
ANS: B In respiratory failure, inadequate gas exchange occurs such that PaO2 ?4= 60 mm Hg or PaCO2 ?= 50 mm Hg with pH ?4= 7.25. Electrolyte imbalances do not occur, but changes in blood gas values do. Hematocrit may be unaffected. pH will be decreased.
A patient reports tiring easily, having difficulty rising from a sitting position, and the inability to stand on toes. The nurse would expect a diagnosis of: a. Parkinson disease. b. hypotonia. c. Huntington disease. d. paresis.
ANS: B Individuals with hypotonia tire easily (asthenia) or are weak. They may have difficulty rising from a sitting position, sitting down without using arm support, and walking up and down stairs, as well as an inability to stand on their toes. Individuals with Parkinson disease have rigidity and stiffness. Symptoms of Huntington disease include irregular, uncontrolled, and excessive movement. Paresis, or weakness, is partial paralysis with incomplete loss of muscle power. REF: pp. 376-377
After receiving change-of-shift report about the following four patients, which patient should the nurse assess first? a. A 31-year-old female with Cushing syndrome and a blood glucose level of 244 mg/dL b. A 70-year-old female taking levothyroxine (Synthroid) who has an irregular pulse of 134 c. A 53-year-old male who has Addison's disease and is due for a scheduled dose of hydrocortisone (Solu-Cortef). d. A 22-year-old male admitted with syndrome of inappropriate antidiuretic hormone (SIADH) who has a serum sodium level of 130 mEq/L
ANS: B Initiation of thyroid replacement in older adults may cause angina and cardiac dysrhythmias. The patient's high pulse rate needs rapid investigation by the nurse to assess for and intervene with any cardiac problems. The other patients also require nursing assessment and/or actions but are not at risk for life-threatening complications DIF: Cognitive Level: Analyze (analysis) REF: 1169 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
A 35-year-old who was severely burned is now demonstrating symptomology associated with acute tubular necrosis (ATN). Which form of renal failure is this patient experiencing? a. Prerenal b. Intrarenal c. Extrarenal d. Postrenal
ANS: B Intrarenal acute kidney failure is associated with several systemic diseases but is commonly related to ATN. Prerenal renal failure occurs anterior to the kidney. Extrarenal renal failure occurs outside the kidney. Postrenal is due to diseases that obstruct the flow of urine from the kidneys. REF: p. 761
The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia. The nurse will plan to check the laboratory results for the a. Schilling test. c. gastric analysis. b. bilirubin level. d. stool occult blood.
ANS: B Jaundice is caused by the elevation of bilirubin level associated with red blood cell hemolysis. The other tests would not be helpful in monitoring or treating a hemolytic anemia. DIF: Cognitive Level: Apply (application) REF: 615 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
3. A diabetic patients arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg; HCO3 18 mEq/L. The nurse would expect which finding? a. Intercostal retractions b. Kussmaul respirations c. Low oxygen saturation (SpO2) d. Decreased venous O2 pressure
ANS: B Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis. The low pH and low bicarbonate result indicate metabolic acidosis. Intercostal retractions, a low oxygen saturation rate, and a decrease in venous O2 pressure would not be caused by acidosis. DIF: Cognitive Level: Apply (application) REF: 479 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
What type of breathing will the nurse observe while assessing a patient experiencing both metabolic acidosis and Kussmaul respirations? a. Audible wheezing or stridor b. Increased rate, large tidal volumes, and no expiratory pause c. Rapid respirations with periods of apnea d. Very slow inhalations and rapid expirations
ANS: B Kussmaul respirations are characterized by a slightly increased ventilatory rate, very large tidal volumes, and no expiratory pause. Audible wheezing is usually associated with conditions such as asthma, and stridor indicates a narrowed airway. Cheyne-Stokes respirations are characterized by alternating periods of deep and shallow breathing, with periods of apnea lasting from 15 to 60 seconds. Kussmaul respirations do not have slow inhalations; bronchiolar disorders have these characteristics.
22. 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.
ANS: B Labeling of specimens is within the scope of practice of UAP. The other actions require nursing judgment and should be done by licensed nursing personnel. DIF: Cognitive Level: Apply (application) REF: 15 OBJ: Special Questions: Delegation TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
Which nursing intervention is likely to be most effective when assisting the patient with coronary artery disease to make appropriate dietary changes? a. Inform the patient about a diet containing no saturated fat and minimal salt. b. Help the patient modify favorite high-fat recipes by using monounsaturated oils. c. Emphasize the increased risk for heart problems unless the patient makes the dietary changes. d. Give the patient a list of low-sodium, low-cholesterol foods that should be included in the diet.
ANS: B Lifestyle changes are more likely to be successful when consideration is given to the patient's values and preferences. The highest percentage of calories from fat should come from monounsaturated or polyunsaturated fats. Although low-sodium and low-cholesterol foods are appropriate, providing the patient with a list alone is not likely to be successful in making dietary changes. Completely removing saturated fat from the diet is not a realistic expectation. Up to 7% of calories in the therapeutic lifestyle changes diet can come from saturated fat. Telling the patient about the increased risk without assisting further with strategies for dietary change is unlikely to be successful. DIF: Cognitive Level: Analyze (analysis)
4. Which of the following patients should the nurse assess for a decreased oncotic pressure in the capillaries? A patient with: a. A high-protein diet b. Liver failure c. Low blood pressure d. Low blood glucose
ANS: B Liver failure leads to lost or diminished plasma albumin production, and this contributes to decreased plasma oncotic pressure. A high-protein diet would provide albumin for the maintenance of oncotic pressure. Low blood pressure would lead to decreased hydrostatic pressure. Decreased glucose does not affect oncotic pressure.
When thought content and arousal level are intact but a patient cannot communicate and is immobile, the patient is experiencing: a. cerebral death. b. locked-in syndrome. c. dysphagia. d. cerebellar motor syndrome.
ANS: B Locked-in syndrome occurs when the individual cannot communicate through speech or body movement but is fully conscious, with intact cognitive function. In cerebral death, the person is in a coma with eyes closed. Dysphagia is difficulty speaking. Cerebellar motor syndrome is characterized by problems with coordinated movement. REF: p. 365
Which question will the nurse in the endocrine clinic ask to help determine a patient's risk factors for goiter? a. "How much milk do you drink?" b. "What medications are you taking?" c. "Are your immunizations up to date?" d. "Have you had any recent neck injuries?"
ANS: B Medications that contain thyroid-inhibiting substances can cause goiter. Milk intake, neck injury, and immunization history are not risk factors for goiter DIF: Cognitive Level: Understand (comprehension) REF: 1162 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
Which problem reported by a patient with hemophilia is most important for the nurse to communicate to the health care provider? a. Leg bruises c. Skin abrasions b. Tarry stools d. Bleeding gums
ANS: B Melena is a sign of gastrointestinal bleeding and requires collaborative actions such as checking hemoglobin and hematocrit and administration of coagulation factors. The other problems indicate a need for patient teaching about how to avoid injury but are not indicators of possible serious blood loss. DIF: Cognitive Level: Analyze (analysis) REF: 628 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
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).
ANS: B Methotrexate use can lead to folic acid deficiency. Supplementation with oral folic acid supplements is the usual treatment. The other nutrients would not correct folic acid deficiency, although they would be used to treat other types of anemia. DIF: Cognitive Level: Apply (application) REF: 612 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
Jan is a 70-year-old retired nurse who is interested in nondrug, mind-body therapies, self-management, and alternative strategies to deal with joint discomfort from rheumatoid arthritis. What options should you consider in her plan of care considering her expressed wishes? a. Stationary exercise bicycle, free weights, and spinning class b. Mind-body therapies such as music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy c. Chamomile tea and IcyHot gel d. Acupuncture and attending church services
ANS: B Mind-body therapies are designed to enhance the mind's capacity to affect bodily function and symptoms and include music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy, among many others. Stationary exercise bicycle, free weights, and spinning are not mind-body therapies. They are classified as exercise therapies. Chamomile tea and IcyHot gel are not mid-body therapies per se. They are classified as herbal and topical thermal treatments. Acupuncture is an ancient Chinese complementary therapy, while attending church services is a religious prayer mind-body therapy capable of enhancing the mind's capacity to affect bodily function and symptoms.
A patient asks how oxygen is transported in the body. The nurse's best response is that most oxygen (O2) is transported: a. dissolved in the plasma. b. bound to hemoglobin. c. in the form of carbon dioxide (CO2). d. as a free-floating molecule.
ANS: B Most O2 is transported bound to hemoglobin, not as a free-floating molecule; only a small amount is dissolved in plasma. O2 is not transported in the form of CO2. O2 is transported bound to hemoglobin.
A patient who has been on long-term corticosteroid therapy has had surgery to correct an abdominal hernia. The nurse keeps in mind that which potential effect of this medication may have the most impact on the patient's recovery?" a Hypotension b Delayed wound healing c Muscle weakness d Osteoporosis
ANS: B Muscle weakness and osteoporosis may also result from long-term therapy, but delayed wound healing would have the most impact on the patient's recovery from abdominal surgery at this time. Hypertension, not hypotension, may result from long-term corticosteroid therapy.
13. A patient has been searching on the Internet about natriuretic hormones. When the patient asks the nurse what do these hormones do, how should the nurse respond? Natriuretic hormones affect the balance of: a. Calcium b. Sodium c. Magnesium d. Potassium
ANS: B Natriuretic hormones are sometimes called a "third factor" in sodium regulation. Natriuretic hormones are a factor in sodium balance, not calcium. Natriuretic hormones are a factor in sodium balance, not magnesium. Natriuretic hormones are a factor in sodium balance, not potassium.
Understanding classifications of pain helps nurses develop a plan of care. A 62-year-old male has fallen while trimming tree branches sustaining tissue injury. He describes his condition as an aching, throbbing back. This is characteristic of a. neuropathic pain. b. nociceptive pain. c. chronic pain. d. mixed pain syndrome.
ANS: B Nociceptive pain refers to the normal functioning of physiological systems that leads to the perception of noxious stimuli (tissue injury) as being painful. Patients describe this type of pain as aching, cramping, or throbbing. Neuropathic pain is pathologic and results from abnormal processing of sensory input by the nervous system as a result of damage to the brain, spinal cord, or peripheral nerves. Patients describe this type of pain as burning, sharp, and shooting. Chronic pain is constant and unrelenting such as pain associated with cancer. Mixed pain syndrome is not easily recognized, is unique with multiple underlying and poorly understood mechanisms like fibromyalgia and low back pain.
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.
ANS: B Nursing care for patients with anemia should alternate periods of rest and activity to encourage activity without causing undue fatigue. There is no indication that the patient has a bleeding disorder, so a diet high in vitamin K or teaching about how to avoid injury is not needed. Protective isolation might be used for a patient with aplastic anemia, but it is not indicated for hemolytic anemia. DIF: Cognitive Level: Apply (application) REF: 608 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
A patient who has 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. discuss the need for insurance to cover post-HSCT care. b. ask whether there are questions or concerns about HSCT. c. emphasize the positive outcomes of a bone marrow transplant. d. explain that a cure is not possible with any treatment except HSCT.
ANS: B Offering the patient an opportunity to ask questions or discuss concerns about HSCT will encourage the patient to voice concerns about this treatment and 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. DIF: Cognitive Level: Apply (application) REF: 635 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
A patient is receiving heparin therapy as part of the treatment for a pulmonary embolism. The nurse monitors the results of which laboratory test to check the drug's effectiveness? a. Bleeding times b. Activated partial thromboplastin time (aPTT) c. Prothrombin time/international normalized ratio (PT/INR) d. Vitamin K levels
ANS: B Ongoing aPTT values are used to monitor heparin therapy. PT/INR is used to monitor warfarin therapy. The other two options are not used to monitor anticoagulant therapy. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 432 TOP: NURSING PROCESS: Evaluation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
The nurse will plan to monitor a patient diagnosed with a pheochromocytoma for a. flushing. b. headache. c. bradycardia. d. hypoglycemia.
ANS: B The classic clinical manifestations of pheochromocytoma are hypertension, tachycardia, severe headache, diaphoresis, and abdominal or chest pain. Elevated blood glucose may also occur because of sympathetic nervous system stimulation. Bradycardia and flushing would not be expected DIF: Cognitive Level: Apply (application) REF: 1181 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
A patient who had radical neck surgery to remove a malignant tumor developed hypoparathyroidism. The nurse should plan to teach the patient about a. bisphosphonates to reduce bone demineralization. b. calcium supplements to normalize serum calcium levels. c. increasing fluid intake to decrease risk for nephrolithiasis. d. including whole grains in the diet to prevent constipation.
ANS: B Oral calcium supplements are used to maintain the serum calcium in normal range and prevent the complications of hypocalcemia. Whole grain foods decrease calcium absorption and will not be recommended. Bisphosphonates will lower serum calcium levels further by preventing calcium from being reabsorbed from bone. Kidney stones are not a complication of hypoparathyroidism and low calcium levels DIF: Cognitive Level: Apply (application) REF: 1174 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
A 20 year old presents reporting difficulty breathing when lying down. What term should the nurse use to document this condition? a. Dyspnea b. Orthopnea c. Apnea d. Tachypnea
ANS: B Orthopnea is dyspnea that occurs when an individual lies flat. Dyspnea is shortness of breath that occurs with activity. Apnea is cessation of breathing, and tachypnea is rapid breathing.
A 60 year old undergoes surgery for a bone fracture. Which nursing measure would be most effective for preventing pulmonary embolism (PE) in this patient? a. Ensure that patient uses supplemental oxygen. b. Prevent deep vein thrombosis formation. c. Check hematocrit and hemoglobin levels frequently during the postoperative period. d. Promote aggressive fluid intake.
ANS: B PE most commonly results from embolization of a clot from deep venous thrombosis (DVT) involving the lower leg; thus, preventing these will help prevent pulmonary emboli. Oxygen will neither prevent emboli nor check hemoglobin and hematocrit. Fluid intake will help, but it is not as important as preventing DVT.
The nurse is preparing to transfuse a patient with a unit of packed red blood cells (PRBCs). Which patient would be best treated with this transfusion?" a A patient with a coagulation disorder b A patient with severe anemia c A patient who has lost a massive amount of blood after an accident d A patient who has a clotting-factor deficiency
ANS: B PRBCs are given to increase the oxygen-carrying capacity in patients with anemia, in patients with substantial hemoglobin deficits, and in patients who have lost up to 25% of their total blood volume. Patients with coagulation disorder or clotting-factor deficiency would receive fresh frozen plasma; a patient who has lost a massive amount of blood would receive whole blood.
It is important for the nurse providing care for a patient with sickle cell crisis to a. limit the patient's 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.
ANS: B Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control. Fluid intake should be increased to reduce blood viscosity and improve perfusion. Rest is usually ordered to decrease metabolic requirements. Patients are instructed about the need for dietary folic acid, but high-protein, high-calorie diets are not emphasized. DIF: Cognitive Level: Apply (application) REF: 618 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
A 50 year old is diagnosed with lung cancer. The health history includes a 30-year history of smoking, exposure to air pollution, asbestos, and radiation. What had the greatest impact on the development of his cancer? a. Radiation b. Cigarette smoke c. Asbestos d. Air pollution
ANS: B The most common cause of lung cancer is tobacco smoking. While considered risk factors, neither exposure to radiation, asbestos, nor air pollution is the most common of the known triggers.
A 16-year-old male fell off the bed of a pickup truck and hit his forehead on the road. He now has resistance to passive movement that varies proportionally with the force applied. He is most likely suffering from: a. spasticity. b. paratonia. c. rigidity. d. dystonia.
ANS: B Paratonia is manifested by resistance to passive movement that varies in direct proportion to force applied. Spasticity is manifested by a gradual increase in tone causing increased resistance until tone suddenly reduces. Rigidity is manifested by muscle resistance to passive movement of a rigid limb that is uniform in both flexion and extension throughout the motion. Dystonia is manifested by sustained involuntary twisting movement. REF: p. 377, Table 15-16
A patient is taking fludrocortisone (Florinef) for Addison's disease, and his wife is concerned about all of the problems that may occur with this therapy. When teaching them about therapy with this drug, the nurse will include which information?" a It may cause severe postural hypotension. b It needs to be taken with food or milk to minimize gastrointestinal upset. c The medication needs to be stopped immediately if nausea or vomiting occurs. d Weight gain of 5 pounds or more in 1 week is an expected adverse effect.
ANS: B Patients receiving fludrocortisone need to take it with food or milk to minimize gastrointestinal upset; weight gain of 5 pounds or more in 1 week needs to be reported to the physician; abrupt withdrawal is not recommended because it may precipitate an adrenal crisis. Adverse effects are related to the fluid retention and may include heart failure and hypertension.
The nurse suspects that the patient with stable angina is experiencing a side effect of the prescribed drug metoprolol (Lopressor) if the a. patient is restless and agitated. b. blood pressure is 90/54 mm Hg. c. patient complains about feeling anxious. d. heart monitor shows normal sinus rhythm.
ANS: B Patients taking -adrenergic blockers should be monitored for hypotension and bradycardia. Because this class of medication inhibits the sympathetic nervous system, restlessness, agitation, hypertension, and anxiety will not be side effects. Normal sinus rhythm is a normal and expected heart rhythm. DIF: Cognitive Level: Apply (application)
The most common cause of pulmonary edema is: a. right heart failure. b. left heart failure. c. asthma. d. lung cancer.
ANS: B The most common cause of pulmonary edema is left-sided heart disease, not right-sided. Pulmonary edema is not commonly caused by asthma or lung cancer.
After the nurse teaches the patient about the use of carvedilol (Coreg) in preventing anginal episodes, which statement by a patient indicates that the teaching has been effective? a. "Carvedilol will help my heart muscle work harder." b. "It is important not to suddenly stop taking the carvedilol." c. "I can expect to feel short of breath when taking carvedilol." d. "Carvedilol will increase the blood flow to my heart muscle."
ANS: B Patients who have been taking -adrenergic blockers can develop intense and frequent angina if the medication is suddenly discontinued. Carvedilol (Coreg) decreases myocardial contractility. Shortness of breath that occurs when taking -adrenergic blockers for angina may be due to bronchospasm and should be reported to the health care provider. Carvedilol works by decreasing myocardial O2 demand, not by increasing blood flow to the coronary arteries. DIF: Cognitive Level: Apply (application)
A 16-year-old's level of arousal was altered after taking a recreational drug. Physical exam revealed a negative Babinski sign, equal and reactive pupils, and roving eye movements. Which of the following diagnoses will the nurse most likely see on the chart? a. Psychogenic arousal alteration b. Metabolically induced coma c. Structurally induced coma d. Structural arousal alteration
ANS: B Persons with metabolically induced coma generally retain ocular reflexes even when other signs of brainstem damage are present. Psychogenic arousal activation demonstrates a general psychiatric disorder. Structurally induced coma is manifested by asymmetric responses. Structural arousal alteration does not have drug use as its etiology. REF: p. 360, Table 15-2
After reviewing a patient's history, vital signs, physical assessment, and laboratory data, which information shown in the accompanying figure is most important for the nurse to communicate to the health care provider? a. Hyperglycemia c. Q waves on ECG b. Bilateral crackles d. Elevated troponin
ANS: B Pulmonary congestion suggests that the patient may be developing heart failure, a complication of myocardial infarction (MI). Hyperglycemia is common after MI because of the inflammatory process that occurs with tissue necrosis. Troponin levels will be elevated for several days after MI. Q waves often develop with ST-segment-elevation MI. DIF: Cognitive Level: Analyze (analysis)
When considering pyelonephritis, where is the site of the infection? a. Bladder b. Renal pelvis c. Renal tubules d. Glomerulus
ANS: B Pyelonephritis is an infection of one or both upper urinary tracts (ureter, renal pelvis, and interstitium). Pyelonephritis is not associated with the bladder, renal tubules, or glomerulus. REF: p. 754
Which assessment finding by the nurse caring for a patient who has had coronary artery bypass grafting using a right radial artery graft is most important to communicate to the health care provider? a. Complaints of incisional chest pain b. Pallor and weakness of the right hand c. Fine crackles heard at both lung bases d. Redness on both sides of the sternal incision
ANS: B The changes in the right hand indicate compromised blood flow, which requires immediate evaluation and actions such as prescribed calcium channel blockers or surgery. The other changes are expected or require nursing interventions. DIF: Cognitive Level: Analyze (analysis)
A 75-year-old reports loss of urine with cough, sneezing, or laughing. These symptoms support which diagnosis? a. Urge incontinence b. Stress incontinence c. Overflow incontinence d. Functional incontinence
ANS: B Reduced resistance is associated with the symptom of stress incontinence, which is incontinence with coughing or sneezing. Urge incontinence is the inability to hold the urine when the urge is felt. There is coordination between the contracting bladder and the external sphincter, but the detrusor is too weak to empty the bladder, resulting in urinary retention with overflow or stress incontinence. Functional incontinence is similar to overflow and is not associated with coughing. REF: p. 750, Table 30-1
6. A patient with a chronic cough has a bronchoscopy. After the procedure, which intervention by the nurse is most appropriate? a. Elevate the head of the bed to 80 to 90 degrees. b. Keep the patient NPO until the gag reflex returns. c. Place on bed rest for at least 4 hours after bronchoscopy. d. Notify the health care provider about blood-tinged mucus.
ANS: B Risk for aspiration and maintaining an open airway is the priority. Because a local anesthetic is used to suppress the gag/cough reflexes during bronchoscopy, the nurse should monitor for the return of these reflexes before allowing the patient to take oral fluids or food. Blood-tinged mucus is not uncommon after bronchoscopy. The patient does not need to be on bed rest, and the head of the bed does not need to be in the high-Fowlers position. DIF: Cognitive Level: Apply (application) REF: 492 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
A patient who is recovering from an acute myocardial infarction (AMI) asks the nurse when sexual intercourse can be resumed. Which response by the nurse is best? a. "Most patients are able to enjoy intercourse without any complications." b. "Sexual activity uses about as much energy as climbing two flights of stairs." c. "The doctor will provide sexual guidelines when your heart is strong enough." d. "Holding and cuddling are good ways to maintain intimacy after a heart attack."
ANS: B Sexual activity places about as much physical stress on the cardiovascular system as most moderate-energy activities such as climbing two flights of stairs. The other responses do not directly address the patient's question or may not be accurate for this patient. DIF: Cognitive Level: Apply (application)
Which information will the nurse include when teaching a 50-year-old male patient about somatropin (Genotropin)? a. The medication will be needed for 3 to 6 months. b. Inject the medication subcutaneously every day. c. Blood glucose levels may decrease when taking the medication. d. Stop taking the medication if swelling of the hands or feet occurs.
ANS: B Somatropin is injected subcutaneously on a daily basis, preferably in the evening. The patient will need to continue on somatropin for life. If swelling or other common adverse effects occur, the health care provider should be notified. Growth hormone will increase blood glucose levels DIF: Cognitive Level: Apply (application) REF: 1158 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
Spinal shock is characterized by: a. loss of voluntary motor function with preservation of reflexes. b. cessation of spinal cord function below the lesion. c. loss of spinal cord function at the level of the lesion only. d. temporary loss of spinal cord function above the lesion.
ANS: B Spinal shock is the complete cessation of spinal cord function below the lesion. The reflexes are not preserved in spinal shock. Spinal shock is the complete cessation of spinal cord function below the lesion, not at the lesion only. REF: p. 382
. An 80-year-old male patient is in the ICU status fractured femur and MVA. You are making rounds and notice he is somnolent, with no response to verbal or physical stimulation. He has been on round the clock opioids doses q 4 hours. The best immediate course of nursing action is to a. call a Code Blue. b. stop opioid; consider administering naloxone, call Rapid Response Team (Code Blue); stay with patient, stimulate, and support respiration as indicated by patient status. c. call the primary hospitalist in charge of patient. d. call the anesthesia provider on call.
ANS: B Stop opioid; consider administering naloxone; call Rapid Response Team (Code Blue); stay with patient, stimulate, and support respiration as indicated by patient status; notify primary or anesthesia provider; and monitor respiratory status and sedation level closely until sedation level is stable at less than 3 and respiratory status is satisfactory. Calling a Code Blue solely for a somnolent patient is not indicated as a solitary response. Calling the hospitalist assigned to the patient is an option only after the immediate treatment plan is enacted to reverse the opioid. Calling anesthesia is appropriate after stopping the opioid first
Which intervention will the nurse include in the plan of care for a 52-year-old male patient with syndrome of inappropriate antidiuretic hormone (SIADH)? a. Monitor for peripheral edema. b. Offer patient hard candies to suck on. c. Encourage fluids to 2 to 3 liters per day. d. Keep head of bed elevated to 30 degrees.
ANS: B Sucking on hard candies decreases thirst for a patient on fluid restriction. Patients with SIADH are on fluid restrictions of 800 to 1000 mL/day. Peripheral edema is not seen with SIADH. The head of the bed is elevated no more than 10 degrees to increase left atrial filling pressure and decrease antidiuretic hormone (ADH) release DIF: Cognitive Level: Apply (application) REF: 1161 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
A newborn is in respiratory distress and requires ventilation. Tests reveal that he does not produce surfactant due to the absence of: a. mucus-producing cells. b. type II alveolar cells. c. alveolar macrophages. d. goblet cells.
ANS: B Surfactant is produced by the type II alveolar cells. Surfactant is not produced by mucus-producing cells, alveolar macrophages, or goblet cells.
When monitoring a patient who is taking a systemically administered glucocorticoid, the nurse will monitor for signs of which condition?" a Dehydration b Hypokalemia c Hyponatremia d Hypoglycemia
ANS: B Systemic glucocorticoid drugs may cause potassium depletion, hyperglycemia, and hypernatremia. The other options are incorrect.
A patient who has 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.
ANS: B TRALI is caused by a reaction between the donor and the patient leukocytes that causes pulmonary inflammation and capillary leaking. The other actions may help prevent respiratory problems caused by circulatory overload or by allergic reactions, but they will not prevent TRALI. DIF: Cognitive Level: Apply (application) REF: 651 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
When a diabetic patient asks about maintaining adequate blood glucose levels, which of the following statements by the nurse relates most directly to the necessity of maintaining blood glucose levels no lower than about 74 mg/dl? a. "Glucose is the only type of fuel used by body cells to produce the energy needed for physiologic activity." b. "The central nervous system cannot store glucose and needs a continuous supply of glucose for fuel." c. "Without a minimum level of glucose circulating in the blood, erythrocytes cannot produce ATP." d. "The presence of glucose in the blood counteracts the formation of lactic acid and prevents acidosis."
ANS: B The brain cannot synthesize or store significant amounts of glucose; thus a continuous supply from the body's circulation is needed to meet the fuel demands of the central nervous system.
Which of the following buffer pairs is considered the major plasma buffering system? a. Protein/fat b. Carbonic acid/bicarbonate c. Sodium/potassium d. Amylase/albumin
ANS: B The carbonic acid/bicarbonate buffer pair operates in both the lung and the kidney and is a major extracellular buffer. Protein and fat are nutrients not related to the buffering system. Sodium and potassium are electrolytes for fluid and electrolyte balance, not the major plasma buffering system for acid-base balance. Amylase is a carbohydrate enzyme, and albumin is a protein; neither is a buffering system.
A patient is admitted to the neurological critical care unit with a severe closed head injury. All four extremities are in rigid extension, the forearms are hyperpronated, and the legs are in plantar extension. How should the nurse chart this condition? a. Decorticate posturing b. Decerebrate posturing c. Dystonic posturing d. Basal ganglion posturing
ANS: B The description is of a patient in decerebrate posturing. The description provided is not associated with decorticate, dystonic, or basal ganglion posturing. REF: p. 385
Which action will the admitting nurse include in the care plan for a patient who has neutropenia? a. Avoid intramuscular injections. b. Check temperature every 4 hours. c. Omit fruits or vegetables from the diet. d. Place a "No Visitors" sign on the door.
ANS: B The earliest sign of infection in a neutropenic patient is an elevation in temperature. Although unpeeled fresh fruits and vegetables should be avoided, fruits and vegetables that are peeled or cooked are acceptable. Injections may be required for administration of medications such as filgrastim (Neupogen). The number of visitors may be limited and visitors with communicable diseases should be avoided, but a "no visitors" policy is not needed. DIF: Cognitive Level: Apply (application) REF: 632 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
3. While planning care for elderly individuals, the nurse remembers the elderly are at a higher risk for developing dehydration because they have a(n): a. Higher total body water volume b. Decreased muscle mass c. Increase in thirst d. Increased tendency towards developing edema
ANS: B The elderly are at higher risk for dehydration due to a decrease in muscle mass. The elderly have a decrease in total body water, not an increase. The elderly have a decrease in thirst. The elderly may develop edema, but this does not lead to dehydration.
When titrating IV nitroglycerin for a patient with a myocardial infarction (MI), which action will the nurse take to evaluate the effectiveness of the drug? a. Monitor heart rate. c. Check blood pressure. b. Ask about chest pain. d. Observe for dysrhythmias.
ANS: B The goal of IV nitroglycerin administration in MI is relief of chest pain by improving the balance between myocardial oxygen supply and demand. The nurse will also monitor heart rate and blood pressure and observe for dysrhythmias, but these parameters will not indicate whether the medication is effective. DIF: Cognitive Level: Apply (application)
Which patient at the cardiovascular clinic requires the most immediate action by the nurse? a. Patient with type 2 diabetes whose current blood glucose level is 145 mg/dL b. Patient with stable angina whose chest pain has recently increased in frequency c. Patient with familial hypercholesterolemia and a total cholesterol of 465 mg/dL d. Patient with chronic hypertension whose blood pressure today is 172/98 mm Hg
ANS: B The history of more frequent chest pain suggests that the patient may have unstable angina, which is part of the acute coronary syndrome spectrum. This will require rapid implementation of actions such as cardiac catheterization and possible percutaneous coronary intervention. The data about the other patients suggest that their conditions are stable. DIF: Cognitive Level: Analyze (analysis)
The nurse is caring for a patient with type A hemophilia being admitted to the hospital with severe pain and swelling in the right knee. The nurse should a. apply heat to the knee. b. immobilize the knee joint. c. assist the patient with light weight bearing. d. perform passive range of motion to the knee.
ANS: B The initial action should be total rest of the knee to minimize bleeding. Ice packs are used to decrease bleeding. Range of motion (ROM) and weight-bearing exercise are contraindicated initially, but after the bleeding stops, ROM and physical therapy are started. DIF: Cognitive Level: Apply (application) REF: 626 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
A 45-year-old presents with hypertension, anorexia, nausea and vomiting, and anemia and is diagnosed with chronic renal failure. What is the cause of this patient's anemia? a. Red blood cells being lost in the urine b. Inadequate production of erythropoietin c. Inadequate iron absorption in the gut d. Red blood cells being injured as they pass through the glomerulus
ANS: B The kidneys are inadequate in their production of erythropoietin; red cells may be lost in the urine, but it is the lack of erythropoietin that leads to anemia. The anemia is not associated with inadequate iron absorption or red cell destruction. REF: p. 764, Table 30-13
A 20-year history of smoking causes airways to be obstructed as a result of: a. excessive mucus production. b. loss of elastic recoil. c. infection and inflammation. d. airway edema.
ANS: B The major mechanism of airflow limitation is a loss of elastic recoil, not excessive mucus as with bronchitis. The major mechanism of airflow limitation in this situation is not associated with infection or airway edema.
Which organism does the nurse suspect is the most likely cause of empyema? a. Virus b. Staphylococcus aureus c. Fungus d. Moraxella catarrhalis
ANS: B The most likely cause of empyema is S. aureus; it is not due to a virus. Empyema is not due to M. catarrhalis or to a fungal infection.
A 37-year-old patient has just arrived in the postanesthesia recovery unit (PACU) after a thyroidectomy. Which information is most important to communicate to the surgeon? a. The patient reports 7/10 incisional pain. b. The patient has increasing neck swelling. c. The patient is sleepy and difficult to arouse. d. The patient's cardiac rate is 112 beats/minute.
ANS: B The neck swelling may lead to respiratory difficulty, and rapid intervention is needed to prevent airway obstruction. The incisional pain should be treated but is not unusual after surgery. A heart rate of 112 is not unusual in a patient who has been hyperthyroid and has just arrived in the PACU from surgery. Sleepiness in the immediate postoperative period is expected. DIF: Cognitive Level: Analyze (analysis) REF: 1168 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
A 38-year-old male patient is admitted to the hospital in Addisonian crisis. Which patient statement supports a nursing diagnosis of ineffective self-health management related to lack of knowledge about management of Addison's disease? a. "I frequently eat at restaurants, and my food has a lot of added salt." b. "I had the stomach flu earlier this week, so I couldn't take the hydrocortisone." c. "I always double my dose of hydrocortisone on the days that I go for a long run." d. "I take twice as much hydrocortisone in the morning dose as I do in the afternoon."
ANS: B The need for hydrocortisone replacement is increased with stressors such as illness, and the patient needs to be taught to call the health care provider because medication and IV fluids and electrolytes may need to be given. The other patient statements indicate appropriate management of the Addison's disease. DIF: Cognitive Level: Apply (application) REF: 1179 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
A patient who is being admitted to the emergency department with intermittent chest pain gives the following list of daily medications to the nurse. Which medication has the most immediate implications for the patient's care? a. captopril c. furosemide (Lasix) b. sildenafil (Viagra) d. warfarin (Coumadin)
ANS: B The nurse will need to avoid giving nitrates to the patient because nitrate administration is contraindicated in patients who are using sildenafil because of the risk of severe hypotension caused by vasodilation. The other home medications should also be documented and reported to the health care provider but do not have as immediate an impact on decisions about the patient's treatment. DIF: Cognitive Level: Analyze (analysis)
An older patient is being discharged from the ambulatory surgical unit following left eye surgery. The patient tells the nurse, "I do not know if I can take care of myself with this patch over my eye." Which action by the nurse is most appropriate? a. Refer the patient for home health care services. b. Discuss the specific concerns regarding self-care. c. Give the patient written instructions regarding care. d. Assess the patient's support system for care at home.
ANS: B The nurse's initial action should be to assess exactly the patient's concerns about self-care. Referral to home health care and assessment of the patient's support system may be appropriate actions but will be based on further assessment of the patient's concerns. Written instructions should be given to the patient, but these are unlikely to address the patient's stated concern about self-care
Three days after experiencing a myocardial infarction (MI), a patient who is scheduled for discharge asks for assistance with hygiene activities, saying, "I am too nervous about my heart to be alone while I get washed up." Based on this information, which nursing diagnosis is appropriate? a. Activity intolerance related to weakness b. Anxiety related to change in health status c. Denial related to lack of acceptance of the MI d. Altered body image related to cardiac disease
ANS: B The patient data indicate anxiety about the impact of the MI is a concern. The other nursing diagnoses may be appropriate for some patients after an MI, but the data for this patient do not support denial, activity intolerance, or altered body image. DIF: Cognitive Level: Apply (application)
An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy twice a day. Which collaborative problem should the nurse identify as a priority for this patient? a. Potential complication: hypovolemic shock b. Potential complication: venous thromboembolism c. Potential complication: fluid and electrolyte imbalance d. Potential complication: impaired surgical wound healing
ANS: B The patient is older and relatively immobile, which are two risk factors for development of deep vein thrombosis. The other potential complications are possible postoperative problems, but they are not supported by the data about this patient
A patient who has acute myelogenous leukemia develops an absolute neutrophil count of 850/μL while receiving outpatient chemotherapy. Which action by the outpatient clinic nurse is most appropriate? a. Discuss the need for hospital admission to treat the neutropenia. b. Teach the patient to administer filgrastim (Neupogen) injections. c. Plan to discontinue the chemotherapy until the neutropenia resolves. d. Order a high-efficiency particulate air (HEPA) filter for the patient's home.
ANS: B The patient may be taught to self-administer filgrastim injections. Although chemotherapy may be stopped with severe neutropenia (neutrophil count <500/μL), administration of filgrastim usually allows the chemotherapy to continue. Patients with neutropenia are at higher risk for infection when exposed to other patients in the hospital. HEPA filters are expensive and are used in the hospital, where the number of pathogens is much higher than in the patient's home environment. DIF: Cognitive Level: Apply (application) REF: 633 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
Which nursing action will be included in the plan of care for a 55-year-old patient with Graves' disease who has exophthalmos? a. Place cold packs on the eyes to relieve pain and swelling. b. Elevate the head of the patient's bed to reduce periorbital fluid. c. Apply alternating eye patches to protect the corneas from irritation. d. Teach the patient to blink every few seconds to lubricate the corneas.
ANS: B The patient should sit upright as much as possible to promote fluid drainage from the periorbital area. With exophthalmos, the patient is unable to close the eyes completely to blink. Lubrication of the eyes, rather than eye patches, will protect the eyes from developing corneal scarring. The swelling of the eye is not caused by excessive blood flow to the eye, so cold packs will not be helpful DIF: Cognitive Level: Apply (application) REF: 1167 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
A 63-year-old patient with primary hyperparathyroidism has a serum phosphorus level of 1.7 mg/dL (0.55 mmol/L) and calcium of 14 mg/dL (3.5 mmol/L). Which nursing action should be included in the plan of care? a. Restrict the patient to bed rest. b. Encourage 4000 mL of fluids daily. c. Institute routine seizure precautions. d. Assess for positive Chvostek's sign.
ANS: B The patient with hypercalcemia is at risk for kidney stones, which may be prevented by a high fluid intake. Seizure precautions and monitoring for Chvostek's or Trousseau's sign are appropriate for hypocalcemic patients. The patient should engage in weight-bearing exercise to decrease calcium loss from bone DIF: Cognitive Level: Apply (application) REF: 1173 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
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. A 44-yr-old with sickle cell anemia who says his eyes always look sort of yellow b. A 23-yr-old with no previous health problems who has a nontender lump in the axilla c. A 50-yr-old with early-stage chronic lymphocytic leukemia who reports chronic fatigue d. A 19-yr-old with hemophilia who wants to learn to self-administer factor VII replacement
ANS: B The patient's age and presence of a nontender axillary lump suggest possible lymphoma, which needs rapid diagnosis and treatment. The other patients have questions about treatment or symptoms that are consistent with their diagnosis but do not need to be seen urgently. DIF: Cognitive Level: Analyze (analysis) REF: 641 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
In the postanesthesia care unit (PACU), a patient's vital signs are blood pressure 116/72, pulse 74, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take first? a. Place the patient in a side-lying position. b. Encourage the patient to take deep breaths. c. Prepare to transfer the patient to a clinical unit. d. Increase the rate of the postoperative IV fluids.
ANS: B The patient's borderline SpO2 and sleepiness indicate hypoventilation. The nurse should stimulate the patient and remind the patient to take deep breaths. Placing the patient in a lateral position is needed when the patient first arrives in the PACU and is unconscious. The stable blood pressure and pulse indicate that no changes in fluid intake are required. The patient is not fully awake and has a low SpO2, indicating that transfer from the PACU to a clinical unit is not appropriate
A patient who had a subtotal thyroidectomy earlier today develops laryngeal stridor and a cramp in the right hand upon returning to the surgical nursing unit. Which collaborative action will the nurse anticipate next? a. Suction the patient's airway. b. Administer IV calcium gluconate. c. Plan for emergency tracheostomy. d. Prepare for endotracheal intubation.
ANS: B The patient's clinical manifestations of stridor and cramping are consistent with tetany caused by hypocalcemia resulting from damage to the parathyroid glands during surgery. Endotracheal intubation or tracheostomy may be needed if the calcium does not resolve the stridor. Suctioning will not correct the stridor DIF: Cognitive Level: Apply (application) REF: 1168 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
One of the functions of the pulmonary system is the: a. expelling of bacteria. b. exchange of gases between the environment and blood. c. movement of blood into and out of the capillaries. d. principal mechanism for cooling of the heart.
ANS: B The pulmonary system promotes exchange of gases between the environment and the blood. Neither expelling bacteria, moving blood in and out of the capillaries, nor cooling of the heart is considered a function of the pulmonary system.
Which action could the postanesthesia care unit (PACU) nurse delegate to unlicensed assistive personnel (UAP) who help with the transfer of a patient to the clinical unit? a. Clarify the postoperative orders with the surgeon. b. Help with the transfer of the patient onto a stretcher. c. Document the appearance of the patient's incision in the chart. d. Provide hand off communication to the surgical unit charge nurse.
ANS: B The scope of practice of UAP includes repositioning and moving patients under the supervision of a nurse. Providing report to another nurse, assessing and documenting the wound appearance, and clarifying physician orders with another nurse require registered-nurse (RN) level education and scope of practice
The nasopharynx is lined with a ciliated mucosal membrane with a highly vascular blood supply. One function of this membrane is to: a. absorb air. b. humidify air. c. cool air. d. exchange gases
ANS: B These structures are lined with a ciliated mucosa that warms and humidifies inspired air and removes foreign particles from it. Air is not absorbed or cooled by the ciliated mucosal membrane. Gas exchange occurs in the alveoli.
A patient who has acute myelogenous leukemia (AML) asks the nurse whether the planned chemotherapy 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 don't need to make a decision about treatment right now because leukemias in adults tend to progress slowly."
ANS: B This response uses therapeutic communication by addressing the patient's question and giving accurate information. The other responses either give inaccurate information or fail to address the patient's question, which will discourage the patient from asking the nurse for information. DIF: Cognitive Level: Apply (application) REF: 636 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
The patient has severe hyperthyroidism and will have surgery tomorrow. What assessment is most important for the nurse to assess in order to detect development of the acid-base imbalance for which the patient has highest risk? a. Urine output and color b. Level of consciousness c. Heart rate and blood pressure d. Lung sounds in lung bases
ANS: B Thyroid hormone increases metabolic rate, causing a patient with severe hyperthyroidism to have high risk of metabolic acidosis from increased production of metabolic acids. Metabolic acidosis decreases level of consciousness. Changes in urine output, urine color, and lung sounds are not signs of metabolic acidosis. Although metabolic acidosis often causes tachycardia, many other factors influence heart rate and blood pressure, including thyroid hormone.
A 50 year old presents with hypotension, hypoxemia, and tracheal deviation to the left. Tests reveal that the air pressure in the pleural cavity exceeds barometric pressure in the atmosphere. Based upon these assessment findings, what does the nurse suspect the patient is experiencing? a. Pleural effusion b. Tension pneumothorax c. Open pneumothorax d. Transudative pneumothorax
ANS: B Tracheal deviation suggests tension pneumothorax, not pleural effusion. With an open pneumothorax, a sucking sound would be heard without tracheal deviation. Tracheal deviation suggests a tension, not transudative pneumothorax.
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.
ANS: B UAP education includes measurement of vital signs. UAP would report the vital signs to the registered nurse (RN). The other actions require more education and a larger scope of practice and should be done by licensed nursing staff members. DIF: Cognitive Level: Apply (application) REF: 632 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
A 55-year-old presents reporting urinary retention. Tests reveal a lower urinary tract obstruction. Which of the following is of most concern to the nurse? a. Vesicoureteral reflux and pyelonephritis b. Formation of renal calculi c. Glomerulonephritis d. Increased bladder compliance
ANS: B Urine stasis occurs with urinary tract obstruction and can lead to the formation of renal calculi. Reflux and pyelonephritis would not lead to calculi as much as stasis would. Neither glomerulonephritis nor increased bladder compliance causes the stasis that would lead to calculus formation. REF: p. 748
The primary care provider states that the patient is experiencing vasogenic edema. The nurse realizes vasogenic edema is clinically important because: a. it usually has an infectious cause. b. the blood-brain barrier is disrupted. c. ICP is excessively high. d. it always causes herniation.
ANS: B Vasogenic edema is clinically important because the blood-brain barrier (selective permeability of brain capillaries) is disrupted, and plasma proteins leak into the extracellular spaces. Vasogenic edema does not have an infectious cause. ICP is increased, but not more so than other forms of edema. Vasogenic edema does not always cause herniation. REF: p. 375
A patient who has been anticoagulated with warfarin (Coumadin) has been admitted for gastrointestinal bleeding. The history and physical examination indicates that the patient may have taken too much warfarin. The nurse anticipates that the patient will receive which antidote? a. Vitamin E b. Vitamin K c. Protamine sulfate d. Potassium chloride
ANS: B Vitamin K is given to reverse the anticoagulation effects of warfarin toxicity. Protamine sulfate is the antidote for heparin overdose. The other options are incorrect. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 416 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
A 20-year-old experiences a severe closed head injury as a result of a motor vehicle accident. Which of the following structures is most likely keeping the patient in a vegetative state (VS) 1 month after the accident? a. Cerebral cortex b. Brainstem c. Spinal cord d. Cerebellum
ANS: B When a person loses cerebral function, the reticular activating system and brainstem can maintain a crude waking state known as a VS. Cognitive cerebral functions, however, cannot occur without a functioning reticular activating system. A VS is not associated with the cerebral cortex, spinal cord, or cerebellum. REF: p. 364
What phrase describes the condition in which a series of alveoli in the left lower lobe receive adequate ventilation but lack adequate perfusion? a. A right-to-left shunt b. Alveolar dead space c. A low ventilation-perfusion ratio d. Pulmonary hypotension
ANS: B When certain areas of the alveoli experience inadequate perfusion, it is referred to as dead space. The situation is not referred to as either a right-to-left shunt or as pulmonary hypotension. Shunting is due to a low ventilation-perfusion ratio.
When evaluating the effectiveness of preoperative teaching with a patient scheduled for coronary artery bypass graft (CABG) surgery using the internal mammary artery, the nurse determines that additional teaching is needed when the patient says which of the following? a. "They will circulate my blood with a machine during surgery." b. "I will have incisions in my leg where they will remove the vein." c. "They will use an artery near my heart to go around the area that is blocked." d. "I will need to take an aspirin every day after the surgery to keep the graft open."
ANS: B When the internal mammary artery is used there is no need to have a saphenous vein removed from the leg. The other statements by the patient are accurate and indicate that the teaching has been effective. DIF: Cognitive Level: Apply (application)
The nurse is providing counseling to a woman who is HIV positive and has just discovered that she is pregnant. Which anti-HIV drug is given to HIV-infected pregnant women to prevent transmission of the virus to the infant? a. Acyclovir (Zovirax) b. Zidovudine (Retrovir) c. Ribavirin (Virazole) d. Foscarnet (Foscavir)
ANS: B Zidovudine, along with various other antiretroviral drugs, is given to HIV-infected pregnant women and even to newborn babies to prevent maternal transmission of the virus to the infant. The other drugs are non-HIV antiviral drugs.
When a patient's CT scan reveals a lesion above the pontine micturition center, which condition would the nurse expect? a. Dyssynergia b. Detrusor hyperreflexia c. Detrusor areflexia d. Detrusor sphincter dyssynergia
ANS: B testbanks_and_xanax Neurologic disorders that develop above the pontine micturition center result in detrusor hyperreflexia, also known as an uninhibited or reflex bladder. Lesions that develop in upper motor neurons of the brain and spinal cord result in dyssynergia. Lesions that involve the sacral micturition center (below S1; may also be termed cauda equina syndrome) or peripheral nerve lesions result in detrusor areflexia (acontractile detrusor), a lower motor neuron disorder. Neurologic lesions that occur below the pontine micturition center but above the sacral micturition center (between C2 and S1) are also upper motor neuron lesions and result in detrusor hyperreflexia with vescico-sphincter dyssynergia. REF: p. 750
24. A patient who has a right-sided chest tube after a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is appropriate? a. Adjust the dial on the wall regulator. b. Continue to monitor the collection device. c. Document the presence of a large air leak. d. Notify the surgeon of a possible pneumothorax
ANS: B Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. Increasing or decreasing the vacuum source will not adjust the suction pressure. The amount of suction applied is regulated by the amount of water in this chamber and not by the amount of suction applied to the system.
45. An experienced nurse instructs a new nurse about how to care for a patient with dyspnea caused by a pulmonary fungal infection. Which action by the new nurse indicates a need for further teaching? a. Listening to the patient's lung sounds several times during the shift b. Placing the patient on droplet precautions in a private hospital room c. Monitoring patient serology results to identify the infecting organism d. Titrating the O2 flowrate as prescribed to keep the O2 saturation over 90%
ANS: B Fungal infections are not transmitted from person to person. Therefore, no isolation procedures are necessary. The other actions by the new nurse are appropriate.
30. A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first? a. Chest x-ray via stretcher b. Blood cultures from two sites c. Ciprofloxacin (Cipro) 400 mg IV d. Acetaminophen (Tylenol) suppository
ANS: B Initiating antibiotic therapy rapidly is essential, but it is important to obtain the cultures before antibiotic administration. The chest x-ray and acetaminophen administration can be done last.
37. The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first? a. A 77-yr-old patient with tuberculosis (TB) who has four medications due b. A 46-yr-old patient on bed rest who reports sudden onset of shortness of breath c. A 35-yr-old patient with pneumonia who has a temperature of 100.2° F (37.8° C) d. A 23-yr-old patient with cystic fibrosis who has pulmonary function testing scheduled
ANS: B Patients on bed rest who are immobile are at high risk for deep vein thrombosis (DVT). Sudden onset of shortness of breath in a patient with a DVT suggests a pulmonary embolism and requires immediate assessment and action such as O2 administration. The other patients should be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration
4. The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement by the patient indicates a good understanding of the instructions? a. "I will call my health care provider if I still feel tired after a week." b. "I will continue to do deep breathing and coughing exercises at home." c. "I will schedule two appointments for the pneumonia and influenza vaccines." d. "I will cancel my follow-up chest x-ray appointment if I feel better next week."
ANS: B Patients should continue to cough and deep breathe after discharge. Fatigue is expected for several weeks. The pneumococcal and influenza vaccines can be given at the same time in different arms. A follow-up chest x-ray needs to be done in 6 to 8 weeks to evaluate resolution of pneumonia.
20. A patient with newly diagnosed lung cancer tells the nurse, "I don't think I'm going to live to see my next birthday." Which is the best initial response by the nurse? a. "Are you ready to talk with family members about dying?" b. "Can you tell me what makes you think you will die so soon?" c. "Do you think that an antidepressant medication would be helpful?" d. "Would you like to talk to the hospital chaplain about your feelings?"
ANS: B The nurse's initial response should be to collect more assessment data about the patient's statement. The answer beginning "Can you tell me what it is" is the most open-ended question and will offer the best opportunity for obtaining more data. The remaining answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate.
19. An hour after a left thoracotomy, a patient reports incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action should the nurse take? a. Clamp the chest tube in two places. b. Administer the prescribed morphine. c. Milk the chest tube to remove any clots. d. Assist the patient with incentive spirometry.
ANS: B Treat the pain. The patient is unlikely to take deep breaths or cough until the pain level is lower. A chest tube output of 100 mL is not unusual in the first hour after thoracotomy. Milking or stripping chest tubes is no longer recommended because these practices can dangerously increase intrapleural pressures and damage lung tissues. Position tubing so that drainage flows freely to negate need for milking or stripping. An air leak is expected in the initial postoperative period after thoracotomy. Clamping the chest tube is not indicated and may lead to dangerous development of a tension pneumothorax.
5. Which action should the nurse plan to prevent aspiration in a high-risk patient? a. Turn and reposition an immobile patient at least every 2 hours. b. Place a patient with altered consciousness in a side-lying position. c. Insert a nasogastric tube for feeding a patient with high-calorie needs. d. Monitor respiratory symptoms in a patient who is immunosuppressed.
ANS: B With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and O2 saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Conditions that increase the risk of aspiration include decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, and nasogastric intubation with or without tube feeding.
13. A patient with a history of chronic obstructive pulmonary disease and type 2 diabetes has been treated for pneumonia for the past week. The patient has been receiving intravenous corticosteroids as well as antibiotics as part of his therapy. At this time, the pneumonia has resolved, but when monitoring the blood glucose levels, the nurse notices that the level is still elevated. What is the best explanation for this elevation? a. The antibiotics may cause an increase in glucose levels. b. The corticosteroids may cause an increase in glucose levels. c. His type 2 diabetes has converted to type 1. d. The hypoxia caused by the chronic obstructive pulmonary disease causes an increased need for insulin.
ANS: B Corticosteroids can antagonize the hypoglycemic effects of insulin, resulting in elevated blood glucose levels. The other options are incorrect. DIF: COGNITIVE LEVEL: Analyzing (Analysis) REF: p. 517 TOP: NURSING PROCESS: Evaluation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
15. A patient has been diagnosed with metabolic syndrome and is started on the biguanide metformin (Glucophage). The nurse knows that the purpose of the metformin, in this situation, is which of these? a. To increase the pancreatic secretion of insulin b. To decrease insulin resistance c. To increase blood glucose levels d. To decrease the pancreatic secretion of insulin
ANS: B Metformin decreases glucose production by the liver; decreases intestinal absorption of glucose; and improves insulin receptor sensitivity in the liver, skeletal muscle, and adipose tissue, resulting in decreased insulin resistance. The other options are incorrect. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 520 TOP: NURSING PROCESS: Planning MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
29. 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)
ANS: C New onset dyspnea suggests a pulmonary embolus, which will require rapid actions such as oxygen administration and notification of the health care provider. The other findings are typical of VTE.
12. The nurse is preparing to administer insulin intravenously. Which statement about the administration of intravenous insulin is true? a. Insulin is never given intravenously. b. Only regular insulin can be administered intravenously. c. Insulin aspart or lispro can be administered intravenously, but there must be a 50% dose reduction. d. Any form of insulin can be administered intravenously at the same dose as that is ordered for subcutaneous administration.
ANS: B Regular insulin is the usual insulin product to be dosed via intravenous bolus, intravenous infusion, or even intramuscularly. These routes, especially the intravenous infusion route, are often used in cases of diabetic ketoacidosis, or coma associated with uncontrolled type 1 diabetes. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 527 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control
17. The nurse is reviewing a patient's medication list and notes that sitagliptin (Januvia) is ordered. The nurse will question an additional order for which drug or drug class? a. glitazone b. insulin c. metformin (Glucophage) d. sulfonylurea
ANS: B Sitagliptin is indicated for management of type 2 diabetes either as monotherapy or in combination with metformin, a sulfonylurea, or a glitazone, but not with insulin. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 524 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
10. After starting treatment for type 2 diabetes mellitus 6 months earlier, a patient is in the office for a follow-up examination. The nurse will monitor which laboratory test to evaluate the patient's adherence to the antidiabetic therapy over the past few months? a. Hemoglobin levels b. Hemoglobin A1C level c. Fingerstick fasting blood glucose level d. Serum insulin levels
ANS: B The hemoglobin A1C level reflects the patient's adherence to the therapy regimen for several months previously, thus evaluating how well the patient has been doing with diet and drug therapy. The other options are incorrect. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 530 TOP: NURSING PROCESS: Evaluation MSC: NCLEX: Health Promotion and Maintenance
16. When administering morning medications for a newly admitted patient, the nurse notes that the patient has an allergy to sulfa drugs. There is an order for the sulfonylurea glipizide (Glucotrol). Which action by the nurse is correct? a. Give the drug as ordered 30 minutes before breakfast. b. Hold the drug, and check the order with the prescriber. c. Give a reduced dose of the drug with breakfast. d. Give the drug, and monitor for adverse effects.
ANS: B There is a potential for cross-allergy in patients who are allergic to sulfonamide antibiotics. Although such an allergy is listed as a contraindication by the manufacturer, most clinicians do prescribe sulfonylureas for such patients. The order needs to be clarified. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 521 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
1. A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient? a. Ask the patient to lie down to complete a full physical assessment. b. Briefly ask specific questions about this episode of respiratory distress. c. Complete the admission database to check for allergies before treatment. d. Delay the physical assessment to first complete pulmonary function tests.
ANS: B When a patient has severe respiratory distress, only information pertinent to the current episode is obtained, and a more thorough assessment is deferred until later. Obtaining a comprehensive health history or full physical examination is unnecessary until the acute distress has resolved. Brief questioning and a focused physical assessment should be done rapidly to help determine the cause of the distress and suggest treatment. Checking for allergies is important, but it is not appropriate to complete the entire admission database at this time. The initial respiratory assessment must be completed before any diagnostic tests or interventions can be ordered. DIF: Cognitive Level: Apply (application) REF: 482 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity;
14. The nurse knows to administer acarbose (Precose), an alpha-glucosidase inhibitor, at which time? a. 30 minutes before breakfast b. With the first bite of each main meal c. 30 minutes after breakfast d. Once daily at bedtime
ANS: B When an alpha-glucosidase inhibitor is taken with the first bite of a meal, excessive postprandial blood glucose elevation (a glucose spike) can be reduced or prevented. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 521 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
A patient is concerned about the adverse effects of the fibric acid derivative she is taking to lower her cholesterol level. Which is an adverse effect of this class of medication? a. Constipation b. Diarrhea c. Joint pain d. Dry mouth
ANS: B Fibric acid derivatives may cause nausea, vomiting, diarrhea, drowsiness, and dizziness. Other effects are listed in Table 27-8. The other options are not adverse effects of fibric acid derivatives.
The nurse will monitor for myopathy (muscle pain) when a patient is taking which class of antilipemic drugs? a. Niacin b. HMG-CoA reductase inhibitors c. Fibric acid derivatives d. Bile acid sequestrants
ANS: B Myopathy (muscle pain) is a clinically important adverse effect that may occur with HMG- CoA reductase inhibitors. It may progress to a serious condition known as rhabdomyolysis. Patients receiving statin therapy need to be advised to report any unexplained muscular pain or discomfort to their health care providers immediately. The other drugs and drug classes do not cause muscle pain or myopathy
When teaching a patient who is beginning antilipemic therapy about possible drug-food interactions, the nurse will discuss which food? a. Oatmeal b. Grapefruit juice c. Licorice d. Dairy products
ANS: B Taking HMG-CoA reductase inhibitors with grapefruit juice may cause complications. Components in grapefruit juice inactivate CYP3A4 in both the liver and intestines. This enzyme plays a key role in statin metabolism. The presence of grapefruit juice in the body may therefore result in sustained levels of unmetabolized statin drug, which increases the risk for major drug toxicity, possibly leading to rhabdomyolysis. The other foods do not interact with these drugs
When a staff member asks which of the following substances are actively secreted by the renal tubules, what is the nurse's best response? a. Sodium and chlorine b. Phosphate and calcium c. Hydrogen and potassium d. Bicarbonate and carbonic acid
ANS: C Principal cells reabsorb sodium and secrete potassium, and intercalated cells reabsorb potassium and bicarbonate and secrete hydrogen.
A patient who has recently started therapy on a statin drug asks the nurse how long it will take until he sees an effect on his serum cholesterol. Which statement would be the nurse's best response? a. "Blood levels return to normal within a week of beginning therapy." b. "It takes 6 to 8 weeks to see a change in cholesterol levels." c. "It takes at least 6 months to see a change in cholesterol levels." d. "You will need to take this medication for almost a year to see significant results."
ANS: B The maximum extent to which lipid levels are lowered may not occur until 6 to 8 weeks after the start of therapy. The other responses are incorrect
The insulin order reads, "Give 10 units of NPH insulin and 5 units of regular insulin, subcut, every morning before breakfast." Choose the proper syringe for this injection.
ANS: B The proper syringe for insulin injection is the insulin syringe, which is marked in units. The other syringes listed are not correct for use with insulin because they are not marked in units.
Antilipemic drug therapy is prescribed for a patient, and the nurse is providing instructions to the patient about the medication. Which instructions will the nurse include? (Select all that apply . ) a. Limit fluid intake to prevent fluid overload. b. Eat extra servings of raw vegetables and fruit. c. Report abnormal or unusual bleeding or yellow discoloration of the skin. d. Report the occurrence of muscle pain immediately. e. Drug interactions are rare with antilipemics. f. Take the drug 1 hour before or 2 hours after meals to maximize absorption
ANS: B, C, D Instructions need to include preventing constipation by encouraging a diet that is plentiful in raw vegetables, fruit, and bran. Forcing fluids (up to 3000 mL/day unless contraindicated) may also help to prevent constipation. Notify the prescriber if there are any new or troublesome symptoms, abnormal or unusual bleeding, yellow discoloration of the skin, or muscle pain. These drugs are highly protein bound, therefore they interact with many drugs. Taking these drugs with food may help to reduce gastrointestinal distress
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
ANS: B, D, E Hyperventilation is a risk factor for respiratory alkalosis. Respiratory alkalosis can cause perioral and digital paresthesias and pedal spasms. Pallor, cold skin, and tachycardia are characteristic of activation of the sympathetic nervous system, not respiratory alkalosis.
During diuretic therapy, the nurse monitors the fluid and electrolyte status of the patient. Which assessment findings are symptoms of hyponatremia? (Select all that apply.)" a Red, flushed skin b Lethargy c Decreased urination d Hypotension e Stomach cramps f Elevated temperature
ANS: B, D, E Hyponatremia is manifested by lethargy, hypotension, stomach cramps, vomiting, diarrhea, and seizures. The other options are symptoms of hypernatremia.
2. A patient with a history of angina will be started on ranolazine (Ranexa). The nurse is reviewing the patient's history and will note potential contraindications to this drug therapy if which condition is present? (Select all that apply.) a. Type 2 diabetes mellitus b. Prolonged QT interval on the electrocardiogram c. Heart failure d. Closed-angle glaucoma e. Decreased liver function
ANS: B, E Ranolazine is contraindicated in patients with pre-existing QT prolongation or hepatic impairment. The other options are not contraindications. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 370 TOP: NURSING PROCESS: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
A patient's complete blood count (CBC) shows a hemoglobin of 19 g/dL and a hematocrit of 54%. Which question should the nurse ask to determine possible causes of this finding? a. "Have you had a recent weight loss?" b. "Do you have any history of lung disease?" c. "Have you noticed any dark or bloody stools?" d. "What is your dietary intake of meats and protein?"
ANS: B. "Do you have any history of lung disease?" The hemoglobin and hematocrit results indicate polycythemia, which can be associated with chronic obstructive pulmonary disease. The other questions would be appropriate for patients who are anemic.
A patient with pancytopenia has a bone marrow aspiration from the left posterior iliac crest. Which action would be important for the nurse to take after the procedure? a. Elevate the head of the bed to 45 degrees. b. Have the patient lie on the left side for 1 hour. c. Apply a sterile 2-inch gauze dressing to the site. d. Use a half-inch sterile gauze to pack the wound.
ANS: B. Have the patient lie on the left side for 1 hour. To decrease the risk for bleeding, the patient should lie on the left side for 30 to 60 minutes. After a bone marrow biopsy, the wound is small and will not be packed with gauze. A pressure dressing is used to cover the aspiration site. There is no indication to elevate the patient's head.
The nurse is reviewing laboratory results and notes a patient's activated partial thromboplastin time (aPTT) level of 28 seconds. The nurse should notify the health care provider in anticipation of adjusting which medication? a. Aspirin b. Heparin c. Warfarin d. Erythropoietin
ANS: B. Heparin aPTT assesses intrinsic coagulation by measuring factors I, II, V, VIII, IX, X, XI, XII. aPTT is increased (prolonged) in heparin administration. aPTT is used to monitor whether heparin is at a therapeutic level (needs to be greater than the normal range of 25 to 35 sec). Prothrombin time (PT) and international normalized ratio (INR) are most commonly used to test for therapeutic levels of warfarin (Coumadin). Aspirin affects platelet function. Erythropoietin is used to stimulate red blood cell production.
Which information shown in the table below about a patient who has just arrived in the emergency department is most urgent for the nurse to communicate to the health care provider? Assessment • BP 110/68 • Pulse 98 beats/min • Brisk capillary refill • Multiple ecchymoses on arms Complete Blood Count • Hgb 10.6 g/dL • Hct 30% • WBC 5100/µL • Platelets 19,500/µL Patient History • Occasional aspirin use • Abdominal pain x 1 week • Large, dark stool this morning a. Heart rate b. Platelet count c. Abdominal pain d. White blood cell count
ANS: B. Platelet count The platelet count is severely decreased and places the patient at risk for spontaneous bleeding. The other information is also pertinent but not as indicative of the need for rapid treatment as the platelet count.
7. 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.
ANS: C Capillary refill is prolonged in PAD because of the slower and decreased blood flow to the periphery. The other listed clinical manifestations are consistent with chronic venous disease.
14. 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.
ANS: C Elastic compression stockings are applied with the legs elevated to reduce pressure in the lower legs. Walking is recommended to prevent recurrent varicosities. Sitting and standing are both risk factors for varicose veins and venous insufficiency. An aspirin a day is not adequate to prevent venous thrombosis and would not be recommended for the patient who had just had sclerotherapy.
12. 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 mostappropriate? 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."
ANS: C 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.
19. A 23-year-old patient tells the health care provider about experiencing cold, numb fingers when running during the winter and Raynaud's phenomenon is suspected. The nurse will anticipate teaching the patient about tests for a. hyperglycemia. b. hyperlipidemia. c. autoimmune disorders. d. coronary artery disease.
ANS: C Secondary Raynaud's phenomenon may occur in conjunction with autoimmune diseases such as rheumatoid arthritis. Patients should be screened for autoimmune disorders. Raynaud's phenomenon is not associated with hyperlipidemia, hyperglycemia, or coronary artery disease.
18. Which action by a nurse who is giving fondaparinux (Arixtra) to a patient with a lower leg venous thromboembolism (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.
ANS: C The air bubble is not ejected before giving fondaparinux to avoid loss of medication. The other actions by the nurse are appropriate.
31. 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
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.
41. The nurse is caring for a patient with idiopathic pulmonary arterial hypertension (IPAH). Which assessment information requires the most immediate action by the nurse? a. The O2 saturation is 90%. b. The blood pressure is 98/56 mm Hg. c. The epoprostenol (Flolan) infusion is disconnected. d. The international normalized ratio (INR) is prolonged.
ANS: C The half-life of this drug is 6 minutes, so the nurse will need to restart the infusion as soon as possible to prevent rapid clinical deterioration. The other data also indicate a need for ongoing monitoring or intervention, but the priority action is to reconnect the infusion.
44. Which action by the nurse will be most effective in decreasing the spread of pertussis in a community setting? a. Providing supportive care to patients diagnosed with pertussis b. Teaching family members about the need for careful hand washing c. Teaching patients about the need for adult pertussis immunizations d. Encouraging patients to complete the prescribed course of antibiotics
ANS: C The increased rate of pertussis in adults is thought to be caused by decreasing immunity after childhood immunization. Immunization is the most effective method of protecting communities from infectious diseases. Hand washing should be taught, but pertussis is spread by droplets and contact with secretions. Supportive care does not shorten the course of the disease or the risk for transmission. Taking antibiotics as prescribed does assist with decreased transmission, but patients are likely to have already transmitted the disease by the time the diagnosis is made.
On average the kidneys receive approximately _____ of the cardiac output. a. 10% to 14% b. 15% to 19% c. 20% to 25% d. 26% to 35%
ANS: C The kidney receives 20% to 25% of the cardiac output.
A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature of 102° F (38.9° C), and severe back pain. Which prescribed action 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.
ANS: C The patient's blood pressure indicates hypovolemia caused by blood loss and should be addressed immediately to improve perfusion to vital organs. The other actions are also appropriate and should be rapidly implemented, but improving perfusion is the priority for this patient. DIF: Cognitive Level: Analyze (analysis) REF: 629 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
23. 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
ANS: C The patient's presentation is consistent with dissecting thoracic aneurysm, which will require rapid intervention. The other patients do not need urgent interventions.
While planning care for a patient with urinary problems, the nurse recalls that the renin-angiotensin system will be activated by: a. Increased blood volume b. Elevated sodium concentrations c. Decreased blood pressure in the afferent arterioles d. Renal hypertension
ANS: C The renin-angiotensin system is activated by decreased blood pressure. Decreased blood pressure, not increased volume, leads to activation of the renin-angiotensin system. Decreased blood pressure, not elevated sodium, leads to activation of the renin-angiotensin system. Decreased blood pressure, not hypertension, leads to activation of the renin-angiotensin system.
A patient's T-tube is draining dark green fluid after gallbladder surgery. What action by the nurse is the most appropriate? a. Notify the patient's surgeon. b. Place the patient on bed rest. c. Document the color and amount of drainage. d. Irrigate the T-tube with sterile normal saline.
ANS: C A T-tube normally drains dark green to bright yellow drainage, so no action other than to document the amount and color of the drainage is needed. The other actions are not necessary
A 54-year-old male with a long history of smoking complains of excessive tiredness, shortness of breath, and overall ill feelings. Lab results reveal decreased pH, increased CO2, and normal bicarbonate ion. These findings help to confirm the diagnosis of: a. Respiratory alkalosis b. Metabolic acidosis c. Respiratory acidosis d. Metabolic alkalosis
ANS: C A decreased pH indicates acidosis. With increased CO2, it is respiratory acidosis. The decreased pH indicates acidosis, not alkalosis. It is acidosis, but the bicarbonate is normal, so it cannot be metabolic. The decreased pH indicates acidosis, not alkalosis.
A 26 year old recently underwent surgery and is now experiencing dyspnea, cough, fever, and leukocytosis. Tests reveal a collapsed lung caused by the removal of air from obstructed alveoli. Which term is used to document this condition? a. Compression atelectasis b. Bronchiectasis c. Absorption atelectasis d. Hypoventilation
ANS: C Absorption atelectasis results from removal of air from obstructed or hypoventilated alveoli or from inhalation of concentrated oxygen or anesthetic agents. Compression atelectasis is caused by external pressure exerted by tumor, fluid, or air in the pleural space or by abdominal distention pressing on a portion of lung. Bronchiectasis is a dilation of the bronchi, not atelectasis. Hypoventilation is inadequate alveolar ventilation of the lungs; it is not due to removal of air.
3. A patient has been diagnosed with angina and will be given a prescription for sublingual nitroglycerin tablets. When teaching the patient how to use sublingual nitroglycerin, the nurse will include which instruction? a. Take up to 5 doses at 15-minute intervals for an angina attack. b. If the tablet does not dissolve quickly, chew the tablet for maximal effect. c. If the chest pain is not relieved after one tablet, call 911 immediately. d. Wait 1 minute between doses of sublingual tablets, up to 3 doses.
ANS: C According to current guidelines, if the chest pain or discomfort is not relieved in 5 minutes, after 1 dose, the patient (or family member) must call 911 immediately. The patient may take one more tablet while awaiting emergency care and may take a third tablet 5 minutes later, but no more than a total of three tablets. The sublingual dose is placed under the tongue, and the patient needs to avoid swallowing until the tablet has dissolved. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 373 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Safe and Effective Care Environment: Management of Care
A 29-year-old woman with systemic lupus erythematosus has been prescribed 2 weeks of high-dose prednisone therapy. Which information about the prednisone is most important for the nurse to include? a. "Weigh yourself daily to monitor for weight gain caused by increased appetite." b. "A weight-bearing exercise program will help minimize the risk for osteoporosis." c. "The prednisone dose should be decreased gradually rather than stopped suddenly." d. "Call the health care provider if you experience mood alterations with the prednisone."
ANS: C Acute adrenal insufficiency may occur if exogenous corticosteroids are suddenly stopped. Mood alterations and weight gain are possible adverse effects of corticosteroid use, but these are not life-threatening effects. Osteoporosis occurs when patients take corticosteroids for longer periods. DIF: Cognitive Level: Analyze (analysis) REF: 1177 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
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
ANS: C Administration of subcutaneous medications is included in LPN/LVN education and scope of practice. Patient teaching, assessment, and developing the plan of care require RN level education and scope of practice. DIF: Cognitive Level: Apply (application) REF: 649 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
10. While assessing a patient who is taking a beta blocker for angina, the nurse knows to monitor for which adverse effect? a. Nervousness b. Hypertension c. Bradycardia d. Dry cough
ANS: C Adverse effects of beta blockers include bradycardia, hypotension, dizziness, lethargy, impotence, and several other effects, but not dry cough or nervousness. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 367 TOP: NURSING PROCESS: Evaluation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
The nurse is caring for a patient following an adrenalectomy. The highest priority in the immediate postoperative period is to a. protect the patient's skin. b. monitor for signs of infection. c. balance fluids and electrolytes. d. prevent emotional disturbances.
ANS: C After adrenalectomy, the patient is at risk for circulatory instability caused by fluctuating hormone levels, and the focus of care is to assess and maintain fluid and electrolyte status through the use of IV fluids and corticosteroids. The other goals are also important for the patient but are not as immediately life threatening as the circulatory collapse that can occur with fluid and electrolyte disturbances DIF: Cognitive Level: Analyze (analysis) REF: 1177 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
A patient has just arrived on the unit after a thyroidectomy. Which action should the nurse take first? a. Observe the dressing for bleeding. b. Check the blood pressure and pulse. c. Assess the patient's respiratory effort. d. Support the patient's head with pillows.
ANS: C Airway obstruction is a possible complication after thyroidectomy because of swelling or bleeding at the site or tetany. The priority nursing action is to assess the airway. The other actions are also part of the standard nursing care postthyroidectomy but are not as high of a priority DIF: Cognitive Level: Analyze (analysis) REF: 1168 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
11. Which statement by the staff indicates teaching was successful concerning aldosterone? Secretion of aldosterone results in: a. Decreased plasma osmolality b. Increased serum potassium levels c. Increased blood volume d. Localized edema
ANS: C Aldosterone promotes renal sodium and water reabsorption and excretion of potassium, thus, increasing blood volume. Aldosterone secretion would cause increased plasma osmolality. Secretion of aldosterone decreases potassium levels because it causes potassium excretion. Secretion of aldosterone does not promote the development of localized edema; it affects blood volume.
17. 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).
ANS: C Although the O2 saturation is adequate, the left shift in the oxyhemoglobin dissociation curve will decrease the amount of oxygen delivered to tissues, so high oxygen concentrations should be given. Bicarbonate would worsen the patients condition. A head-to-toe assessment and repeat ABGs may be implemented. However, the priority intervention is to give high-flow oxygen. DIF: Cognitive Level: Apply (application) REF: eTable 26-1 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
The nasogastric (NG) tube is removed on the second postoperative day, and the patient is placed on a clear liquid diet. Four hours later, the patient complains of sharp, cramping gas pains. What action by the nurse is the most appropriate? a. Reinsert the NG tube. b. Give the PRN IV opioid. c. Assist the patient to ambulate. d. Place the patient on NPO status.
ANS: C Ambulation encourages peristalsis and the passing of flatus, which will relieve the patient's discomfort. If distention persists, the patient may need to be placed on NPO status, but usually this is not necessary. Morphine administration will further decrease intestinal motility. Gas pains are usually caused by trapping of flatus in the colon, and reinsertion of the NG tube will not relieve the pains
The nurse notes in the patient's medication orders that the patient will be starting anticoagulant therapy. What is the primary goal of anticoagulant therapy? a. Stabilizing an existing thrombus b. Dissolving an existing thrombus c. Preventing thrombus formation d. Dilating the vessel around a clot
ANS: C Anticoagulants prevent thrombus formation but do not dissolve or stabilize an existing thrombus, nor do they dilate vessels around a clot. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 414 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
After a 22-year-old female patient with a pituitary adenoma has had a hypophysectomy, the nurse will teach about the need for a. sodium restriction to prevent fluid retention. b. insulin to maintain normal blood glucose levels. c. oral corticosteroids to replace endogenous cortisol. d. chemotherapy to prevent malignant tumor recurrence.
ANS: C Antidiuretic hormone (ADH), cortisol, and thyroid hormone replacement will be needed for life after hypophysectomy. Without the effects of adrenocorticotropic hormone (ACTH) and cortisol, the blood glucose and serum sodium will be low unless cortisol is replaced. An adenoma is a benign tumor, and chemotherapy will not be needed DIF: Cognitive Level: Apply (application) REF: 1158 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
A neurologist explains that arousal is mediated by the: a. cerebral cortex. b. medulla oblongata. c. reticular activating system. d. cingulate gyrus.
ANS: C Arousal is mediated by the reticular activating system, which regulates aspects of attention and information processing and maintains consciousness. The cerebral cortex affects movement. The medulla oblongata controls things such as hiccups and vomiting. The cingulate gyrus plays other roles in response. REF: p. 359
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 for left upper quadrant pain. c. Schedule immunization with the pneumococcal vaccine (e.g., Pneumovax). d. Avoid the use of acetaminophen (Tylenol) for at least 2 weeks prior to surgery.
ANS: C Asplenic patients are at high risk for infection with pneumococcal infections and immunization reduces this risk. There is no need to avoid acetaminophen use before surgery, but nonsteroidal antiinflammatory drugs (NSAIDs) may increase bleeding risk and should be avoided. The enlarged spleen may decrease respiratory depth, and the patient should be encouraged to take deep breaths. DIF: Cognitive Level: Apply (application) REF: 640 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
A compensatory alteration in the diameter of cerebral blood vessels in response to increased intracranial pressure is called: a. herniation. b. vasodilation. c. autoregulation. d. amyotrophy.
ANS: C Autoregulation is the compensatory alteration in the diameter of the intracranial blood vessels designed to maintain a constant blood flow during changes in cerebral perfusion pressure. Herniation is the downward protrusion of the brainstem. Vasodilation is an enlargement in vessel diameter and a part of autoregulation, but the vessels should not dilate in the presence of increased intracranial pressure. Amyotrophy is involved with the anterior horn cells of the spinal cord and not related to autoregulation. REF: p. 374
During a blood transfusion, the patient begins to have chills and back pain. What is the nurse's priority action?" a Observe for other symptoms. b Slow the infusion rate of the blood. c Discontinue the infusion immediately, and notify the prescriber. d Tell the patient that these symptoms are a normal reaction to the blood product.
ANS: C Because of the possibility of a transfusion reaction, the infusion should be discontinued immediately and the prescriber notified. The intravenous line should be kept patent with isotonic normal saline solution infusing at a slow rate, and the health care institution's protocol for transfusion reactions should always be followed. The other options are inappropriate actions.
A 52-yr-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, a. "I need to start eating more red meat and liver." b. "I will stop having a glass of wine with dinner." c. "I could choose nasal spray rather than injections of vitamin B12." d. "I will need to take a proton pump inhibitor such as omeprazole (Prilosec)."
ANS: C Because pernicious anemia prevents the absorption of vitamin B12, this patient requires injections or intranasal administration of cobalamin. Alcohol use does not cause cobalamin deficiency. Proton pump inhibitors decrease the absorption of vitamin B12. Eating more foods rich in vitamin B12 is not helpful because the lack of intrinsic factor prevents absorption of the vitamin. DIF: Cognitive Level: Apply (application) REF: 612 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
A patient is transferred from the postanesthesia care unit (PACU) to the clinical unit. Which action by the nurse on the clinical unit should be performed first? a. Assess the patient's pain. b. Orient the patient to the unit. c. Take the patient's vital signs. d. Read the postoperative orders.
ANS: C Because the priority concerns after surgery are airway, breathing, and circulation, the vital signs are assessed first. The other actions should take place after the vital signs are obtained and compared with the vital signs before transfer
Which information about a patient who has been receiving thrombolytic therapy for an acute myocardial infarction is most important for the nurse to communicate to the health care provider? a. An increase in troponin levels from baseline b. A large bruise at the patient's IV insertion site c. No change in the patient's reported level of chest pain d. A decrease in ST-segment elevation on the electrocardiogram
ANS: C Continued chest pain suggests that the thrombolytic therapy is not effective and that other interventions such as percutaneous coronary intervention may be needed. Bruising is a possible side effect of thrombolytic therapy, but it is not an indication that therapy should be discontinued. The decrease of the ST-segment elevation indicates that thrombolysis is occurring and perfusion is returning to the injured myocardium. An increase in troponin levels is expected with reperfusion and is related to the washout of cardiac biomarkers into the circulation as the blocked vessel is opened. DIF: Cognitive Level: Analyze (analysis)
15. Which of the following patients is the most at risk for developing hypernatremia? A patient with: a. Vomiting b. Diuretic use c. Dehydration d. Hypoaldosteronism
ANS: C Dehydration leads to hypernatremia because an increase in sodium occurs with a net loss in water. Vomiting leads to hyponatremia. Diuretic use would lead to sodium loss. Hypoaldosteronism leads to hyponatremia.
During an infusion of albumin, the nurse monitors the patient closely for the development of which adverse effect? a Hypernatremia b Fluid volume deficit c Fluid volume overload d Transfusion reaction
ANS: C During the infusion of albumin, the development of fluid volume overload must be monitored by the nurse, especially in those at risk for heart failure. The other options are incorrect.
Individuals with a recent diagnosis of emphysema should be assessed for which most common presenting factor? a. A productive cough b. Cyanosis c. Dyspnea d. Cor pulmonale
ANS: C Dyspnea, not a productive cough, is the most common presenting factor of emphysema. Neither cyanosis nor cor pulmonale is a common presenting factor of emphysema.
A patient has been instructed to take one enteric-coated low-dose aspirin a day as part of therapy to prevent strokes. The nurse will provide which instruction when providing patient teaching about this medication? a. Aspirin needs to be taken on an empty stomach to ensure maximal absorption. b. Low-dose aspirin therapy rarely causes problems with bleeding. c. Take the medication with 6 to 8 ounces of water and with food. d. Coated tablets may be crushed if necessary for easier swallowing.
ANS: C Enteric-coated aspirin is best taken with 6 to 8 ounces of water and with food to help decrease gastrointestinal upset. Enteric-coated tablets should not be crushed. Risk for bleeding increases with aspirin therapy, even at low doses. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 431 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
Which instruction will the nurse plan to include in discharge teaching for a 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.
ANS: C Exposure to crowds increases the patient's risk for infection, the most common cause of sickle cell crisis. There is no restriction on caffeine use. Iron supplementation is generally not recommended. A high-fluid intake is recommended. DIF: Cognitive Level: Apply (application) REF: 617 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
7. 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
ANS: C Fine crackles are likely to be heard in the early phase of heart failure. Fine crackles are discontinuous, highpitched sounds of short duration heard on inspiration. Rhonchi are continuous rumbling, snoring, or rattling sounds mainly on expiration. Course crackles are a series of long-duration, discontinuous, low-pitched sounds during inspiration. Wheezes are continuous high-pitched musical sounds on inspiration and expiration. DIF: Cognitive Level: Apply (application) REF: 489 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
9. 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.
ANS: C For PFT, the patient should inhale deeply and exhale as long, hard, and fast as possible. The other actions are not needed with PFT. The administration of inhaled bronchodilators should be avoided 6 hours before the procedure. DIF: Cognitive Level: Apply (application) REF: 493-495 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
A patient is receiving an infusion of fresh frozen plasma. Based on this order, the nurse interprets that this patient has which condition?" a Hypovolemic shock b Anemia c Coagulation disorder d Previous transfusion reaction
ANS: C Fresh frozen plasma is used as an adjunct to massive blood transfusion in the treatment of patients with underlying coagulation disorders. The other options are not indications for fresh frozen plasma.
Heparin is ordered for a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI). What is the purpose of the heparin? a. Heparin enhances platelet aggregation at the plaque site. b. Heparin decreases the size of the coronary artery plaque. c. Heparin prevents the development of new clots in the coronary arteries. d. Heparin dissolves clots that are blocking blood flow in the coronary arteries.
ANS: C Heparin helps prevent the conversion of fibrinogen to fibrin and decreases coronary artery thrombosis. It does not change coronary artery plaque, dissolve already formed clots, or enhance platelet aggregation. DIF: Cognitive Level: Understand (comprehension)
A 60-year-old female is diagnosed with hyperkalemia. Which assessment finding should the nurse expect to observe? a. Weak pulse b. Excessive thirst c. Oliguria d. Constipation
ANS: C Hyperkalemia is manifested by oliguria. Hypokalemia is manifested by a weak pulse; it is not caused by hyperkalemia. Hypokalemia is manifested by excessive thirst. Diarrhea, not constipation, is a manifestation of hyperkalemia.
Airway hyperresponsiveness in asthma is related to: a. increased sympathetic nervous system response. b. the release of stress hormones. c. exposure to an allergen causing mast cell degranulation. d. hereditary decrease in IgE responsiveness.
ANS: C Hyperresponsiveness is due to mast cell degranulation. An increased sympathetic response would lead to bronchiolar dilation. Hyperresponsiveness is not due to release of stress hormones. Heredity is associated with asthma, but the problem is the mast cells.
Bone fractures are a risk factor in chronic renal failure because: a. calcium is lost in the urine. b. osteoblast activity is excessive. c. the kidneys fail to activate vitamin D. d. autoantibodies to calcium molecules develop.
ANS: C Hypocalcemia is accelerated by impaired renal synthesis of 1,25 - dihydroxy-vitamin D3. The combined effect of vitamin D deficiency can result in renal osteodystrophies with increased risk for fractures. Calcium is not lost in the urine. Osteoblast activity is not accelerated. Antibodies do not develop. REF: pp. 765-766
What physiology is present at the base of the lungs? a. Arterial perfusion pressure is less than that of alveolar gas pressure. b. Arterial perfusion pressure and alveolar gas pressure are less than they are at the apex. c. Arterial perfusion pressure exceeds alveolar gas pressure. d. Arterial perfusion and alveolar gas pressure are equal
ANS: C In the base of the lungs, both arterial and venous pressures are greater than alveolar pressure, and blood flow is not affected by alveolar pressure. It is in the apex that alveolar pressure exceeds pulmonary arterial and venous pressures. In zone II, also part of the apex, alveolar pressure is greater than venous pressure, but not arterial pressure
A nurse is reviewing the results of an arterial blood gas (ABG) and finds reduced oxygenation of arterial blood. What term should the nurse use to describe this condition? a. Ischemia b. Hypoxia c. Hypoxemia d. Hypocapnia
ANS: C Hypoxemia is a reduction of oxygen in arterial blood. Ischemia is a lack of blood supply to tissues. Hypoxia is reduced oxygen in tissues. Hypocapnia is decreased CO2.
8. A 70-year-old male with chronic renal failure presents with edema. Which of the following is the most likely cause of this condition? a. Increased capillary oncotic pressure b. Decreased interstitial oncotic pressure c. Increased capillary hydrostatic pressure d. Increased interstitial hydrostatic pressure
ANS: C Increased capillary hydrostatic pressure would facilitate increased movement from the capillary to the interstitial space, leading to edema. Increased capillary (plasma) oncotic pressure attracts water from the interstitial space back into the capillary. Decreased interstitial oncotic pressure would keep water in the capillary. Increased interstitial hydrostatic pressure would facilitate increased water movement from the interstitial space into the capillary.
During inspiration, muscular contraction of the diaphragm causes air to move into the lung. The mechanism that drives air movement during inspiration results in a(n): a. decrease in intra-alveolar pressure and shortening of the rib cage. b. decrease in the size of the thorax and alveolar expansion. c. increase in the size of the thorax and decrease in intrapleural pressure. d. increase in atmospheric pressure and intrapleural pressure.
ANS: C Inspiration occurs due to an increase in the size of the thorax and a decrease in intrapleural pressure, thus creating a negative pressure that draws air into the lungs. The rib cage lengthens, not shortens. The size of the thorax increases, not decreases. Intrapleural pressure decreases, not increases.
A diabetic patient is brought into the emergency department unresponsive. The arterial pH is 7.28. Besides the blood pH, which clinical manifestation is seen in uncontrolled diabetes mellitus and ketoacidosis? a. Oral temperature of 38.9° Celsius b. Severe orthostatic hypotension c. Increased rate and depth of respiration d. Extremity tremors followed by seizure activity
ANS: C Ketoacidosis decreases the pH of the blood, stimulating the respiratory control area of the brain to buffer the effects of the increasing acidosis. The rate and depth of respirations are increased (Kussmaul's respirations) to excrete more acids by exhalation.
10. 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.
ANS: C Listening only during inspiration indicates the student needs a review of respiratory assessment skills. At each placement of the stethoscope, listen to at least one cycle of inspiration and expiration. During chest auscultation, instruct the patient to breathe slowly and a little deeper than normal through the mouth. Auscultation should proceed from the lung apices to the bases, comparing opposite areas of the chest, unless the patient is in respiratory distress or will tire easily. If so, start at the bases (see Fig. 26-7). Place the stethoscope over lung tissue, not over bony prominences. DIF: Cognitive Level: Apply (application) REF: 486 TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
Which organ system should the nurse monitor when the patient has long-term potassium deficits? a. Central nervous system (CNS) b. Lungs c. Kidneys d. Gastrointestinal tract
ANS: C Long-term potassium deficits lasting more than 1 month may damage renal tissue, with interstitial fibrosis and tubular atrophy. Long-term potassium deficits damage the kidneys, not the CNS. Long-term potassium deficits damage the kidneys, not the lungs. Long-term potassium deficits damage the kidneys, not the gastrointestinal tract.
Which information will the nurse teach a 48-year-old patient who has been newly diagnosed with Graves' disease? a. Exercise is contraindicated to avoid increasing metabolic rate. b. Restriction of iodine intake is needed to reduce thyroid activity. c. Antithyroid medications may take several months for full effect. d. Surgery will eventually be required to remove the thyroid gland.
ANS: C Medications used to block the synthesis of thyroid hormones may take 2 to 3 months before the full effect is seen. Large doses of iodine are used to inhibit the synthesis of thyroid hormones. Exercise using large muscle groups is encouraged to decrease the irritability and hyperactivity associated with high levels of thyroid hormones. Radioactive iodine is the most common treatment for Graves' disease although surgery may be used DIF: Cognitive Level: Apply (application) REF: 1165 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
The nurse is caring for a patient the first postoperative day following a laparotomy for a small bowel obstruction. The nurse notices new bright-red drainage about 5 cm in diameter on the dressing. Which action should the nurse take first? a. Reinforce the dressing. b. Apply an abdominal binder. c. Take the patient's vital signs. d. Recheck the dressing in 1 hour for increased drainage.
ANS: C New bright-red drainage may indicate hemorrhage, and the nurse should initially assess the patient's vital signs for tachycardia and hypotension. The surgeon should then be notified of the drainage and the vital signs. The dressing may be changed or reinforced, based on the surgeon's orders or institutional policy. The nurse should not wait an hour to recheck the dressing
An elderly Chinese woman is interested in biologically based therapies to relieve osteoarthritis pain (OA). You are preparing a plan of care for her OA. Options most conducive to her expressed wishes may include a. Pilates, breathing exercises, and aloe vera. b. guided imagery, relaxation breathing, and meditation. c. herbs, vitamins, and tai chi. d. alternating ice and heat to relieve pain and inflammation.
ANS: C Nonpharmacologic strategies encompass a wide variety of nondrug treatments that may contribute to comfort and pain relief. These include the body-based (physical) modalities, such as massage, acupuncture, and application of heat and cold, and the mind-body methods, such as guided imagery, relaxation breathing, and meditation. There are also biologically based therapies which involve the use of herbs and vitamins, and energy therapies such as reiki and tai chi. Pilates, breathing exercises, aloe vera, guided imagery, relaxation breathing, meditation, and alternating ice and heat are multimodal therapies for pain management. They are not exclusively biologically based, which involves the use of herbs and vitamins.
The patient generally acquires nosocomial pneumonia: a. at day care centers. b. on airplanes. c. during hospitalization. d. in the winter season.
ANS: C Nosocomial infections are acquired in the hospital. Nosocomial infections are not associated with day care centers or airplanes and may happen in any season.
A postoperative patient has a nursing diagnosis of ineffective airway clearance. The nurse determines that interventions for this nursing diagnosis have been successful if which is observed? a. Patient drinks 2 to 3 L of fluid in 24 hours. b. Patient uses the spirometer 10 times every hour. c. Patient's breath sounds are clear to auscultation. d. Patient's temperature is less than 100.4° F orally.
ANS: C One characteristic of ineffective airway clearance is the presence of adventitious breath sounds such as rhonchi or crackles, so clear breath sounds are an indication of resolution of the problem. Spirometer use and increased fluid intake are interventions for ineffective airway clearance but may not improve breath sounds in all patients. Elevated temperature may occur with atelectasis, but a normal or near-normal temperature does not always indicate resolution of respiratory problems
A patient who is severely anemic also has acute heart failure with severe edema due to fluid overload. The prescriber wants to raise the patient's hemoglobin and hematocrit levels. The nurse anticipates that the patient will receive which blood product?" a Fresh frozen plasma b Albumin c Packed red blood cells (PRBCs) d Whole blood
ANS: C PRBCs are given to increase the oxygen-carrying capacity in a patient with anemia, in a patient with substantial hemoglobin deficits, and in a patient who has lost up to 25% of total blood volume. A patient with a coagulation disorder or a clotting-factor deficiency would receive fresh frozen plasma; a patient who has lost a massive amount of blood would receive whole blood.
When reviewing the health history of a patient, the nurse will note that a potential contraindication to potassium supplements exists if the patient has which problem?" a Burns b Diarrhea c Renal disease d Cardiac tachydysrhythmias
ANS: C Potassium supplements are contraindicated in the presence of renal disease; the other conditions listed may be treated with potassium supplements.
Diltiazem (Cardizem) is ordered for a patient with newly diagnosed Prinzmetal's (variant) angina. When teaching the patient, the nurse will include the information that diltiazem will a. reduce heart palpitations. b. prevent coronary artery plaque. c. decrease coronary artery spasms. d. increase contractile force of the heart.
ANS: C Prinzmetal's angina is caused by coronary artery spasm. Calcium channel blockers (e.g., diltiazem, amlodipine [Norvasc]) are a first-line therapy for this type of angina. Lipid-lowering drugs help reduce atherosclerosis (i.e., plaque formation), and -adrenergic blockers decrease sympathetic stimulation of the heart (i.e., palpitations). Medications or activities that increase myocardial contractility will increase the incidence of angina by increasing O2 demand. DIF: Cognitive Level: Apply (application)
A patient is receiving cidofovir (Vistide) as part of treatment for a viral infection, and the nurse is preparing to administer probenecid, which is also ordered. Which is the rationale for administering probenecid along with the cidofovir treatment? a. Probenecid has a synergistic effect when given with cidofovir, thus making the antiviral medication more effective. b. The probenecid also prevents replication of the virus. c. Concurrent drug therapy with probenecid reduces the nephrotoxicity of the cidofovir. d. The probenecid reduces the adverse gastrointestinal effects of the cidofovir.
ANS: C Probenecid is recommended as concurrent drug therapy with cidofovir to help alleviate the nephrotoxic effects of probenecid. The other options are incorrect.
A patient has received an overdose of intravenous heparin, and is showing signs of excessive bleeding. Which substance is the antidote for heparin overdose? a. Vitamin E b. Vitamin K c. Protamine sulfate d. Potassium chloride
ANS: C Protamine sulfate is a specific heparin antidote and forms a complex with heparin, completely reversing its anticoagulant properties. Vitamin K is the antidote for warfarin (Coumadin) overdose. The other options are incorrect. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 416 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
A 37-year-old patient is being admitted with a diagnosis of Cushing syndrome. Which findings will the nurse expect during the assessment? a. Chronically low blood pressure b. Bronzed appearance of the skin c. Purplish streaks on the abdomen d. Decreased axillary and pubic hair
ANS: C Purplish-red striae on the abdomen are a common clinical manifestation of Cushing syndrome. Hypotension and bronzed-appearing skin are manifestations of Addison's disease. Decreased axillary and pubic hair occur with androgen deficiency DIF: Cognitive Level: Understand (comprehension) REF: 1175 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
Which finding would support the diagnosis of respiratory acidosis? a. Vomiting b. Hyperventilation c. Pneumonia d. An increase in noncarbonic acids
ANS: C Respiratory acidosis occurs with hypoventilation, and pneumonia leads to hypoventilation. Vomiting leads to loss of acids and then to alkalosis. Hyperventilation leads to respiratory alkalosis, not acidosis. Metabolic acidosis is caused by an increase in noncarbonic acids.
A patient has memory loss of events that occurred before a head injury. What cognitive disorder does the nurse suspect the patient is experiencing? a. Selective memory deficit b. Anterograde amnesia c. Retrograde amnesia d. Executive memory deficit
ANS: C Retrograde amnesia is manifested by loss of past personal history memories or past factual memories. In selective memory deficit, the person reports inability to focus attention and has failure to perceive objects and other stimuli. Anterograde amnesia is a loss of the ability to form new memories. Executive memory deficit involves the failure to stay alert and oriented to stimuli. REF: p. 365
Which finding about a patient with polycythemia vera is most important for the nurse to report to the health care provider? a. Hematocrit 55% c. Calf swelling and pain b. Presence of plethora d. Platelet count 450,000/L
ANS: C 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. DIF: Cognitive Level: Analyze (analysis) REF: 620 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
A 70-year-old patient is being closely monitored in the neurological critical care unit for a severe closed head injury. After 48 hours, signs of deterioration occur: pupils are small and sluggish, pulse pressure is widening, and heart rate is bradycardic. These clinical findings are evidence of what stage of intracranial hypertension? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4
ANS: C Stage 3 is characterized by decreasing levels of arousal or central neurogenic hyperventilation, widened pulse pressure, bradycardia, and pupils that become small and sluggish. Stage 1 is characterized by an ICP that may not change because of the effective compensatory mechanisms, and there may be few symptoms. Stage 2 is characterized by subtle and transient symptoms, including episodes of confusion, restlessness, drowsiness, and slight pupillary and breathing changes. Stage 4 is characterized by cessation of cerebral blood flow. REF: p. 374
The nurse is describing the receptors in the lung that decrease ventilatory rate and volume when stimulated. Which receptors is the nurse discussing? a. Carbon dioxide receptors b. Baroreceptors c. Stretch receptors d. Chemoreceptors
ANS: C Stretch receptors, not carbon dioxide receptors, decrease ventilatory rate and volume when stimulated. Baroreceptors regulate blood pressure. Chemoreceptors increase the rate and depth of respiration.
Which information obtained by the nurse in the endocrine clinic about a patient who has been taking prednisone (Deltasone) 40 mg daily for 3 weeks is most important to report to the health care provider? a. Patient's blood pressure is 148/94 mm Hg. b. Patient has bilateral 2+ pitting ankle edema. c. Patient stopped taking the medication 2 days ago. d. Patient has not been taking the prescribed vitamin D.
ANS: C Sudden cessation of corticosteroids after taking the medication for a week or more can lead to adrenal insufficiency, with problems such as severe hypotension and hypoglycemia. The patient will need immediate evaluation by the health care provider to prevent and/or treat adrenal insufficiency. The other information will also be reported, but does not require rapid treatment DIF: Cognitive Level: Analyze (analysis) REF: 1176 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
Surfactant facilitates alveolar distention and ventilation by: a. decreasing thoracic compliance. b. attracting water to the alveolar surface. c. decreasing surface tension in alveoli. d. increasing diffusion in alveoli.
ANS: C Surfactant decreases surface tension in alveoli, allowing the lungs to inflate. Surfactant does not decrease thoracic compliance, attract water, or increase diffusion.
A patient with hyperlipidemia has a new order for colesevelam (Welchol). Which nursing action is appropriate when scheduling this medication? a. Administer the medication at the patient's usual bedtime. b. Have the patient take the colesevelam 1 hour before breakfast. c. Give the patient's other medications 2 hours after colesevelam. d. Have the patient take the dose at the same time as the prescribed aspirin.
ANS: C The bile acid sequestrants interfere with the absorption of many other drugs and giving other medications at the same time should be avoided. Taking an aspirin concurrently with the colesevelam may increase the incidence of gastrointestinal side effects such as heartburn. For maximum effect, colesevelam should be administered with meals. DIF: Cognitive Level: Apply (application)
During the administration of the thrombolytic agent to a patient with an acute myocardial infarction, the nurse should stop the drug infusion if the patient experiences a. bleeding from the gums. b. increase in blood pressure. c. a decrease in level of consciousness. d. a nonsustained episode of ventricular tachycardia.
ANS: C The change in level of consciousness indicates that the patient may be experiencing intracranial bleeding, a possible complication of thrombolytic therapy. Some bleeding of the gums is an expected side effect of the therapy but not an indication to stop infusion of the thrombolytic medication. A decrease in blood pressure could indicate internal bleeding. A nonsustained episode of ventricular tachycardia is a common reperfusion dysrhythmia and may indicate that the therapy is effective. DIF: Cognitive Level: Apply (application)
The nurse obtains the following data when assessing a patient who experienced an ST-segment-elevation myocardial infarction (STEMI) 2 days previously. Which information is most important to report to the health care provider? a. The troponin level is elevated. b. The patient denies having a heart attack. c. Bilateral crackles in the mid-lower lobes. d. Occasional premature atrial contractions (PACs).
ANS: C The crackles indicate that the patient may be developing heart failure, a possible complication of myocardial infarction (MI). The health care provider may need to order medications such as diuretics or angiotensin-converting enzyme inhibitors for the patient. Elevation in troponin level at this time is expected. PACs are not life-threatening dysrhythmias. Denial is a common response in the immediate period after the MI. DIF: Cognitive Level: Analyze (analysis)
Which assessment finding of a 42-year-old patient who had a bilateral adrenalectomy requires the most rapid action by the nurse? a. The blood glucose is 176 mg/dL. b. The lungs have bibasilar crackles. c. The blood pressure (BP) is 88/50 mm Hg. d. The patient reports 5/10 incisional pain.
ANS: C The decreased BP indicates possible adrenal insufficiency. The nurse should immediately notify the health care provider so that corticosteroid medications can be administered. The nurse should also address the elevated glucose, incisional pain, and crackles with appropriate collaborative or nursing actions, but prevention and treatment of acute adrenal insufficiency is the priority after adrenalectomy. DIF: Cognitive Level: Analyze (analysis) REF: 1176 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
8. 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.
ANS: C 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. DIF: Cognitive Level: Apply (application) REF: 480 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
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 11 g/dL.
ANS: C The frequent transfusions used to treat thalassemia major lead to iron toxicity in patients unless iron chelation therapy is consistently used. Iron supplementation is avoided in patients with thalassemia. There is no need to avoid intramuscular injections. The goal for patients with thalassemia major is to maintain a hemoglobin of 10 g/dL or greater. DIF: Cognitive Level: Apply (application) REF: 611 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
After entering a room of chemical fog, a 20-year-old male cannot stop coughing. Which of the following structures are primarily responsible for his response? a. Upper respiratory tract mucosa b. Irritant receptors in the trachea and large airways c. Irritant receptors in the nostrils d. Upper respiratory nasal hairs and turbinates
ANS: C The irritant receptors in the nostrils are responsible for coughing, not those found in the upper respiratory tract mucosa or in the trachea. The cough is not related to stimulation of upper respiratory nasal hairs or the turbinates.
Airway obstruction contributing to increased airflow resistance and hypoventilation in asthma is caused by: a. type II alveolar cell injury and decreased surfactant. b. alveolar fibrosis and pulmonary edema. c. mucous secretion, bronchoconstriction, and airway edema. d. collapse of the cartilaginous rings in the bronchi.
ANS: C The mediators of asthma cause vasodilation, increased capillary permeability, mucosal edema, bronchial smooth muscle contraction (bronchospasm), and mucous secretion from mucosal goblet cells with narrowing of the airways and obstruction to airflow. Acute respiratory distress syndrome involves type II injury. Alveolar fibrosis with pulmonary edema is not associated with asthma. Asthma is not associated with collapse of bronchiolar rings.
What is the most likely cause of chronic bronchitis in a 25 year old? a. Chronic asthma b. Air pollution c. Cigarette smoke d. Recurrent pneumonias
ANS: C The most likely cause of chronic bronchitis is cigarette smoke. Chronic bronchitis in such a patient is not commonly associated with chronic asthma. Air pollution and recurrent infections may contribute, but smoking is the most common cause.
1. When the nurse is administering topical nitroglycerin ointment, which technique is correct? a. Apply the ointment on the skin on the forearm. b. Apply the ointment only in the case of a mild angina episode. c. Remove the old ointment before new ointment is applied. d. Massage the ointment gently into the skin, and then cover the area with plastic wrap.
ANS: C The old ointment should be removed before a new dose is applied. The ointment should be applied to clean, dry, hairless skin of the upper arms or body, not below the elbows or below the knees. The ointment is not massaged or spread on the skin, and it is not indicated for the treatment of acute angina. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 372 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Safe and Effective Care Environment: Management of Care
After reviewing information shown in the accompanying figure from the medical records of a 43-yr-old patient, which risk factor modification for coronary artery disease should the nurse include in patient teaching? a. Importance of daily physical activity b. Effect of weight loss on blood pressure c. Dietary changes to improve lipid levels d. Cardiac risk associated with previous tobacco use
ANS: C The patient has an elevated low-density lipoprotein cholesterol and low high-density lipoprotein cholesterol, which will increase the risk of coronary artery disease. Although the blood pressure is in the prehypertensive range, the patient's waist circumference and body mass index indicate an appropriate body weight. The risk for coronary artery disease a year after quitting smoking is the same as a nonsmoker. The patient's occupation indicates that daily activity is at the levels suggested by national guidelines. DIF: Cognitive Level: Analyze (analysis)
Which electrocardiographic (ECG) change is most important for the nurse to report to the health care provider when caring for a patient with chest pain? a. Inverted P wave c. ST-segment elevation b. Sinus tachycardia d. First-degree atrioventricular block
ANS: C The patient is likely to be experiencing an ST-segment-elevation myocardial infarction. Immediate therapy with percutaneous coronary intervention or thrombolytic medication is indicated to minimize myocardial damage. The other ECG changes may also suggest a need for therapy but not as rapidly. DIF: Cognitive Level: Analyze (analysis)
An experienced nurse orients a new nurse to the postanesthesia care unit (PACU). Which action by the new nurse, if observed by the experienced nurse, indicates that the orientation was successful? a. The new nurse assists a nauseated patient to a supine position. b. The new nurse positions an unconscious patient supine with the head elevated. c. The new nurse turns an unconscious patient to the side upon arrival in the PACU. d. The new nurse places a patient in the Trendelenburg position when the blood pressure drops.
ANS: C The patient should initially be positioned in the lateral "recovery" position to keep the airway open and avoid aspiration. The Trendelenburg position is avoided because it increases the work of breathing. The patient is placed supine with the head elevated after regaining consciousness
In preparation for discharge, the nurse teaches a patient with chronic stable angina how to use the prescribed short-acting and long-acting nitrates. Which patient statement indicates that the teaching has been effective? a. "I will check my pulse rate before I take any nitroglycerin tablets." b. "I will put the nitroglycerin patch on as soon as I get any chest pain." c. "I will stop what I am doing and sit down before I put the nitroglycerin under my tongue." d. "I will be sure to remove the nitroglycerin patch before taking any sublingual nitroglycerin."
ANS: C The patient should sit down before taking the nitroglycerin to decrease cardiac workload and prevent orthostatic hypotension. Transdermal nitrates are used prophylactically rather than to treat acute pain and can be used concurrently with sublingual nitroglycerin. Although the nurse should check blood pressure before giving nitroglycerin, patients do not need to check the pulse rate before taking nitrates. DIF: Cognitive Level: Apply (application)
When caring for a patient with acute coronary syndrome who has returned to the coronary care unit after having angioplasty with stent placement, the nurse obtains the following assessment data. Which data indicate the need for immediate action by the nurse? a. Heart rate 102 beats/min c. Report of severe chest pain b. Pedal pulses 1+ bilaterally d. Blood pressure 103/54 mm Hg
ANS: C The patient's chest pain indicates that restenosis of the coronary artery may be occurring and requires immediate actions, such as administration of oxygen and nitroglycerin, by the nurse. The other information indicates a need for ongoing assessments by the nurse. DIF: Cognitive Level: Analyze (analysis)
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. Give the PRN diphenhydramine . b. Send a urine specimen to the laboratory. c. Administer PRN acetaminophen (Tylenol). d. Draw blood for a new type and crossmatch.
ANS: C The patient's clinical manifestations are consistent with a febrile, nonhemolytic transfusion reaction. The transfusion should be stopped and antipyretics administered for the fever as ordered. A urine specimen is needed if an acute hemolytic reaction is suspected. Diphenhydramine is used for allergic reactions. This type of reaction does not indicate incorrect crossmatching. DIF: Cognitive Level: Apply (application) REF: 650 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which action is most important for the nurse to take? a. Avoid other venipunctures. b. Apply dressings to the sites. c. Notify the health care provider. d. Give prescribed proton-pump inhibitors.
ANS: C The patient's new onset of bleeding and diagnosis of sepsis suggest that disseminated intravascular coagulation (DIC) may have developed, which will require collaborative actions such as diagnostic testing, blood product administration, and heparin administration. The other actions are also appropriate, but the most important action should be to notify the health care provider so that DIC treatment can be initiated rapidly. DIF: Cognitive Level: Analyze (analysis) REF: 629 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
After obtaining the information shown in the accompanying figure regarding a patient with Addison's disease, which prescribed action will the nurse take first? Assessment * Complains of fatigue * Bronze colored skin * Poor skin turgor Vital Signs * BP 76/40 mm Hg * Heart rate 126 b/m * RR 24 * SpO2 94% Lab Data * Sodium 1123 mEq/L * Potassium 5.1 mEq/L * Glucose 62 mg/dL a. Give 4 oz of fruit juice orally. b. Recheck the blood glucose level. c. Infuse 5% dextrose and 0.9% saline. d. Administer O2 therapy as needed.
ANS: C The patient's poor skin turgor, hypotension, and hyponatremia indicate an Addisonian crisis. Immediate correction of the hypovolemia and hyponatremia is needed. The other actions may also be needed but are not the initial action for the patient. DIF: Cognitive Level: Analyze (analysis) REF: 1179 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
A patient recovering from a myocardial infarction (MI) develops chest pain on day 3 that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take as focused follow-up on this symptom? a. Assess the feet for pedal edema. b. Palpate the radial pulses bilaterally. c. Auscultate for a pericardial friction rub. d. Check the heart monitor for dysrhythmias.
ANS: C The patient's symptoms are consistent with the development of pericarditis, a possible complication of MI. The other assessments listed are not consistent with the description of the patient's symptoms. DIF: Cognitive Level: Apply (application)
A patient develops carpopedal spasms and tingling of the lips following a parathyroidectomy. Which action should the nurse take first? a. Administer the ordered muscle relaxant. b. Give the ordered oral calcium supplement. c. Have the patient rebreathe from a paper bag. d. Start the PRN oxygen at 2 L/min per cannula.
ANS: C The patient's symptoms suggest mild hypocalcemia. The symptoms of hypocalcemia will be temporarily reduced by having the patient breathe into a paper bag, which will raise the PaCO2 and create a more acidic pH. The muscle relaxant will have no impact on the ionized calcium level. Although severe hypocalcemia can cause laryngeal stridor, there is no indication that this patient is experiencing laryngeal stridor or needs oxygen. Calcium supplements will be given to normalize calcium levels quickly, but oral supplements will take time to be absorbed DIF: Cognitive Level: Apply (application) REF: 1174 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
Which assessment finding for a 33-year-old female patient admitted with Graves' disease requires the most rapid intervention by the nurse? a. Bilateral exophthalmos b. Heart rate 136 beats/minute c. Temperature 103.8° F (40.4° C) d. Blood pressure 166/100 mm Hg
ANS: C The patient's temperature indicates that the patient may have thyrotoxic crisis and that interventions to lower the temperature are needed immediately. The other findings also require intervention but do not indicate potentially life-threatening complications DIF: Cognitive Level: Analyze (analysis) REF: 1165 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
A patient who has chest pain is admitted to the emergency department (ED), and all of the following are ordered. Which one should the nurse arrange to be completed first? a. Chest x-ray c. Electrocardiogram (ECG) b. Troponin level d. Insertion of a peripheral IV
ANS: C The priority for the patient is to determine whether an acute myocardial infarction (AMI) is occurring so that the appropriate therapy can begin as quickly as possible. ECG changes occur very rapidly after coronary artery occlusion, and an ECG should be obtained as soon as possible. Troponin levels will increase after about 3 hours. Data from the chest x-ray may impact the patient's care but are not helpful in determining whether the patient is experiencing a myocardial infarction. Peripheral access will be needed but not before the ECG. DIF: Cognitive Level: Analyze (analysis)
A patient with diabetes mellitus and chronic stable angina has a new order for captopril . The nurse should teach the patient that the primary purpose of captopril is to a. decrease the heart rate. c. prevent changes in heart muscle. b. control blood glucose levels. d. reduce the frequency of chest pain.
ANS: C The purpose for angiotensin-converting enzyme (ACE) inhibitors in patients with chronic stable angina who are at high risk for a cardiac event is to decrease ventricular remodeling. ACE inhibitors do not directly impact angina frequency, blood glucose, or heart rate. DIF: Cognitive Level: Apply (application)
A nurse recalls regulation of acid-base balance through removal or retention of volatile acids is accomplished by the: a. Buffer systems b. Kidneys c. Lungs d. Liver
ANS: C The volatile acid is carbonic acid (H2CO3), which readily dissociates into carbon dioxide (CO2) and water (H2O). The CO2 is then eliminated by the lungs. Buffer systems are throughout the body and operate in the extracellular and intracellular systems. The kidneys release hydrogen ions, not volatile acids. The liver does not regulate acid-base balance.
A 62-year-old patient with hyperthyroidism is to be treated with radioactive iodine (RAI). The nurse instructs the patient a. about radioactive precautions to take with all body secretions. b. that symptoms of hyperthyroidism should be relieved in about a week. c. that symptoms of hypothyroidism may occur as the RAI therapy takes effect. d. to discontinue the antithyroid medications taken before the radioactive therapy.
ANS: C There is a high incidence of postradiation hypothyroidism after RAI, and the patient should be monitored for symptoms of hypothyroidism. RAI has a delayed response, with the maximum effect not seen for 2 to 3 months, and the patient will continue to take antithyroid medications during this time. The therapeutic dose of radioactive iodine is low enough that no radiation safety precautions are needed DIF: Cognitive Level: Apply (application) REF: 1166 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
A young adult calls the clinic to ask for a prescription for "that new flu drug." He says he has had the flu for almost 4 days and just heard about a drug that can reduce the symptoms. What is the nurse's best response to his request? a. "Now that you've had the flu, you will need a booster vaccination, not the antiviral drug." b. "We will need to do a blood test to verify that you actually have the flu." c. "Drug therapy should be started within 2 days of symptom onset, not 4 days." d. "We'll get you a prescription. As long as you start treatment within the next 24 hours, the drug should be effective."
ANS: C These drugs need to be started within 2 days of influenza symptom onset; they can be used for prophylaxis and treatment of influenza. The other options are incorrect.
A patient will be receiving a thrombolytic drug as part of the treatment for acute myocardial infarction. The nurse explains to the patient that this drug is used for which purpose? a. To relieve chest pain b. To prevent further clot formation c. To dissolve the clot in the coronary artery d. To control bleeding in the coronary vessels
ANS: C Thrombolytic drugs lyse, or dissolve, thrombi. They are not used to prevent further clot formation or to control bleeding. As a result of dissolving of the thrombi, chest pain may be relieved, but that is not the primary purpose of thrombolytic therapy. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 414 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
A patient with ST-segment elevation in three contiguous electrocardiographic leads is admitted to the emergency department and diagnosed as having an ST-segment-elevation myocardial infarction. Which question should the nurse ask to determine whether the patient is a candidate for thrombolytic therapy? a. "Do you have any allergies?" b. "Do you take aspirin on a daily basis?" c. "What time did your chest pain begin?" d. "Can you rate your chest pain using a 0 to 10 scale?"
ANS: C Thrombolytic therapy should be started within 6 hours of the onset of the myocardial infarction, so the time at which the chest pain started is a major determinant of the appropriateness of this treatment. The other information is not a factor in the decision about thrombolytic therapy. DIF: Cognitive Level: Apply (application)
A 42-year-old female patient is scheduled for transsphenoidal hypophysectomy to treat a pituitary adenoma. During preoperative teaching, the nurse instructs the patient about the need to a. cough and deep breathe every 2 hours postoperatively. b. remain on bed rest for the first 48 hours after the surgery. c. avoid brushing teeth for at least 10 days after the surgery. d. be positioned flat with sandbags at the head postoperatively.
ANS: C To avoid disruption of the suture line, the patient should avoid brushing the teeth for 10 days after surgery. It is not necessary to remain on bed rest after this surgery. Coughing is discouraged because it may cause leakage of cerebrospinal fluid (CSF) from the suture line. The head of the bed should be elevated 30 degrees to reduce pressure on the sella turcica and decrease the risk for headaches DIF: Cognitive Level: Apply (application) REF: 1159 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
11. When teaching a patient who has a new prescription for transdermal nitroglycerin patches, the nurse tells the patient that these patches are most appropriately used for which situation? a. To prevent low blood pressure b. To relieve shortness of breath c. To prevent the occurrence of angina d. To keep the heart rate from rising too high during exercise
ANS: C Transdermal dosage formulations of nitroglycerin are used for the long-term prophylactic management (prevention) of angina pectoris. Transdermal nitroglycerin patches are not appropriate for the relief of shortness of breath, to prevent palpitations, or to control the heart rate during exercise. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 366 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
A patient who is diagnosed with shingles is taking topical acyclovir, and the nurse is providing instructions about adverse effects. The nurse will discuss which adverse effects of topical acyclovir therapy? a. Insomnia and nervousness b. Temporary swelling and rash c. Burning when applied d. This medication has no adverse effects.
ANS: C Transient burning may occur with topical application of acyclovir. The other options are incorrect.
The patient diagnosed with tuberculosis can transmit this disease through: a. skin contact. b. fecal-oral contact. c. airborne droplets. d. blood transfusions.
ANS: C Tuberculosis is transmitted through airborne droplets. Tuberculosis is not transmitted through skin contact, fecal-oral contact, or through a blood transfusion.
A 30-year-old male is demonstrating hematuria with red blood cell casts and proteinuria exceeding 3-5 grams per day, with albumin being the major protein. The most probable diagnosis the nurse will see documented on the chart is: a. cystitis. b. chronic pyelonephritis. c. acute glomerulonephritis. d. renal calculi.
ANS: C Two major symptoms distinctive of more severe glomerulonephritis are: (i) hematuria with red blood cell casts and (ii) proteinuria exceeding 3-5 grams per day with albumin (macroalbuminuria) as the major protein. Cystitis is not associated with proteinuria and so is not relevant to the diagnosis of glomerulonephritis. Chronic pyelonephritis is manifested by dysuria, not proteinuria. Proteinuria is not seen with renal calculi. REF: p. 755 | p. 757
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
ANS: C Type B COPD is a chronic disease that causes impaired excretion of carbonic acid, thus causing respiratory acidosis, with PaCO2 high and pH low. This chronic disease exists long enough for some renal compensation to occur, manifested by high HCO3-. Answers that include low or normal bicarbonate are not correct, because the renal compensation for respiratory acidosis involves excretion of more hydrogen ions than usual, with retention of bicarbonate in the blood. High pH occurs with alkalosis, not acidosis.
The most common condition associated with the development of acute pyelonephritis is: a. cystitis. b. renal cancer. c. urinary tract obstruction. d. nephrotic syndrome.
ANS: C Urinary obstruction and reflux of urine from the bladder are the most common underlying risk factors. Risk factors do not include cystitis, renal cancer, or nephrotic syndrome. REF: p. 754
The nurse associates which assessment finding in the diabetic patient with decreasing renal function? a. Ketone bodies in the urine during acidosis b. Glucose in the urine during hyperglycemia c. Protein in the urine during a random urinalysis d. White blood cells in the urine during a random urinalysis
ANS: C Urine should not contain protein. Proteinuria in a diabetic heralds the beginning of renal insufficiency or diabetic nephropathy with subsequent progression to end stage renal disease. Chronic elevated blood glucose levels can cause renal hypertension and excess kidney perfusion with leakage from the renal vasculature. This leaking allows protein to be filtered into the urine.
A patient presents to the emergency room (ER) reporting excessive vomiting. A CT scan of the brain reveals a mass in the: a. skull fractures. b. thalamus. c. medulla oblongata. d. frontal lobe.
ANS: C Vomiting is due to disruptions in the medulla oblongata. Skull fractures can result in vomiting but would not be related to the mass. The thalamus controls other things such as temperature. The frontal lobe deals with emotions. REF: p. 363
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
Which patient is most prone to metabolic alkalosis? A patient with: a. Retention of metabolic acids b. Hypoaldosteronism c. Excessive loss of chloride (Cl) d. Hyperventilation
ANS: C When acid loss is caused by vomiting, renal compensation is not very effective because loss of Cl stimulates renal retention of bicarbonate, leading to alkalosis. Retention of metabolic acids would lead to acidosis, not alkalosis. Hypoaldosteronism leads to hyponatremia and does not cause alkalosis. Hyperventilation leads to respiratory alkalosis, not metabolic alkalosis.
A 10 year old is brought to the ER with prolonged bronchospasm and severe hypoxemia. The symptomology supports which diagnosis? a. Exercise-induced asthma b. Chronic obstructive pulmonary disease (COPD) c. Status asthmaticus d. Bronchiectasis
ANS: C When bronchospasm is not reversed by the usual measures, the individual is considered to have severe bronchospasm or status asthmaticus since exercise-induced asthma resolves. COPD is manifested by air trapping and hypercapnia, not by bronchospasm. Bronchiectasis is manifested by bronchiolar changes, not by bronchospasm.
A 42-year-old male is involved in a motor vehicle accident that has resulted in prerenal failure. What is the most likely cause of this patient's condition? a. Kidney stones b. Immune complex deposition in the glomerulus c. Inadequate renal blood flow d. Obstruction of the proximal tubule
ANS: C With blood loss, renal failure is due to inadequate blood flow since the trigger occurs outside of the kidney (prerenal). Kidney stones will lead to postrenal renal failure. Intrarenal renal failure is due to glomerular nephritis or obstruction of the proximal tubule. testbanks_and_xanax REF: p. 760
An 82-year-old patient in a long-term care facility has several medications prescribed. After the patient is newly diagnosed with hypothyroidism, the nurse will need to consult with the health care provider before administering a. docusate (Colace). b. ibuprofen (Motrin). c. diazepam (Valium). d. cefoxitin (Mefoxin).
ANS: C Worsening of mental status and myxedema coma can be precipitated by the use of sedatives, especially in older adults. The nurse should discuss the use of diazepam with the health care provider before administration. The other medications may be given safely to the patient DIF: Cognitive Level: Apply (application) REF: 1169 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
40. The nurse notes that a patient has incisional pain, a poor cough effort, and scattered coarse crackles after a thoracotomy. Which action should the nurse take first? a. Assist the patient to sit upright in a chair. b. Splint the patient's chest during coughing. c. Medicate the patient with prescribed morphine. d. Observe the patient use the incentive spirometer.
ANS: C A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain (which increases with deep breathing and coughing). The first action by the nurse should be to medicate the patient to minimize incisional pain. The other actions are all appropriate ways to improve airway clearance but should be done after the morphine is given.
27. Which finding indicates to the nurse that the administered nifedipine (Procardia) was effective for a patient who has idiopathic pulmonary arterial hypertension (IPAH)? a. Heart rate is between 60 and 100 beats/min. b. Patient's chest x-ray indicates clear lung fields. c. Patient reports a decrease in exertional dyspnea. d. Blood pressure (BP) is less than 140/90 mm Hg.
ANS: C Because a major symptom of IPAH is exertional dyspnea, an improvement in this symptom would indicate that the medication was effective. Nifedipine will affect BP and heart rate, but these parameters would not be used to monitor the effectiveness of therapy for a patient with IPAH. The chest x-ray will show clear lung fields even if the therapy is not effective.
43. A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan? a. Purpose of antibiotic therapy b. Ways to limit oral fluid intake c. Appropriate use of cough suppressants d. Safety concerns with home O2 therapy
ANS: C Cough suppressants are frequently prescribed for acute bronchitis. Because most acute bronchitis is viral in origin, antibiotics are not prescribed unless there are systemic symptoms. Fluid intake is encouraged. Home O2 is not prescribed for acute bronchitis, although it may be used for chronic bronchitis.
3. A patient with bacterial pneumonia has coarse crackles and thick sputum. Which action should the nurse plan to promote airway clearance? a. Restrict oral fluids during the day. b. Encourage pursed-lip breathing technique. c. Help the patient to splint the chest when coughing. d. Encourage the patient to wear the nasal O2 cannula.
ANS: C Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal O2 will improve gas exchange but will not improve airway clearance. Pursed-lip breathing can improve gas exchange in patients with chronic obstructive pulmonary disease but will not improve airway clearance.
12. A patient diagnosed with active tuberculosis (TB) is homeless and has a history of chronic alcohol use. Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen? a. Repeat warnings about the high risk for infecting others several times. b. Give the patient written instructions about how to take the medications. c. Arrange for a daily meal and drug administration at a community center. d. Arrange for the patient's friend to administer the medication on schedule.
ANS: C Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen. Arranging a daily meal will help ensure that the patient is available to receive the medication. The other nursing interventions may be appropriate for some patients but are not likely to be as helpful for this patient's situation.
25. The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy. Which information should the nurse include about the patient's postoperative care? a. Bed rest for the first 24 hours b. Positioning only on the right side c. Frequent use of an incentive spirometer d. Chest tube placement to continuous suction
ANS: C Frequent deep breathing and coughing are needed after chest surgery to prevent atelectasis. To promote gas exchange, patients after pneumonectomy are positioned on the surgical side. Early mobilization decreases the risk for postoperative complications such as pneumonia and deep vein thrombosis. In a pneumonectomy, chest tubes may or may not be placed in the space from which the lung was removed. If a chest tube is used, it is clamped and only released by the surgeon to adjust the volume of serosanguineous fluid that will fill the space vacated by the lung. If the cavity overfills, it could compress the remaining lung and compromise the cardiovascular and pulmonary function. Daily chest x-rays can be used to assess the volume and space.
18. A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The patient tells the nurse, "I would rather have chemotherapy than surgery." Which response by the nurse is most appropriate? a. "Are you afraid that the surgery will be very painful?" b. "Did you have bad experiences with previous surgeries?" c. "Tell me what you know about the treatments available." d. "Surgery is the treatment of choice for stage I lung cancer."
ANS: C More assessment of the patient's concerns about surgery is indicated. An open-ended response will elicit the most information from the patient. The answer beginning, "Surgery is the treatment of choice" is accurate, but it discourages the patient from sharing concerns about surgery. The remaining two answers indicate that the nurse has jumped to conclusions about the patient's reasons for not wanting surgery. Chemotherapy is the primary treatment for small cell lung cancer. In non-small cell lung cancer, chemotherapy may be used in the treatment of nonresectable tumors or as adjuvant therapy to surgery
10. A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which response by the nurse reflects accurate knowledge about the medication and the patient's illness? a. Ask the patient about any visual changes in red-green color discrimination. b. Question the patient about experiencing shortness of breath, hives, or itching. c. Explain that orange discolored urine and tears are normal while taking this medication. d. Advise the patient to stop the drug and report the symptoms to the health care provider.
ANS: C Orange-colored body secretions are a side effect of rifampin. The patient does not have to stop taking the medication. The findings are not indicative of an allergic reaction. Alterations in red-green color discrimination commonly occur when taking ethambutol, which is a different tuberculosis medication.
22. A patient has a chest wall contusion as a result of being struck in the chest with a baseball bat. Which initial assessment finding is of most concern to the emergency department nurse? a. Report of chest wall pain b. Heart rate of 110 beats/min c. Paradoxical chest movement d. Large bruised area on the chest
ANS: C Paradoxical chest movement indicates that the patient may have flail chest, which can severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange.
16. An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action recommended by the nurse is intended to prevent lung disease? a. Treat workers with pulmonary fibrosis. b. Teach about symptoms of lung disease. c. Require the use of protective equipment. d. Monitor workers for coughing and wheezing.
ANS: C Prevention of lung disease requires the use of appropriate protective equipment such as masks. The other actions will help in recognition or early treatment of lung disease but will not be effective in prevention of lung damage. Repeated exposure eventually results in diffuse pulmonary fibrosis. Fibrosis is the result of tissue repair after inflammation.
7. The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take? a. Teach about the reason for the blood tests. b. Schedule an appointment for a chest x-ray. c. Teach the patient about providing specimens for 3 consecutive days. d. Instruct the patient to collect several separate sputum specimens today.
ANS: C Sputum specimens are obtained on 2 to 3 consecutive days for bacteriologic testing for Mycobacterium tuberculosis. The patient should not provide all the specimens at once. Blood cultures are not used to test for tuberculosis. A chest x-ray is not bacteriologic testing. Although the findings on chest x-ray examination are important, it is not possible to make a diagnosis of TB solely based on chest x-ray findings because other diseases can mimic the appearance of TB.
9. The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective? a. "I will take the bus instead of driving." b. "I will stay indoors whenever possible." c. "My spouse will sleep in another room." d. "I will keep the windows closed at home."
ANS: C Teach the patient how to minimize exposure to close contacts and household members. Homes should be well ventilated, especially the areas where the infected person spends a lot of time. While still infectious, the patient should sleep alone, spend as much time as possible outdoors, and minimize time in congregate settings or on public transportation
21. The nurse monitors a patient in the emergency department after chest tube placement for a hemopneumothorax. Which assessment finding is of most concern? a. A large air leak in the water-seal chamber b. Report of pain with each deep inspiration c. 400 mL of blood in the collection chamber d. Subcutaneous emphysema at the insertion site
ANS: C The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. An air leak would be expected after chest tube placement for a pneumothorax. Initially, brisk bubbling of air occurs in this chamber when a pneumothorax is evacuated. The pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with pneumothorax. A small amount of subcutaneous air is harmless and will be reabsorbed.
6. A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment is effective? a. Bronchial breath sounds are heard at the right base. b. The patient coughs up small amounts of green mucus. c. The patient's white blood cell (WBC) count is 6000/µL. d. Increased tactile fremitus is palpable over the right chest.
ANS: C The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed.
17. After change-of-shift report, which patient should the nurse assess first? a. A 40-yr-old with a pleural effusion who reports severe stabbing chest pain b. A 72-yr-old with cor pulmonale who has 4+ bilateral edema in his legs and feet c. A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter insertion d. A 28-yr-old with a history of a lung transplant 1 month ago and a fever of 101° F (38.3° C)
ANS: C The patient's history and symptoms suggest possible tension pneumothorax, a medical emergency. The other patients also require assessment as soon as possible, but tension pneumothorax will require immediate treatment to avoid death from inadequate cardiac output or hypoxemia.
28. Which action should the nurse take to prepare a patient with a pleural effusion for a thoracentesis? a. Remind the patient not to eat or drink 6 hours. b. Start a peripheral IV line to administer sedation. c. Position the patient sitting up on the side of the bed. d. Obtain a collection device to hold 3 liters of pleural fluid.
ANS: C When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and can more easily be located and removed. The patient does not usually require sedation for the procedure, and there are no restrictions on oral intake because the patient is not sedated or unconscious. Usually only 1000 to 1200 mL of pleural fluid is removed at one time. Rapid removal of a large volume can result in hypotension, hypoxemia, or pulmonary edema.
4. When monitoring a patient's response to oral antidiabetic drugs, the nurse knows that which laboratory result would indicate a therapeutic response? a. Random blood glucose level above 170 mg/dL b. Blood glucose level of less than 50 mg/dL after meals c. Fasting blood glucose level between 70 and 100 mg/dL d. Evening blood glucose level below 80 mg/dL
ANS: C A fasting blood glucose level between 70 and 100 mg/dL indicates a therapeutic response to drugs that decrease glucose levels. The other options are incorrect. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 511 TOP: NURSING PROCESS: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. When teaching about hypoglycemia, the nurse will make sure that the patient is aware of the early signs of hypoglycemia, including a. hypothermia and seizures. b. nausea and diarrhea. c. confusion and sweating. d. fruity, acetone odor to the breath.
ANS: C Early symptoms of hypoglycemia include the central nervous system (CNS) manifestations of confusion, irritability, tremor, and sweating. Hypothermia and seizures are later symptoms of hypoglycemia. The other options are incorrect. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 525 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Health Promotion and Maintenance
7. The nurse is reviewing instructions for a patient with type 2 diabetes who also takes insulin injections as part of the therapy. The nurse asks the patient, "What should you do if your fasting blood glucose is 47 mg/dL?" Which response by the patient reflects a correct understanding of insulin therapy? a. "I will call my doctor right away." b. "I will give myself the regular insulin." c. "I will take an oral form of glucose." d. "I will rest until the symptoms pass."
ANS: C Hypoglycemia can be reversed if the patient eats glucose tablets or gel, corn syrup, or honey, or drinks fruit juice or a nondiet soft drink or other quick sources of glucose, which must always be kept at hand. She should not wait for instructions from her physician, nor delay taking the glucose by resting. The regular insulin would only lower her blood glucose levels more. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 525 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
11. A patient in the emergency department was showing signs of hypoglycemia and had a fingerstick glucose level of 34 mg/dL. The patient has just become unconscious. What is the nurse's next action? a. Have the patient eat glucose tablets. b. Have the patient consume fruit juice, a nondiet soft drink, or crackers. c. Administer intravenous glucose (50% dextrose). d. Call the lab to order a fasting blood glucose level.
ANS: C Intravenous glucose raises blood glucose levels when the patient is unconscious and unable to take oral forms of glucose. DIF: COGNITIVE LEVEL: Analyzing (Analysis) REF: p. 525 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Safe and Effective Care Environment: Management of Care
6. A patient who has type 2 diabetes is scheduled for an oral endoscopy and has been NPO (nothing by mouth) since midnight. What is the best action by the nurse regarding the administration of her oral antidiabetic drugs? a. Administer half the original dose. b. Withhold all medications as ordered. c. Contact the prescriber for further orders. d. Give the medication with a sip of water.
ANS: C When the diabetic patient is NPO, the prescriber needs to be contacted for further orders regarding the administration of the oral antidiabetic drugs. The other options are incorrect. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 529 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
When reviewing patients' histories, the nurse recognizes that which patient would be a likely candidate for drug therapy for cholesterol reduction? a. A patient who has coronary heart disease and an LDL level of 100 mg/dL b. A patient who has one risk factor, an LDL level of 170 mg/dL, and no history of coronary heart disease c. A patient who has coronary heart disease and an LDL level of 165 mg/dL d. A patient who has two risk factors and a low-density lipoprotein (LDL) level of 100 mg/dL, without coronary heart disease
ANS: C A patient with coronary heart disease is considered to be at high or very high risk, and with an LDL level greater than or equal to 130 mg/dL, drug therapy will be initiated. The other situations would warrant dietary therapy, initially
A patient reports having adverse effects with nicotinic acid (niacin). The nurse can suggest performing which action to minimize these undesirable effects? a. Take the drug on an empty stomach. b. Take the medication every other day until the effects subside. c. Take an aspirin tablet 30 minutes before taking the drug. d. Take the drug with large amounts of fiber
ANS: C The undesirable effects of nicotinic acid can be minimized by starting with a low initial dose, taking the drug with meals, and taking small doses of aspirin with the drug to minimize cutaneous flushing. Fiber intake has no effect on niacin's adverse effects, and it is not within the nurse's scope of practice to suggest a change of medication dosage.
The nurse assesses a patient who has numerous petechiae on both arms. Which question should the nurse ask the patient? a. "Are you taking any oral contraceptives?" b. "Have you been prescribed antiseizure drugs?" c. "Do you take medication containing salicylates?" d. "How long have you taken antihypertensive drugs?"
ANS: C. "Do you take medication containing salicylates?" Salicylates interfere with platelet function and can lead to petechiae and ecchymoses. Antiseizure drugs may cause anemia but not clotting disorders or bleeding. Oral contraceptives increase a person's clotting risk. Antihypertensives do not usually cause problems with decreased clotting.
The health care provider's progress note for a patient states that the complete blood count (CBC) shows a "shift to the left." Which assessment finding will the nurse expect? a. Cool extremities b. Pallor and weakness c. Elevated temperature d. Low oxygen saturation
ANS: C. Elevated temperature The term "shift to the left" indicates that the number of immature polymorphonuclear neutrophils (bands) is elevated and that finding is a sign of infection. There is no indication that the patient is at risk for hypoxemia, pallor or weakness, or cool extremities.
The nurse notes pallor of the skin and nail beds in a newly admitted patient. The nurse should ensure that which laboratory test has been ordered? a. Platelet count b. Neutrophil count c. Hemoglobin level d. White blood cell count
ANS: C. Hemoglobin level Pallor of the skin or nail beds is indicative of anemia, which would be indicated by a low Hgb level. Platelet counts indicate a person's clotting ability. A neutrophil is a type of white blood cell that helps to fight infection.
1. When discussing risk factor modification for a 63-year-old patient who has a 5-cm abdominal aortic aneurysm, the nurse will focus discharge teaching on which patient risk factor? a. Male gender b. Turner syndrome c. Abdominal trauma history d. Uncontrolled hypertension
ANS: D All of the factors contribute to the patient's risk, but only hypertension can potentially be modified to decrease the patient's risk for further expansion of the aneurysm.
30. Which nursing intervention for a patient who had an open repair of an abdominal aortic aneurysm 2 days previously 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.
ANS: D Assisting a patient who has already been taught how to cough is part of routine postoperative care and within the education and scope of practice for UAP. Patient teaching and assessment of essential postoperative functions such as circulation and movement should be done by RNs.
32. 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 patient's toes. d. Check for presence of lipodermatosclerosis.
ANS: D Clinical signs of post-thrombotic syndrome include lipodermatosclerosis. In this situation, the skin on the lower leg becomes scarred, and the leg becomes tapered like an "inverted bottle." The other assessments would be done for patients with peripheral arterial disease.
15. 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
ANS: D Compression of the leg is essential to healing of venous stasis ulcers. High dietary intake of protein, rather than carbohydrates, is needed. Prophylactic antibiotics are not routinely used for venous ulcers. Moist dressings are used to hasten wound healing.
20. While working in the outpatient clinic, the nurse notes that a patient has a history of intermittent claudication. 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."
ANS: D Cramping that is precipitated by a consistent level of exercise is descriptive of intermittent claudication. Finger pain associated with cold weather is typical of Raynaud's 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.
32. A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and severe pleuritic chest pain. Which prescribed medication should the nurse give first? a. Codeine b. Guaifenesin c. Acetaminophen (Tylenol) d. Piperacillin/tazobactam (Zosyn)
ANS: D Early initiation of antibiotic therapy has been shown to reduce mortality. The other medications are also appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy.
When a nurse is checking the urinalysis, plasma proteins should be absent from the urine because: a. All proteins filtered are subsequently reabsorbed. b. All of the plasma proteins are too large to fit through the filtration slits. c. All proteins filtered are subsequently degraded before elimination. d. The negative charge of the glomerular filtration membrane repels the plasma proteins.
ANS: D Like other capillary membranes, the glomerulus is freely permeable to water and relatively impermeable to large colloids, such as plasma proteins. The molecule's size and electrical charge affect the permeability of substances crossing the glomerulus.
29. The nurse completes discharge teaching for a patient who has had a lung transplant. Which patient statement indicates that the teaching has been effective? a. "I will make an appointment to see the doctor every year." b. "I will stop taking the prednisone if I experience a dry cough." c. "I will not worry if I feel a little short of breath with exercise." d. "I will call the health care provider right away if I develop a fever."
ANS: D Low-grade fever may indicate infection or acute rejection, so the patient should notify the health care provider immediately if the temperature is elevated. Patients require frequent follow-up visits with the transplant team. Annual health care provider visits would not be sufficient. Home O2 use is not an expectation after lung transplant. Shortness of breath should be reported. Low-grade fever, fatigue, dyspnea, dry cough, and O2 desaturation are signs of rejection. Immunosuppressive therapy, including prednisone, needs to be continued to prevent rejection.
38. The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is important for the nurse to ask before the skin test? a. "Do you take any over-the-counter (OTC) medications?" b. "Do you have any family members with a history of TB?" c. "How long has it been since you moved to the United States?" d. "Did you receive the bacille Calmette-Guérin (BCG) vaccine for TB?"
ANS: D Patients who have received the BCG vaccine will have a positive Mantoux test. Another method for screening (e.g., chest x-ray) will need to be used in determining whether the patient has a TB infection. The other information also may be valuable but is not as pertinent to the decision about doing TB skin testing.
3. 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.
ANS: D The decreased urine output suggests decreased renal perfusion, and monitoring of renal function is needed. There is no indication that infection is a concern, so antibiotic therapy and a WBC count are not needed. The IV rate may be increased because hypovolemia may be contributing to the patient's decreased urinary output.
6. 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.
ANS: D The nurse should assess for other clinical manifestations of peripheral arterial disease in a patient who describes intermittent claudication. Changes in skin color that occur in response to cold are consistent with Raynaud's phenomenon. Tortuous veins on the legs suggest venous insufficiency. Unilateral leg swelling, redness, and tenderness indicate venous thromboembolism (VTE).
5. 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.
ANS: D The patient's history and clinical manifestations are consistent with acute arterial occlusion, and resting the leg will decrease the oxygen demand of the tissues and minimize ischemic damage until circulation can be restored. Elevating the leg or applying an elastic wrap will further compromise blood flow to the leg. Exercise will increase oxygen demand for the tissues of the leg.
10. 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 patient's 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.
ANS: D 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 urologist is discussing a structure that supplies blood to the medulla. What is the urologist describing? a. Renal arteries b. Arcuate arteries c. Peritubular capillaries d. Vasa recta
ANS: D The vasa recta is a network of capillaries that forms loops and closely follows the loops of Henle and is the only blood supply to the medulla.
Which of the following patients is at highest risk for developing pulmonary embolism (PE)? a. A 21-year-old male with a hemophilia bleeding disorder b. A 28-year-old woman who had a baby 6 months earlier c. A 36-year-old woman with a history of alcohol abuse who is recovering from a gastric ulcer d. A 72-year-old male who is recovering from hip replacement surgery in the hospital
ANS: D A 72-year-old is at risk for immobility and at increased risk for PE.
14. A 5-year-old male presents to the ER with delirium and sunken eyes. After diagnosing him with severe dehydration, the primary care provider orders fluid replacement. The nurse administers a hypertonic intravenous solution. Which of the following would be expected? a. Symptoms subside quickly b. Increased ICF volume c. Decreased ECF volume d. Intracellular dehydration
ANS: D A hypertonic solution would cause fluid to move into the extracellular space, leading to intracellular dehydration. With this solution, his symptoms will not subside quickly because his cells will lose fluid. His intracellular volume will decrease, not increase. His extracellular volume will increase, not decrease.
A 23-year-old patient is admitted with diabetes insipidus. Which action will be most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Titrate the infusion of 5% dextrose in water. b. Teach the patient how to use desmopressin (DDAVP) nasal spray. c. Assess the patient's hydration status every 8 hours. d. Administer subcutaneous DDAVP.
ANS: D Administration of medications is included in LPN/LVN education and scope of practice. Assessments, patient teaching, and titrating fluid infusions are more complex skills and should be done by the RN. DIF: Cognitive Level: Apply (application) REF: 1161 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
After receiving change-of-shift report about the following four patients on the cardiac care unit, which patient should the nurse assess first? a. A 39-yr-old patient with pericarditis who is complaining of sharp, stabbing chest pain b. A 56-yr-old patient with variant angina who is scheduled to receive nifedipine (Procardia) c. A 65-yr-old patient who had a myocardial infarction (MI) 4 days ago and is anxious about today's planned discharge d. A 59-yr-old patient with unstable angina who has just returned after a percutaneous coronary intervention (PCI)
ANS: D After PCI, the patient is at risk for hemorrhage from the arterial access site. The nurse should assess the patient's blood pressure, pulses, and the access site immediately. The other patients should also be assessed as quickly as possible, but assessment of this patient has the highest priority. DIF: Cognitive Level: Analyze (analysis)
A patient admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI) is restless and anxious. The blood pressure is 86/40 mm Hg, and heart rate is 132 beats/min. Based on this information, which nursing diagnosis is a priority for the patient? a. Acute pain related to myocardial infarction b. Anxiety related to perceived threat of death c. Stress overload related to acute change in health d. Decreased cardiac output related to cardiogenic shock
ANS: D All the nursing diagnoses may be appropriate for this patient, but the hypotension and tachycardia indicate decreased cardiac output and shock from the damaged myocardium. This will result in decreased perfusion to all vital organs (e.g., brain, kidney, heart) and is a priority. DIF: Cognitive Level: Analyze (analysis)
15. The nurse analyzes the results of a patients arterial blood gases (ABGs). Which finding would require immediate 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.
ANS: D All the values are abnormal, but the low PaO2 indicates that the patient is at the point on the oxyhemoglobin dissociation curve where a small change in the PaO2 will cause a large drop in the O2 saturation and a decrease in tissue oxygenation. The nurse should intervene immediately to improve the patients oxygenation. DIF: Cognitive Level: Apply (application) REF: eTable 26-1 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
Which statement made by a patient with coronary artery disease after the nurse has completed teaching about the therapeutic lifestyle changes (TLC) diet indicates that further teaching is needed? a. "I will switch from whole milk to 1% milk." b. "I like salmon and I will plan to eat it more often." c. "I can have a glass of wine with dinner if I want one." d. "I will miss being able to eat peanut butter sandwiches."
ANS: D Although only 30% of the daily calories should come from fats, most of the fat in the TLC diet should come from monounsaturated fats such as are found in nuts, olive oil, and canola oil. The patient can include peanut butter sandwiches as part of the TLC diet. The other patient comments indicate a good understanding of the TLC diet. DIF: Cognitive Level: Apply (application)
Which statement by a patient indicates good understanding of the nurse's 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."
ANS: D Because infection is the most common cause of a sickle cell crisis, influenza, Haemophilus influenzae, pneumococcal pneumonia, and hepatitis immunizations should be administered. Although continuous dose opioids and oxygen may be administered during a crisis, patients do not receive these therapies to prevent crisis. Hydroxyurea (Hydrea) is a medication used to decrease the number of sickle cell crises. DIF: Cognitive Level: Apply (application) REF: 617 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
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 c. Liver function b. Hematocrit d. Serum iron level
ANS: D Because iron chelating agents are used to lower serum iron levels, the most useful information will be the patient's iron level. The other parameters will also be monitored, but are not the most important to monitor when determining the effectiveness of deferoxamine. DIF: Cognitive Level: Analyze (analysis) REF: 620 OBJ: Special Questions: Prioritization TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
Nadolol (Corgard) is prescribed for a patient with chronic stable angina and left ventricular dysfunction. To determine whether the drug is effective, the nurse will monitor for a. decreased blood pressure and heart rate. b. fewer complaints of having cold hands and feet. c. improvement in the strength of the distal pulses. d. participation in daily activities without chest pain.
ANS: D Because the drug is ordered to improve the patient's angina, effectiveness is indicated if the patient is able to accomplish daily activities without chest pain. Blood pressure and heart rate may decrease, but these data do not indicate that the goal of decreased angina has been met. The noncardioselective -adrenergic blockers can cause peripheral vasoconstriction, so the nurse would not expect an improvement in distal pulse quality or skin temperature. DIF: Cognitive Level: Apply (application)
A patient is taking a combination of antiviral drugs as treatment for early stages of a viral infection. While discussing the drug therapy, the patient asks the nurse if the drugs will kill the virus. When answering, the nurse keeps in mind which fact about antiviral drugs? a. They are given for palliative reasons only. b. They will be effective as long as the patient is not exposed to the virus again. c. They can be given in large enough doses to eradicate the virus without harming the body's healthy cells. d. They may also kill healthy cells while killing viruses.
ANS: D Because viruses reproduce in human cells, selective killing is difficult; consequently, many healthy human cells, in addition to virally infected cells, may be killed in the process, and this results in the serious toxicities that are involved with these drugs. The other options are incorrect.
7. When planning care for a dehydrated patient, the nurse remembers the principle of water balance is closely related to _____ balance. a. Potassium b. Chloride c. Bicarbonate d. Sodium
ANS: D Because water follows the osmotic gradients established by changes in salt concentration, water balance is tied to sodium balance. Because water follows the osmotic gradients established by changes in salt concentration, water balance is tied to sodium balance, not potassium. Because water follows the osmotic gradients established by changes in salt concentration, water balance is tied to sodium balance, not chloride. Because water follows the osmotic gradients established by changes in salt concentration, water balance is tied to sodium balance, not bicarbonate.
8. A patient has been taking a beta blocker for 4 weeks as part of his antianginal therapy. He also has type II diabetes and hyperthyroidism. When discussing possible adverse effects, the nurse will include which information? a. "Watch for unusual weight loss." b. "Monitor your pulse for increased heart rate." c. "Use the hot tub and sauna at the gym as long as time is limited to 15 minutes." d. "Monitor your blood glucose levels for possible hypoglycemia or hyperglycemia."
ANS: D Beta blockers can cause both hypoglycemia and hyperglycemia. They may also cause weight gain if heart failure is developing, and decreased pulse rate. The use of hot tubs and saunas is not recommended because of the possibility of hypotensive episodes. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 367 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control
A patient is receiving thrombolytic therapy, and the nurse monitors the patient for adverse effects. What is the most common undesirable effect of thrombolytic therapy? a. Dysrhythmias b. Nausea and vomiting c. Anaphylactic reactions d. Internal and superficial bleeding
ANS: D Bleeding, both internal and superficial, as well as intracranial, is the most common undesirable effect of thrombolytic therapy. The other options list possible adverse effects of thrombolytic drugs, but they are not the most common effects. DIF: COGNITIVE LEVEL: Remembering (Knowledge) REF: p. 424 TOP: NURSING PROCESS: Evaluation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
1. A nurse is reviewing lab reports. The nurse recalls blood plasma is located in which of the following fluid compartments? a. Intracellular fluid (ICF) b. Extracellular fluid (ECF) c. Interstitial fluid d. Intravascular fluid
ANS: D Blood plasma is the intravascular fluid. ICF is fluid in the cells. ECF is all the fluid outside the cells. Interstitial fluid is fluid between the cells and outside the blood vessels.
A patient who is HIV- positive has been receiving medication therapy that includes zidovudine (Retrovir). However, the prescriber has decided to stop the zidovudine because of its dose-limiting adverse effect. Which of these conditions is the dose-limiting adverse effect of zidovudine therapy? a. Retinitis b. Renal toxicity c. Hepatotoxicity d. Bone marrow suppression
ANS: D Bone marrow suppression is often the reason that a patient with HIV infection has to be switched to another anti-HIV drug such as didanosine. The two drugs can be taken together, cutting back on the dosages of both and thus decreasing the likelihood of toxicity. The other options are incorrect.
A patient experiences a severe head injury hitting a tree while riding a motorcycle. Breathing becomes deep and rapid but with normal pattern. What term should the nurse use for this condition? a. Gasping b. Ataxic breathing c. Apneusis d. Central neurogenic hyperventilation
ANS: D Central neurogenic hyperventilation is a sustained, deep, rapid, but regular, pattern (hyperpnea) of breathing. Gasping is a pattern of deep "all-or-none" breaths accompanied by a slow respiratory rate. Ataxic breathing is completely irregular breathing that occurs with random shallow and deep breaths and irregular pauses. Apneusis is manifested by a prolonged inspiratory pause alternating with an end-expiratory pause. REF: p. 362, Table 15-4
A patient is experiencing respiratory difficulty and retaining too much carbon dioxide. Which receptor sites would be stimulated in an attempt to maintain a normal homeostatic state? a. Irritant b. Stretch c. Peripheral d. Central
ANS: D Chemoreceptors monitor arterial blood indirectly by sensing changes in the pH of cerebrospinal fluid (CSF). The central chemoreceptors are sensitive to very small changes in the pH of CSF and can maintain a normal PaCO2. Irritant receptors sense the need to expel unwanted substances. Stretch receptors decrease ventilatory rate and volume when stimulated. The peripheral chemoreceptors become the major stimulus to ventilation when the central chemoreceptors are reset.
Which information from a patient helps the nurse confirm the previous diagnosis of chronic stable angina? a. "The pain wakes me up at night." b. "The pain is level 3 to 5 (0 to 10 scale)." c. "The pain has gotten worse over the last week." d. "The pain goes away after a nitroglycerin tablet."
ANS: D Chronic stable angina is typically relieved by rest or nitroglycerin administration. The level of pain is not a consistent indicator of the type of angina. Pain occurring at rest or with increased frequency is typical of unstable angina. DIF: Cognitive Level: Understand (comprehension)
An adult is diagnosed with communicating hydrocephalus. The form of hydrocephalus in adults is most often caused by: a. overproduction of CSF. b. intercellular edema. c. elevated arterial blood pressure. d. defective CSF reabsorption.
ANS: D Communicating hydrocephalus occurs because of defective reabsorption of the fluid. Hydrocephalus can occur because of overproduction of CSF, but in adults it occurs most often because of defective reabsorption of the fluid. Hydrocephalus is not due to either intercellular edema or elevated arterial blood pressure.
6. A calcium channel blocker (CCB) is prescribed for a patient, and the nurse provides instructions to the patient about the medication. Which instruction is correct? a. Chew the tablet for faster release of the medication. b. To increase the effect of the drug, take it with grapefruit juice. c. If the adverse effects of chest pain, fainting, or dyspnea occur, discontinue the medication immediately. d. A high-fiber diet with plenty of fluids will help prevent the constipation that may occur.
ANS: D Constipation is a common effect of CCBs, and a high-fiber diet and plenty of fluids will help to prevent it. Grapefruit juice decreases the metabolism of CCBs. Extended-release tablets must never be chewed or crushed. These medications should never be discontinued abruptly because of the risk for rebound hypertension. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 373 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
A 15 year old is diagnosed with restrictive lung disease caused by fibrosis. Which pulmonary function test finding is expected? a. Increased compliance b. Increased tidal volume c. Decreased respiratory rate d. Decreased functional residual capacity
ANS: D Fibrosis progressively obliterates the alveoli, respiratory bronchioles, and interstitium (fibrosing alveolitis), which can result in chronic pulmonary insufficiency, and functional residual capacity declines. Compliance decreases in restrictive disease. In restrictive disease, tidal volume decreases. Respirations may increase with restrictive disease.
16. 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
ANS: D Crackles in the lower half of the lungs indicate that the patient may have an acute problem such as heart failure. The nurse should immediately accomplish further assessments, such as oxygen saturation, and notify the health care provider. A barrel-shaped chest, hyperresonance to percussion, and a weak cough effort are associated with aging. Further evaluation may be needed, but immediate action is not indicated. An older patient has a less forceful cough and fewer and less functional cilia. Mucous membranes tend to be drier. DIF: Cognitive Level: Apply (application) REF: 489 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
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."
ANS: D 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.
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 c. Total lymphocyte count b. Reticulocyte count d. Absolute neutrophil count
ANS: D Filgrastim increases the neutrophil count and function in neutropenic patients. Although total lymphocyte, platelet, and reticulocyte counts are also important to monitor in this patient, the absolute neutrophil count is used to evaluate the effects of filgrastim. DIF: Cognitive Level: Apply (application) REF: 634 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
When giving report, what term should the nurse use to describe the coughing up of bloody secretions? a. Hematemesis b. Cyanosis c. Rhinitis d. Hemoptysis
ANS: D Hemoptysis is the coughing up of bloody secretions. Hematemesis is bloody vomiting. Cyanosis is a bluish color to the skin. Rhinitis is a runny nose
Which of the following patients is most prone to hypochloremia? A patient with: a. Hypernatremia b. Hypokalemia c. Hypercalcemia d. Increased bicarbonate intake
ANS: D Hypochloremia is the result of elevated bicarbonate concentration, as occurs in metabolic alkalosis. Hypochloremia is the result of hyponatremia, not hypernatremia. Hypochloremia is the result of hyponatremia, not hypokalemia. Hypochloremia is the result of hyponatremia, not hypercalcemia.
11. 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 percent to 90 percent). 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.
ANS: D 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. DIF: Cognitive Level: Apply (application) REF: 484 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
The progress notes read: the cerebellar tonsil has shifted through the foramen magnum due to increased pressure within the posterior fossa. The nurse would identify this note as a description of _____ herniation. a. supratentorial b. central c. cingulated gyrus d. infratentorial
ANS: D In infratentorial herniation, the cerebellar tonsil shifts through the foramen magnum because of increased pressure within the posterior fossa. Supratentorial herniation involves temporal lobe and hippocampal gyrus shifting from the middle fossa to posterior fossa. Central herniation is a type of supratentorial herniation and is the straight downward shift of the diencephalon through the tentorial notch. Gyrus herniation occurs when the cingulate gyrus shifts under the falx cerebri. Little is known about its clinical manifestations. REF: p. 375, Box 15-5
6. An experiment was designed to test the effects of the Starling forces on fluid movement. Which of the following alterations would result in fluid moving into the interstitial space? a. Increased capillary oncotic pressure b. Increased interstitial hydrostatic pressure c. Decreased capillary hydrostatic pressure d. Increased interstitial oncotic pressure
ANS: D Increased interstitial oncotic pressure would attract water from the capillary into the interstitial space. Increased capillary oncotic pressure would attract water from the interstitial space back into the capillary. Increased interstitial hydrostatic pressure would attract movement of water from the interstitial spaces into the capillary. Decreased capillary hydrostatic pressure would move water into the capillaries.
What term is used to describe receptors that respond to increased pulmonary capillary pressure? a. Irritant receptors b. Chemoreceptors c. Stretch receptors d. J-receptor
ANS: D J-receptors (juxtapulmonary capillary receptors) are located near the capillaries in the alveolar septa. They are sensitive to increased pulmonary capillary pressure, which stimulates them to initiate rapid, shallow breathing, hypotension, and bradycardia. Neither irritant receptors, chemoreceptors, nor stretch receptors respond to increased pulmonary capillary pressure.
The nurse is reviewing new medication orders for a patient who has an epidural catheter for pain relief. One of the orders is for enoxaparin (Lovenox), a low-molecular-weight heparin (LMWH). What is the nurse's priority action? a. Give the LMWH as ordered. b. Double-check the LMWH order with another nurse, and then administer as ordered. c. Stop the epidural pain medication, and then administer the LMWH. d. Contact the prescriber because the LMWH cannot be given if the patient has an epidural catheter.
ANS: D LMWHs are contraindicated in patients with an indwelling epidural catheter; they can be given 2 hours after the epidural is removed. This is very important to remember, because giving an LMWH with an epidural has been associated with epidural hematoma. DIF: COGNITIVE LEVEL: Analyzing (Analysis) REF: p. 416 TOP: NURSING PROCESS: Planning MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
A patient had a non-ST-segment-elevation myocardial infarction (NSTEMI) 3 days ago. Which nursing intervention included in the plan of care is appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Evaluation of the patient's response to walking in the hallway b. Completion of the referral form for a home health nurse follow-up c. Education of the patient about the pathophysiology of heart disease d. Reinforcement of teaching about the purpose of prescribed medications
ANS: D LPN/LVN education and scope of practice include reinforcing education that has previously been done by the RN. Evaluating the patient's response to exercise after a NSTEMI requires more education and should be done by the RN. Teaching and discharge planning and referral are skills that require RN education and scope of practice. DIF: Cognitive Level: Apply (application)
A patient who has non-Hodgkin's lymphoma is receiving combination treatment with rituximab (Rituxan) and chemotherapy. Which patient assessment finding requires the most rapid action by the nurse? a. Anorexia c. Oral ulcers b. Vomiting d. Lip swelling
ANS: D Lip swelling in angioedema may indicate a hypersensitivity reaction to the rituximab. The nurse should stop the infusion and further assess for anaphylaxis. The other findings may occur with chemotherapy but are not immediately life threatening. DIF: Cognitive Level: Analyze (analysis) REF: 642 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
A patient is in an urgent care center and is receiving treatment for mild hyponatremia after spending several hours doing gardening work in the heat of the day. The nurse expects that which drug therapy will be used to treat this condition?" a Oral supplementation of fluids b Intravenous bolus of lactated Ringer's solution c Normal saline infusion, administered slowly d Oral administration of sodium chloride tablets
ANS: D Mild hyponatremia is usually treated by oral administration of sodium chloride tablets. Pronounced sodium depletion is treated by intravenous normal saline or lactated Ringer's solution.
An expected action by the nurse caring for a patient who has an acute exacerbation of polycythemia vera is to a. place the patient on bed rest. c. avoid use of aspirin products. b. administer iron supplements. d. monitor fluid intake and output.
ANS: D 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. Iron is contraindicated in patients with polycythemia vera. DIF: Cognitive Level: Apply (application) REF: 621 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
When monitoring a patient for signs of hypokalemia, the nurse looks for what early sign?" a Seizures b Cardiac dysrhythmias c Diarrhea d Muscle weakness
ANS: D Muscle weakness is an early symptom of hypokalemia, as are hypotension, lethargy, mental confusion, and nausea. Cardiac dysrhythmias are a late symptom of hypokalemia. The other options are incorrect.
Which finding by the nurse when assessing a patient with a large pituitary adenoma is most important to report to the health care provider? a. Changes in visual field b. Milk leaking from breasts c. Blood glucose 150 mg/dL d. Nausea and projectile vomiting
ANS: D Nausea and projectile vomiting may indicate increased intracranial pressure, which will require rapid actions for diagnosis and treatment. Changes in the visual field, elevated blood glucose, and galactorrhea are common with pituitary adenoma, but these do not require rapid action to prevent life-threatening complications DIF: Cognitive Level: Analyze (analysis) REF: 1157 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
A patient experiences a stroke and now has difficulty writing and producing language. This condition is most likely caused by occlusion of the: a. anterior communicating artery. b. posterior communicating artery. c. circle of Willis. d. middle cerebral artery.
ANS: D Occlusion of the left middle cerebral artery leads to the inability to find words and difficulty with writing. The inability to find words and difficulty with writing are not associated with occlusions of the anterior or posterior communicating arteries or the circle of Willis. REF: p. 367
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
ANS: D Platelet aggregation in HIT causes neutralization of heparin, so the activated partial thromboplastin time will be shorter, and more heparin will be needed to maintain therapeutic levels. The other data will not be affected by HIT. DIF: Cognitive Level: Understand (comprehension) REF: 622 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
A 60 year old with a history of cirrhosis presents with dyspnea, impaired ventilation, and pleural pain. A diagnosis of pleural effusion is made, and a watery fluid is drained. When giving report, the nurse will refer to this fluid as: a. exudative. b. purulent. c. infected. d. transudative.
ANS: D Pleural effusions that enter the pleural space from intact blood vessels can be transudative (watery). The fluid is watery; thus, it is not exudative, which is composed of white cells. Effusion is not purulent or infected.
Pneumonia is caused by: a. use of anesthetic agents in surgery. b. atelectasis. c. chronic lung changes seen with aging. d. viral or bacterial infections.
ANS: D Pneumonia is caused by a viral or bacterial infection; infections are not caused by anesthetic agents. Neither atelectasis nor lung changes associated with normal aging cause pneumonia.
A 42-year-old female presents to her primary care provider reporting muscle weakness and cardiac abnormalities. Laboratory tests indicate that she is hypokalemic. Which of the following could be the cause of her condition? a. Respiratory acidosis b. Constipation c. Hypoglycemia d. Primary hyperaldosteronism
ANS: D Primary hyperaldosteronism, with excessive secretion of aldosterone from an adrenal adenoma (tumor) also causes potassium wasting. Acidosis is related to hyperkalemia, not hypokalemia. Constipation can occur with hypokalemia but does not cause it. Hypoglycemia is not related to muscle weakness.
Which patient should the nurse assess for both hyperkalemia and metabolic acidosis? A patient diagnosed with: a. Diabetes insipidus b. Pulmonary disorders c. Cushing syndrome d. Renal failure
ANS: D Renal failure is associated with hyperkalemia and metabolic acidosis. Diabetes insipidus results in hypernatremia. Pulmonary disorders are a cause of respiratory acidosis or alkalosis but do not affect hyperkalemia. Cushing syndrome results in hypernatremia.
A patient is diagnosed with renal calculus that is causing a urinary obstruction. Which symptoms would be most likely experienced? a. Anuria b. Hematuria c. Pyuria d. Flank pain
ANS: D Significant flank pain is the most common manifestation. Neither anuria nor pyuria is a common manifestation. Hematuria does occur, but it is not the most common manifestation. REF: p. 749
A teenager sustains a severe closed head injury following an all-terrain vehicle (ATV) accident and is in a state of deep sleep that requires vigorous stimulation to elicit eye opening. How should the nurse document this in the chart? a. Confusion b. Coma c. Obtundation d. Stupor
ANS: D Stupor is a condition of deep sleep or unresponsiveness from which a person may be aroused or caused to open his or her eyes only by vigorous and repeated stimulation. Confusion is the loss of the ability to think rapidly and clearly and is characterized by impaired judgment and decision making. Coma is a condition in which there is no verbal response to the external environment or to any stimuli; noxious stimuli such as deep pain or suctioning do not yield motor movement. Obtundation is a mild-to-moderate reduction in arousal (awakeness) with limited response to the environment. REF: p. 361, Table 15-3
Following successful treatment of Hodgkin's lymphoma for a 55-yr-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
ANS: D The chemotherapy used in treating Hodgkin's lymphoma results in a high incidence of secondary malignancies; follow-up screening is needed. The fertility of a 55-yr-old woman will not be impacted by chemotherapy. Maintenance chemotherapy is not used for Hodgkin's lymphoma. Pruritus is a clinical manifestation of lymphoma but should not be a concern after treatment. DIF: Cognitive Level: Apply (application) REF: 640 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
After the nurse has finished teaching a patient about the use of sublingual nitroglycerin (Nitrostat), which patient statement indicates that the teaching has been effective? a. "I can expect nausea as a side effect of nitroglycerin." b. "I should only take nitroglycerin when I have chest pain." c. "Nitroglycerin helps prevent a clot from forming and blocking blood flow to my heart." d. "I will call an ambulance if I still have pain after taking three nitroglycerin 5 minutes apart."
ANS: D The emergency response system (ERS) should be activated when chest pain or other symptoms are not completely relieved after three sublingual nitroglycerin tablets taken 5 minutes apart. Nitroglycerin can be taken to prevent chest pain or other symptoms from developing (e.g., before intercourse). Gastric upset (e.g., nausea) is not an expected side effect of nitroglycerin. Nitroglycerin does not impact the underlying pathophysiology of coronary artery atherosclerosis. DIF: Cognitive Level: Apply (application)
The nurse recognizes which patient as having the greatest risk for undiagnosed diabetes mellitus? a. Young white man b. Middle-aged African-American man c. Young African-American woman d. Middle-aged Native American woman
ANS: D The highest incidence of diabetes in the United States occurs in Native Americans. With age, the incidence of diabetes increases in all races and ethnic groups.
13. 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.
ANS: D The increased need for a rapid-acting bronchodilator should alert the patient that an acute attack may be imminent and that a change in therapy may be needed. The patient should be taught to contact a health care provider if this occurs. The other data do not indicate any need for additional teaching. DIF: Cognitive Level: Apply (application) REF: 482 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
An infant has been hospitalized with a severe lung infection caused by the respiratory syncytial virus (RSV) and will be receiving medication via the inhalation route. The nurse expects which drug to be used? a. Acyclovir (Zovirax) b. Ganciclovir (Cytovene) c. Amantadine (Symmetrel) d. Ribavirin (Virazole)
ANS: D The inhalational form of ribavirin (Virazole) is used primarily in the treatment of hospitalized infants with severe lower respiratory tract infections caused by RSV. The other drugs listed are not used for the treatment of RSV.
A 25-year-old female is diagnosed with a urinary tract infection. When the nurse checks the culture results, which of the following organisms is most likely infecting her urinary tract? a. Streptococcus b. Candida albicans c. Chlamydia d. Escherichia coli
ANS: D The most common infecting microorganisms are uropathic strains of Escherichia coli. Urinary tract infections are not associated with Streptococcus, Candida albicans, or Chlamydia. REF: p. 754
A 44-year-old female patient with Cushing syndrome is admitted for adrenalectomy. Which intervention by the nurse will be most helpful for a nursing diagnosis of disturbed body image related to changes in appearance? a. Reassure the patient that the physical changes are very common in patients with Cushing syndrome. b. Discuss the use of diet and exercise in controlling the weight gain associated with Cushing syndrome. c. Teach the patient that the metabolic impact of Cushing syndrome is of more importance than appearance. d. Remind the patient that most of the physical changes caused by Cushing syndrome will resolve after surgery.
ANS: D The most reassuring communication to the patient is that the physical and emotional changes caused by the Cushing syndrome will resolve after hormone levels return to normal postoperatively. Reassurance that the physical changes are expected or that there are more serious physiologic problems associated with Cushing syndrome are not therapeutic responses. The patient's physiological changes are caused by the high hormone levels, not by the patient's diet or exercise choices DIF: Cognitive Level: Apply (application) REF: 1177 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
2. The nurse is giving intravenous nitroglycerin to a patient who has just been admitted because of an acute myocardial infarction. Which statement is true regarding the administration of the intravenous form of this medication? a. The solution will be slightly colored green or blue. b. The intravenous form is given by bolus injection. c. It can be given in infusions with other medications. d. Non-polyvinylchloride (non-PVC) plastic intravenous bags and tubing must be used.
ANS: D The non-PVC infusion kits are used to avoid absorption and/or uptake of the nitrate by the intravenous tubing and bag and/or decomposition of the nitrate. The medication is given by infusion via an infusion pump and not with other medications. It is not given by bolus injection. If the parenteral solution is discolored blue or green, it should be discarded. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 372 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Safe and Effective Care Environment: Management of Care
What is the partial pressure of oxygen in the lung given the following conditions? Percentage of oxygen in air: 20 Barometric pressure: 700 mm Hg a. 111 mm Hg b. 124 mm Hg c. 131 mm Hg d. 140 mm Hg
ANS: D The partial pressure of oxygen is equal to the percentage of oxygen in the air, 20, times the total pressure (700 mm Hg), or 140 mm Hg (700 ´ 0.20 = 140)
An older male presents with flank pain and polyuria. Tests reveal that he has an enlarged prostate. Which type of renal failure is this patient at risk for? a. Prerenal b. Intrarenal c. Extrarenal d. Postrenal
ANS: D The patient will experience postrenal renal failure due to obstruction by the prostate. REF: p. 762
An athletic activity the nurse should recommend for a school-age child with pulmonary-artery hypertension is A. Cross-country running. B. Soccer. C. Golf. D. Basketball.
C
A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurse's 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.
ANS: D The patient's symptoms indicate a possible acute hemolytic reaction caused by the transfusion. The first action should be to disconnect the transfusion and infuse normal saline. The other actions also are needed but are not the highest priority. DIF: Cognitive Level: Analyze (analysis) REF: 650 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
The pressure required to inflate an alveolus is inversely related to: a. wall thickness. b. surface tension. c. minute volume. d. alveolar radius.
ANS: D The radius of the alveoli is inversely related to the pressure required to inflate it. The pressure required is not associated with wall thickness, surface tension, or minute volume.
A patient involved in a motor vehicle accident experiences a severe head injury and dies as a result of the loss of respirations. The nurse suspects the area of the brain most likely damaged is the: a. cerebral cortex. b. thalamus. c. basal ganglia. d. brainstem.
ANS: D The respiratory center in the brainstem controls respiration by transmitting impulses to the respiratory muscles, causing them to contract and relax. Respirations are not controlled by the cerebral cortex, the thalamus, or the basal ganglia.
21. Using the illustrated technique, the nurse is assessing for which finding in a patient with chronic obstructive pulmonary disease (COPD)? a. Hyperresonance b. Tripod positioning c. Accessory muscle use d. Reduced chest expansion
ANS: D The technique for palpation for chest expansion is shown in the illustrated technique. Reduced chest movement would be noted on palpation of a patients chest with COPD. Hyperresonance would be assessed through percussion. Accessory muscle use and tripod positioning would be assessed by inspection. DIF: Cognitive Level: Understand (comprehension) REF: 486 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
2. A 35-year-old male weighs 70 kg. Approximately how much of this weight is ICF? a. 5 L b. 10 L c. 28 L d. 42 L
ANS: D The total volume of body water for a 70-kg person is about 42 L. 5 L is incorrect because a 70-kg person has about 42 L of body water. 10 L is incorrect because a 70-kg person has about 42 L of body water. 28 L is incorrect because a 70-kg person has about 42 L of body water.
2. 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
ANS: D The upright position with the arms supported increases lung expansion, allows fluid to collect at the lung bases, and expands the intercostal space so that access to the pleural space is easier. The other positions would increase the work of breathing for the patient and make it more difficult for the health care provider performing the thoracentesis. DIF: Cognitive Level: Apply (application) REF: 492 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
19. The laboratory has just called with the arterial blood gas (ABG) results on four patients. Which result is most 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
ANS: D These ABGs indicate uncompensated respiratory acidosis and should be reported to the health care provider. The other values are normal or close to normal. DIF: Cognitive Level: Apply (application) REF: 479 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
A patient has been prescribed warfarin (Coumadin) in addition to a heparin infusion. The patient asks the nurse why he has to be on two medications. The nurse's response is based on which rationale? a. The oral and injection forms work synergistically. b. The combination of heparin and an oral anticoagulant results in fewer adverse effects than heparin used alone. c. Oral anticoagulants are used to reach an adequate level of anticoagulation when heparin alone is unable to do so. d. Heparin is used to start anticoagulation so as to allow time for the blood levels of warfarin to reach adequate levels.
ANS: D This overlap therapy is required in patients who have been receiving heparin for anticoagulation and are to be switched to warfarin so that prevention of clotting is continuous. This overlapping is done purposefully to allow time for the blood levels of warfarin to rise, so that when the heparin is eventually discontinued, therapeutic anticoagulation levels of warfarin will have been achieved. Recommendations are to continue overlap therapy of the heparin and warfarin for at least 5 days; the heparin is stopped after day 5 when the international normalized ratio (INR) is above 2. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 417 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
5. 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.
ANS: D 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 pneumothorax or atelectasis. The vibration is increased in conditions such as pneumonia, lung tumors, thick bronchial secretions, and pleural effusion. Turning, coughing, and deep breathing is an appropriate intervention for atelectasis, 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. DIF: Cognitive Level: Apply (application) REF: 486 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
9. What action is often recommended to help reduce tolerance to transdermal nitroglycerin therapy? a. Omit a dose once a week. b. Leave the patch on for 2 days at a time. c. Cut the patch in half for 1 week until the tolerance subsides. d. Remove the patch at bedtime, and then apply a new one in the morning.
ANS: D To prevent tolerance, remove the transdermal patch at night for 8 hours, and apply a new patch in the morning. Transdermal patches must never be cut or left on for 2 days, and doses must not be omitted. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 365 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
A patient who has had chest pain for several hours is admitted with a diagnosis of rule out acute myocardial infarction (AMI). Which laboratory test should the nurse monitor to best determine whether the patient has had an AMI? a. Myoglobin c. C-reactive protein b. Homocysteine d. Cardiac-specific troponin
ANS: D Troponin levels increase about 4 to 6 hours after the onset of myocardial infarction (MI) and are highly specific indicators for MI. Myoglobin is released within 2 hours of MI, but it lacks specificity and its use is limited. The other laboratory data are useful in determining the patient's risk for developing coronary artery disease but are not helpful in determining whether an acute MI is in progress. DIF: Cognitive Level: Understand (comprehension)
The nurse is working with a graduate nurse to prepare an intravenous dose of potassium. Which statement by the graduate nurse reflects a need for further teaching?" a "We will need to monitor this infusion closely." b "The infusion rate should not go over 10 mEq/hr." c "The intravenous potassium will be diluted before we give it." d "The intravenous potassium dose will be given undiluted."
ANS: D When giving intravenous potassium, the medication must always be given in a diluted form and administered slowly. Intravenous bolus or undiluted forms may cause cardiac arrest. Intravenous rates are not to exceed 10 mEq/hr unless the patient is on a cardiac monitor. Oral forms should be mixed with juice or water or taken according to instructions.
The nurse assesses a patient on the second postoperative day after abdominal surgery to repair a perforated duodenal ulcer. Which finding is most important for the nurse to report to the surgeon? a. Tympanic temperature 99.2° F (37.3° C) b. Fine crackles audible at both lung bases c. Redness and swelling along the suture line d. 200 mL sanguineous fluid in the wound drain
ANS: D Wound drainage should decrease and change in color from sanguineous to serosanguineous by the second postoperative day. The color and amount of drainage for this patient are abnormal and should be reported. Redness and swelling along the suture line and a slightly elevated temperature are normal signs of postoperative inflammation. Atelectasis is common after surgery. The nurse should have the patient cough and deep breathe, but there is no urgent need to notify the surgeon
34. A patient with pneumonia has a fever of 101.4° F (38.6° C), a nonproductive cough, and an O2 saturation of 88%. The patient is weak and needs assistance to get out of bed. Which patient problem should the nurse assign as the priority? a. Fatigue b. Hyperthermia c. Impaired mobility d. Impaired gas exchange
ANS: D All these problems are appropriate for the patient, but the patient's O2 saturation indicates that all body tissues are at risk for hypoxia unless the gas exchange is improved.
33. A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the health care provider? a. The Mantoux test had an induration of 7 mm. b. The chest x-ray showed infiltrates in the lower lobes. c. The patient has a cough that is productive of blood-tinged mucus. d. The patient is being treated with antiretrovirals for HIV infection.
ANS: D Drug interactions can occur between the antiretrovirals used to treat HIV infection and the medications used to treat TB. The other data are expected in a patient with HIV and TB.
The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate? a. Avoid using friction when cleaning around the CVAD insertion site. b. Use the push-pause method to flush the CVAD after giving medications. c. Obtain an order from the health care provider to change CVAD dressing. d. Position the patient's face toward the CVAD during injection cap changes.
B. Use the push-pause method to flush the CVAD after giving medications. The push-pause enhances the removal of debris from the CVAD lumen and decreases the risk for clotting.
46. Which intervention will the nurse include in the plan of care for a patient who is diagnosed with a lung abscess? a. Assist the patient with chest physiotherapy and postural drainage. b. Teach the patient to avoid the use of over-the-counter expectorants. c. Notify the health care provider immediately about any bloody or foul-smelling sputum. d. Teach about the need for prolonged antibiotic therapy after discharge from the hospital.
ANS: D Long-term antibiotic therapy is needed for effective eradication of the infecting organisms in lung abscess. Chest physiotherapy and postural drainage are not recommended for lung abscess because they may lead to spread of the infection. Foul-smelling and bloody sputum are common clinical manifestations in lung abscess. Expectorants may be used because the patient is encouraged to cough.
35. The nurse supervises unlicensed assistive personnel (UAP) providing care for a patient who has right lower lobe pneumonia. Which action by the UAP requires the nurse to intervene? a. UAP assists the patient to ambulate to the bathroom. b. UAP helps splint the patient's chest during coughing. c. UAP transfers the patient to a bedside chair for meals. d. UAP lowers the head of the patient's bed to 15 degrees.
ANS: D Positioning the patient with the head of the bed lowered will decrease ventilation. The other actions are appropriate for a patient with pneumonia
47. The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which patient statement indicates that teaching has been effective? a. "I am going to buy a rib binder to wear during the day." b. "I can take shallow breaths to prevent my chest from hurting." c. "I should plan on taking the pain pills only at bedtime so I can sleep." d. "I will use the incentive spirometer every hour or two during the day."
ANS: D Prevention of the complications of atelectasis and pneumonia is a priority after rib fracture. This can be ensured by deep breathing and coughing. Use of a rib binder, shallow breathing, and taking pain medications only at night are likely to result in atelectasis.
8. A patient is hospitalized with active tuberculosis (TB). Which assessment finding indicates to the nurse that prescribed airborne precautions are likely to be discontinued? a. Chest x-ray shows no upper lobe infiltrates. b. TB medications have been taken for 6 months. c. Mantoux testing shows an induration of 10 mm. d. Sputum smears for acid-fast bacilli are negative.
ANS: D Repeated negative sputum smears indicate that M. tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route. Chest x-rays are not used to determine whether treatment has been successful. Taking medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Repeat Mantoux testing would not be done because the result will not change even with effective treatment.
39. A patient is admitted to the emergency department with an open stab wound to the left chest. What action should the nurse take? a. Keep the head of the patient's bed positioned flat. b. Cover the wound tightly with an occlusive dressing. c. Position the patient so that the left chest is dependent. d. Tape a nonporous dressing on three sides over the wound.
ANS: D The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the patient on the left side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The head of the bed should be elevated to 30 to 45 degrees to facilitate breathing.
36. A patient with a possible pulmonary embolism reports chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, and respirations of 42 breaths/min. Which action should the nurse take first? a. Administer anticoagulant drug therapy. b. Notify the patient's health care provider. c. Prepare patient for a spiral computed tomography (CT). d. Elevate the head of the bed to a semi-Fowler's position.
ANS: D The patient has symptoms consistent with a pulmonary embolism (PE). Elevating the head of the bed will improve ventilation and gas exchange. The other actions can be performed after the head is elevated and O2 is started. The health care provider may order a spiral CT to identify PE. Anticoagulants may be ordered after confirmation of the diagnosis of PE.
23. The emergency department nurse notes tachycardia and absent breath sounds over the right thorax of a patient who has just arrived after an automobile accident. For which intervention will the nurse prepare the patient? a. Emergency pericardiocentesis b. Stabilization of the chest wall c. Bronchodilator administration d. Chest tube connected to suction
ANS: D The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage to suction. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patient's clinical manifestations are not consistent with these problems.
3. The nurse is teaching a group of patients about self-administration of insulin. What content is important to include? a. Patients need to use the injection site that is the most accessible. b. If two different insulins are ordered, they need to be given in separate injections. c. When mixing insulins, the cloudy (such as NPH) insulin is drawn up into the syringe first. d. When mixing insulins, the clear (such as regular) insulin is drawn up into the syringe first.
ANS: D If mixing insulins in one syringe, the clear (regular) insulin is always drawn up in to the syringe first. Patients always need to rotate injection sites. Mixing of insulins may be ordered. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 527 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
18. The nurse is teaching a review class to nurses about diabetes mellitus. Which statement by the nurse is correct? a. "Patients with type 2 diabetes will never need insulin." b. "Oral antidiabetic drugs are safe for use during pregnancy." c. "Pediatric patients cannot take insulin." d. "Insulin therapy is possible during pregnancy if managed carefully."
ANS: D Oral medications are generally not recommended for pregnant patients because of a lack of firm safety data. For this reason, insulin therapy is the only currently recommended drug therapy for pregnant women with diabetes. Insulin is given to pediatric patients, with extreme care. Patients with type 2 diabetes may require insulin in certain situations or as their disease progresses. DIF: COGNITIVE LEVEL: Applying (Application) REF: pp. 517-518 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
8. The nurse is teaching patients about self-injection of insulin. Which statement is true regarding injection sites? a. Avoid the abdomen because absorption there is irregular. b. Choose a different site at random for each injection. c. Give the injection in the same area each time. d. Rotate sites within the same location for about 1 week before rotating to a new location.
ANS: D Patients taking insulin injections need to be instructed to rotate sites, but to do so within the same location for about 1 week (so that all injections are rotated in one area—for example, the right arm—before rotating to a new location, such as the left arm). Also, each injection needs to be at least to 1 inch away from the previous site. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 528 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
20. When teaching a patient who is starting metformin (Glucophage), which instruction by the nurse is correct? a. "Take metformin if your blood glucose level is above 150 mg/dL." b. "Take this 60 minutes after breakfast." c. "Take the medication on an empty stomach 1 hour before meals." d. "Take the medication with food to reduce gastrointestinal (GI) effects."
ANS: D The GI adverse effects of metformin can be reduced by administering it with meals. The other options are incorrect. DIF: COGNITIVE LEVEL: Analyzing (Analysis) REF: p. 520 TOP: NURSING PROCESS: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
While a patient is receiving antilipemic therapy, the nurse knows to monitor the patient closely for the development of which problem? a. Neutropenia b. Pulmonary problems c. Vitamin C deficiency d. Liver dysfunction
ANS: D Antilipemic drugs may adversely affect liver function; therefore, liver function studies need to be closely monitored. The other options do not reflect problems that may occur with antilipemic drugs
The nurse is conducting a class about antilipemic drugs. The antilipemic drug ezetimibe (Zetia) works by which mechanism? a. Inhibiting HMG-CoA reductase b. Preventing resorption of bile acids from the small intestines c. Activating lipase, which breaks down cholesterol d. Inhibiting cholesterol absorption in the small intestine
ANS: D Ezetimibe selectively inhibits absorption in the small intestine of cholesterol and related sterols. The other options are incorrect
A patient with risk factors for coronary artery disease asks the nurse about the "good cholesterol" laboratory values. The nurse knows that "good cholesterol" refers to which lipids? a. Triglycerides b. Low-density lipoproteins (LDLs) c. Very-low-density lipoproteins (VLDLs) d. High-density lipoproteins (HDLs)
ANS: D HDLs are responsible for the "recycling" of cholesterol. HDLs are sometimes referred to as the "good" lipid (or good cholesterol) because they are believed to be cardioprotective. LDLs are known as the "bad" cholesterol
The health care provider orders a liver and spleen scan for a patient who has been in a motor vehicle crash. Which action should the nurse take before this procedure? a. Check for any iodine allergy. b. Insert a large-bore IV catheter. c. Administer prescribed sedatives. d. Assist the patient to a flat position.
ANS: D. Assist the patient to a flat position. During a liver and spleen scan, a radioactive isotope is injected IV, and images from the radioactive emission are used to evaluate the structure of the spleen and liver. An indwelling IV catheter and sedation are not needed. The patient is placed in a flat position before the scan.
The nurse is caring for a patient who is being discharged after an emergency splenectomy following a motor vehicle crash. Which instructions should the nurse include in the discharge teaching? a. Check often for swollen lymph nodes. b. Watch for excess bleeding or bruising. c. Take iron supplements to prevent anemia. d. Wash hands and avoid persons who are ill.
ANS: D. Wash hands and avoid persons who are ill. Splenectomy increases the risk for infection, especially with gram-positive bacteria. The risks for lymphedema, bleeding, and anemia are not increased after a person has a splenectomy.
A nurse reviews the laboratory data for an older patient. The nurse would be most concerned about which finding? a. Hematocrit of 35% b. Hemoglobin of 11.8 g/dL c. Platelet count of 400,000/µL d. White blood cell (WBC) count of 2800/µL
ANS: D. White blood cell (WBC) count of 2800/µL Because the total WBC count is not usually affected by aging, the low WBC count in this patient would indicate that the patient's immune function may be compromised and the underlying cause of the problem needs to be investigated. The platelet count is normal. The slight decrease in hemoglobin and hematocrit are not unusual for an older patient.
A patient is admitted to the intensive care unit with a closed head injury sustained in a motorcycle accident. The injury has caused severe damage to the posterior pituitary. Which of the following complications should the nurse anticipate? a. Dilutional hyponatremia b. Dehydration from polyuria c. Cardiac arrest from hyperkalemia d. Metabolic acidosis
B - Diabetes insipidus is a well-recognized complication of closed head injury and is manifested by polyuria leading to dehydration. The patient will experience hypernatremia, not hyponatremia. Electrolytes other than sodium are typically not affected with diabetes insipidus. Acidosis is not associated with diabetes insipidus.
Common nonspecific manifestations that may alert the nurse to endocrine dysfunction include a. goiter and alopecia. b. exophthalmos and tremors. c. weight loss, fatigue, and depression. d. polyuria, polydipsia, and polyphagia.
C
While planning care for a patient from general anesthesia, which principle should the nurse remember? A side effect of some general anesthetic agents is _____ diabetes insipidus. a. neurogenic b. nephrogenic c. psychogenic d. allogenic
B - General anesthetics can lead to nephrogenic diabetes insipidus (DI). General anesthetics are not associated with any of the other forms of DI.
During the admission process, the nurse obtains information about a patient through the physical assessment and diagnostic testing. Based on the data shown in the accompanying figure, which nursing diagnosis is appropriate? a. Deficient fluid volume b. Impaired gas exchange c. Risk for injury: Seizures d. Risk for impaired skin integrity
C
While observing a patient self-administer enoxaparin (Lovenox), the nurse identifies the need for further teaching when the patient performs which self-injection action? a. Does not aspirate before injecting the medication b. Massages the site after administration of the medication c. Administers the medication into subcutaneous (fatty) tissue d. Injects the medication greater than 2 inches away from the umbilicus
B
Individuals with Raynaud disease need to be counseled to avoid which of the following conditions to prevent severe symptoms? a. Allergic reactions b. Cold exposure c. Hot water immersion d. Tissue injury
B. Cold exposure Raynaud disease demonstrates symptoms when extremities are exposed to cold. It is not an allergic reaction, and it is not due to hot water immersion or tissue injury.
A nurse is caring for a 14 year-old child who has been diagnosed with Congestive Heart Failure (CHF). Treatment began 3 days ago and has included digoxin and furosemide. The child no longer has retractions, lungs are clear and equal bilaterally, and heart rate is 70 beats per minute while the child sleeps. The nurse is confident that the child has diuresed successfully and has good renal perfusion when the nurse notes that the child's urine output is A. 0.4 mL/kg/hr B. 1 mL/kg/hr C. 2 mL/kg/hr D. 3 mL/kg/hr E. 30 mL/hr F. 1 ounce/hr
B
The nurse is explaining to a student nurse about impaired central perfusion. The nurse knows the student understands this problem when the student makes which statement? a. "Central perfusion is monitored only by the physician." b. "Central perfusion involves the entire body." c. "Central perfusion is decreased with hypertension." d. "Central perfusion is toxic to the cardiac system."
B
The nurse is giving discharge instructions to a patient prescribed warfarin (Coumadin) for atrial fibrillation. Which statement by the patient indicates a need for further instruction from the nurse? a. "I will take my medication in the early evening each day." b. "I will increase the dark green leafy vegetables in my diet." c. "I will contact my health care provider if I develop excessive bruising." d. "I will avoid activities that have a risk for injury such as contact sports."
B
The nurse is preparing a patient with acute chest pain for an emergency angioplasty. The nurse would anticipate administering which medication to prevent platelet aggregation? a. Warfarin (Coumadin) b. Tirofiban (Aggrastat) c. Aminocaproic acid (Amicar) d. Protamine (Protamine sulfate)
B
The nurse is teaching the parents of a group of cardiac patients. The nurse includes in the information that a child who has undergone cardiac surgery A. Should be restricted from most play activities. B. Should be evaluated to determine if prophylactic antibiotics for dental, oral, or upper-respiratory-tract procedures are necessary. C. Should not receive routine immunizations. D. Can be expected to have a fever for several weeks following the surgery.
B
The patient is brought to the emergency department after a motor vehicle accident. The patient is diagnosed with internal bleeding. What is the priority of care for this patient? a. Mental alertness b. Perfusion c. Pain d. Reaction to medications
B
What manifestations of endocrine problems in the older adult are commonly attributed to the aging process? a. Tremors and paresthesias b. Fatigue and mental impairment c. Hyperpigmentation and oily skin d. Fluid retention and hypertension
B
Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Administer IV antibiotics through the implantable port. b. Monitor the IV sites for redness, swelling, or tenderness. c. Remove the patient's nontunneled subclavian central venous catheter. d. Adjust the flow rate of the 0.9% normal saline in the peripheral IV line.
B
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. Teach the patient signs of hypoglycemia. b. Have the patient add dietary salt to meals. c. Suggest decreasing intake of dietary fat and calories. d. Instruct the patient about pancreatic enzyme replacements.
B 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) administered before 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) must be supplemented because they are malabsorbed. Use of caloric supplements improves nutritional status. Hyperglycemia caused by pancreatic insufficiency is more likely to occur than hypoglycemia.
A 34 y/o has a new diagnosis of type 2 diabetes. The nurse will discuss the need to schedule a dilated eye exam a) every 2 years b) as soon as possible c) when the patient is 39 years old d) within the first year after diagnosis
B Because many patients have some diabetic retinopathy when they are first diagnosed w/ type 2 diabetes, a dilated eye exam is recommended at the time of diagnosis and annually thereafter.
After change-of-shift report, which patient should the nurse assess first? a) 19 y/o w/ type 1 diabetes who has an A1C of 12% b) 23 y/o w/ type 1 diabetes who has a blood glucose of 40 mg/dL c) 40 y/o who is pregnancy and whose oral glucose tolerance test is 202 mg/dL d) 50 y/o who uses exenatide (Byetta) and is complaining of acute abdominal pain
B Because the brain requires glucose to function, untreated hypoglycemia can cause unconsciousness, seizures, and death.
The nurse is preparing to teach a 43 y/o man who is newly diagnosed w/ type 2 diabetes about home management of the disease. Which action should the nurse take first? a) Ask the patient's family to participate in the diabetes education program b) Assess the patient's perception of what it means to have DM c) Demonstrate how to check glucose using capillary blood glucose monitoring d) Discuss the need for the patient to actively participate in diabetes management
B Before planning teaching, the nurse should assess the patient's interest in and ability to self-manage the diabetes.
Which patient action indicates good understanding of the nurse's teaching about administration of aspart (NovoLog) insulin? a) The patient avoids injecting the insulin into the upper abdominal area b) The patient cleans the skin w/ soap and water before insulin administration c) The patient stores the insulin in the freezer after administering the prescribed dose d) The patient pushes the plunger down while removing the syringe from the injection site
B Cleaning the skin w/ soap and water or w/ alcohol is acceptable.
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 High-calorie foods such as ice cream are an appropriate snack for patients with COPD. Fluid intake of 3 L/day is recommended, but fluids should be taken between meals rather than with meals to improve oral intake of solid foods. The patient should avoid exercise for an hour before meals to prevent fatigue while eating. Meat and dairy products are high in protein and are good choices for the patient with COPD.
The nurse is taking a health history from a 29 y/o pregnant patient at the first prenatal visit. The patient reports no personal history of diabetes but has a parent who is diabetic. Which action will the nurse plan to take first? a) Teach the patient about administering regular insulin b) Schedule the patient for a fasting blood glucose level c) Discuss an oral glucose test for the 24th week of pregnancy d) Provide teaching about an increased risk for fetal problems w/ gestational diabetes
B Patients at high risk for gestational diabetes should be screened for diabetes on the initial prenatal visit.
Which action should the nurse take after a 36 y/o patient treated w/ intramuscular glucagon for hypoglycemia regains consciousness? a) Assess the patient for symptoms of hyperglycemia b) Give the patient a snack of peanut butter and crackers c) Have the patient drink a glass of orange juice or nonfat milk d) Administer a continuous infusion of 5% dextrose for 24 hours
B Rebound hypoglycemia can occur after glucagon administration, but having a meal containing complex carbohydrates plus protein and fat will help prevent hypoglycemia.
Which lab value reported to the nurse by the UAP indicates the most urgent need for the nurse's assessment of the patient? a) Bedtime glucose of 140 mg/dL b) Noon blood glucose of 52 mg/dL c) Fasting blood glucose of 130 mg/dL d) 2hr postprandial glucose of 220 mg/dL
B The nurse should assess the patient w/ a blood glucose level of 52 mg/dL for symptoms of hypoglycemia and give the patient a carb-containing beverage such as orange juice.
The nurse identifies a need for additional teaching when the patient who is self-monitoring blood glucose a) washes the puncture site using warm water and soap b) choose a puncture site in the center of the finger pad c) hangs the arm down for a minutes before puncturing the site d) says the result of 120 mg indicates good blood sugar control
B The patient is taught to choose a puncture site at the side of the finger pad because there are fewer nerve endings along the side of the finger pad.
Which information will the nurse include when teaching a 50 y/o patient who has type 2 diabetes about glyburide? a) Glyburide decreases glucagon secretion from the pancreas b) Glyburide stimulates insulin production and release from the pancreas c) Glyburide should be taken even if the morning blood glucose level is low d) Glyburide should not be used for 48 hours after receiving IV contrast media
B The sulfonylureas stimulate the production and release of insulin from the pancreas.
An active 28 y/o male w/ type 1 diabetes is being seen in the endocrine clinic. Which finding may indicate the need for a change in therapy? a) A1C level 6.2% b) BP 146/88 mmHg c) HR at rest 58 bpm d) HDL level of 65 mg/dL
B To decrease the incidence of macrovascular and microvascular problems in patients w/ diabetes, the goal BP is usually 130/80.
A diabetic patient who has reported burning foot pain at night receives a new prescription. Which information should the nurse teach the patient about amitriptyline (Elavil)? a) It decreases the depression caused by your foot pain b) It helps prevent transmission of pain impulses to the brain c) It corrects some of the blood vessel changes that cause pain d) It improves sleep and makes you less aware of nighttime pain
B Tricyclic antidepressants decrease the transmission of pain impulses to the spinal cord and brain.
The nurse receives a change-of-shift report on the following patients with chronic obstructive pulmonary disease (COPD). Which patient should the nurse assess first? a. A patient with loud expiratory wheezes b. A patient with a respiratory rate of 38 breaths/min c. A patient who has a cough productive of thick, green mucus d. A patient with jugular venous distention and peripheral edema
B A respiratory rate of 38/min indicates severe respiratory distress, and the patient needs immediate assessment and intervention to prevent possible respiratory arrest. The other patients also need assessment as soon as possible, but they do not need to be assessed as urgently as the patient with tachypnea.
A patient with chronic obstructive pulmonary disease (COPD) has coarse crackles throughout the lung fields and a chronic, nonproductive cough. Which nursing intervention will be most effective? a. Change the O2 flow rate to the highest prescribed rate. b. Teach the patient to use the Flutter airway clearance device. c. Reinforce the ongoing use of pursed-lip breathing techniques. d. Teach the patient about consistent use of inhaled corticosteroids.
B Airway clearance devices assist with moving mucus into larger airways, where it can more easily be expectorated. The other actions may be appropriate for some patients with COPD, but they are not indicated for this patient's problem of thick mucus secretions.
The nurse reviews the medication administration record (MAR) for a patient having an acute asthma attack. Which medication should the nurse administer first? a. Methylprednisolone (Solu-Medrol) 60 mg IV b. Albuterol (Ventolin HFA) 2.5 mg per nebulizer c. Salmeterol (Serevent) 50 mcg per dry-powder inhaler (DPI) d. Ipratropium (Atrovent) 2 puffs per metered-dose inhaler (MDI)
B Albuterol is a rapidly acting bronchodilator and is the first-line medication to reverse airway narrowing in acute asthma attacks. The other medications work more slowly.
A patient with a possible pituitary adenoma is scheduled for a computed tomography (CT) scan with contrast media. Which patient information is important for the nurse to communicate to the health care provider before the test? a. Bilateral poor peripheral vision b. Allergies to iodine and shellfish c. Recent weight loss of 20 lb d. Complaint of ongoing headaches
B Because the usual contrast media is iodine-based, the health care provider will need to know about the allergy before the CT scan. The other findings are common with any mass in the brain such as a pituitary adenoma.
Which information about a patient who is scheduled for an oral glucose tolerance test should be reported to the health care provider before starting the test? a. The patient reports having occasional orthostatic dizziness. b. The patient takes oral corticosteroids for rheumatoid arthritis. c. The patient has had a 10-lb weight gain in the last month. d. The patient drank several glasses of water an hour previously.
B Corticosteroids can affect blood glucose results. The other information will be provided to the health care provider but will not affect the test results.
A patient seen in the emergency department for severe headache and acute confusion has a serum sodium level of 118 mEq/L. The nurse will anticipate the need for which diagnostic test? a. Urinary 17-ketosteroids b. Antidiuretic hormone level c. Growth hormone stimulation test d. Adrenocorticotropic hormone level
B Elevated levels of antidiuretic hormone will cause water retention and decrease serum sodium levels. The other tests would not be helpful in determining possible causes of the patient's hyponatremia.
Which assessment finding in a patient who has received omalizumab (Xolair) is most important to report immediately to the health care provider? a. Pain at injection site b. Flushing and dizziness c. Peak flow reading 75% of normal d. Respiratory rate 24 breaths/minute
B Flushing and dizziness may indicate that the patient is experiencing an anaphylactic reaction, and immediate intervention is needed. The other information should also be reported, but do not indicate possibly life-threatening complications of omalizumab therapy.
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. Absence of wheezes or crackles d. Respiratory rate of 18 breaths/min
B For the nursing diagnosis of impaired gas exchange, the best data for evaluation are arterial blood gases (ABGs) or pulse oximetry. The other data may indicate either improvement or impending respiratory failure caused by fatigue.
A patient with chronic obstructive pulmonary disease (COPD) has poor gas exchange. Which action by the nurse would support the patient's ventilation? a. Have the patient rest in bed with the head elevated to 15 to 20 degrees. b. Encourage the patient to sit up at the bedside in a chair and lean forward. c. Ask the patient to rest in bed in a high-Fowler's position with the knees flexed. d. Place the patient in the Trendelenburg position with pillows behind the head.
B Patients with COPD improve the mechanics of breathing by sitting up in the "tripod" position. Resting in bed with the head elevated in a semi-Fowler's position would be an alternative position if the patient was confined to bed, but sitting in a chair allows better ventilation. The Trendelenburg position or sitting upright in bed with the knees flexed would decrease the patient's ability to ventilate well.
The home health nurse is visiting a patient with chronic obstructive pulmonary disease (COPD). Which nursing action is appropriate to implement for a nursing diagnosis of impaired breathing pattern related to anxiety? a. Titrate O2 to keep saturation at least 90%. b. Teach the patient how to use pursed-lip breathing. c. Discuss a high-protein, high-calorie diet with the patient. d. Suggest the use of over-the-counter sedative medications.
B Pursed-lip breathing techniques assist in prolonging the expiratory phase of respiration and decrease air trapping. There is no indication that the patient requires O2 therapy or an improved diet. Sedative medications should be avoided because they decrease respiratory drive.
An 11-year-old is newly diagnosed with type 1 DM. Which classic symptoms should the nurse assess the patient for? a. Recurrent infections, visual changes, fatigue, and paresthesia b. Polydipsia, polyuria, polyphagia, and weight loss c. Vomiting, abdominal pain, sweet, fruity breath, dehydration, and Kussmaul breathing d. Weakness, vomiting, hypotension, and mental confusion
B - Classic symptoms of type 1 DM include polydipsia, polyuria, polyphagia, and weight loss. Recurrent infections and visual changes are complications of diabetes. Vomiting, abdominal pain, and sweet breath are signs of diabetic ketoacidosis. Weakness, hypotension, and mental confusion are signs of hypoglycemia.
The nurse is caring for a patient with cor pulmonale. The nurse should monitor the patient for which expected finding? a. Chest pain c. Peripheral edema b. Finger clubbing d. Elevated temperature
C Cor pulmonale causes clinical manifestations of right ventricular failure, such as peripheral edema. The other clinical manifestations may occur in the patient with other complications of chronic obstructive pulmonary disease but are not indicators of cor pulmonale.
A patient has been newly diagnosed with type 2 diabetes mellitus. Which information about the patient will be most useful to the nurse who is helping the patient develop strategies for successful adaptation to this disease? a. Ideal weight b. Value system c. Activity level d. Visual changes
B When dealing with a patient with a chronic condition such as diabetes, identification of the patient's values and beliefs can assist the interprofessional team in choosing strategies for successful lifestyle change. The other information also will be useful but is not as important in developing an individualized plan for the necessary lifestyle changes.
A patient is receiving 35% O2 via a Venturi mask. To ensure the correct amount of O2 delivery, which action by the nurse is important? a. Teach the patient to keep the mask on during meals. b. Keep the air entrainment ports clean and unobstructed. c. Give a high enough flow rate to keep the bag from collapsing. d. Drain moisture condensation from the corrugated tubing every hour.
B The air entrainment ports regulate the O2 percentage delivered to the patient, so they must be unobstructed. The other options refer to other types of O2 devices. A high O2 flow rate is needed when giving O2by partial rebreather or nonrebreather masks. Draining O2 tubing is necessary when caring for a patient receiving mechanical ventilation. The mask can be removed or changed to a nasal cannula at a prescribed setting when the patient eats.
The nurse is admitting a patient diagnosed with an acute exacerbation of chronic obstructive pulmonary disease (COPD). How should the nurse determine the appropriate O2 flow rate? a. Minimize O2 use to avoid O2 dependency. b. Maintain the pulse oximetry level at 90% or greater. c. Administer O2 according to the patient's level of dyspnea. d. Avoid administration of O2 at a rate of more than 2 L/min.
B The best way to determine the appropriate O2 flow rate is by monitoring the patient's oxygenation either by arterial blood gases (ABGs) or pulse oximetry. An O2 saturation of 90% indicates adequate blood O2 level without the danger of suppressing the respiratory drive. For patients with an exacerbation of COPD, an O2 flow rate of 2 L/min may not be adequate. Because O2 use improves survival rate in patients with COPD, there is no concern about O2 dependency. The patient's perceived dyspnea level may be affected by other factors (e.g., anxiety) besides blood O2 level.
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. O2saturation is >90%. c. Accessory muscle use has decreased. d. Respiratory rate is 16 breaths/minute.
B The goal for treatment of an asthma attack is to keep the O2 saturation above 90%. The other patient data may occur when the patient is too fatigued to continue with the increased work of breathing required in an asthma attack.
A young adult female patient with cystic fibrosis (CF) tells the nurse that she is considering getting married and wondering about having children. Which initial response by the nurse is best? a. "Are you aware of the normal lifespan for patients with CF?" b. "Would like more 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 The nurse's initial response should be to assess the patient's knowledge level and need for information. Although the lifespan for patients with CF is likely to be shorter than normal, it would not be appropriate for the nurse to address this as the initial response to the patient's comments. The other responses have accurate information, but the nurse should first assess the patient's understanding about the issues surrounding pregnancy.
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 rapidly inhales the medication. c. The patient attaches a spacer to the Diskus. d. The patient performs huff coughing after inhalation.
B The patient should inhale the medication rapidly. Otherwise the dry particles will stick to the tongue and oral mucosa and not get inhaled into the lungs. Advair Diskus is a dry powder inhaler; shaking is not recommended. Spacers are not used with dry powder inhalers. Huff coughing is a technique to move mucus into larger airways to expectorate. The patient should not huff cough or exhale forcefully after taking Advair in order to keep the medication in the lungs.
The nurse teaches a patient about pursed-lip breathing. Which action by the patient would indicate to the nurse that further teaching is needed? a. The patient inhales slowly through the nose. b. The patient puffs up the cheeks while exhaling. c. The patient practices by blowing through a straw. d. The patient's ratio of inhalation to exhalation is 1:3.
B The patient should relax the facial muscles without puffing the cheeks while doing pursed-lip breathing. The other actions by the patient indicate a good understanding of pursed-lip breathing.
The clinic nurse makes a follow-up telephone call to a patient with asthma. The patient reports having a baseline peak flow reading of 600 L/min, and the current peak flow is 420 L/min. 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 (Ventolin HFA). c. Ask about recent exposure to any new allergens or asthma triggers. d. Question the patient about use of the prescribed inhaled corticosteroids.
B The patient's peak flow is 70% of normal, indicating a need for immediate use of short-acting b2 -adrenergic SABA medications. Assessing for correct use of medications or exposure to allergens is also appropriate, but would not address the current decrease in peak flow. Because the patient is currently in the yellow zone, hospitalization is not needed.
A patient with severe chronic obstructive pulmonary disease (COPD) tells the nurse, "I wish I were dead! I'm just a burden on everybody." Based on this information, which nursing diagnosis is most appropriate? a. Complicated grieving related to expectation of death b. Chronic low self-esteem related to physical dependence c. Ineffective coping related to unknown outcome of illness d. Deficient knowledge related to lack of education about COPD
B The patient's statement about not being able to do anything for himself or herself supports this diagnosis. Although deficient knowledge, complicated grieving, and ineffective coping may also be appropriate diagnoses for patients with COPD, the data for this patient do not support these diagnoses.
During the nurse's physical examination of a young adult, the patient's thyroid gland cannot be felt. The most appropriate action by the nurse is to a. palpate the patient's neck more deeply. b. document that the thyroid was nonpalpable. c. notify the health care provider immediately. d. teach the patient about thyroid hormone testing.
B The thyroid is frequently nonpalpable. The nurse should simply document the finding. There is no need to notify the health care provider immediately about a normal finding. There is no indication for thyroid-stimulating hormone (TSH) testing unless there is evidence of thyroid dysfunction. Deep palpation of the neck is not appropriate.
What is the purpose of the glycosylated hemoglobin (hemoglobin A1c) test? a. Measuring fasting glucose levels. b. Monitoring long-term serum glucose control. c. Detecting acute complications of diabetes. d. Checking for hyperlipidemia.
B - Glycosylated hemoglobin refers to the permanent attachment of glucose to hemoglobin molecules and reflects the average plasma glucose exposure over the life of a red blood cell (approximately 120 days). Glycosylated hemoglobin does not measure fasting, but rather glucose control over time. Glycosylated hemoglobin does not identify complications but could provide data if the patient is at risk. Glycosylated hemoglobin does not check for hyperlipidemia.
A 30-year-old diagnosed with Graves disease is admitted to a hospital unit for the surgical removal of the thyroid gland. During the postoperative period, the nurse notes that the patient's serum calcium is low. The nurse should observe the patient for which of the following signs/symptoms? a. Muscle weakness and constipation b. Laryngeal spasms and hyperreflexia c. Abdominal pain and fever d. Anorexia, nausea, and vomiting
B - Symptoms of low calcium are associated with tetany, a condition characterized by muscle spasms, hyperreflexia, tonic-clonic convulsions, and laryngeal spasms. Symptoms of low calcium are not associated with muscle weakness, constipation, abdominal pain, anorexia, nausea, or vomiting.
What common neurologic disturbances should the nurse assess for in a patient with a pituitary adenoma? a. Coma b. Visual disturbances c. Confused states d. Breathing abnormalities
B - The clinical manifestations of pituitary adenomas are visual changes including visual field impairments (often beginning in one eye and progressing to the other) and temporary blindness. Coma, confusion, and breathing abnormalities are not associated with pituitary adenomas.
What is the most common cause of elevated levels of antidiuretic hormone (ADH) secretion? a. Autoimmune disease b. Cancer c. Pregnancy d. Heart failure
B - The most common cause of elevated levels of ADH is cancer, not autoimmune disorders, pregnancy, or heart failure.
What causes the chronic microvascular and macrovascular complications of DM? a. Pancreatic changes b. Hyperglycemia c. Ketone toxicity d. Hyperinsulinemia
B - The underlying cause of the microvascular and macrovascular diseases is related to hyperglycemia, not pancreatic changes, ketone toxicity, or hyperinsulinemia.
Which physical feature supports the diagnosis of Cushing syndrome? a. Weight loss and muscle wasting b. Truncal obesity and moon face c. Pallor and swollen tongue d. Depigmented skin and eyelid lag
B - Weight gain is the most common feature and results from the accumulation of adipose tissue in the trunk, facial, and cervical areas. These characteristic patterns of fat deposition have been described as "truncal obesity," "moon face," and "buffalo hump." Weight gain, not loss, is the most common feature of Cushing syndrome. Pallor is not associated with Cushing syndrome. The skin of the patient with Cushing syndrome is bronze in color.
Which abnormal assessment findings are related to thyroid dysfunction (select all that apply)? a. Tetanic muscle spasms with hypofunction b. Heat intolerance caused by hyperfunction c. Exophthalmos associated with excessive secretion d. Hyperpigmentation associated with hypofunction e. A goiter with either hyperfunction or hypofunction f. Increase in hand and foot size associated with excessive secretion
B,C,E
A 10-year-old male presents with fever, lymphadenopathy, arthralgia, and nosebleeds and is diagnosed with rheumatic heart disease. While planning care, which characteristic changes should the nurse remember? a. Blood-borne organisms that adhere to the valvular surface. b. Antigens that bind to the valvular lining, triggering an autoimmune response. c. High fevers that damage collagen in valve leaflets. d. Rheumatoid factor in the blood, stimulating valvular degeneration.
B. Antigens that bind to the valvular lining, triggering an autoimmune response. The immune response cross-reacts with molecularly similar self-antigens in heart, muscle, joints, and the brain, causing an autoimmune response resulting in diffuse, proliferative, and exudative inflammatory lesions in these tissues. It is not due to blood-borne organisms, high fevers, or rheumatoid factors.
A 67 year old was previously diagnosed with rheumatic heart disease. Tests now reveal lipoprotein deposition with chronic inflammation that impairs blood flow from the left ventricle into the aorta. Which diagnosis does this history support? a. Aortic regurgitation b. Aortic stenosis c. Mitral regurgitation d. Mitral stenosis
B. Aortic stenosis Aortic stenosis would impair blood flow from the left ventricle to the aorta. Aortic regurgitation would allow blood to flow back into the left ventricle. Mitral regurgitation would allow blood to flow from the left ventricle to the left atrium. Mitral stenosis would impair blood flow from the left atrium to the left ventricle.
A 49-year-old male presents reporting chest pain. EKG reveals ST elevation. He is diagnosed with myocardial ischemia. Which of the following interventions would be most beneficial? a. Administer a diuretic to decrease volume. b. Apply oxygen to increase myocardial oxygen supply. c. Encourage exercise to increase heart rate. d. Give an antibiotic to decrease infection.
B. Apply oxygen to increase myocardial oxygen supply. Increasing the myocardial oxygen supply is indicated to treat ischemia. A decrease in fluid volume is not appropriate. Heart rate should be decreased to decrease cardiac workload. Antibiotics are not the most beneficial; oxygen is.
A 15-year-old male who is allergic to peanuts eats a peanut butter cup. He then goes into anaphylactic shock. Which assessment findings will the nurse assess for? a. Bradycardia, decreased arterial pressure, and oliguria b. Bronchoconstriction, hives or edema, and hypotension c. Hypertension, anxiety, and tachycardia d. Fever, hypotension, and erythematous rash
B. Bronchoconstriction, hives or edema, and hypotension Anaphylactic shock is characterized by bronchoconstriction, hives, and hypotension; it does not involve oliguria, bradycardia, or hypotension. Septic shock, not anaphylactic shock, is manifested by fever and rash.
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 patient's blood pressure. c. Draw blood for serum electrolyte levels. d. Ask about any extremity numbness or tingling.
B. Check the patient's blood pressure. Because the patient's history suggests that fluid volume deficit may be a problem, assessment for adequate circulation is the highest priority. Because the patient's history suggests that fluid volume deficit may be a problem, assessment for adequate circulation is the highest priority. The other actions are also appropriate, but are not as essential as determining the patient's perfusion status
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 is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age. Considerable excess fluid volume may be present before fluid moves into the interstitial space and causes edema. Although very important, hourly urine outputs do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds.
An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation? a. Pallor b. Edema c. Confusion d. Restlessness
B. Edema; The normal range for total protein is 6.4 to 8.3 g/dL. Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels.
A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction and is complaining of anxiety and incisional pain. The patient's 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. The patient's respiratory alkalosis is caused by the increased respiratory rate associated with pain and anxiety. The nurse's first action should be to medicate the patient for pain.
An 82-year-old female was admitted to the hospital with confusion and severe hypotension. Her body's compensatory mechanisms are increased heart rate, vasoconstriction, and movement of large volumes of interstitial fluid to the vascular compartment. What kind of shock does the nurse suspect the patient is experiencing? a. Anaphylactic b. Hypovolemic c. Neurogenic d. Septic
B. Hypovolemic In hypovolemic shock, heart rate and SVR increase, boosting both cardiac output and tissue perfusion pressures. Interstitial fluid moves into the vascular compartment. In anaphylactic shock, bronchoconstriction occurs with hypotension. In neurogenic shock, hypotension occurs, but fluid does not shift. In septic shock, interstitial fluid shift does not occur.
IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take? a. Administer the KCl as a rapid IV bolus. b. Infuse the KCl at a rate of 10 mEq/hour. c. Only give the KCl through a central venous line. d. Discontinue cardiac monitoring during the infusion.
B. Infuse the KCl at a rate of 10 mEq/hour. IV KCl is administered at a maximal rate of 10 mEq/hr. Rapid IV infusion of KCl can cause cardiac arrest. Although the preferred concentration for KCl is no more than 40 mEq/L, concentrations up to 80 mEq/L may be used for some patients. KCl can cause inflammation of peripheral veins, but it can be administered by this route. Cardiac monitoring should be continued while patient is receiving potassium because of the risk for dysrhythmias.
Which of the following findings in the patient with Raynaud disease would indicate a need for further teaching? a. The patient eats bananas twice a day. b. The patient smokes cigarettes. c. The patient wears mittens outside. d. The patient takes calcium channel blockers.
B. The patient smokes cigarettes. Cigarette smoking should be stopped to eliminate the vasoconstricting effects of nicotine. The bananas do not cause problems in this patient. The patient should wear mittens outside. Calcium channel blockers are an acceptable treatment for Raynaud disease.
A 75-year-old obese female presents to her primary care provider reporting edema in the lower extremities. Physical exam reveals that she has varicose veins. Upon performing the history, which of the following is a possible cause for the varicose veins? a. extreme exercise b. long periods of standing c. trauma to deep veins d. ischemia
B. Long periods of standing The probable cause of the patient's varicose veins is gradual venous distention caused by the action of gravity on blood in the legs due to long periods of standing. Varicose veins are most likely due to long periods of standing leading to the action of gravity promoting venous distention. Exercise would help prevent this. Trauma can occur, but usually this affects the more superficial veins. Ischemia affects arteries, not veins.
When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patient's food tray? a. Grape juice b. Milk carton c. Mixed green salad d. Fried chicken breast
B. Milk carton Foods high in phosphate include milk and other dairy products, so these are restricted on low-phosphate diets.
A 75-year-old male has severe chest pain and dials 911. Based upon the lab findings indicating a patient has elevated levels of cardiac troponins I and T, the nurse suspects which of the following has occurred? a. Raynaud disease b. Myocardial infarction (MI) c. Orthostatic hypotension d. Angina
B. Myocardial infarction (MI) The diagnosis of acute MI is made on the basis of serial cardiac biomarker alterations. The cardiac troponins (troponins I and T) are the most specific indicators of MI. Elevated troponins I and T are indicative of MI, not Raynaud disease, orthostatic hypotension, or angina.
4. A patient is questioning the nurse about circulation and perfusion. What is the nurse's best response? A. Perfusion assists the body by preventing clots and increasing stamina. B. Perfusion assists the cell by delivering oxygen and removing waste products. C. Perfusion assists the heart by increasing the cardiac output. D. Perfusion assists the brain by increasing mental alertness.
B. Perfusion assists the cell by delivering oxygen and removing waste products. Perfusion delivers much needed oxygen to the cells of the body and then helps to remove waste products. Perfusion does not prevent clots, does not increase cardiac output, and does not increase mental alertness. Awarded 1.0 points out of 1.0 possible points.
A 52-year-old male presents with pooling of blood in the veins of the lower extremities and edema. The diagnosis is chronic venous insufficiency, and an expected assessment finding of this disorder is: a. deep vein thrombus formation b. skin hyperpigmentation c. gangrene d. edema above the knee
B. Skin Hyperpigmentation Symptoms include edema of the lower extremities and hyperpigmentation of the skin of the feet and ankles but deep vein thrombi do not form. Edema in these areas may extend to the knees but not above. Gangrene does not occur in veins but in arteries.
A nurse takes an adult patient's blood pressure and determines it to be normal. What reading did the nurse obtain? a. Systolic pressure between 140 and 150 mm Hg b. Systolic pressure less than 120 mm Hg and diastolic pressure less than 80 mm Hg c. Systolic pressure less than 100 mm Hg regardless of diastolic pressure d. Systolic pressure greater than 140 mm Hg and a diastolic pressure of 100 mm Hg
B. Systolic pressure less than 120 mm Hg and diastolic pressure less than 80 mm Hg Normal blood pressure has a systolic pressure less than 120 mm Hg and diastolic pressure less than 80 mm Hg. A systolic pressure of 140 mm Hg or more would indicate stage I hypertension. A systolic pressure of less than 100 mm Hg would indicate low blood pressure. A diastolic pressure greater than 90 mm Hg would indicate hypertension.
When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which finding should the nurse report to the health care provider immediately? a. The bibasilar breath sounds are decreased. b. The patellar and triceps reflexes are absent. c. The patient has been sleeping most of the day. d. The patient reports feeling "sick to my stomach."
B. The patellar and triceps reflexes are absent. The loss of the deep tendon reflexes indicates that the patient's magnesium level may be reaching toxic levels.
A 65-year-old male with a history of untreated hypertension is now experiencing left heart failure. A nurse recalls his untreated hypertension led to: a. ventricular dilation and wall thinning. b. myocardial hypertrophy and ventricular remodeling. c. inhibition of renin and aldosterone. d. alterations in alpha and beta receptor function.
B. myocardial hypertrophy and ventricular remodeling. With hypertension comes increased afterload and resistance to ventricular emptying and more workload for the ventricle, which responds with hypertrophy of the myocardium and ventricular remodeling. Ventricular dilation can occur, but the wall will thicken, not thin. Renin and aldosterone release are increased, not inhibited. Alterations in alpha and beta functioning may occur, but the response to hypertension is myocardial hypertrophy and ventricular remodeling.
A 51-year-old male presents with recurrent chest pain on exertion and is diagnosed with angina pectoris. The pain occurs when: a. cardiac output has fallen below normal levels. b. the myocardial oxygen supply has fallen below demand. c. myocardial stretch has exceeded the upper limits. d. the vagus nerve is stimulated.
B. the myocardial oxygen supply has fallen below demand. Angina is chest pain caused by myocardial ischemia, which develops if the flow or oxygen content of coronary blood is insufficient to meet the metabolic demands of myocardial cells. A decrease in cardiac output would lead to general systemic symptoms, not just chest pain, which is due to a decrease in myocardial oxygenation. Myocardial stretch does not affect angina symptoms. When the vagus nerve is stimulated, a change in rate occurs; it does not precipitate chest pain.
A 35 year old presents with pulmonary hypertension and is diagnosed as being in right heart failure. Which is the most likely cause of this condition? a. Aortic stenosis b. Tricuspid regurgitation c. Aortic regurgitation d. Mitral regurgitation
B. tricuspid regurgitation Tricuspid regurgitation leads to volume overload in the right atrium and ventricle, increased systemic venous blood pressure, and right heart failure. Aortic stenosis is manifested by narrowed pulse pressure. Aortic regurgitation is manifested by widened pulse pressure resulting from increased stroke volume and diastolic backflow. Mitral regurgitation is manifested by heart failure but not pulmonary hypertension.
The pediatric nurse understands that aspirin: (select all that apply) A. Is used on a prophylactic basis to prevent heart attack and stroke in children B. Is used to prevent blood clots from forming in the coronary arteries during the acute phase of Kawasaki disease C. Is used to treat fever in viral illness in children D. Is used to treat joint pain and inflammation in rheumatic fever E. Is used to treat infection in rheumatic fever F. Can be associated with Reye's syndrome, a serious and potentially deadly condition in children and teenagers G. Decreases platelet aggregation and inhibits thrombus formation
BDFG
Nursing interventions to promote a balanced dietary intake of food and fluids in an infant with congestive heart failure include: (select all that apply) A. Keep coaxing the infant to suck on the bottle and to drink all the formula until the bottle is empty, no matter how long it takes. B. Weigh the child daily. C. Hold the infant at a 90-degree angle while feeding. D. Use firm nipples with small openings to slow feedings. E. Use high-calorie concentrated formula. F. Space feedings 3 hours apart. G. Use supplemental tube feedings if the infant is too fatigued to ingest a sufficient amount by mouth. H. Provide large feedings every 5 hours to allow the infant to rest. I. Limit bottle feedings to 20-30 minutes. J. Provide small, frequent feedings
BEFGIJ
The pediatric nurse understands that captopril (Capoten), an ACE-inhibitor: (Select all that Apply) A. Decreases preload B. Decreases afterload C. Increases contractility of the heart D. Has side effects of nausea, vomiting, and anorexia E. Has side effects of hypokalemia, metabolic alkalosis, and hypotension F. Has side effects of hyperkalemia and hypotension G. Promotes vascular relaxation and reduced peripheral vascular resistance
BFG
A client's echocardiogram identified a narrowed valve that has resulted in a decreased blood flow between the left atria and left ventricle. The nurse would interpret this as the: Bicuspid valve Pulmonic valve Aortic valve Tricuspid valve
Bicuspid valve Explanation: The bicuspid valve (also called the mitral valve) controls the flow of blood between the left atria and left ventricle. The aortic valve controls flow between the left ventricle and aorta. The tricuspid controls the flow between the right atria and ventricle. The pulmonic valve controls flow between the right ventricle and pulmonary artery.
A 16 month old child diagnosed with Kawasaki Disease (KD) is very irritable, refuses to eat, and exhibits peeling skin on the hands and feet. Which of the following should the nurse interpret as the priority? A. applying lotions to the hands and feet B. offering foods the toddler likes C. placing the toddler in a quiet environment D. encouraging the parents to get some rest
C
A 5 year old child has been transferred to the pediatric unit after a cardiac catheterization. The nurse has checked the sheath insertion site for bleeding, oozing, or hematoma. In order of priority, which of the following interventions should the nurse do next? A. Monitor the child's comfort level B. Position the child's leg so that it is straight C. Assess the strength and presence of the distal pulses D. Take the vital signs, including blood pressure and oxygen saturation
C
A child has been admitted to the hospital unit in congestive heart failure (CHF). Symptoms related to this admission diagnosis should include A. Weight loss. B. Bradycardia. C. Tachycardia. D. Increased blood pressure.
C
A nurse is explaining to a student nurse about perfusion. 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
What is a potential adverse effect of palpation of an enlarged thyroid gland? a. Carotid artery obstruction b. Damage to the cricoid cartilage c. Release of excessive thyroid hormone into circulation d. Hoarseness from pressure on the recurrent laryngeal nerve
C
Which assessment data is most indicative of a potential complication of Kawasaki's disease? A. Dermatitis of extremities; desquamation of the hands and feet. B. Strawberry tongue; redness of the mucous membranes and sores in the mouth. C. Change in blood pressure, pulse, and skin color; complaints of pain in the chest. D. Fever over 5 days; redness and swelling of the eyes.
C
Which evaluation would indicate a toxic dose of digoxin? A. Tachycardia and dysrhythmia. B. Headache and diarrhea. C. Bradycardia and nausea and vomiting. D. Tinnitus and nuchal rigidity.
C
Which statement by a nurse to a patient newly diagnosed w/ type 2 diabetes is correct? a) Insulin is not used to control blood glucose in patient w/ type 2 diabetes b) Complications of type 2 diabetes are less serious than those of type 1 diabetes c) Changes in diet and exercise may control blood glucose levels in type 2 diabetes d) Type 2 diabetes is usually diagnosed when the patient is admitted w/ hyperglycemic coma
C For some patients w/ type 2 diabetes, changes in lifestyle are sufficient to achieve blood glucose control.
When a patient who takes metformin (Glucophage) to manage type 2 diabetes develops an allergic rash from an unknown cause, the HCP prescribes prednisone. The nurse will anticipate that the patient may a) need a diet higher in calories while receiving prednisone b) develop acute hypoglycemia while taking the prednisone c) require administration of insulin while taking prednisone d) have rashes caused by metformin-prednisone interactions
C Glucose levels are increased when patients are taking corticosteroids, and insulin may be required to control blood glucose.
The HCP suspects Somogyi effect in a 50 y/o patient whose 6:00 AM blood glucose is 230 mg/dL. Which action will the nurse teach the patient to take? a) Avoid snacking at bedtime b) Increase the rapid-acting insulin dose c) Check the blood glucose during the night d) Administer a larger dose of long-acting insulin
C If the Somogyi effect is causing the patient's increased morning glucose level, the patient will experience hypoglycemia between 2 and 4 AM.
A 26 y/o patient w/ type 1 diabetes develops a sore throat and runny nose after caring for her sick toddler. The patient calls the clinic for advice about her symptoms and a blood glucose level of 210 mg/dL despite her taking her usual glargine (Lantus) and lispro (Humalog) insulin. The nurse advises the patient to a) use only the lispro insulin until the symptoms are resolved b) limit intake of calories until the glucose is less then 120 mg/dL c) monitor blood glucose every 4 hours and notify the clinic if it continues to rise d) decreased intake of carbohydrates until A1C is less than 7%
C Infection and other stressors increase blood glucose levels and the patient will need to test blood glucose frequently, treat elevations appropriately w/ lispro insulin, and call the HCP if glucose levels continue to be elevated.
When a patient w/ type 2 diabetes is admitted for a cholecystectomy, which nursing action can the nurse delegate to a LPN/LVN? a) Communicate the blood glucose level and insulin dose to the circulating nurse in surgery b) Discuss the reason for the use of insulin therapy during the immediate postoperative period c) Administer the prescribed lispro (Humalog) insulin before transporting the patient to surgery d) Plan strategies to minimize the risk for hypoglycemia or hyperglycemia during the postoperative period
C LPN/LVN education and scope of practice includes administration of insulin.
A 26 y/o patient w/ diabetes rides a bicycle to and from work every day. Which site should the nurse teach the patient to administer the morning insulin? a) thigh b) buttock c) abdomen d) upper arm
C Patients should be taught not to administer insulin into a site that will be exercise because exercise will increase the rate of absorption.
After the nurse has finished teaching a patient who has a new prescription for exenatide (Byetta), which patient statement indicates that the teaching has been effective a) I may feel hungrier than usual when I take this medicine b) I will not need to worry about hypoglycemia with the Byetta c) I should take my daily aspirin at least an hour before the Byetta d) I will take the pill at the same time I eat breakfast in the morning
C Since exenatide slows gastric emptying, oral medications should be taken at least an hour before the exenatide to avoid slowing absorption.
After change-of-shift report, which patient will the nurse assess first? a) 19 y/o w/ type 1 diabetes who was admitted w/ possible dawn phenomenon b) 35 y/o w/ type 1 diabetes whose most recent blood glucose reading was 230 mg/dL c) 60 y/o w/ HHS who has poor skin turgor and dry oral mucosa d) 68 y/o w/ type 2 diabetes who has severe peripheral neuropathy and complains of burning foot pain
C The patient's diagnosis of HHS and signs of dehydration indicate that the nurse should rapidly assess for signs of shock and determine whether increased fluid infusion is needed.
A 48 y/o male patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dL. The nurse will plan to teach the patient about a) self-monitoring of blood glucose b) using low doses of regular insulin c) lifestyle changes to lower blood glucose d) effects of oral hypoglycemic medications
C The patient's impaired fasting glucose indicates prediabetes, and the patient should be counseled about lifestyle changes to prevent the development of type 2 diabetes.
What information is most important for the nurse to report to the HCP before a patient w/ type 2 diabetes is prepare for a coronary angiogram? a) The patient's most recent A1C was 6.5% b) The patient's admission blood glucose is 128 mg/dL c) The patient took the prescribed metformin (Glucophage) today d) The patient took the prescribed captopril (Capoten) this morning
C To avoid lactic acidosis, metformin should be discontinued a day or 2 before the coronary arteriogram and should not be used for 48 hours after IV contrast media are administered.
The nurse interviews a patient with a new diagnosis of chronic obstructive pulmonary disease (COPD). Which information is most specific in confirming a diagnosis of chronic bronchitis? a. The patient tells the nurse about a family history of bronchitis. b. The patient indicates a 30 pack-year cigarette smoking history. c. The patient reports a productive cough for 3 months every winter. d. The patient denies having respiratory problems until the past 12 months.
C A diagnosis of chronic bronchitis is based on a history of having a productive cough for 3 months for at least 2 consecutive years. There is no family tendency for chronic bronchitis. Although smoking is the major risk factor for chronic bronchitis, a smoking history does not confirm the diagnosis.
A patient is taking spironolactone (Aldactone), a drug that blocks the action of aldosterone on the kidney, for hypertension. The nurse will monitor for a. increased serum sodium. b. decreased urinary output. c. elevated serum potassium. d. evidence of fluid overload.
C Because aldosterone increases the excretion of potassium, a medication that blocks aldosterone will tend to cause hyperkalemia. Aldosterone also promotes the reabsorption of sodium and water in the renal tubules, so spironolactone will tend to cause increased urine output, a decreased or normal serum sodium level, and signs of dehydration.
A patient is scheduled for spirometry. 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 Bronchodilators are held before spirometry so that a baseline assessment of airway function can be determined. Testing is repeated after bronchodilator use to determine whether the decrease in lung function is reversible. There is no need for the patient to be NPO. Oral corticosteroids should be held before spirometry. Rescue medications (which are bronchodilators) would not be given until after the baseline pulmonary function was assessed.
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-lb weight gain. b. The patient denies shortness of breath at present. c. The patient takes cimetidine (Tagamet HB) daily. d. The patient complains of coughing up green mucus.
C Cimetidine interferes with the metabolism of theophylline, and concomitant administration may lead rapidly to theophylline toxicity. The other patient information would not affect whether the theophylline should be administered or not.
A patient will be scheduled in the outpatient clinic for blood cortisol testing. Which instruction will the nurse provide? a. "Avoid adding any salt to your foods for 24 hours before the test." b. "You will need to lie down for 30 minutes before the blood is drawn." c. "Come to the laboratory to have the blood drawn early in the morning." d. "Do not have anything to eat or drink before the blood test is obtained."
C Cortisol levels are usually drawn in the morning, when levels are highest. The other instructions would be given to patients who were having other endocrine testing.
A patient with chronic obstructive pulmonary disease (COPD) has a nursing diagnosis of imbalanced nutrition: less than body requirements. Which intervention would be most appropriate for the nurse to include in the plan of care? a. Encourage increased intake of whole grains. b. Increase the patient's intake of fruits and fruit juices. c. Offer high-calorie protein snacks between meals and at bedtime. d. Assist the patient in choosing foods with high vegetable content.
C Eating small amounts more frequently (as occurs with snacking) will increase caloric intake by decreasing the fatigue and feelings of fullness associated with large meals. Patients with COPD should rest before meals. Foods that have a lot of texture such as whole grains may take more energy to eat and get absorbed and lead to decreased intake. Although fruits, juices, and minerals are not contraindicated, foods high in protein are a better choice.
The nurse reviews a patient's glycosylated hemoglobin (A1C) results to evaluate a. fasting preprandial glucose levels. b. glucose levels 2 hours after a meal. c. glucose control over the past 90 days. d. hypoglycemic episodes in the past 3 months.
C Glycosylated hemoglobin testing measures glucose control over the last 3 months. Glucose testing before/after a meal or random testing may reveal impaired glucose tolerance and indicate prediabetes, but it is not done on patients who already have a diagnosis of diabetes. There is no test to evaluate for hypoglycemic episodes in the past.
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 O2 therapy
C Inhaled corticosteroids are more effective in improving asthma than any other drug and are indicated for all patients with persistent asthma. The other therapies would not typically be first-line treatments for newly diagnosed asthma.
A 55-yr-old patient with increasing dyspnea is being evaluated for a possible diagnosis of chronic obstructive pulmonary disease (COPD). When teaching a patient about pulmonary spirometry for this condition, what is the most important question the nurse should ask? a. "Are you claustrophobic?" b. "Are you allergic to shellfish?" c. "Have you taken any bronchodilators today?" d. "Do you have any metal implants or prostheses?"
C Spirometry will help establish the COPD diagnosis. Bronchodilators should be avoided at least 6 hours before the test. Spirometry does not involve being placed in an enclosed area such as for magnetic resonance imaging (MRI). Contrast dye is not used for spirometry. The patient may still have spirometry done if metal implants or prostheses are present because they are contraindications for an MRI.
A patient with cystic fibrosis (CF) has blood glucose levels that are consistently between 180 to 250 mg/dL. Which nursing action will the nurse plan to implement? a. Discuss the role of diet in blood glucose control. b. Evaluate the patient's use of pancreatic enzymes. c. Teach the patient about administration of insulin. d. Give oral hypoglycemic medications before meals.
C The glucose levels indicate that the patient has developed CF-related diabetes, and insulin therapy is required. Because the etiology of diabetes in CF is inadequate insulin production, oral hypoglycemic agents are not effective. Patients with CF need a high-calorie diet. Inappropriate use of pancreatic enzymes would not be a cause of hyperglycemia in a patient with CF.
A patient seen in the asthma clinic has recorded daily peak flow rates 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 scheduled follow-up appointment.
C The patient's peak flow reading indicates that the condition is worsening (yellow zone). The patient should take the bronchodilator and recheck the peak flow. Depending on whether the patient returns to the green zone, indicating well-controlled symptoms, the patient may be prescribed oral corticosteroids or a change in dosing of other medications. Keeping the next appointment is appropriate, but the patient also needs to be taught how to control symptoms now and use the bronchodilator.
A patient hospitalized with chronic obstructive pulmonary disease (COPD) is being discharged home on O2 therapy. Which instruction should the nurse include in the discharge teaching? a. Travel is not possible with the use of O2 devices. b. O2 flow should be increased if the patient has more dyspnea. c. O2 use can improve the patient's prognosis and quality of life. d. Storage of O2 requires large metals tanks that each last 4 to 6 hours.
C The use of home O2 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 health care provider rather than increasing the O2 flow rate if dyspnea becomes worse. O2 can be supplied using liquid, storage tanks, or concentrators, depending on individual patient circumstances. Travel is possible using portable O2 concentrators.
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 b-Blockers such as propranolol can cause bronchospasm in some patients with asthma. The other information will be documented in the health history but does not indicate a need for a change in therapy.
What is the cause of the hyperpigmentation seen in people with Cushing syndrome? a. Abnormal levels of cortisol b. Permissive effects of aldosterone when cortisol levels are altered c. Elevated levels of ACTH d. Hypersensitivity of melanocytes with sun exposure
C - Bronze or brownish hyperpigmentation of the skin, mucous membranes, and hair occurs when there are very high levels of ACTH. The pigmentation changes associated with Cushing syndrome and Addison disease are not due to increased levels of cortisol or hypersensitivity of melanocytes. Aldosterone affects fluid balance.
Which condition is considered the ultimate cause of death in the patient with diabetes? a. Renal disease b. Stroke c. Cardiovascular disease d. Cancer
C - Cardiovascular disease, not renal disease, stroke, or cancer, is the ultimate cause of death in up to 68% of people with diabetes.
A nurse checks lab results as both Cushing disease and Addison disease can manifest with elevated levels of: a. ADH. b. estrogen. c. adrenocorticotropic hormone (ACTH). d. aldosterone.
C - Cushing disease and Addison disease are related to elevated levels of ACTH, not ADH, estrogen, or aldosterone.
A 45-year-old diagnosed with Graves disease underwent surgical removal of the thyroid gland. During the postoperative period, the patient's serum calcium is low. The most probable reason for her low serum calcium is: a. hyperparathyroidism secondary to Graves disease. b. myxedema secondary to surgery. c. hypoparathyroidism caused by surgical injury to the parathyroid glands. d. hypothyroidism resulting from lack of thyroid replacement.
C - Hypoparathyroidism is most commonly caused by damage to the parathyroid glands during thyroid surgery, not secondary to Graves disease, myxedema, or the lack of thyroid replacement.
A nurse is caring for a patient diagnosed with SIADH. What severe complication should the nurse assess for? a. Stroke b. Diabetes insipidus c. Neurologic damage d. Renal failure
C - When the hyponatremia of SIADH becomes severe, 110-115 milliequivalents per liter, confusion, lethargy, muscle twitching, convulsions, and severe and sometimes irreversible neurologic damage may occur. Neither stroke, diabetes insipidus, nor renal failure is associated with SIADH.
A 25-year-old male presents to his primary care provider reporting changes in facial features. CT scan reveals a mass on the anterior pituitary, and lab tests reveal severely elevated growth hormone (GH). Which of the following would the nurse also expect to find? a. Decreased IGF-1 b. Hypotension c. Muscular atrophy d. Height increases
C - With elevated levels of GH, there is resulting bony and soft tissue overgrowth; nerve entrapment occurs, leading to peripheral nerve damage manifested by weakness, muscular atrophy, foot drop, and sensory changes in the hands. IGF-1 increases, and there is an overgrowth of bone but not an increase in height or hypotension.
A patient diagnosed with Addison disease reports weakness and is easily fatigued. What is the root of these symptoms? a. Hyperkalemia b. Hypoglycemia c. Hypocortisolism d. Metabolic acidosis
C - With mild-to-moderate hypocortisolism, symptoms usually begin with weakness and easy fatigability. The weakness is not due to hyperkalemia, hypoglycemia, or metabolic acidosis.
4. A patient who is dehydrated has been experiencing confusion. The daughter is concerned about taking the patient home in a confused state. What statement by the nurse is correct? a. "Don't worry; the patient should be fine once they are in a familiar environment." b. "I can make a referral for a home health aide to assist with the patient." c. "Once the dehydration is corrected, the patient's confusion should improve." d. "I can show you how to care for the patient once you return home."
C". "once the dehydration is correct3d, the patient's confusion should improve"
Upon assessment of the patient, the nurse finds a widened pulse pressure and throbbing peripheral pulses. Which valve disorder does the nurse suspect? a. Mitral regurgitation b. Mitral stenosis c. Aortic regurgitation d. Aortic stenosis
C. Aortic Regurgitation Aortic regurgitation is manifested by widened pulse pressure resulting from increased stroke volume and diastolic backflow. Mitral regurgitation is manifested by heart failure. Mitral stenosis is manifested by pulmonary edema and heart failure. Aortic stenosis is manifested by narrowed pulse pressure.
The most common cause of myocardial ischemia is: a. idiopathic vasospasm. b. arterial emboli from a heart valve. c. atherosclerosis. d. venous emboli.
C. Atherosclerosis The most common cause of myocardial ischemia is atherosclerosis. Myocardial ischemia is not caused by idiopathic vasospams or venous emboli. Arterial emboli may cause ischemia, but atherosclerosis is the major cause of myocardial ischemia.
An older adult is diagnosed with cerebral aneurysm. Where does the nurse suspect the cerebral aneurysm is located? a. Vertebral arteries b. Basilar artery c. Circle of Willis d. Carotid arteries
C. Circle of Willis Cerebral aneurysms often occur in the circle of Willis. Such an aneurysm is not associated with the vertebral arteries, the basilar artery, or the carotid arteries.
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 patient's 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 Edema is caused by low oncotic pressure in individuals with low serum protein levels. The decrease in edema indicates an improvement in the patient's protein status.
A patient presents with severe chest pain and shortness of breath and is diagnosed with pulmonary embolism. The embolism most likely originated from the: a. left ventricle. b. systemic arteries. c. deep veins of the leg. d. superficial veins of the arm.
C. Deep veins of the leg The most likely origin of the embolism is from the deep veins of the legs. An embolism is not likely to originate in the left ventricle, the systemic arteries, or the arms.
Superior vena cava syndrome (SVCS), causing venous distention in the upper extremities, is a result of progressive superior vena cava: a. inflammation b. occlusion c. distention d. sclerosis
C. Distention SVCS is a progressive occlusion of the SVC that leads to venous distention in the upper extremities and head. This distention is not a result of progressive inflammation, distention, or sclerosis.
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 patient's history and change in LOC could be indicative of fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information is needed to determine the cause of the change in LOC and the appropriate interventions.
The nurse is assigned a group of patients. Which patient finding would the nurse identify as a factor leading to increased risk for impaired 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 Correct The hemoglobin is low (anemia), therefore the ability of the blood to carry oxygen is decreased. High blood glucose and/or anticoagulants do not alter the oxygen carrying capacity of the blood. A heart rate of 100 beats/min and blood pressure of 100/60 are not indicative of oxygen carrying capacity of the blood.
A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (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. Hyponatremia is the most important finding to report. SIADH causes water retention and a decrease in serum sodium level. Hyponatremia can cause confusion and other central nervous system effects. A critically low value likely needs to be treated. At least 30 mL/hr of urine output indicates adequate kidney function. The hematocrit level is normal. Weight gain is expected with SIADH because of water retention.
5. An older adult who is cognitively impaired is admitted to the hospital with pneumonia. Which sign or symptom would the nurse expect to be exhibited by the patient? a. Severe headache b. Flank pain c. Increased confusion d. Decreased blood glucose
C. Increased confusion
The nurse realizes the patient diagnosed with mitral stenosis has incomplete emptying of the: a. right atrium. b. right ventricle. c. left atrium. d. left ventricle.
C. Left Atrium Mitral stenosis would result in incomplete emptying of the left atrium, as the mitral valve is located between the left atrium and left ventricle.
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, initially causing confusion, which may progress to coma or seizures.
An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. 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 patient's neurologic symptoms and indicates a need for immediate action to prevent further serious complications such as seizures. The elevated serum sodium level is consistent with the patient's 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.
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 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.
A 62-year-old male presents to his primary care provider reporting chest pain at rest and with exertion. He does not have a history of coronary artery disease and reports that the pain often occurs at night. He is most likely experiencing which type of angina? a. Unstable b. Stable c. Prinzmetal d. Silent
C. Prinzmetal Chest pain that occurs at rest and at night is descriptive of Prinzmetal angina. Unstable angina is a form of acute coronary syndrome that results from reversible myocardial ischemia. Stable angina is predictable and occurs with activity. Silent angina has few, if any, symptoms.
A patient most prone to multiple organ dysfunction syndrome (MODS) is a patient with: a. myocardial infarction (MI). b. pulmonary disease. c. septic shock. d. autoimmune disease.
C. Septic shock The most common cause of MODS is septic shock, not MI, pulmonary disease, and autoimmune disease.
Which valvular condition is characterized by the valve opening being constricted and narrowed, causing the valve leaflets, or cusps, to fail to open completely? a. Regurgitation b. Insufficiency c. Stenosis d. Incompetence
C. Stenosis Valvular stenosis occurs when the valve opening is constricted and narrowed. Valvular regurgitation occurs when blood moves backward into the chamber from which it came. Valvular insufficiency occurs when blood regurgitates backward into the chamber from which it came. Valvular incompetence leads to regurgitation.
A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a peripherally 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." The 25% dextrose solution is hypertonic. Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered IV. Blood glucose testing is not more accurate when samples are obtained from a central line. The infection risk is higher with a central catheter than with peripheral IV lines. Hypertonic or concentrated IV solutions are not given rapidly.
2. The nurse is reviewing new medication orders for several patients in a long-term care facility. Which patient does the nurse recognize as being at the highest risk for having cognitive impairment related to prescribed medications? A. The patient prescribed an antibiotic for a urinary tract infection. B. The patient prescribed a cholinesterase inhibitor for early Alzheimer's disease. C. The patient prescribed a beta-blocker for hypertension.. D. The patient prescribed a bisphosphonate for osteoporosis.
C. The patient prescribed a beta-blocker for hypertension.
A patient presents to a primary care provider reporting chest pain and is diagnosed with atherosclerosis. This disease is caused by: a. arterial wall thinning and weakening. b. abnormally dilated arteries and veins. c. abnormal thickening and hardening of vessel walls. d. autonomic nervous system imbalances.
C. abnormal thickening and hardening of vessel walls. Atherosclerosis is a form of arteriosclerosis characterized by thickening and hardening of the vessel wall. Affected arteries are narrowed, not dilated. Atherosclerosis is not related to autonomic nervous system imbalances, which would lead to changes in rate or rhythm.
A 10-year-old male presents with fever, lymphadenopathy, arthralgia, and nosebleeds. He is diagnosed with rheumatic heart disease. The most likely cause of this disease is: a. congenital heart defects. b. human immunodeficiency virus (HIV) infections. c. group A beta-hemolytic streptococcus infections. d. acute pericarditis.
C. group A beta-hemolytic streptococcus infections. Rheumatic fever is a systemic, inflammatory disease caused by a delayed exaggerated immune response to infection by the group A beta-hemolytic streptococcus, not by congenital heart defects, HIV infections, or acute pericarditis.
Foam cells in a fatty streak are: a. deposited adipose cells. b. injured neutrophils. c. macrophages that engulf low-density lipoprotein (LDL). d. lipid-laden mast cells.
C. macrophages that engulf low-density lipoprotein (LDL). Foam cells are lipid-laden macrophages that engulf LDL. They are deposited in vessels, not adipose cells. Foam cells are not injured neutrophils nor are they mast cells.
Inflammatory cells have difficulty limiting the colonization of microorganisms in infective endocarditis because the: a. microorganisms are resistant. b. valves are avascular. c. microorganisms are sequestered in a fibrin clot. d. colonies overwhelm the phagocytes.
C. microorganisms are sequestered in a fibrin clot. In endocarditis, bacterial colonies are inaccessible to host defenses because they are embedded in the protective fibrin clots; it is not because the microorganisms are resistant, that the valves are avascular, or that the colonies overwhelm the phagocytes.
A 55-year-old male died of a myocardial infarction. Autopsy would most likely reveal: a. embolization of plaque from the aorta. b. decreased ventricular diastolic filling time. c. platelet aggregation within the atherosclerotic coronary artery. d. smooth muscle dysplasia in the coronary artery.
C. platelet aggregation within the atherosclerotic coronary artery. The autopsy would reveal platelet aggregation within an atherosclerotic coronary artery. The cause of death is most likely occlusion of the coronary artery, not emboli from the aorta, decreased filling time, or dysplasia in the artery.
A patient with left heart failure starts to have a cough and dyspnea. Pulmonary symptoms common to left heart failure are a result of: a. inflammatory pulmonary edema. b. decreased cardiac output. c. pulmonary vascular congestion. d. bronchoconstriction.
C. pulmonary vascular congestion. The clinical manifestations of left heart failure are the result of pulmonary vascular congestion and inadequate perfusion of the systemic circulation. Pulmonary edema does occur, but it is not due to inflammation. Decreased cardiac output does occur, but the pulmonary symptoms are related to pulmonary congestion. Pulmonary symptoms are not due to bronchoconstriction.
When a nurse checks the patient for orthostatic hypotension, what activity did the nurse have the patient engage in? a. physical exertion b. eating c. standing up d. lying down
C. standing up Orthostatic hypotension refers to a drop in blood pressure when standing up, not a drop with exertion, eating, or lying down.
A 50-year-old male with a 30-year history of smoking was diagnosed with bronchogenic cancer. He developed edema and venous distention in the upper extremities and face. Which of the following diagnosis will the nurse observe on the chart? a. thromboembolism b. deep vein thrombosis c. superior vena cava syndrome (SVCS) d. chronic venous insufficiency
C. superior vena cava syndrome (SVCS) SVCS is a progressive occlusion of the superior vena cava that leads to venous distention in the upper extremities and head. Thromboembolism would not lead to the generalized symptoms described in the patient. Deep vein thrombosis would not lead to upper extremity symptoms. Chronic venous insufficiency would primarily affect one extremity.
The pediatric nurse understands that lanoxin (digoxin): (select all that apply) A. Decreases preload B. Decreases afterload C. Increases contractility of the heart D. Has side effects of nausea, vomiting, anorexia, and bradycardia E. Has side effects of hypokalemia, metabolic alkalosis, and hypotension F. Has side effects of hyperkalemia and hypotension G. Can interact with over-the-counter medications, herbal preparations, and antibiotics.
CDG
Select the correct sequence of blood return to the heart. Capillaries, arterioles, veins, left atrium Capillaries, arterioles, arteries, right atrium Capillaries, venules, veins, right atrium Capillaries, venules, veins, left atrium
Capillaries, venules, veins, right atrium Explanation: The correct pathway for blood returning back to the heart is the capillaries, venules, veins, and right atrium. The other options do not support normal blood flow.
The heart controls the direction of blood flow. What is the role of the aortic valve? Controls the direction of blood flow from the atria to the ventricles Controls the direction of blood flow from the ventricles to the artia Controls the direction of blood flow from the left side of the heart to the lungs Controls the direction of blood flow from the left side of the heart to the systemic circulation
Controls the direction of blood flow from the left side of the heart to the systemic circulation Explanation: The heart valves control the direction of blood flow from the atria to the ventricles (the AV valves), from the right side of the heart to the lungs (pulmonic valves) and from the left side of the heart to the systemic circulation (aortic valve).
The heart valves control the direction of blood flow. What is the function of the pulmonic valve? Controls the direction of blood flow from the right side of the heart to the lungs Controls the direction of blood flow from the right side of the heart to the systemic circulation Controls the direction of blood flow from the left side of the heart to the systemic circulation Controls the direction of blood flow from the left side of the heart to the lungs
Controls the direction of blood flow from the right side of the heart to the lungs Explanation: The heart valves control the direction of blood flow from the atria to the ventricles (the AV valves), from the right side of the heart to the lungs (pulmonic valve), and from the left side of the heart to the systemic circulation (aortic valve).
A client is admitted with a diagnosis of "rule out rheumatic fever." Based on Jones criteria, the nurse assesses for A. Polyarthritis and dental caries. B. Fever, headache, and low red blood cell count. C. Chorea, muscle weakness, and decreased erythrocyte sedimentation rate. D. Erythema, polyarthritis, and elevated antistreptolysin-O (ASO) titer.
D
A patient is prescribed oral anticoagulant therapy while still receiving IV heparin infusion. The patient is concerned about risk for bleeding. What is the nurse's best response? a. "Bleeding is a common adverse effect of taking warfarin. If bleeding occurs, your health care provider will prescribe an injection of medication to stop the bleeding." b. "Because you are now getting out of bed and walking around, you have a higher risk of blood clot formation and therefore need to be on both medications." c. "Because of your mechanical valve replacement, it is especially important for you to be fully anticoagulated, and the heparin and warfarin together are more effective than one alone." d. "It usually takes 4 to 5 days to achieve a full therapeutic effect for warfarin, so the heparin infusion is continued to help prevent blood clots until the warfarin reaches its therapeutic effect."
D
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
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 dysthymia
D
A toddler has been started on digoxin (Lanoxin) for cardiac failure. If the child develops digoxin (Lanoxin) toxicity, the first sign the nurse notes should be A. Lowered blood pressure. B. Tinnitus. C. Ataxia. D. A change in heart rhythm.
D
After a pediatric client has a cardiac catheterization, which intervention should have the highest priority in the immediate postoperative period? A. Encourage intake of small amounts of fluid. B. Teach the parents signs of congestive heart failure. C. Monitor the site for signs of infection. D. Observe cath insertion site for bleeding. If bleeding is found, the nurse should immediately glove, and apply direct manual pressure to the site (without leaving the patient's bedside) until hemostasis is obtained.
D
Before emergency surgery, the nurse would anticipate administering which medication to a patient receiving heparin? a. Vitamin K (Phytonadione) b. Vitamin E c. Phenytoin (Dilantin) d. Protamine (Protamine sulfate)
D
Enoxaparin sodium (Lovenox) is an anticoagulant used to prevent and treat deep vein thrombosis and pulmonary embolism. This medication is in which drug class? a. Thrombolytic drug b. Oral anticoagulant c. Glycoprotein IIb/IIIa inhibitor d. Low-molecular-weight heparin
D
How do hormones respond following the ingestion of a high-protein, carbohydrate-free meal? a. Both insulin and glucagon are inhibited because blood glucose levels are unchanged. b. Insulin is inhibited by low glucose levels, and glucagon is released to promote gluconeogenesis. 315 c. Insulin is released to facilitate the breakdown of amino acids into glucose, and glucagon is inhibited. d. Glucagon is released to promote gluconeogenesis, and insulin is released to facilitate movement of amino acids into muscle cells.
D
In a normal heart, the blood follows this cycle: body-heart-lungs-heart-body. When a child has this congenital heart defect, the blood leaving the heart does not follow this path. It has only one vessel, instead of two separate ones for the lungs and body. With only one artery, there is no specific path to the lungs for oxygen before returning to the heart to deliver oxygen to the body. In addition, there is usually a hole between the two lower chambers of the heart known as a ventricular septal defect. As a result of this heart defect, oxygen-poor blood that should go to the lungs and oxygen-rich blood that should go to the rest of the body are mixed together. This creates severe circulatory problems. What is the name of this congenital heart defect? A. Atroventricular canal defect B. Hypoplastic left heart syndrome C. Tetralogy of Fallot D. Truncus arteriosus E. Transposition of the great arteries
D
Which statement about the adrenal medulla hormones is accurate? a. Overproduction of androgens may cause masculinization in women. b. Both the adrenal medulla and the thyroid gland have a negative feedback system to the hypothalamus. c. Cortisol levels would be altered in a person who normally works a night shift from 11:00 PM to 7:00 AM and sleeps from 8:00 AM to 3:00 PM. d. Catecholamines are considered hormones when they are secreted by the adrenal medulla and neurotransmitters when they are secreted by nerve cells.
D
A hospitalized diabetic patient received 38 U of NPH insulin at 7:00 AM. At 1:00 PM, the patient has been away from the nursing unit for 2 hours, missing the lunch delivery while awaiting a chest x-ray. To prevent hypoglycemia, the best action by the nurse is to a) save the lunch tray for the patient's return later to the unit b) ask the diagnostic testing area staff to start a 5% dextrose IV c) send a glass of milk or orange juice to the patient in diagnostic testing area d) request that if testing is further delayed, the patient be returned to the unit to eat
D Consistency for mealtimes assists w/ regulation of blood glucose, so the best option is for the patient to have lunch at the usual time.
The nurse teaches a patient who has asthma about peak flow meter use. Which action by the patient indicates that teaching was successful? a. The patient inhales rapidly through the peak flow meter mouthpiece. b. The patient takes montelukast (Singulair) for peak flows in the red zone. c. The patient calls the health care provider when the peak flow is in the green zone. d. The patient uses an albuterol (Ventolin HFA) inhaler for peak flows in the yellow zone.
D Readings in the yellow zone indicate a decrease in peak flow. The patient should use short-acting b2-adrenergic (SABA) medications. Readings in the green zone indicate good asthma control. The patient should exhale quickly and forcefully through the peak flow meter mouthpiece to obtain the readings. Readings in the red zone do not indicate good peak flow, and the patient should take a fast-acting bronchodilator and call the health care provider for further instructions. Singulair is not indicated for acute attacks but rather is used for maintenance therapy.
The nurse is interviewing a new patient w/ diabetes who receives rosiglitazone (Avandia) through a restricted access medication program. What is most important for the nurse to report immediately to the HCP? a) The patient's BP is 154/92 b) The patient has a history of a emphysema c) The patient's blood glucose is 86 mg/dL d) The patient has chest pressure when walking
D Rosiglitazone can cause myocardial ischemia.
The nurse has been teaching a patient w/ type 2 diabetes about managing blood glucose levels and taking glipizide (Glucotrol). Which patient statement indicates a need for additional teaching? a) If I overeat a meal, I will still take the usual dose of medication b) Other medications beside the Glucotrrol may affect my blood sugar c) When I'm ill, I may have to take insulin to control my blood sugar d) My diabetes won't cause complications because I don't need insulin
D The patient should understand that type 2 diabetes places the patient at risk for many complications and that good glucose control is as important when taking oral agents as when using insulin.
A 28 y/o male patient w/ type 1 diabetes reports how he manages his exercise and glucose control. Which behavior indicates that the nurse should implement additional teaching? a) The patient always carries hard candies when engaging in exercise b) The patient goes for a vigorous walk when his glucose is 200 mg/dL c) The patient has a peanut butter sandwich before going for a bicycle ride d) The patient increases daily exercise when ketones are present in the urine
D When the patient is ketotic, exercise may result in an increase in blood glucose level.
Which statement by a 50-yr-old female patient indicates to the nurse that further assessment of thyroid function may be necessary? a. "I notice my breasts are tender lately." b. "I am so thirsty that I drink all day long." c. "I get up several times at night to urinate." d. "I feel a lump in my throat when I swallow."
D Difficulty in swallowing can occur with a goiter. Nocturia is associated with diseases such as diabetes mellitus, diabetes insipidus, or chronic kidney disease. Breast tenderness would occur with excessive gonadal hormone levels. Thirst is a sign of disease such as diabetes.
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 appropriate for the nurse to include in the plan of care? a. Stop exercising when you feel 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 a day at least 3 times/week.
D 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 exercise to ADLs will not improve the patient's exercise tolerance. A 70-yr-old patient should have a pulse rate of 120 beats/min or less with exercise (80% of the maximal heart rate of 150 beats/min ).
An 18-yr-old male patient with small stature is scheduled for a growth hormone stimulation test. In preparation for the test, the nurse will obtain a. ice in a basin. b. glargine insulin. c. a cardiac monitor. d. 50% dextrose solution.
D Hypoglycemia is induced during the growth hormone stimulation test, and the nurse should be ready to administer 50% dextrose immediately. Regular insulin is used to induce hypoglycemia (glargine is never given IV). The patient does not require cardiac monitoring during the test. Although blood samples for some tests must be kept on ice, this is not true for the growth hormone stimulation test.
The nurse completes an admission assessment on a patient with asthma. Which information given by patient is indicates a need for a change in therapy? a. The patient uses albuterol (Ventolin HFA) before aerobic exercise. b. The patient says that the asthma symptoms are worse every spring. c. The patient's heart rate increases after using the albuterol (Ventolin HFA) inhaler. d. The patient's only medications are albuterol (Ventolin HFAl) and salmeterol (Serevent).
D Long-acting b2-agonists should be used only in patients who also are using an inhaled corticosteroid for long-term control. Salmeterol should not be used as the first-line therapy for long-term control. Using a bronchodilator before exercise is appropriate. The other information given by the patient requires further assessment by the nurse but is not unusual for a patient with asthma.
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 Routine scheduling of airway clearance techniques is an essential intervention for patients with CF. A sweat chloride test is used to diagnose CF, but it does not provide any information about the effectiveness of therapy. There is no indication that the patient is terminally ill. Patients with CF lose excessive sodium in their sweat and require high amounts of dietary sodium.
Diabetes insipidus, diabetes mellitus (DM), and SIADH share which of the following assessment manifestations? a. Polyuria b. Edema c. Vomiting d. Thirst
D - All three share thirst as a common clinical manifestation. SIADH does not have polyuria as a clinical manifestation. Diabetes insipidus does not have edema as a clinical manifestation. SIADH is manifested by gastrointestinal symptoms; the other two are not.
A 44-year-old patient with pulmonary tuberculosis is evaluated for SIADH. Which assessment finding would support this diagnosis? a. Peripheral edema b. Tachycardia c. Low blood pressure d. Concentrated urine
D - Clinical manifestations of SIADH include urine that is inappropriately concentrated with respect to serum osmolarity. Symptomology of SIADH does not include peripheral edema, tachycardia, or low blood pressure.
A 35-year-old female took corticosteroid therapy for several months. Which of the following would the nurse expect to find? a. Renal toxicity b. Episodes of hypoglycemia c. Hypotension d. Type 2 DM
D - Overt DM develops in approximately 20% of individuals with hypercortisolism. Diabetes develops not renal toxicity, but hyperglycemia and hypertension may occur.
A 30-year-old presents with hypertension, headache, tachycardia, impaired glucose tolerance, and weight loss. Which of the following diagnoses is supported by this symptomology? a. Addison disease b. Conn disease c. Cushing disease d. Pheochromocytoma
D - Symptoms of pheochromocytoma include hypertension, palpitations, tachycardia, glucose intolerance, excessive sweating, and constipation. Manifestations of Addison disease include weakness, fatigability, hypoglycemia and related metabolic problems, lowered response to stressors, hyperpigmentation, vitiligo, and manifestations of hypovolemia and hyperkalemia. Hypertension and hypokalemia are the hallmarks of Conn disease. Weight gain is the most common feature in Cushing disease and results from the accumulation of adipose tissue in the trunk, facial, and cervical areas. These characteristic patterns of fat deposition have been described as "truncal obesity," "moon face," and "buffalo hump."
The body's inability to conserve water and sodium when affected by Addison disease is explained by which of the following conditions? a. Elevated levels of cortisol b. Decreased levels of ACTH c. Hypersecretion of ADH d. Aldosterone deficiency
D - The symptoms of Addison disease are primarily a result of hypocortisolism, elevated serum ACTH, and hypoaldosteronism. ADH does not play a role in Addison disease.
Which of the following alterations would the nurse expect to find in a patient with untreated Cushing disease or syndrome? a. Bradycardia b. Tachypnea c. Hyperkalemia d. Hypertension
D - With elevated cortisol levels, vascular sensitivity to catecholamines increases significantly, leading to vasoconstriction and hypertension. Tachycardia is more likely than bradycardia due to increased sensitivity to catecholamines. Tachypnea does not occur; the patient experiences hypertension. Hyokalemia, not hyperkalemia, occurs.
A 19-year-old female with type 1 DM was admitted to the hospital with the following lab values: serum glucose 500 milligrams per deciliter (high), urine glucose and ketones 4+ (high), and arterial pH 7.20 (low). Her parents state that she has been sick with the "flu" for a week. Which of the following statements best explains her acidotic state? a. Increased insulin levels promote protein breakdown and ketone formation. b. Her uncontrolled diabetes has led to renal failure. c. Low serum insulin promotes lipid storage and a corresponding release of ketones. d. Insulin deficiency promotes lipid metabolism and ketone formation.
D - With insulin deficiency, lipolysis is enhanced, and there is an increase in the amount of nonesterified fatty acids delivered to the liver. The consequence is increased glyconeogenesis contributing to hyperglycemia and production of ketone bodies (acetoacetate, hydroxybutyrate, and acetone) by the mitochondria of the liver at a rate that exceeds peripheral use. Insulin levels are decreased. There is no evidence that the patient is in renal failure. Insulin is low, but the ketones are the result of fatty acid breakdown due to lack of insulin, not because of lipid storage.
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." Because spironolactone is a potassium-sparing diuretic, patients should be taught to choose low-potassium foods (e.g., apple juice) rather than foods that have higher levels of potassium (e.g., citrus fruits). Because the patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid intake. Teach patients to avoid salt substitutes, which are high in potassium.
A 3-month-old infant is at increased risk for developing anemia. The nurse would identify which principle contributing to this risk? 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. Fetal hemoglobin is present for about 5 months. The fetal hemoglobin begins deteriorating, and around 2 to 3 months the infant is at increased risk of developing an anemia due to decreasing levels of hemoglobin. Breast milk or formula is the primary food intake up to around 6 months. Often iron supplemented formula is offered, and/or an iron supplement is given if the infant is breastfed.
Which condition should cause the nurse to assess for high-output failure in a patient? a. Metabolic alkalosis b. Hypothyroidism c. Hypovolemia d. Anemia
D. Anemia Common causes of high-output failure include anemia, not metabolic alkalosis, hypothyroidism, and hypovolemia.
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. Generalized weakness is a manifestation of hypokalemia. After the health care provider orders the metabolic panel, the nurse should check the potassium level. Facial muscle spasms might occur with hypocalcemia. Orange juice is high in potassium and would be advisable to drink if the patient was hypokalemic. Loose stools are associated with hyperkalemia.
For an infection to progress to septic shock, what must occur? a. The individual must be immunosuppressed. b. The myocardium must be impaired. c. The infection must be gram negative. d. Bacteria must enter the bloodstream.
D. Bacteria must enter the bloodstream. For septic shock to occur, bacteria must enter the bloodstream. Septic shock can occur in individuals who are not immunosuppressed. In septic shock, the myocardium is not impaired. Many organisms in addition to gram-negative bacteria can cause septic shock.
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 Trousseau's and Chvostek's signs. d. Encourage fluid intake up to 4000 mL every day.
D. Encourage fluid intake up to 4000 mL every day. To decrease the risk for renal calculi, the patient should have a fluid intake of 3000 to 4000 mL daily. To decrease the risk for renal calculi, the patient should have a fluid intake of 3000 to 4000 mL daily. Ambulation helps decrease the loss of calcium from bone and is encouraged in patients with hypercalcemia. Trousseau's and Chvostek's signs are monitored when there is a possibility of hypocalcemia. There is no indication that the patient needs frequent assessment of lung sounds, although these would be assessed every shift.
A group of cells isolated in the laboratory have membrane-bound granules in their cytoplasm, and they show phagocytic activity. Which of the following cells is most similar? a. Monocyte b. Macrophage c. Lymphocyte d. Eosinophil
D. Eosinophil
A 30-year-old White female was recently diagnosed with primary hypertension. She reports that she eats fairly well, usually moderate red meat consumption. She also reports that her father has hypertension as well. A nurse determines which of the following risk factors is most likely associated with this diagnosis? a. race b. diet c. age d. genetic
D. Genetic Genetic factors, such as family history of hypertension, are the number one factor in the development of hypertension. Race and diet may be factors, but genetic factors are primary. Age is a factor, but not in this case; since the patient is 30, genetics are a greater factor.
3. The nurse is developing a care plan for a patient newly admitted to a unit that cares for patients with cognitive impairment. What is an important component of care for the patients on this unit? A. Allow food selections from a menu with several choices. B. Schedule frequent field trips off the unit for cognitive stimulation. C. Plan for attendance at activities with several other patients on the unit. D. Plan for a structured daily routine of events and caregivers.
D. Plan for a structured daily routine of events and caregivers.
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.
The nurse is establishing a therapeutic environment for a patient admitted with dementia and influenza. Which intervention would be important for the nurse to implement? A. Keep a radio on all the time to provide sound for the patient. B. Decrease patient confusion by limiting verbal interactions. C. Limit family visits to one person for 30 minutes per day. D. Provide a quiet environment in a private room.
D. Provide a quiet environment in a private room.
The nurse is establishing a therapeutic environment for a patient admitted with dementia and influenza. Which intervention would be important for the nurse to implement? A. Keep a radio on all the time to provide sound for the patient. B. Decrease patient confusion by limiting verbal interactions. C. Limit family visits to one person for 30 minutes per day. D. Provide a quiet environment in a private room.
D. Provide a quiet environment in a private room. The patient experiencing dementia needs a quiet environment with a minimum of unfamiliar stimulation from a roommate. A patient with dementia does not need extra stimulation from having a radio on continually. The nurse should speak clearly and quietly to the patient before any procedure or assistance to decrease agitation. Family visits would be encouraged because family members are familiar to the patient and their presence increases a sense of security.
The nurse is reviewing the needs of a patient with cognitive impairment. What is the priority concern that the nurse should address for this patient? A. Promoting at least 6 hours of sleep a night B. Encouraging an oral intake of 1200 calories per day C. Managing the patient's pain from arthritis D. Supervising medication administration
D. Supervising medication administration. Safety is the priority concern for the cognitively impaired patient; safely taking medication addresses safety needs for the patient. Sleep, nutrition, and management of pain are important components of the patient's care and can affect overall health, but safety is the highest priority.
A 75-year-old female has been critically ill with multiple organ dysfunction syndrome (MODS) for longer than a week and has developed a severe oxygen supply and demand imbalance. The statement that best describes this imbalance is which of the following? a. Increased oxygen delivery to cells fails to meet decreased oxygen demands. b. The amount of oxygen consumed by cells depends only on the needs of cells, because there is oxygen in reserve. c. The situation results in supply-independent consumption. d. The reserve has been exhausted, and the amount of oxygen consumed depends on the amount the circulation is able to deliver.
D. The reserve has been exhausted, and the amount of oxygen consumed depends on the amount the circulation is able to deliver. In MODS, the reserve has been exhausted and the body cannot meet the oxygenation demands. It is true that oxygen fails to meet demand, but there is no increase in oxygen because reserves are exhausted. There is no oxygen in reserve. The situation is supply and demand, but the demand cannot be met.
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 patient's radial pulse is 105 beats/minute. b. There is sediment and blood in the patient's 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. Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a life-threatening adverse effect of hypertonic solutions.
Which type of white blood cell contains preformed granules of vasoactive amines? a. Neutrophil b. Eosinophil c. Monocyte d. Basophil
D. basophil
The predominant phagocyte of early inflammation is the: a. eosinophil. b. lymphocyte. c. macrophage. d. neutrophil.
D. neutrophil
A patient is diagnosed with coronary artery disease. Which of the following modifiable risk factors would the nurse suggest the patient change? a.Eating meat b. Living arrangements c. Drinking tomato juice d. Smoking cigarettes
D. smoking cigarettes Cigarette smoking leads to vasoconstriction and should be the first behavior the patient changes. Eating meat alone would not lead to the development of coronary artery disease. The living arrangement of the patient's home would not lead to the development of coronary artery disease. Drinking tomato juice would not lead to the development of coronary artery disease.
A patient is diagnosed with orthostatic hypotension. Which of the following symptoms would most likely be reported? a. headache and blurred vision b. nausea and vomiting c. chest pain and palpitations d. syncope and fainting
D. syncope and fainting Orthostatic hypotension is often accompanied by dizziness, blurring or loss of vision, and syncope or fainting, not by headache or blurred vision, which are symptoms of hypertension. Chest pain and palpitations may be symptomatic of myocardial infarction. Nausea and vomiting are associated with gastrointestinal issues.
A 60-year-old female has survived a myocardial infarction. The nurse is providing care for impaired ventricular function because: a. there is a temporary alteration in electrolyte balance. b. there is too much stress on the heart. c. the cells become hypertrophic. d. the resulting ischemia leads to hypoxic injury and myocardial cell death.
D. the resulting ischemia leads to hypoxic injury and myocardial cell death. The patient has impaired ventricular functioning because a portion of the myocardium has died due to ischemia. Impaired ventricular function is due to damage to the myocardium; it is not due to electrolyte imbalance. There was stress on the heart, but the impaired functioning is due to myocardial damage secondary to ischemia. The impaired ventricular dysfunction is due to myocardial cell death, not hypertrophy.
A patient presents to the emergency department reporting difficulty swallowing and shortness of breath. A CT scan would most likely reveal an aneurysm in the: a. cerebral vessels b. renal arteries c. inferior vena cava d. thoracic aorta
D. thoracic aorta Thoracic aortic aneurysms can cause dysphagia (difficulty swallowing) and dyspnea (breathlessness). Aneurysms in cerebral vessels will produce a headache. Aneurysms in the renal arteries will produce flank pain. Aneurysms in the inferior vena cava may produce chest pain.
2. The nurse is assessing a patient for sleep patterns. The patient reports that he has trouble sleeping when lying flat. The best response from the nurse is A. open a window to let fresh air into the room. B. use nasal strips to assist with breathing. C. sleep in a side-lying position. D. use pillows to prop yourself up while sleeping.
D. use pillows to prop yourself up while sleeping. Correct Using pillows to prop himself up during sleep allows the patient to breathe more easily and comfortably. Nasal strips will help with breathing, but they do not always bring relief when one is lying flat. Sleeping in a side position or opening a window does not help one to breathe more easily when one is lying flat. Awarded 1.0 points out of 1.0 possible points.
The pediatric nurse understands that sildenafil (Revatio, Viagra) is prescribed to A. Decrease systemic blood pressure (afterload). B. Decrease the stickiness of the platelets in the blood. C. Decrease heart rate and increase contractility. D. Increase the central venous pressure (preload). E. Relax and widen the blood vessels in the lungs.
E
The school nurse is doing a health class on the functional organization of the circulatory system. What is the function of the capillaries in the circulatory system? Distribute oxygenated blood to the tissues Pump blood Exchange gases, nutrients, and wastes Collect deoxygenated blood from the tissues
Exchange gases, nutrients, and wastes Explanation: The circulatory system consists of the heart, which pumps blood; the arterial system, which distributes oxygenated blood to the tissues; the venous system, which collects deoxygenated blood from the tissues and returns it to the heart; and the capillaries, where exchange of gases, nutrients, and waste takes place.
The nurse assesses that the oxygen saturation is 89% in an unconscious patient who was transferred from surgery to the postanesthesia care unit (PACU) 15 minutes ago. Which action should the nurse take first? a. Elevate the patient's head. b. Suction the patient's mouth. c. Increase the oxygen flow rate. d. Perform the jaw-thrust maneuver.
In an unconscious postoperative patient, a likely cause of hypoxemia is airway obstruction by the tongue, and the first action is to clear the airway by maneuvers such as the jaw thrust or chin lift. Increasing the oxygen flow rate and suctioning are not helpful when the airway is obstructed by the tongue. Elevating the patient's head will not be effective in correcting the obstruction but may help with oxygenation after the patient is awake
5. Exercise and activity are included in a cardiac rehabilitation program for which purposes? (Select all that apply.) Increase cardiac output Increase serum lipids Increase blood pressure Increase blood flow to the arteries Increase muscle mass Increase flexibility
Increase cardiac output Increase blood flow to the arteries Increase muscle mass Increase flexibility A cardiac rehabilitation program seeks to increase cardiac output, blood flow to the arteries, muscle mass, and flexibility. The rehabilitation program does not want to increase serum lipids or blood pressure. Awarded 1.0 points out of 1.0 possible points. Continue
A patient is taking intravenous aminophylline for a severe exacerbation of chronic obstructive pulmonary disease. The nurse will assess for which therapeutic response? a. Increased sputum production b. Increased heart rate c. Increased respiratory rate d. Increased ease of breathing
Increased ease of breathing The therapeutic effects of bronchodilating drugs such as xanthine derivatives include increased ease of breathing. The other responses are incorrect.
Which of the following is true regarding pulmonary circulation? The system functions with an increased arterial pressure to circulate through the distal parts of the body. It is the larger of the two circulatory systems. It is a low-pressure system that allows for improved gas exchange. It consists of the left side of the heart, the aorta, and its branches.
It is a low-pressure system that allows for improved gas exchange. Explanation: The pulmonary circulation consists of the right heart and the pulmonary artery, capillaries, and veins. It is the smaller of the systems and functions at a lower pressure to assist with gas exchange.
The nurse is providing instructions about the Advair inhaler (fluticasone propionate and salmeterol). Which statement about this inhaler is accurate? a. It is indicated for the treatment of acute bronchospasms. b. It needs to be used with a spacer for best results. c. Patients need to avoid drinking water for 1 hour after taking this drug. d. It is used for prevention of bronchospasms.
It is used for prevention of bronchospasms. Salmeterol is a long-acting beta2 agonist bronchodilator, while fluticasone is a corticosteroid. In combination, they are used for the maintenance treatment of asthma and COPD. As a long-acting inhaler, Advair is not appropriate for treatment of acute bronchospasms. The other statements are incorrect.
The prescriber has changed the patient's medication regimen to include the leukotriene receptor antagonist montelukast (Singulair) to treat asthma. The nurse will emphasize which point about this medication? a. The proper technique for inhalation must be followed. b. The patient needs to keep it close by at all times to treat acute asthma attacks. c. It needs to be taken every day on a continuous schedule, even if symptoms improve. d. When the asthma symptoms improve, the dosage schedule can be tapered and eventually discontinued.
It needs to be taken every day on a continuous schedule, even if symptoms improve. These drugs are indicated for chronic, not acute, asthma and are to be taken every day on a continuous schedule, even if symptoms improve. These drugs are taken orally.
Which of the following blood flow patterns reduces friction, allowing the blood layers to slide smoothly over one another? Axially Laminar Crosswise Turbulent
Laminar Explanation: Laminar blood flow reduces friction by allowing the blood layers to slide smoothly over one another, with the axial layer having the most rapid rate of flow. Axially, crosswise, and turbulent blood flow would result in increased friction. In turbulent flow, the laminar stream is disrupted and the flow becomes mixed, moving radially (crosswise) and axially (lengthwise).
Which of the following blood flow patterns reduces friction, allowing the blood layers to slide smoothly over one another? Axially Laminar Turbulent Crosswise
Laminar Explanation: Laminar blood flow reduces friction by allowing the blood layers to slide smoothly over one another, with the axial layer having the most rapid rate of flow. Axially, crosswise, and turbulent blood flow would result in increased friction. In turbulent flow, the laminar stream is disrupted and the flow becomes mixed, moving radially (crosswise) and axially (lengthwise).
The physician states that a client has adequate collateral circulation. The nurse interprets this as: Development of increased collagen Anastomosis of the arterial and venous circulation Establishment of compensatory lymphatic drainage Long-term compensatory regulation of blood flow
Long-term compensatory regulation of blood flow Explanation: Collateral circulation is a mechanism for the long-term regulation of local blood flow. In the heart and other vital structures, anastomotic channels exist between some of the smaller arteries. These channels permit perfusion of an area by more than one artery. When one artery becomes occluded, these anastomotic channels increase in size, allowing blood from a patent artery to perfuse the area supplied by the occluded vessel. Lymph node removal requires establishment of compensatory lymphatic drainage. The aging process produces the development of increased collagen.
A nurse is assessing a female client and notes that her left arm is swollen from the shoulder down to the fingers, with non-pitting edema. The right arm is normal. The client had a left-sided mastectomy 1 year ago. What does the nurse suspect is the problem? Deep vein thrombosis Lymphedema Venous stasis Arteriosclerosis
Lymphedema Explanation: The lymphatic system filters fluid at the lymph nodes and removes foreign particles such as bacteria. When lymph flow is obstructed, a condition called lymphedema occurs. Involvement of lymphatic structures by malignant tumors and removal of lymph nodes at the time of cancer surgery are common causes of lymphedema.
Which related circulatory complication can result from surgical treatment for metastatic breast cancer? Lymphedema in the affected arm Tachycardia when at rest Irregular heart rate Hypotension upon standing
Lymphedema in the affected arm Explanation: Involvement of lymphatic structures by malignant tumors and removal of lymph nodes at the time of cancer surgery are common causes of lymphedema. The other options are not related to the surgery that would have removed any affected lympth nodes.
Questions 1. The nurse is assessing a female patient at the neighborhood clinic. The patient is complaining of "feeling tired all the time." The nurse knows that fatigue may be an underlying symptom of which condition? A. Ischemia B. Pneumonia C. Myocardial infarction D. Peptic ulcer disease
Myocardial infarction Fatigue is an atypical symptom of myocardial infarction in women.
A patient has excessive movement. What disorder will the nurse see documented on the chart? a. Hypokinesia b. Akinesia c. Hyperkinesia d. Dyskinesia
REF: p. 378 ANS: C Excessive movement is the definition of hyperkinesia. Hypokinesia is decreased movement. Akinesia is loss of movement. Dyskinesia is abnormal movement.
A client has had an acute myocardial infarction (MI). The brother of the client has a history of angina. The client asks how he will know if his brother's pain is angina or if the brother is actually having an MI. Which statement is correct? Chest pain with angina only occurs during the day; MI pain is more likely at night. Rest and intake of nitroglycerin relieve chest pain with angina; they do not relieve chest pain with an MI. Chest pain with angina only occurs at rest; MI pain occurs during a stressful time. Pain is more severe and lasts longer with angina than with an MI.
Rest and intake of nitroglycerin relieve chest pain with angina; they do not relieve chest pain with an MI. Explanation: Rest and intake of nitroglycerin relieve chest pain with angina but not with an MI. Pain with angina and MI is a subjective symptom for each client. Pain with angina and MI can occur at a variety of times.
With acyanotic heart defects, there is a left-to-right shunt. There is increased pulmonary blood flow and the blood is oxygenated. True or false?
True
With cyanotic heart defects, there is a right-to-left shunt: blood is shunted from the right side of the heart (pulmonary) to the left (systemic) side. Pulmonary circulation is bypassed. True or false?
True
Which blood vessel layer is made primarily of muscle? Tunica media Tunica adventitia Tunica intima Tunica externa
Tunica media Explanation: The middle layer (tunica media) of a vessel is largely a smooth muscle layer that constricts to regulate and control the diameter of the vessel. The outermost layer of a vessel is called the tunica externa (or tunica adventitia) and is composed of loosely woven collagen fibers. The innermost layer is the tunica intima, which consists of a single layer of flattened endothelial cells.
25. An older adult is prescribed digoxin (Lanoxin) and hydrochlorothiazide daily as well as lorazepam (Ativan) as needed for anxiety. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. What is the most likely reason for the patients change in mental status? a. Drug actions and interactions c. Hypotensive episodes b. Benzodiazepine withdrawal d. Renal failure
a. Drug actions and interactions Drug actions and interactions are common among elderly persons and predispose this population to delirium. Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The patient takes lorazepam on a PRN basis, so withdrawal is unlikely. Hypotensive episodes or problems with renal function may occur associated with the patients drug regime, but interactions are more likely the problem. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 433-434 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
2. Which assessment findings would the nurse expect in a patient experiencing delirium? Select all that apply. a. Impaired level of consciousness b. Disorientation to place, time c. Wandering attention d. Apathy e. Agnosia
a. Impaired level of consciousness b. Disorientation to place, time c. Wandering attention Disorientation to place and time is an expected finding. Orientation to person (self) usually remains intact. Attention span is short, and difficulty focusing or shifting attention as directed is often noted. Patients with delirium commonly experience illusions and hallucinations. Fluctuating levels of consciousness are expected. Agnosia occurs with dementia. Apathy is associated with depression. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 433 | Page 439 (Table 23-2) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
21. An older adult with moderately severe dementia forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the patients family? a. Label the bathroom door. b. Take the older adult to the bathroom hourly. c. Place the older adult in disposable adult briefs. d. Limit the intake of oral fluids to 1000 ml per day.
a. Label the bathroom door. The patient with moderately severe dementia has memory loss that begins to interfere with activities. This patient may be able to use environmental cues such as labels on doors to compensate for memory loss. Regular toileting may be helpful, but a 2-hour schedule is often more reasonable. Placing the patient in disposable briefs is more appropriate at a later stage. Severely limiting oral fluid intake would predispose the patient to a urinary tract infection. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 443 (Table 23-4) | Page 447 (Table 23-7) | Page 449 (Table 23-9) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment
The nurse has obtained the health history, physical assessment data, and laboratory results shown in the accompanying figure for a patient admitted with aplastic anemia. Which information is most important to communicate to the health care provider? History Fatigue, which has increased over last month Frequent constipation Physical Assessment Conjunctiva pale pink, moist Multiple bruises Clear lung sounds Laboratory Results Hct 33% WBC 1500/μL Platelets 70,000/μL a. Neutropenia c. Increasing fatigue b. Constipation d. Thrombocytopenia
a. Neutropenia c. Increasing fatigue b. Constipation d. Thrombocytopenia ANS: A The low white blood cell count indicates that the patient is at high risk for infection and needs immediate actions to diagnose and treat the cause of the leukopenia. The other information may require further assessment or treatment but does not place the patient at immediate risk for complications. DIF: Cognitive Level: Analyze (analysis) REF: 632 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
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
1. A patient diagnosed with moderately severe Alzheimers disease has a self-care deficit of dressing and grooming. Designate appropriate interventions to include in the patients plan of care. Select all that apply. a. Provide clothing with elastic and hook-and-loop closures. b. Label clothing with the patients name and name of the item. c. Administer anti-anxiety medication before bathing and dressing. d. Provide necessary items and direct the patient to proceed independently. e. If the patient resists dressing, use distraction and try again after a short interval.
a. Provide clothing with elastic and hook-and-loop closures. b. Label clothing with the patients name and name of the item. e. If the patient resists dressing, use distraction and try again after a short interval. Providing clothing with elastic and hook-and-loop closures facilitates patient independence. Labeling clothing with the patients name and the name of the item maintains patient identity and dignity (provides information if the patient has agnosia). When a patient resists, it is appropriate to use distraction and try again after a short interval because patient moods are often labile. The patient may be willing to cooperate given a later opportunity. Providing the necessary items for grooming and directing the patient to proceed independently are inappropriate. Be prepared to coach by giving step-by-step directions for each task as it occurs. Administering anxiolytic medication before bathing and dressing is inappropriate. This measure would result in unnecessary overmedication. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 443 (Table 23-4) | Page 447 (Table 23-7) | Page 452 (Nursing Care Plan 23-1) TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance
4. What is the priority nursing diagnosis for a patient with fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations? a. Risk for injury related to altered cerebral function, fluctuating levels of consciousness, disturbed orientation, and misperception of the environment b. Bathing/hygiene self-care deficit related to cerebral dysfunction, as evidenced by confusion and inability to perform personal hygiene tasks c. Disturbed thought processes related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations d. Fear related to sensory perceptual alterations as evidenced by visual and tactile hallucinations
a. Risk for injury related to altered cerebral function, fluctuating levels of consciousness, disturbed orientation, and misperception of the environment The physical safety of the patient is of highest priority among the diagnoses given. Many opportunities for injury exist when a patient misperceives the environment as distorted, threatening, or harmful or when the patient exercises poor judgment or when the patients sensorium is clouded. The other diagnoses may be concerns, but are lower priorities. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 435 | Page 442-443 | Page 452 (Nursing Care Plan 23-1) TOP: Nursing Process: Diagnosis/Analysis MSC: Client Needs: Safe, Effective Care Environment
A patient is receiving instructions regarding warfarin therapy and asks the nurse about what medications she can take for headaches. The nurse will tell her to avoid which type of medication? Select all that apply. a. aspirin b. acetaminophen c. NSAIDs d. The herbal product gingko e. Caffeine
a. aspirin c. NSAIDs d. The herbal product gingko
Cystic fibrosis (CF) is an _____ disease. a. autosomal recessive b. autosomal dominant c. X-linked recessive d. X-linked dominant
a. autosomal recessive
1. An older adult patient takes multiple medications daily. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of: a. delirium. c. amnestic syndrome. b. dementia. d. Alzheimers disease.
a. delirium. Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The onset of dementia or Alzheimers disease, a type of dementia, is more insidious. Amnestic syndrome involves memory impairment without other cognitive problems. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 432 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
The greatest proportion of total body iron is located in the: a. erythrocytes. b. spleen pulp. c. bone marrow. d. liver tissue.
a. erythrocytes.
26. A hospitalized patient diagnosed with delirium misinterprets reality, while a patient diagnosed with dementia wanders about the home. Which outcome is the priority in both scenarios? The patients will: a. remain safe in the environment. c. communicate verbally. b. participate actively in self-care. d. acknowledge reality.
a. remain safe in the environment. Risk for injury is the nurses priority concern. Safety maintenance is the desired outcome. The other outcomes are lower priorities and may not be realistic. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 435 | Page 442 | Page 452 (Nursing Care Plan 23-1) TOP: Nursing Process: Outcomes Identification MSC: Client Needs: Safe, Effective Care Environment
20. Goals of care for an older adult patient diagnosed with delirium caused by fever and dehydration will focus on: a. returning to premorbid levels of function. b. identifying stressors negatively affecting self. c. demonstrating motor responses to noxious stimuli. d. exerting control over responses to perceptual distortions.
a. returning to premorbid levels of function. The desired overall goal is that the delirious patient will return to the level of functioning held before the development of delirium. Demonstrating motor response to noxious stimuli is an indicator appropriate for a patient whose arousal is compromised. Identifying stressors that negatively affect the self is too nonspecific to be useful for a patient with delirium. Exerting control over responses to perceptual distortions is an unrealistic indicator for a patient with sensorium problems related to delirium. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 435 TOP: Nursing Process: Outcomes Identification MSC: Client Needs: Physiological Integrity
A 10-year-old is diagnosed with obstructive sleep apnea. When the parents ask, the nurse shares that the initial treatment will be: a. tonsillectomy and adenoidectomy (T&A). b. weight loss. c. continuous positive airway pressure. d. drug therapy.
a. tonsillectomy and adenoidectomy (T&A).
Which of the following nutritional components will the nurse encourage a patient to consume as it is needed for erythropoiesis? a. Vitamin B12 b. Vitamin B1 c. Vitamin D d. Zinc
a. vit b12
7. A newborn experiencing respiratory distress syndrome (RDS) will demonstrate signs: a. within minutes of birth. b. 2-3 hours after birth. c. within the first 12-24 hours after birth. d. 24-48 hours after exposure to an infectious organism.
a. within minutes of birth
A patient has a severe kidney obstruction leading to removal of the affected kidney. which of the following would the nurse expect to occur? a. atrophy of the remaining kidney b. compensatory hypertorphy of the remaining kidney c. dysplasia in the remaining kidney d. renal failure
ans: b the remaining kidney would hypertrophy to compensate for the increased workload of the loss of the affected kidney. compensation for such a situation would not include atrophy or a change in cell structure of the remaining kidney. rena failure would be avoided. ref: p. 748
A patient is diagnosed with urinary tract obstruction. While planning care, the nurse realizes that the patient is expected to have hydronephrosis and a decreased glomerular filtration rate caused by: a. decreased renal blood flow b. decreased peritubular capillary pressure c. dilation of the renal pelvis and calyces proximal to a blockage d. stimulation of antidiuretic hormone
ans: c hydronephrosis occurs due to dilaton of the renal pelvis and calyces proximal to a blockage. Hydronephrosis is not the result of a decrease in renal blood flow, or peritubular capillary pressure, or stimulation of the antidiuretic hormone ref: p. 747
A patient is being discharged on anticoagulant therapy. The nurse will include in the patient-education conversation that it is important to avoid herbal products that contain which substance? a. Valerian b. Ginkgo c. Soy d. Saw palmetto
b. Ginkgo
A patient who has been anticoagulated with warfarin (Coumadin) has been admitted for gastrointestinal bleeding. The history and physical examination indicates that the patient may have taken too much warfarin. The nurse anticipates that the patient will receive which antidote? a. Vitamin E b. Vitamin K c. Protamine sulfate d. Potassium chloride
b. Vitamin K
Which statement made by a student nurse indicates the need for further teaching about pituitary insufficiency? a. "Synthetic human growth hormone may be prescribed for children who are small for gestational age." b. "Testosterone supplements may be prescribed for women with gonadotropin deficiency." c. "Estrogen is known to regulate the action of growth hormone in men and women." d. "Chronic kidney disease treatment may include synthetic growth hormone replacement."
b. "Testosterone supplements may be prescribed for women with gonadotropin deficiency." Synthetic human growth hormone (HGH) is used for growth hormone deficiencies caused by pituitary insufficiency, as well as other conditions such as Turner's syndrome, chronic kidney disease, and children small for gestation age. Testosterone is used as supplement for men with gonadotropin deficiency. Estrogen and progesterone supplements, also referred to as hormone replacement therapy (HRT), is indicated for women with gonadotropin deficiency and for the relief of post-menopausal symptoms. Estrogen is also known to regulate secretion and action of GH in men and women.
Radioactive iodine is indicated for the treatment of hyperthyroidism. The nurse should include which teaching in this patient's plan of care? a. Isolation is required for 6-8 weeks b. An additional dose may be needed c. Thyroid replacement therapy is prescribed d. An overnight hospital stay is required
b. An additional dose may be needed Radioactive iodine (RAI) is indicated for the treatment of hyperthyroidism. It is given as an oral preparation, usually as a single dose on an outpatient basis. The radioactive iodine makes its way to the thyroid gland where it destroys some of the cells that produce thyroid hormone. The RAI is completely eliminated from the body after about 4 weeks. The extent of thyroid cell destruction is variable, thus the patient has ongoing monitoring of thyroid function. If thyroid production remains too high a second dose may be needed. The goal of this procedure is to destroy thyroid hormone producing cells; additional thyroid hormone is not prescribed.
A 75-year-old patient experienced a lacunar stroke. When looking through the history of the patient's chart, which of the following would the nurse expect to find? a. An embolus b. An ischemic lesion c. A hemorrhage d. An aneurysm
b. An ischemic lesion
A patient presents to a primary care provider reporting fever, headache, nuchal rigidity, and decreased consciousness. History includes a previously treated sinusitis. Which medical diagnosis is best supported by this assessment data? a. Aseptic meningitis b. Bacterial meningitis c. Fungal meningitis d. Nonpurulent meningitis
b. Bacterial meningitis
5. What is the priority intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations? a. Distraction using sensory stimulation c. Avoidance of physical contact b. Careful observation and supervision d. Activation of the bed alarm
b. Careful observation and supervision Careful observation and supervision are of ultimate importance because an appropriate outcome would be that the patient will remain safe and free from injury. Physical contact during care cannot be avoided. Activating a bed alarm is only one aspect of providing for the patients safety. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 436 (Box 23-1) | Page 452 (Nursing Care Plan 23-1) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment
8. Consider these health problems: Lewy body disease, frontal-temporal lobar degeneration, and Huntingtons disease. Which term unifies these problems? a. Cyclothymia c. Delirium b. Dementia d. Amnesia
b. Dementia The listed health problems are all forms of dementia. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 437 | Page 451 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
13. A patient with stage 3 Alzheimers disease tires easily and prefers to stay home rather than attend social activities. The spouse does the grocery shopping because the patient cannot remember what to buy. Which nursing diagnosis applies at this time? a. Self-care deficit c. Caregiver role strain b. Impaired memory d. Adult failure to thrive
b. Impaired memory Memory impairment begins at stage 2 and progresses in stage 3. This patient is able to perform most self-care activities. Caregiver role strain and adult failure to thrive occur later. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 439 (Table 23-2) | Page 442-443 (Table 23-5) | Page 452 (Nursing Care Plan 23-1) TOP: Nursing Process: Diagnosis/Analysis MSC: Client Needs: Psychosocial Integrity 14. A patient has progressive memory deficits associated with dementia. Which nursing intervention would best help the individual function in the environment? a. Assist the patient to perform simple tasks by giving step-by-step directions. b. Reduce frustration by performing activities of daily living for the patient. c. Stimulate intellectual function by discussing new topics with the patient. d. Read one story from the newspaper to the patient every day. a. Assist the patient to perform simple tasks by giving step-by-step directions. Patients with cognitive impairment should perform all tasks of which they are capable. When simple directions are given in a systematic fashion, the patient is better able to process information and perform simple tasks. Stimulating intellectual functioning by discussing new topics is likely to prove frustrating for the patient. Patients with cognitive deficits may enjoy the attention of someone reading to them, but this activity does not promote their function in the environment. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 445 (Table 23-6) | Page 447 (Table 23-7) TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
After falling, a patient's Glasgow Coma Scale (GCS) was 5 initially and 7 after 1 day. The patient remained unconscious for 2 weeks but is now awake, confused, and experiencing anterograde amnesia. This history supports which medical diagnosis? a. Mild diffuse brain injury b. Moderate diffuse brain injury c. Severe diffuse brain injury d. Postconcussive syndrome
b. Moderate diffuse brain injury
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.
27. An elderly patient is admitted with delirium secondary to a urinary tract infection. The family asks whether the patient will ever recover. Select the nurses best response. a. The health care provider is the best person to answer your question. b. The confusion will probably get better as we treat the infection. c. Unfortunately, delirium is a progressively disabling disorder. d. I will be glad to contact the chaplain to talk with you.
b. The confusion will probably get better as we treat the infection. Usually, as the underlying cause of the delirium is treated, the symptoms of delirium clear. The distracters mislead the family. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 433-434 | Page 439 (Table 23-2) TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
Which important teaching point should the nurse include in the plan of care for a patient diagnosed with Cushing's disease? a. Daily weight using same scale b. Wash hands frequently c. Use exfoliating soaps when bathing d. Avoid yearly influenza vaccine
b. Wash hands frequently Cushing's syndrome is characterized by chronic excess glucocorticoid (cortisol) secretion from the adrenal cortex. This is caused by the hypothalamus, or the anterior pituitary gland, or the adrenal cortex. Cushing's syndrome can also be caused by taking corticosteroids in the form of medication (such as prednisone) over time - referred to as exogenous Cushing syndrome. Regardless of the cause, excess secretion of cortisol has a systemic affect affecting immunity, metabolism, and fat distribution (truncal obesity), reduced muscle mass, loss of bone density, hypertension, fragility to microvasculature, as well as thinning of the skin. Washing hands is important because the patient's immune system is suppressed due to the excess glucocorticoid level. Daily weights are not indicated. Exfoliating soaps may damage thin skin. The patient should receive vaccinations due to being immunocompromised.
A 5-year-old presents with high fever, inspiratory stridor, severe respiratory distress, drooling, and dysphagia. Acute epiglottitis is suspected. When assessing the child the nurse would avoid: a. trying to keep the child calm. b. examining the throat for redness. c. auscultating the child's respiratory rate. d. counting the heart rate apically.
b. examining the throat for redness.
A patient is brought to the ER for treatment of injuries received in a motor vehicle accident. An MRI reveals spinal cord injury, and his body temperature fluctuates markedly. The most accurate explanation of this phenomenon is that: a. he developed pneumonia. b. his sympathetic nervous system has been damaged. c. he has a brain injury. d. he has septicemia from an unknown source.
b. his sympathetic nervous system has been damaged
A nurse is discussing a cell that can differentiate into any tissue type. Which term is the nurse describing? a. Hematopoietic b. Pluripotent c. Blastocyst d. Progenitor
b. pluripotent
In addition to playing a role in hemostasis, platelets have the ability to: a. stimulate bone marrow production of erythrocytes. b. release biochemical mediators of inflammation. c. undergo cell division in response to bleeding. d. activate a humoral response.
b. release biochemical mediators of inflammation.
7. Which assessment finding would be likely for a patient experiencing a hallucination? The patient: a. looks at shadows on a wall and says, I see scary faces. b. states, I feel bugs crawling on my legs and biting me. c. reports telepathic messages from the television. d. speaks in rhymes.
b. states, I feel bugs crawling on my legs and biting me. A hallucination is a false sensory perception occurring without a corresponding sensory stimulus. Feeling bugs on the body when none are present is a tactile hallucination. Misinterpreting shadows as faces is an illusion. An illusion is a misinterpreted sensory perception. The other incorrect options apply to thought insertion and clang associations. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 432-434 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
A patient will be receiving a thrombolytic drug as part of the treatment for acute myocardial infarction. The nurse explains to the patient that this drug is used for which purpose? a. To relieve chest pain b. To prevent further clot formation c. To dissolve the clot in the coronary artery d. To control bleeding in the coronary vessels
c. To dissolve the clot in the coronary artery
The nurse is caring for a patient who has undergone a thyroidectomy. Which patient complaint is highest priority requiring further evaluation? a. Pain at surgical site b. Thirst c. Hoarseness d. Nausea
c. Hoarseness Thyroidectomy involves a surgical incision in the anterior neck. Hoarseness may be a sign of airway edema. A patent airway is always a priority of care for any post-operative patient. General anesthesia is used for this surgery requiring insertion of an artificial airway, therefore throat irritation and thirst is expected. Nausea may be a side effect from anesthesia. Pain is expected at the surgical site.
A 65-year-old patient diagnosed with a subarachnoid hemorrhage secondary to uncontrolled hypertension appears drowsy and confused with pronounced focal neurologic deficits. This symptomology would place this hemorrhage at which grade? a. I b. II c. III d. IV
c. III
A 20-year-old female is being admitted to the hospital with fever and septic shock. Which set of assessment findings would the nurse expect the patient to exhibit? a. Bradycardia, palpitations, confusion, truncal rash b. Severe respiratory distress, jugular venous distention, chest pain c. Low blood pressure and tachycardia d. Reduced cardiac output, increased systemic vascular resistance, moist cough
c. Low blood pressure and tachycardia Clinical manifestations of shock will include a low blood pressure and tachycardia. Tachycardia, not bradycardia, will occur. Severe respiratory distress, jugular vein distention, and chest pain are symptoms of heart failure, particularly pulmonary edema. Cardiac output is reduced, but there is a decrease in systemic vascular resistance.
9. Which medication prescribed to patients diagnosed with Alzheimers disease antagonizes N-Methyl-D-Aspartate (NMDA) channels rather than cholinesterase? a. Donepezil (Aricept) c. Memantine (Namenda) b. Rivastigmine (Exelon) d. Galantamine (Razadyne)
c. Memantine (Namenda) Memantine blocks the NMDA channels and is used in moderate-to-late stages of the disease. Donepezil, rivastigmine, and galantamine are all cholinesterace inhibitors. These drugs increase the availability of acetylcholine and are most often used to treat mild-to-moderate Alzheimers disease. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 450 (Table 23-10) TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
11. An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police intervened, they found that this adult was wearing a heavy coat and hat, even though it was July. Which stage of Alzheimers disease is evident? a. Preclinical Alzheimers disease c. Moderately severe cognitive decline b.Mild cognitive decline d. Severe cognitive decline
c. Moderately severe cognitive decline In the moderately severe stage, deterioration is evident. Memory loss may include the inability to remember addresses or the date. Activities such as driving may become hazardous, and frustration by the increasing difficulty of performing ordinary tasks may be experienced. The individual has difficulty with clothing selection. Mild cognitive decline (early-stage) Alzheimers can be diagnosed in some, but not all, individuals. Symptoms include misplacing items and misuse of words. In the stage of severe cognitive decline, personality changes may take place, and the patient needs extensive help with daily activities. This patient has symptoms, so the preclinical stage does not apply. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 438-439 (Table 23-2) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
The nurse is caring for a patient diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). What is the nurse's best action? a. Encourage increased fluid and water intake b. Teach about risk for malignancies c. Monitor for changes in level of consciousness d. Assess labwork for potassium level changes
c. Monitor for changes in level of consciousness As the name suggests, SIADH is a condition in which antidiuretic hormone (ADH) is secreted despite normal or low plasma osmolarity, resulting in water retention and dilutional hyponatremia. In response to increased plasma volume, aldosterone secretion increases and further contributes to sodium loss. Hyponatremia frequently manifests with changes in level of consciousness from confusion to coma. A large number of clinical conditions can cause SIADH including malignancies, pulmonary disorders, injury to the brain, and certain pharmacologic agents. Malignancies often lead to SIADH versus SIADH causing malignant conditions. Water intoxication can lead to hyponatremia, therefore water intake is restricted. The most affected electrolyte from SIADH is sodium versus potassium.
15. Two patients in a residential care facility have dementia. One shouts to the other, Move along, youre blocking the road. The other patient turns, shakes a fist, and shouts, Youre trying to steal my car. What is the nurses best action? a. Administer one dose of an antipsychotic medication to both patients. b. Reinforce reality. Say to the patients, Walk along in the hall. This is not a traffic intersection. c. Separate and distract the patients. Take one to the day room and the other to an activities area. d. Step between the two patients and say, Please quiet down. We do not allow violence here.
c. Separate and distract the patients. Take one to the day room and the other to an activities area. Separating and distracting prevents escalation from verbal to physical acting out. Neither patient loses self-esteem during this intervention. Medication probably is not necessary. Stepping between two angry, threatening patients is an unsafe action, and trying to reinforce reality during an angry outburst will probably not be successful when the patients are cognitively impaired. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 445 (Table 23-6) | Page 452 (Nursing Care Plan 23-1) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment
The nurse is reviewing new medication orders for a patient who has an epidural catheter for administration of pain medications. One of the orders is for enoxaparin (Lovenox), a low-molecular-weight heparin (LMWH). What is the nurse's priority action? a. Give the LMWH as ordered. b. Double-check the LMWH order with another nurse, and then administer as ordered. c. Stop the epidural pain medication, and then administer the LMWH. d. Contact the prescriber because the LMWH cannot be given if the patient has an epidural catheter.
d. Contact the prescriber because the LMWH cannot be given if the patient has an epidural catheter.
A patient has been prescribed warfarin (Coumadin) in addition to a heparin infusion. The patient asks the nurse why he has to be on two medications. The nurse's response is based on which rationale? a. The oral and injection forms work synergistically. b. The combination of heparin and an oral anticoagulant results in fewer adverse effects than heparin used alone. c. The warfarin is used to reach an adequate level of anticoagulation when heparin alone is unable to do so. d. Heparin is used to start anticoagulation so as to allow time for the blood levels of warfarin to reach adequate levels.
d. Heparin is used to start anticoagulation so as to allow time for the blood levels of warfarin to reach adequate levels.
When administering heparin subcutaneously, the nurse will follow which procedure? a. Aspirating the syringe before injecting the medication b. Massaging the site after injection c. Use the same area for each injection. d. Using a 1/2- to 5/8-inch 25- to 27-gauge needle
d. Using a 1/2- to 5/8-inch 25- to 27-gauge needle
17. A patient diagnosed with Alzheimers disease calls the fire department saying, My smoke detectors are going off. Firefighters investigate and discover that the patient misinterpreted the telephone ringing. Which problem is this patient experiencing? a. Hyperorality c. Apraxia b. Aphasia d. Agnosia
d. Agnosia Agnosia is the inability to recognize familiar objects, parts of ones body, or ones own reflection in a mirror. Hyperorality refers to placing objects in the mouth. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movements, such as being unable to dress. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 438 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
3. A patient with fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, Someone get these bugs off me. What is the nurses best response? a. No bugs are on your legs. You are having hallucinations. b. I will have someone stay here and brush off the bugs for you. c. Try to relax. The crawling sensation will go away sooner if you can relax. d. I dont see any bugs, but I can tell you are frightened. I will stay with you.
d. I dont see any bugs, but I can tell you are frightened. I will stay with you. When hallucinations are present, the nurse should acknowledge the patients feelings and state the nurses perception of reality, but not argue. Staying with the patient increases feelings of security, reduces anxiety, offers the opportunity for reinforcing reality, and provides a measure of physical safety. Denying the patients perception without offering help does not support the patient emotionally. Telling the patient to relax makes the patient responsible for self-soothing. Telling the patient that someone will brush the bugs away supports the perceptual distortions. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 436 (Box 23-1) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
The nurse is monitoring a patient who is receiving antithrom-bolytic therapy in the emergency department because of a possible MI. Which adverse effect would be of the greatest concern at this time? a. Dizziness b. Blood pressure of 130/98 mm Hg c. Slight bloody oozing from the IV insertion site d. Irregular heart rhythm
d. Irregular heart rhythm
22. A older patient diagnosed with severe, late-stage dementia no longer recognizes family members. The family asks how long it will be before this patient recognizes them when they visit. What is the nurses best reply? a. Your family member will never again be able to identify you. b. I think that is a question the health care provider should answer. c. One never knows. Consciousness fluctuates in persons with dementia. d. It is disappointing when someone you love no longer recognizes you.
d. It is disappointing when someone you love no longer recognizes you. Therapeutic communication techniques can assist the family to come to terms with the losses and irreversibility dementia imposes on both the loved one and themselves. Two incorrect responses close communication. The nurse should take the opportunity to foster communication. Consciousness does not fluctuate in patients with dementia. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 438 | Page 440 (Table 23-3) | Page 441 | Page 443 (Table 23-5) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
The majority of intervertebral disk herniations occur between which vertebral levels (cervical, C; thoracic, T; lumbar, L; sacral, S)? a. C1-C3 b. T1-T4 c. T12-L3 d. L4-S1
d. L4-S1
24. What is the priority need for a patient with late-stage dementia? a. Promotion of self-care activities b. Meaningful verbal communication c. Preventing the patient from wandering d. Maintenance of nutrition and hydration
d. Maintenance of nutrition and hydration In late-stage dementia, the patient often seems to have forgotten how to eat, chew, and swallow. Nutrition and hydration needs must be met if the patient is to live. The patient is incapable of self-care, ambulation, or verbal communication. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 440 (Table 23-3) TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity
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
Who is most at risk of spinal cord injury because of preexisting degenerative disorders? a. Infants b. Men c. Women d. The elderly
d. The elderly