UNIT 4--ADV MED-SURG

When assessing a patient with possible peripheral artery disease (PAD), the nurse obtains a brachial blood pressure (BP) of 147/82 mm Hg and an ankle pressure of 112/74 mm Hg. 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. Formula: volume/time (min) x gtt 250/2(60) = 250/120 = 2.08 x 10 = 20.8 or 21 gtt/min

Which menu choice by the patient with diverticulosis is best for preventing diverticulitis? a. Navy bean soup and vegetable salad b. Whole grain pasta with tomato sauce c. Baked potato with low-fat sour cream d. Roast beef sandwich on whole wheat bread

ANS: A A diet high in fiber and low in fats and red meat is recommended to prevent diverticulitis. Although all the choices have some fiber, the bean soup and salad will be the highest in fiber and the lowest in fat.

Which patient statement to the nurse is most consistent with the diagnosis of venous insufficiency? a. "I can't get my shoes on at the end of the day." b. "I can't ever seem to get my feet warm enough." c. "I have burning leg pain 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.

The nurse is assessing a patient with abdominal pain. How will the nurse document ecchymosis around the area of umbilicus? a. Cullen sign b. Rovsing sign c. McBurney sign d. Grey-Turner's sign

ANS: A Cullen sign is ecchymosis around the umbilicus. Rovsing sign occurs when palpation of the left lower quadrant causes pain in the right lower quadrant. Grey Turner's sign is bruising over the flanks. Deep tenderness at McBurney's point (halfway between the umbilicus and the right iliac crest), known as McBurney's sign, is a sign of acute appendicitis.

After having frequent diarrhea and a weight loss of 10 lb (4.5 kg) over 2 months, a patient has a new diagnosis of Crohn's disease. What should the nurse plan to teach the patient? a. Medication use b. Fluid restriction c. Enteral nutrition d. Activity restrictions

ANS: A Medications are used to induce and maintain remission in patients with inflammatory bowel disease (IBD). Decreased activity level is indicated only if the patient has severe fatigue and weakness. Fluids are needed to prevent dehydration. There is no advantage to enteral feedings.

Which intervention is most appropriate for the patient with the nursing diagnosis imbalanced nutrition: more than body requirements related to overeating? a. Use of dishware that limits portion sizes b. Menu consisting of purchased premeasured food c. Ketogenic diet that restricts carbohydrate intake d. Crash diet based on lemon juice and cabbage soup

ANS: A A successful weight-loss plan involves sustainable lifestyle modifications that include physical activity, self-monitoring, portion control, and knowledge of energy content of food. Getting the weight off quickly using a crash diet is not healthy. Ketogenic diets can be harmful for some patients. Premeasured food is expensive and it is difficult to keep the weight off afterward.

The nurse is developing a discharge teaching plan for a patient diagnosed with thromboangiitis obliterans (Buerger's disease). Which expected 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.

Which menu option is least likely to cause wide variations in the diabetic's blood sugar? a. Ham sandwich on whole wheat bread b. Sesame bagel with vegetable cream cheese c. Spaghetti with meat sauce and parmesan cheese d. Peanut butter and jelly sandwich on white bread

ANS: A Foods with complex carbohydrates such as whole wheat bread have less impact on blood sugar than simple carbohydrates such as bagels, spaghetti, and wheat bread. The ham sandwich on whole wheat bread will have the least impact on the patient's blood sugar levels.

A patient calls the clinic to report a new onset of severe diarrhea. What should the nurse anticipate that the patient will need to do? a. Collect a stool specimen. b. Prepare for colonoscopy. c. Schedule a barium enema. d. Have blood cultures drawn.

ANS: A Acute diarrhea is usually caused by an infectious process, so stool specimens are obtained for culture and examined for parasites or white blood cells. There is no indication that the patient needs a colonoscopy, blood cultures, or a barium enema.

Which intervention is most appropriate for the nursing diagnosis ineffective breastfeeding related to maternal malnutrition? a. Encourage the mother to eat a diet rich in nutrients and protein. b. Provide a quiet nursing environment to reduce maternal anxiety. c. Allow the infant to room with the mother and breastfeed on demand. d. Avoid supplemental feedings for the infant to promote breastfeeding.

ANS: A Maternal nutrition is the cause of the ineffective breastfeeding so that must be the primary focus. The nursing mother needs to a diet rich in nutrients and protein in order to meet the nutritional needs of the infant as well as her own body. Reducing maternal anxiety and allowing rooming-in do not address maternal malnutrition. The infant may require formula supplements if breastfeeding alone does not provide sufficient nutrition.

Which condiment is the healthiest option for the patient to reduce the chances of having a heart attack? a. Olive oil b. Margarine c. Shortening d. Cream cheese

ANS: A Olive oil contains monounsaturated fats and can help lower cholesterol levels. Margarine and shortening contain trans fats that raise heart attack risk by lowering HDL levels and raising LDL levels. Cream cheese contains saturated fats that also raise heart attack risk.

Which nursing diagnosis is the highest priority for a patient who had the large intestine removed? a. Risk for deficient fluid volume related to excessive fluid loss in stool b. Risk for compromised human dignity related to stigma from ileostomy c. Bathing/hygiene self-care deficit related to presence of ileostomy bag d. Social isolation related to perceived offensive odor from ileostomy bag

ANS: A Risk for deficient fluid volume related to excessive fluid loss in stool as the large intestine functions to absorb water from the stool. Without the large intestine, stools are watery and the patient is at risk for dehydration due to excessive fluid loss. Compromised human dignity, self-care deficit, and social isolation are all lower priority diagnoses.

Which is the highest priority nursing diagnosis for a patient with dysphagia following a stroke? a. Risk for aspiration related to inability to ingest food and fluids safely b. Feeding self-care deficit related to neuromuscular impairment and weakness c. Risk for constipation related to intake of low-fiber foods and thickened liquids d. Imbalanced nutrition: less than body requirements related to swallowing difficulty

ANS: A Risk of aspiration is the highest priority diagnosis as aspiration can lead to pneumonia and respiratory failure. Imbalanced nutrition would be the next highest priority. Feeding self-care deficit is less important because the patient can be assisted at mealtimes. Risk for constipation is less important than aspiration risk and can be minimized with high-fiber soft foods and liquids.

Which laboratory finding indicates that the patient has not been eating well? a. Serum albumin level 2.1 g/dL b. Presence of nitrites in the urine c. Prothrombin time 11.5 seconds d. Serum creatinine level 0.8 mg/dL

ANS: A Serum albumin levels should be 3.5 to 5 g/dL. The patient's low serum albumin level indicates malnutrition. Presence of nitrites in the urine indicates urinary tract infection. The prothrombin time and serum creatinine level are both within normal limits.

Which outcome is most appropriate for a patient with the nursing diagnosis imbalanced nutrition: more than body requirements related to recent pregnancy and childbirth? a. The patient will lose 1 pound per week for the next 6 weeks. b. The patient will use fashion strategies to enhance appearance. c. The patient will regain normal liver enzymes within 1 month. d. The patient will demonstrate adaptation to body changes from pregnancy.

ANS: A The patient should aim for slow, steady weight loss such as 1 pound per week for the next 6 weeks. Fashion strategies to enhance appearance and adaptation to body changes from pregnancy are appropriate for the altered body image nursing diagnosis. There is no mention of abnormal liver enzymes so the patient would not have a goal of regaining normal liver enzymes.

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.

The hospital nurse implements a teaching plan to assist an older patient who lives alone to independently accomplish daily activities. How would the nurse best evaluate the patient's long-term response to the teaching? a. Make a referral to the home health nursing agency for home visits. b. Have the patient demonstrate the learned skills at the end of the teaching session. c. Arrange a physical therapy visit before the patient is discharged from the hospital. d. Check the patient's ability to bathe and get dressed without assistance the next day.

ANS: A A home health referral would allow for the assessment of the patient's long-term response after discharge. The other actions allow evaluation of the patient's short-term response to teaching.

What should the nurse admitting a patient with acute diverticulitis plan for initial care? a. Administer IV fluids. b. Prepare for colonoscopy. c. Encourage a high-fiber diet. d. Give stool softeners and enemas.

ANS: A A patient with acute diverticulitis will be NPO and given parenteral fluids. A diet high in fiber and fluids will be implemented before discharge. Bulk-forming laxatives, rather than stool softeners, are usually given. These will be implemented later in the hospitalization. The patient with acute diverticulitis will not have enemas or a colonoscopy because of the risk for perforation and peritonitis.

A middle-aged patient who has diabetes tells the nurse, "I want to know how to give my own insulin so I don't have to bother my wife all the time." What action should the nurse complete first? a. Demonstrate how to draw up and administer insulin. b. Discuss the use of exercise to decrease insulin needs. c. Teach about differences between the various types of insulin. d. Provide handouts about therapeutic and adverse effects of insulin.

ANS: A Adult education is most effective when focused on information that the patient thinks is needed right now. All the indicated information will need to be included when planning teaching for this patient, but the teaching will be most effective if the nurse starts with the patient's stated priority topic.

A patient with a new ileostomy asks how much it will drain. How many cups of drainage per day should the nurse explain for the patient to expect? a. 2 b. 3 c. 4 d. 5

ANS: A After the proximal small bowel adapts to reabsorb more fluid, the average amount of ileostomy drainage is about 500 mL daily. One cup is about 240 mL.

Which nursing action is of highest priority for a patient with kidney stones who is being admitted to the hospital with gross hematuria and severe colicky left flank pain? a. Administer prescribed analgesics. b. Monitor temperature every 4 hours. c. Encourage increased oral fluid intake. d. Give antiemetics as needed for nausea.

ANS: A Although all the nursing actions may be used for patients with kidney stones, the patient's presentation indicates that management of pain is the highest priority action. If the patient has urinary obstruction, increasing oral fluids may increase the symptoms. There is no evidence of infection or nausea.

Which nursing action will be included in the plan of care for a 25-yr-old male patient with a new diagnosis of irritable bowel syndrome (IBS)? a. Encourage the patient to express concerns and ask questions about IBS. b. Suggest that the patient increase the intake of milk and other dairy products. c. Teach the patient to avoid using nonsteroidal antiinflammatory drugs (NSAIDs). d. Teach the patient about the use of alosetron (Lotronex) to reduce IBS symptoms.

ANS: A Because psychologic and emotional factors can affect the symptoms for IBS, encouraging the patient to discuss emotions and ask questions is an important intervention. Alosetron has serious side effects and is used only for female patients who have not responded to other therapies. Although yogurt may be beneficial, milk is avoided because lactose intolerance can contribute to symptoms in some patients. NSAIDs can be used by patients with IBS.

A patient is admitted to the emergency department with possible renal trauma after an automobile accident. Which prescribed intervention will the nurse implement first? a. Check blood pressure and heart rate. b. Administer morphine sulfate 4 mg IV. c. Transport to radiology for an intravenous pyelogram. d. Insert a urethral catheter and obtain a urine specimen.

ANS: A Because the kidney is very vascular, the initial action with renal trauma will be assessment for bleeding and shock. The other actions may be important after the patient's cardiovascular status has been determined and stabilized.

Which nursing intervention is appropriate for a patient with non-Hodgkin's lymphoma whose platelet count drops to 18,000/µL during chemotherapy? a. Test 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.

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. Obtain vital signs. b. Teach wound care. c. Assess pedal pulses. d. Check the wound site.

ANS: A 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

The nurse is caring for a patient who has had an ileal conduit for several years. Which nursing action could be delegated to unlicensed assistive personnel (UAP)? a. Change the ostomy appliance. b. Choose the appropriate ostomy bag. c. Monitor the appearance of the stoma. d. Assess for possible urinary tract infection (UTI).

ANS: A Changing the ostomy appliance for a stable patient could be done by UAP. Assessments of the site, choosing the appropriate ostomy bag, and assessing for UTI symptoms require more education and scope of practice and should be done by the registered nurse (RN).

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

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

A young woman with Crohn's disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, fecal-smelling urine. What information will the nurse add to a general teaching plan about UTIs in order to individualize the teaching for this patient? a. Fistulas can form between the bowel and bladder. b. Bacteria in the perianal area can enter the urethra. c. Drink adequate fluids to maintain normal hydration. d. Empty the bladder before and after sexual intercourse.

ANS: A Fistulas between the bowel and bladder occur in Crohn's disease and can lead to UTI. Teaching for UTI prevention in general includes good hygiene, adequate fluid intake, and voiding before and after intercourse.

A patient in the urology clinic is diagnosed with monilial urethritis. Which action will the nurse include in the plan of care? a. Teach the patient about the use of antifungal medications. b. Tell the patient to avoid tub baths until the symptoms resolve. c. Instruct the patient to refer recent sexual partners for treatment. d. Tell the patient to avoid nonsteroidal antiinflammatory drugs (NSAIDs).

ANS: A Monilial urethritis is caused by a fungus and antifungal medications such as nystatin or fluconazole are usually used as treatment. Because monilial urethritis is not sexually transmitted, there is no need to refer sexual partners. Warm baths and NSAIDS may be used to treat symptoms.

Which action by the patient with newly diagnosed Raynaud's phenomenon best demonstrates that the nurse's teaching about managing the condition has been effective? a. The patient exercises indoors during the winter months. b. The patient immerses 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.

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.

Which prescribed intervention for a patient with chronic short bowel syndrome should the nurse question? a. Senna 1 tablet daily b. Ferrous sulfate 325 mg daily c. Psyllium (Metamucil) 3 times daily d. Diphenoxylate with atropine (Lomotil) PRN loose stools

ANS: A Patients with short bowel syndrome have diarrhea because of decreased nutrient and fluid absorption and would not need stimulant laxatives. Iron supplements are used to prevent iron-deficiency anemia, bulk-forming laxatives help make stools less watery, and opioid antidiarrheal drugs are helpful in slowing intestinal transit time.

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/uL. b. Blood pressure is 94/56 mm Hg. c. Petechiae are present on the chest. 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/uL 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.

Which group of drugs will the nurse plan to include when teaching a patient who has a new diagnosis of peripheral artery disease (PAD)? a. Statins b. Antibiotics c. Thrombolytics d. Anticoagulants

ANS: A Research indicates that statin use by patients with PAD improves multiple outcomes. There is no research that supports the use of the other drug categories in PAD

A patient with Crohn's disease who is taking infliximab (Remicade) calls the nurse in the outpatient clinic about new symptoms. Which symptom is most important to communicate to the health care provider?a. Fever b. Nausea c. Joint pain d. Headache

ANS: A Since infliximab suppresses the immune response, rapid treatment of infection is essential. Nausea, joint pain, and headache are common side effects of the medication, but they do not indicate any potentially life-threatening complications.

A patient is unable to void after having an open loop resection and fulguration of the bladder. Which nursing action should be implemented? a. Assist the patient to soak in a 15-minute sitz bath. b. Restrict oral fluids to equal previous urine volume. c. Insert a straight urethral catheter and drain the bladder. d. Teach the patient how to do isometric perineal exercises.

ANS: A Sitz baths will relax the perineal muscles and promote voiding. The patient should be to drink fluids. Kegel exercises are helpful in the prevention of incontinence but would not be helpful for a patient experiencing retention. Catheter insertion increases the risk for urinary tract infection and should be avoided when possible.

Which patient statement indicates that the nurse's teaching about sulfasalazine (Azulfidine) for ulcerative colitis has been effective? a. "I should apply sunscreen before going outdoors." b. "The medication will be tapered if I need surgery." c. "I will need to avoid contact with people who are sick." d. "The medication prevents the infections that cause diarrhea."

ANS: A Sulfasalazine may cause photosensitivity in some patients. It is not used to treat infections. Sulfasalazine does not reduce immune function. Unlike corticosteroids, tapering of sulfasalazine is not needed.

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

ANS: A 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.

A patient with a history of polycystic kidney disease is admitted to the surgical unit after having shoulder surgery. Which of the routine postoperative orders is most important for the nurse to discuss with the health care provider? a. Give ketorolac 10 mg PO PRN for pain. b. Infuse 5% dextrose in normal saline at 75 mL/hr. c. Order regular diet after patient is awake and alert. d. Draw blood urea nitrogen (BUN) and creatinine in 2 hours.

ANS: A The nonsteroidal antiinflammatory drugs (NSAIDs) should be avoided in patients with decreased renal function because nephrotoxicity is a potential adverse effect. The other orders do not need any clarification or change.

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/VN) caring for the patient requires the registered nurse (RN) to intervene? a. The LPN/VN tells the patient sit in a chair for 2 hours. b. The LPN/VN gives the prescribed aspirin after breakfast. c. The LPN/VN assists the patient to walk 40 ft in the hallway. d. The LPN/VN places the patient in 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.

Which patient should the nurse assess first after receiving change-of-shift report? a. A 30-yr-old patient who has a distended abdomen and tachycardia b. A 60-yr-old patient whose ileostomy has drained 800 mL over 8 hours c. A 40-yr-old patient with ulcerative colitis who had six liquid stools in 4 hours d. A 50-yr-old patient with familial adenomatous polyposis who has occult blood in the stool

ANS: A The patient's abdominal distention and tachycardia suggest hypovolemic shock caused by problems such as peritonitis or intestinal obstruction, which will require rapid intervention. The other patients should be assessed as quickly as possible, but the data do not indicate any life-threatening complications associated with their diagnoses.

A young adult male patient seen at the primary care clinic reports feeling continued fullness after voiding and a split, spraying urine stream. What should the nurse ask about the patient's history? a. Gonococcal urethritis b. Recent kidney trauma c. Recurrent bladder infection d. Benign prostatic hyperplasia

ANS: A The patient's clinical manifestations are consistent with urethral strictures, a possible complication of gonococcal urethritis. The symptoms are not consistent with benign prostatic hyperplasia, kidney trauma, or bladder infection.

A 76-yr-old with benign prostatic hyperplasia (BPH) is agitated and confused, with a markedly distended bladder. Which intervention prescribed by the health care provider should the nurse implement first? a. Insert an indwelling urinary catheter. b. Draw blood for a serum creatinine level.c. Schedule an intravenous pyelogram (IVP). d. Administer lorazepam (Ativan) 0.5 mg PO

ANS: A The patient's history and clinical manifestations are consistent with acute urinary retention, and the priority action is to relieve the retention by catheterization. The BUN and creatinine measurements can be obtained after the catheter is inserted. The patient's agitation may resolve after the bladder distention is corrected, and sedative drugs should be used cautiously in older patients. The IVP may be done as a diagnostic test but does not need to be done urgently

A patient states, "I told my husband I will go the grocery store to buy fresh fruit, vegetables, and whole grains instead of prepared food snacks." When using the Transtheoretical Model of Health Behavior Change, the nurse identifies that this patient is in which stage of change? a. Preparation b. Termination c. Maintenance d. Contemplation

ANS: A The patient's statement indicating that the plan for change is being shared with someone else indicates that the preparation stage has been achieved. Contemplation of a change would be indicated by a statement like "I know I should exercise." Maintenance of a change occurs when the patient practices the behavior regularly. Termination would be indicated when the change is a permanent part of the lifestyle.

A patient who smokes a pack of cigarettes per day tells the nurse, "I enjoy smoking and have no plans to quit." When using the Transtheoretical Model of Health Behavior Change, the nurse identifies that this patient is in which stage of change? a. Precontemplation b. Contemplation c. Maintenance d. Termination

ANS: A The patient's statement shows that he or she is not considering smoking cessation. In the precontemplation stage, patients are not concerned about their cigarette smoking and are not considering changing their behavior.

A patient is awaiting surgery for acute peritonitis. Which action will the nurse plan to include in the preoperative care? a. Position patient with the knees flexed. b. Avoid use of opioids or sedative drugs. c. Offer frequent small sips of clear liquids. d. Assist patient to breathe deeply and cough.

ANS: A There is less peritoneal irritation with the knees flexed, which will help decrease pain. Opioids and sedatives are typically given to control pain and anxiety. Preoperative patients with peritonitis are given IV fluids for hydration. Deep breathing and coughing will increase the patient's discomfort.

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.

A patient being admitted with an acute exacerbation of ulcerative colitis reports crampy abdominal pain and passing 15 bloody stools a day. What should the nurse include in the plan of care? a. Administer IV metoclopramide (Reglan). b. Discontinue the patient's oral food intake. c. Administer cobalamin (vitamin B12) injections. d. Teach the patient about total colectomy surgery

ANS: B An initial therapy for an acute exacerbation of inflammatory bowel disease (IBD) is to rest the bowel by making the patient NPO. Metoclopramide increases peristalsis and will worsen symptoms. Cobalamin (vitamin B12) is absorbed in the ileum, which is not affected by ulcerative colitis. Although total colectomy is needed for some patients, there is no indication that this patient is a candidate.

Which instruction will the nurse plan to include in discharge teaching for a patient admitted with a sickle cell crisis? a. Limit fluids to 2 to 3 quarts per day. b. Avoid exposure to crowds when possible. c. Take a daily multivitamin supplement with iron. d. Drink no more than two caffeinated beverages daily.

ANS: B 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.

After change-of-shift report, which patient should the nurse assess first? a. Patient who has cloudy urine after bladder reconstruction. b. Patient with a urethral stricture who has not voided for 12 hours. c. Patient who voided bright red urine after returning from lithotripsy. d. Patient with polycystic kidney disease whose blood pressure is 186/98 mm Hg.

ANS: B Not voiding for 12 hours suggests acute urinary retention, which is a medical emergency. The nurse will need to assess the patient and consider whether to insert a retention catheter. The other patients will be assessed, but their findings are consistent with their diagnoses and do not require immediate assessment or intervention.

A patient with blunt abdominal trauma from a motor vehicle crash undergoes peritoneal lavage. If the lavage returns brown fecal drainage, which action will the nurse plan to take next? a. Auscultate the bowel sounds. b. Prepare the patient for surgery. c. Check the patient's oral temperature. d. Obtain information about the accident.

ANS: B Return of brown drainage and fecal material suggests perforation of the bowel and the need for immediate surgery. Auscultation of bowel sounds, checking the temperature, and obtaining information about the accident are appropriate actions, but the priority is to prepare to send the patient for emergency surgery.

A 22-yr-old female patient with an exacerbation of ulcerative colitis is having 15 to 20 stools daily and has excoriated perianal skin. Which patient behavior indicates that teaching regarding maintenance of skin integrity has been effective? a. The patient uses incontinence briefs to contain loose stools. b. The patient uses witch hazel compresses to soothe irritation. c. The patient asks for antidiarrheal medication after each stool. d. The patient cleans the perianal area with soap after each stool.

ANS: B Witch hazel compresses are suggested to reduce anal irritation and discomfort. Incontinence briefs may trap diarrhea and increase the incidence of skin breakdown. Antidiarrheal medications are not given 15 to 20 times a day. The perianal area should be washed with plain water or pH balanced cleanser after each stool.

Which dish must be removed from the meal tray of an orthodox Jewish patient? a. Penne pasta with marinara sauce and soft breadsticks b. Scrambled eggs, bacon, and toast with strawberry jelly c. Stir-fried chicken with noodles, broccoli, and teriyaki d. Green salad with red peppers, carrots, beets, and radishes

ANS: B Orthodox Jewish patients follow a kosher diet that prohibits pork products such as bacon. Pasta, vegetables, chicken, and salad are all acceptable.

Which is the best reason why a gastrostomy tube is ordered rather than parenteral nutrition for a patient with dysphagia? a. Parenteral nutrition can only be administered to the patient in the hospital. b. The gastrostomy tube provides more nutrition and protects intestinal function. c. Parenteral nutrition is significantly more expensive than gastrostomy feedings. d. The gastrostomy tube allows for administration of medications as well as nutrition.

ANS: B Research has demonstrated a beneficial effect of enteral nutrition over parenteral routes in patients with a functional GI tract. Therefore enteral feeding is preferred over parenteral nutrition (intravenous nutrition) because it improves use of nutrients, is generally safer for patients, maintains structure and function of the gut, decreases the risk for infection and sepsis, and is less expensive, not more expensive. Medications can also be given through an IV, so this does not answer the spouse's question. The gastrostomy placement is invasive as the tube is inserted directly into the stomach. Patients can receive parenteral nutrition in the home.

Which action of the patient will facilitate aspiration of food and fluids into the airway? a. The patient avoids talking when eating or swallowing. b. The patient tilts the head backward when swallowing. c. The patient thickens liquids to the consistency of honey. d. The patient clears the throat after every few bites of food.

ANS: B The nurse should remind the patient to not tilt head backward when eating or while drinking because this may cause food and liquid to be misdirected into the airway. Thin liquids such as water and fruit juice are difficult to control in the mouth and pharynx and are more easily aspirated so these need to be thickened. Clearing the throat after every few bites of food helps to maintain a clear airway. The patient should avoid talking when eating or swallowing in order to concentrate on aspiration prevention.

Which soup is appropriate for a patient who follows a vegan diet? a. Cream of broccoli and cheddar cheese soup b. Moroccan carrot, apple, and cauliflower soup c. Minestrone soup with lamb, vegetables, and pasta d. Egg drop soup with chow mein noodles and scallions

ANS: B Vegan diets eat only plant-based foods and do not allow eggs, meat, or dairy products. Moroccan carrot, apple, and cauliflower soup is the best option for the patient following a vegan diet.

Which nursing diagnosis is most appropriate for a newborn who did not receive vitamin K supplementation immediately after birth? a. Ineffective breastfeeding related to inability to latch on b. Ineffective protection related to impaired blood clotting c. Risk for unstable blood glucose related to developmental level d. Disorganized infant behavior related to altered primitive reflexes

ANS: B Vitamin K is needed for blood clotting. Infants are born without sufficient levels of vitamin K and are at risk for bleeding unless supplemental vitamin K is administered immediately after birth. Vitamin K does not affect breastfeeding, blood glucose, or infant reflexes.

What should the nurse include when teaching an adult patient to prevent the recurrence of kidney stones? a. Using a filter to strain all urine b. Drinking 3000 mL of fluid each day c. Avoiding dietary sources of calcium d. Choosing diuretic fluids such as coffee

ANS: B A fluid intake of 2000 to 3000 mL/day is recommended to help flush out minerals before stones can form. Avoidance of calcium is not usually recommended for patients with kidney stones. Coffee tends to increase stone recurrence. Straining all urine routinely after a stone has passed will not prevent stones.

A 33-yr-old male patient with a gunshot wound to the abdomen undergoes surgery, and a colostomy is formed as shown in the accompanying figure. Which information will be included in patient teaching? a. Stool will be expelled from both stomas. b. This type of colostomy is usually temporary. c. Soft, formed stool can be expected as drainage. d. Irrigations can regulate drainage from the stomas.

ANS: B A loop, or double-barrel stoma, is usually temporary. Stool will be expelled from the proximal stoma only. The stool from the transverse colon will be liquid and regulation through irrigations will not be possible.

The nurse has assessed that a patient with newly diagnosed colon cancer does not have basic knowledge about colon cancer. The nurse should initially focus on which learning goal for this patient? a. The patient will state ways of preventing the recurrence of the cancer. b. The patient will explore and select an appropriate colon cancer therapy. c. The patient will demonstrate coping skills needed to manage the disease. d. The patient will choose methods to minimize adverse effects of treatment.

ANS: B Adults learn best when given information that can be used immediately. The first action the patient will need to take after a cancer diagnosis is to explore and choose a treatment option. The other goals may be appropriate as treatment progresses.

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. Give 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.

The nurse is admitting a 67-yr-old patient with new-onset steatorrhea. Which question is most important for the nurse to ask? a. "How much milk do you usually drink?" b. "Have you noticed a recent weight loss?" c. "What time of day do your bowels move?" d. "Do you eat meat or other animal products?"

ANS: B Although all the questions provide useful information, it is most important to determine if the patient has an imbalance in nutrition because of the steatorrhea.

After the nurse provides diet instructions for a patient with diabetes, the patient can restate the information but does not make the recommended diet changes. How would the nurse evaluate this outcome? a. Learning did not occur because the patient's behavior did not change. b. Choosing not to follow the diet is the behavior that resulted from learning. c. The nurse's responsibility for helping the patient make diet changes has been fulfilled. d. The teaching methods were ineffective in helping the patient learn about the necessary diet changes.

ANS: B Although the patient behavior has not changed, the patient's ability to restate the information indicates that learning has occurred, and the patient is choosing at this time not to change the diet. The patient may be in the contemplation or preparation stage in the transtheoretical model. The nurse should reinforce the need for change and continue to provide information and assistance with planning for change.

A patient reports gas pains and abdominal distention 2 days after a small bowel resection. Which nursing action should the nurse take? a. Administer morphine sulfate. b. Encourage the patient to ambulate. c. Offer the prescribed promethazine. d. Instill a mineral oil retention enema.

ANS: B Ambulation will improve peristalsis and help the patient eliminate flatus and reduce gas pain. A mineral oil retention enema is helpful for constipation with hard stool. A return-flow enema might be used to relieve persistent gas pains. Morphine will further reduce peristalsis. Promethazine is used as an antiemetic rather than to decrease gas pains or distention.

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

ANS: B 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.

What should the nurse preparing for the annual physical exam of a 45-yr-old man plan to teach the patient about? a. Endoscopy b. Colonoscopy c. Computerized tomography screening d. Carcinoembryonic antigen (CEA) testing

ANS: B At age 45 years, persons with an average risk for colorectal cancer (CRC) should begin screening for CRC. Colonoscopy is the gold standard for CRC screening. The other diagnostic tests are not recommended as part of a routine annual physical exam at age 45 years.

Which nursing action will the nurse include in the plan of care for a patient admitted with an exacerbation of inflammatory bowel disease (IBD)? a. Restrict oral fluid intake. b. Monitor stools for blood. c. Ambulate six times daily. d. Increase dietary fiber intake.

ANS: B Because anemia or hemorrhage may occur with IBD, stools should be assessed for the presence of blood. The other actions would not be appropriate for the patient with IBD. Dietary fiber may increase gastrointestinal motility and exacerbate the diarrhea, severe fatigue is common with IBD exacerbations, and dehydration may occur.

Nursing staff on a hospital unit are reviewing rates of health care-associated infections (HAI) of the urinary tract. Which nursing action will be most helpful in decreasing the risk for urinary HAI in patients admitted to the hospital? a. Testing urine with a dipstick daily for nitrites b. Avoiding unnecessary urinary catheterization c. Encouraging adequate oral fluid and nutritional intake d. Providing perineal hygiene to patients daily and as needed

ANS: B Because catheterization bypasses many of the protective mechanisms that prevent urinary tract infection (UTI), avoidance of catheterization is the most effective means of reducing HAI. The other actions will also be helpful but are not as useful as decreasing urinary catheter use.

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. Assess the abdominal incision for redness. d. Counsel the patient to plan for a long recovery time.

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.

The nurse is admitting a patient newly diagnosed with peripheral artery disease who takes clopidogrel. Which admission order should the nurse question? a. Cilostazol drug therapy b. Omeprazole drug therapy c. Use of treadmill for exercise d. Exercise to the point of discomfort

ANS: B Because the antiplatelet effect of clopidogrel is reduced when it is used with omeprazole, the nurse should clarify this order with the health care provider. The other interventions are appropriate for a patient with peripheral artery disease.

An older patient with a history of an abdominal aortic aneurysm arrives at the emergency department (ED) with severe back pain and absent pedal pulses. Which action should the nurse take first? a. Draw blood for laboratory testing. b. Check the patient's blood pressure. c. Assess the patient for an abdominal bruit. d. Determine any family history of heart disease.

ANS: B 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 may also be done, but they will not provide information to determine what interventions are needed immediately

The nurse is evaluating the discharge teaching outcomes for a patient with chronic peripheral artery disease (PAD). Which patient statement indicates a need for further instruction? a. "I will buy loose clothes that do not bind across my legs or waist." b. "I will use a heating pad on my feet at night to increase the circulation." c. "I will walk to the point of pain, rest, and walk again for at least 30 minutes 3 times a week." d. "I will change my position every hour and avoid long periods of sitting with my legs crossed."

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.

Which potential complication should the nurse identify as a high risk for a patient admitted to the hospital with idiopathic aplastic anemia? a. Seizures b. Infection c. Neurogenic shock d. 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.

A critically ill patient with sepsis is frequently incontinent of watery stools. What action by the nurse will prevent complications associated with ongoing incontinence? a. Apply incontinence briefs. b. Use a fecal management system. c. Insert a rectal tube with a drainage bag. d. Assist the patient to a commode frequently.

ANS: B Fecal management systems are designed to contain loose stools and can be in place for as long as 4 weeks without causing damage to the rectum or anal sphincters. Although incontinence briefs may be helpful, unless they are changed frequently, they are likely to increase the risk for skin breakdown. Rectal tubes are avoided because of possible damage to the anal sphincter and ulceration of the rectal mucosa. A critically ill patient will not be able to tolerate getting up frequently to use the commode or bathroom.

A 48-yr-old male patient who weighs 242 lb (110 kg) undergoes a nephrectomy for massive kidney trauma from a motor vehicle crash. Which postoperative assessment finding is most important to communicate to the surgeon? a. Blood pressure is 102/58. b. Urine output is 20 mL/hr for 2 hours. c. Incisional pain level reported as 9/10. d. Crackles present at bilateral lung bases.

ANS: B Because the urine output should be at least 0.5 mL/kg/hr, a 40-mL output for 2 hours indicates that the patient may have decreased renal perfusion because of bleeding, inadequate fluid intake, or obstruction at the suture site. The blood pressure requires ongoing monitoring but does not indicate inadequate perfusion at this time. The patient should cough and deep breathe, but the crackles do not indicate a need for an immediate change in therapy. The incisional pain should be addressed, but this is not as potentially life threatening as decreased renal perfusion. In addition, the nurse can medicate the patient for pain.

A 46-yr-old female patient returns to the clinic with continued dysuria after being treated with trimethoprim and sulfamethoxazole for 3 days. Which action will the nurse plan to take? a. Remind the patient about the need to drink 1000 mL of fluids daily. b. Obtain a midstream urine specimen for culture and sensitivity testing. c. Suggest that the patient use acetaminophen (Tylenol) to relieve symptoms. d. Tell the patient to take the trimethoprim and sulfamethoxazole for 3 more days.

ANS: B Because uncomplicated urinary tract infections (UTIs) are usually successfully treated with 3 days of antibiotic therapy, this patient will need a urine culture and sensitivity to determine appropriate antibiotic therapy. Acetaminophen would not be as effective as other over-the-counter medications such as phenazopyridine in treating dysuria. The fluid intake should be increased to at least 1800 mL/day. Because the UTI has persisted after treatment with trimethoprim and sulfamethoxazole, the patient is likely to need a different antibiotic.

Which information obtained by the nurse interviewing a 30-yr-old male patient is most important to communicate to the health care provider? a. The patient has a history of constipation. b. The patient has noticed blood in the stools. c. The patient had an appendectomy at age 27. d. The patient smokes a pack/day of cigarettes.

ANS: B Blood in the stools is a possible clinical manifestation of colorectal cancer and requires further assessment by the health care provider. The other patient information will also be communicated to the health care provider but does not indicate an urgent need for further testing or intervention.

A routine complete blood count for an active older man indicates possible myelodysplastic syndrome. What should the nurse plan to explain to the patient? a. Blood transfusion b. Bone marrow biopsy c. Filgrastim administration d. Erythropoietin 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 later if there is progression of the myelodysplastic syndrome, but the initial action for this asymptomatic patient will be a bone marrow biopsy.

A patient preparing to undergo a colon resection for cancer of the colon asks about the elevated carcinoembryonic antigen (CEA) test result. What should the nurse explain as the reason for the test? a. Identify any metastasis of the cancer. b. Monitor the tumor status after surgery. c. Confirm the diagnosis of a specific type of cancer. d. Determine the need for postoperative chemotherapy.

ANS: B CEA is used to monitor for cancer recurrence after surgery. CEA levels do not help to determine whether there is metastasis of the cancer. Confirmation of the diagnosis is made based on the biopsy. Chemotherapy use is based on factors other than CEA.

What risks will the nurse plan to teach a 27-yr-old woman who smokes two packs of cigarettes daily? a. Kidney stones b. Bladder cancer c. Bladder infection d. Interstitial cystitis

ANS: B Cigarette smoking is a risk factor for bladder cancer. The patient's risk for developing interstitial cystitis, urinary tract infection, or kidney stones will not be reduced by quitting smoking.

Which patient statement supports a history of intermittent claudication? a. "When I stand too long, my feet start to swell." b. "My legs cramp when I walk more than a block." c. "I get short of breath when I climb a lot of stairs." d. "My fingers hurt when I go outside in cold weather."

ANS: B 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.

Which assessment finding should the nurse caring for a patient with thrombocytopenia communicate immediately to the health care provider? a. Bruises on the patient's back. b. The patient is difficult to arouse. c. Purpura on the patient's oral mucosa. d. The patient's platelet count is 52,000/µL.

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.

Which finding on a patient's nursing admission assessment is congruent with the initial medical diagnosis of a 6-cm thoracic aortic aneurysm? 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

After a total proctocolectomy and permanent ileostomy, the patient tells the nurse, "I cannot manage all this. I don't want to look at the stoma." What action should the nurse take? a. Reassure the patient that ileostomy care will become easier. b. Ask the patient about the concerns with stoma management. c. Postpone any teaching until the patient adjusts to the ileostomy. d. Develop a detailed written list of ostomy care tasks for the patient.

ANS: B Encouraging the patient to share concerns assists in helping the patient adjust to the body changes. Acknowledgment of the patient's feelings and concerns is important rather than offering false reassurance. Because the patient indicates that the feelings about the ostomy are the reason for the difficulty with the many changes, development of a detailed ostomy care plan will not improve the patient's ability to manage the ostomy. Although detailed ostomy teaching could be postponed, the nurse should begin to offer teaching about some aspects of living with an ostomy.

A patient seen in the clinic for a bladder infection describes the following symptoms. Which information is most important for the nurse to report to the health care provider? a. Urinary urgency b. Left-sided flank pain c. Intermittent hematuriad. Burning with urination

ANS: B Flank pain indicates that the patient may have developed pyelonephritis as a complication of the bladder infection. The other clinical manifestations are consistent with a lower urinary tract infection.

Which information will the nurse include in teaching a patient who had a proctocolectomy and ileostomy for ulcerative colitis? a. Restrict fluid intake to prevent constant liquid drainage from the stoma. b. Use care when eating high-fiber foods to avoid obstruction of the ileum. c. Irrigate the ileostomy daily to avoid having to wear a drainage appliance. d. Change the pouch every day to prevent leakage of contents onto the skin.

ANS: B High-fiber foods are introduced gradually and should be well chewed to avoid obstruction of the ileostomy. Patients with ileostomies lose the absorption of water in the colon and need to take in increased amounts of fluid. The pouch should be drained frequently but is changed every 5 to 7 days. The drainage from an ileostomy is liquid and continuous, so control by irrigation is not possible.

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

ANS: B 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.

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.

The nurse observes scleral jaundice in a patient being admitted with hemolytic anemia. Which laboratory result the nurse should check? a. Schilling test b. Bilirubin level c. Stool occult blood d. Gastric acid analysis

ANS: B Jaundice is caused by the elevation of bilirubin level associated with red blood cell hemolysis. Other tests would not be helpful in monitoring hemolytic anemia.

Which information will the nurse plan to teach a patient who has lactose intolerance? a. Ice cream is relatively low in lactose. b. Live-culture yogurt is usually tolerated. c. Heating milk will break down the lactose. d. Nonfat milk is tolerated better than whole milk.

ANS: B Lactose-intolerant persons can usually eat yogurt without experiencing discomfort. Ice cream, nonfat milk, and milk that have been heated are all high in lactose.

A patient with diabetic neuropathy requires teaching about foot care. Which learning goal should the nurse include in the teaching plan?a. The nurse will demonstrate the proper technique for trimming toenails. b. The patient will list three ways to protect the feet from injury by discharge. c. The nurse will instruct the patient on appropriate foot care before discharge. d. The patient will understand the rationale for proper foot care after instruction.

ANS: B Learning goals should state clear, measurable outcomes of the learning process. Demonstrating technique for trimming toenails and providing instructions on foot care are actions that the nurse will take rather than behaviors that indicate that patient learning has occurred. A learning goal that states that the patient will understand the rationale for proper foot care is too vague and nonspecific to measure whether learning has occurred.

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 accurate? a. "Taking both blood thinners greatly reduces the risk for another clot to form." b. "Enoxaparin will work right away, but warfarin takes several days to begin preventing clots." c. "Enoxaparin will start to dissolve the clot, and warfarin will prevent any more clots from forming." 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: B 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. Anticoagulants do not thin the blood.

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. Wrap both legs in a warming blanket. b. Notify the surgeon and anesthesiologist. c. Document the findings and recheck in 15 minutes. d. Compare findings to the preoperative assessment of the pulses.

ANS: B 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 surgeon immediately because this is an emergency situation. Because pulses are marked before surgery, the nurse would know whether pulses were present before 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.

Which problem reported by a patient with hemophilia is most important for the nurse to communicate to the health care provider? a. Leg bruises b. Tarry stools c. Skin abrasions 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.

A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. Which nutrient supplement should the nurse plan to explain to the patient? 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.

The nurse is planning a teaching session with a patient newly diagnosed with migraine headaches. To assess the patient's readiness to learn, which question should the nurse ask first? a. "What kind of work and leisure activities do you do?" b. "What information do you think you need right now?" c. "Can you describe the types of activities that help you learn new information?" d. "Do you have any religious beliefs that are inconsistent with the planned treatment?"

ANS: B Motivation and readiness to learn depend on what the patient values and perceives as important. The other questions are also important in developing the teaching plan, but do not address what information most interests the patient at present.

A patient who has acute myelogenous leukemia (AML) is considering treatment with a hematopoietic stem cell transplant (HSCT). What is the best approach for the nurse to assist the patient with this treatment decision? a. Discuss the need for insurance to cover post-HSCT care. b. Inquire 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.

To prevent recurrence of uric acid kidney stones, the nurse teaches the patient to avoid eating: a. milk and cheese. b. sardines and liver. c. spinach and chocolate. d. legumes and dried fruit.

ANS: B Organ meats and fish such as sardines increase purine levels and uric acid. Spinach, chocolate, and tomatoes should be avoided in patients who have oxalate stones. Milk, dairy products, legumes, and dried fruits may increase the incidence of calcium-containing stones

After change-of-shift report, which patient should the nurse assess first? a. A 40-yr-old male patient with celiac disease who has frequent frothy diarrhea b. A 30-yr-old female patient with a femoral hernia who has abdominal pain and vomiting c. A 30-yr-old male patient with ulcerative colitis who has severe perianal skin breakdown d. A 40-yr-old female patient with a colostomy bag that is pulling away from the adhesive wafer

ANS: B Pain and vomiting with a femoral hernia suggest strangulation, which will require emergency surgery. All the other patients require assessment or care but have less urgent problems.

Which nursing intervention is important when providing care for a patient with sickle cell crisis? a. Limiting the patient's intake of oral and IV fluids b. Evaluating the effectiveness of opioid analgesics c. Encouraging the patient to ambulate as much as tolerated d. Teaching 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.

A 19-yr-old patient has familial adenomatous polyposis (FAP). Which action will the nurse in the gastrointestinal clinic include in the plan of care? a. Obtain blood samples for DNA analysis. b. Schedule the patient for yearly colonoscopy. c. Provide preoperative teaching about total colectomy. d. Discuss lifestyle modifications to decrease cancer risk.

ANS: B Patients with FAP should have annual colonoscopy starting at age 16 years and usually have total colectomy by age 25 years to avoid developing colorectal cancer. DNA analysis is used to make the diagnosis but is not needed now for this patient. Lifestyle modifications will not decrease cancer risk for this patient.

A patient who is morbidly obese states, "I've recently decreased my fat intake, and I've stopped smoking." Which statement, if made by the nurse, is the best initial response? a. "Although those are important, it is essential that you make other changes." b. "You have accomplished changes that are important for the health of your heart." c. "Are you having any difficulty in maintaining the changes you have already made?" d. "Which additional changes in your lifestyle would you like to implement at this time?"

ANS: B Positive reinforcement of the learner's achievements is critical in making lifestyle changes. This patient is in the action stage of the Transtheoretical Model when reinforcement of the changes being made is an important nursing intervention. The other responses are also appropriate but are not the best initial response.

A postoperative patient and caregiver need discharge teaching. Which actions included in the teaching plan can the nurse delegate to unlicensed assistive personnel (UAP)? a. Evaluate whether the patient and caregiver understand the teaching. b. Give the patient a pamphlet to reinforce teaching done by the nurse. c. Plan for the discharge teaching session with the patient and caregiver. d. Show the caregiver how to accurately check the patient's temperature.

ANS: B Providing a pamphlet to a patient to reinforce previously taught material does not require nursing judgment and can safely be delegated to UAP. Demonstration of how to take a temperature accurately, determining the best time for teaching, and evaluation of the success of patient teaching all require judgment and critical thinking and should be done by the registered nurse.

Which instructions should the nurse include in a teaching plan for an older adult patient newly diagnosed with peripheral artery disease (PAD)? 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 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 PRBCs slowly over 4 hours. b. Transfuse leukocyte-reduced PRBCs. c. Administer the prescribed 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.

A patient had a cystectomy with an ileal conduit yesterday. Which new assessment data is most important for the nurse to communicate to the health care provider? a. Cloudy appearing urine b. Heart rate 102 beats/min c. Hypoactive bowel sounds d. Continuous stoma drainage

ANS: B Tachycardia may indicate infection, hemorrhage, or hypovolemia, which are all serious complications of this surgery. The urine from an ileal conduit normally contains mucus and is cloudy. Hypoactive bowel sounds are expected after bowel surgery. Continuous drainage of urine from the stoma is normal.

The nurse has started discharge teaching for a patient who is to continue warfarin (Coumadin) after hospitalization for venous thromboembolism (VTE). Which patient statement indicates a need for additional teaching? a. "I should get a Medic Alert device stating that I take warfarin."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 warfarin." d. "I will check with my health care provider before I begin any new drugs."

ANS: B Teach patients taking warfarin to follow a consistent diet regarding foods that are high in vitamin K, such as green, leafy vegetables. The other patient statements are accurate

A young adult who has von Willebrand disease is admitted to the hospital for minor knee surgery. Which laboratory value should the nurse monitor? a. Platelet count b. Bleeding timec. Thrombin 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.

Several hours after a patient had 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 45 mL. What should the nurse anticipate will be prescribed? a. Hemoglobin count b. Increased IV fluids c. Additional antibiotics d. Serum creatinine level

ANS: B 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

The nurse and the patient who is diagnosed with hypertension develop this goal: "The patient will select a 2-g sodium diet from the hospital menu for 3 days." Which evaluation method will the nurse use to determine whether teaching was effective? a. Have the patient list substitutes for favorite foods that are high in sodium. b. Check the sodium content of the patient's menu choices over the next 3 days. c. Compare the patient's sodium intake before and after the teaching was implemented. d. Ask the patient to identify which foods on the hospital menus are high in sodium for 3 days in a row.

ANS: B The desired patient behaviors in the learning objective are most clearly addressed by evaluating the sodium content of the patient's menu choices. Other answers address the patient's sodium intake but not the specific goal.

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. Place a "No Visitors" sign on the door. d. Omit fruits and vegetables from the diet.

ANS: B The earliest sign of infection in a neutropenic patient is an elevation in temperature. While 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.

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. Which action should the nurse take? 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.

Which finding for a patient who has just been admitted with acute pyelonephritis is most important for the nurse to report to the health care provider? a. Flank tenderness to palpation b. Blood pressure 90/48 mm Hg c. Cloudy and foul-smelling urine d. Temperature 100.1° F (57.8° C)

ANS: B The low blood pressure indicates that urosepsis and septic shock may be occurring and should be immediately reported. The other findings are typical of pyelonephritis.

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?a. Bruising b. Neutropenia c. Increasing fatigue d. Thrombocytopenia

ANS: B 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.

A 74-yr-old male patient tells the nurse that growing old causes constipation, so he has been using a suppository to prevent constipation every morning. Which action should the nurse take first? a. Encourage the patient to increase oral fluid intake. b. Question the patient about risk factors for constipation. c. Suggest that the patient increase intake of high-fiber foods. d. Teach the patient that a daily bowel movement is unnecessary.

ANS: B The nurse's initial action should be further assessment of the patient for risk factors for constipation and for his usual bowel pattern. The other actions may be appropriate but will be based on the assessment.

A patient receiving outpatient chemotherapy for myelogenous leukemia develops an absolute neutrophil count of 850/µL. Which collaborative action should the outpatient clinic nurse anticipate?? 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.

An adult patient is admitted to the hospital with new-onset nephrotic syndrome. Which assessment data will the nurse expect? a. Poor skin turgor b. Recent weight gain c. Elevated urine ketones d. Decreased blood pressure

ANS: B The patient with a nephrotic syndrome will have weight gain associated with edema. Hypertension is a clinical manifestation of nephrotic syndrome. Skin turgor is normal because of the edema. Urine protein is high. Ketones are not related to nephrotic syndrome.

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 yellow b. A 23-yr-old with no previous health problems who has a nontender axillary lump 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.

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. Send a urine specimen to the laboratory. b. Administer PRN acetaminophen (Tylenol). c. Draw blood for a new type and crossmatch. d. Give the prescribed PRN diphenhydramine.

ANS: B 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.

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

ANS: B The patient's presentation of sudden sharp and severe upper back pain is consistent with dissecting thoracic aneurysm, which will require the most rapid intervention. The other patients also require rapid intervention but not before the patient with severe pain.

The nurse prepares written handouts to be used as part of the standardized teaching plan for patients who have been recently diagnosed with diabetes. What statement is written at a level appropriate to include in the handouts? a. Polyphagia, polydipsia, and polyuria are common symptoms of diabetes.b. Eating the right foods can help in keeping blood glucose at a near-normal level. c. Some patients with diabetes control blood glucose with oral medications, injections, or dietary interventions. d. Diabetes is characterized by chronic hyperglycemia and the associated symptoms than can lead to long-term complications.

ANS: B The reading level for patient teaching materials should be at the fifth-grade level. The other responses have words with three or more syllables, use many medical terms, or are too long.

Which action will the nurse anticipate taking for an otherwise healthy 50-yr-old who has just been diagnosed with stage 1 renal cell carcinoma? a. Prepare patient for a renal biopsy. b. Provide preoperative teaching about nephrectomy. c. Teach the patient about chemotherapy medications. d. Schedule for a follow-up appointment in 3 months.

ANS: B The treatment of choice in patients with localized renal tumors who have no co-morbid conditions is partial or total nephrectomy. A renal biopsy will not be needed in a patient who has already been diagnosed with renal cancer. Chemotherapy is used for metastatic renal cancer. Because renal cell cancer frequently metastasizes, treatment will be started as soon as possible after the diagnosis.

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 often 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.

Which care activity for a patient with a paralytic ileus is appropriate for the registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)? a. Auscultating for bowel sounds b. Brushing the teeth and tongue c. Assessing the nares for irritation d. Irrigating the nasogastric (NG) tube

ANS: B UAP education and scope of practice include patient hygiene such as oral care. The other actions require education and scope of practice appropriate to the RN.

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 patient's temperature and blood pressure 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.

A patient who was admitted to the hospital with hyperglycemia and newly diagnosed diabetes is scheduled for discharge the second day after admission. When implementing patient teaching, what is the priority action for the nurse? a. Provide detailed information about dietary control of glucose. b. Teach glucose self-monitoring and medication administration. c. Give information about the effects of exercise on glucose control. d. Instruct about the risk for cardiovascular disease with hyperglycemia

ANS: B When time is limited, the nurse should focus on the priorities of teaching. In this situation, the patient should know how to test blood glucose and administer medications to control glucose levels. The patient will need further teaching about the role of diet, exercise, various medications, and the many potential complications of diabetes, but these topics can be addressed through planning for appropriate referrals.

Which information will the nurse include when teaching a patient how to avoid chronic constipation? (Select all that apply.) a. Stimulant and saline laxatives can be used regularly. b. Bulk-forming laxatives are an excellent source of fiber. c. Walking or cycling frequently will help bowel motility. d. A good time for a bowel movement may be after breakfast. e. Some over-the-counter (OTC) medications cause constipation.

ANS: B, C, D, E Stimulant and saline laxatives should be used infrequently. Use of bulk-forming laxatives, regular early morning timing of defecation, regular exercise, and avoiding many OTC medications will help the patient avoid constipation.

Which nursing diagnoses are priorities for a patient taking prednisone 40 mg PO daily for chronic inflammation? (Select all that apply.) a. Risk for deficient fluid volume related to excessive hormonal fluid loss through kidneys b. Risk for unstable blood glucose related to hyperglycemic side effects of corticosteroids c. Risk for impaired dentition related to loss of minerals for teeth and bone support within the jaw d. Risk for constipation related to side effects of corticosteroids with loss of urge to defecate e. Risk for imbalanced nutrition: more than body requirements related to increased appetite

ANS: B, C, E Corticosteroids such as prednisone cause increased appetite leading to risk for imbalanced nutrition: more than body requirements. Corticosteroids cause hyperglycemia leading to risk for unstable blood glucose. Corticosteroids cause osteoporosis and thinning of bones leading to risk for impaired dentition. Corticosteroids cause diarrhea and fluid retention.

A patient has been diagnosed with urinary tract stones that are high in uric acid. Which foods will the nurse teach the patient to avoid? (Select all that apply.) a. Milk b. Liver c. Spinach d. Chicken e. Cabbage f. Chocolate

ANS: B, D Meats contain purines, which are metabolized to uric acid. The other foods might be restricted in patients who have calcium or oxalate stones.

Which foods are recommended options for a patient with high cholesterol? (Select all that apply.) a. Pure Irish butter with sea salt added b. Unsalted cashews, pecans, and pistachios c. Cottage cheese made with 2% milk d. Salad dressing made with vinegar and olive oil e. Guacamole made with fresh avocado and tomato

ANS: B, D, E Ingestion of saturated fatty acids appears to increase blood cholesterol levels. Cottage cheese and butte contain saturated fatty acids. Saturated fats should be limited to lower cholesterol. Monounsaturated fatty acids appear to lower blood cholesterol levels. Nuts, olive oil, and avocado contain monounsaturated fatty acids.

Which nursing diagnoses are priorities for a patient receiving parenteral nutrition? (Select all that apply.) a. Impaired oral mucus membranes related to irritation from nasogastric tube b. Risk for infection related to invasive peripherally inserted central catheter line c. Situational low self-esteem related to presence of gastrostomy tube in abdomen d. Risk for impaired blood glucose levels related to concentrated IV dextrose solution e. Health-seeking behaviors related to desire to manage parenteral nutrition at home

ANS: B, D, E Parenteral nutrition is administered through specialized IV lines such as peripherally inserted central catheters. These catheters pose a risk for infection. Parenteral nutrition solutions contain high levels of dextrose the put the patient at risk for hyperglycemia. The patient who wishes to manage parenteral nutrition at home demonstrates health-seeking behaviors. Parenteral nutrition is not administered via gastrostomy or nasogastric tubes.

A patient had an abdominal-perineal resection for colon cancer. Which nursing action is most important to include in the plan of care for the day after surgery? a. Teach about a low-residue diet. b. Monitor output from the stoma. c. Assess the perineal drainage and incision. d. Encourage acceptance of the colostomy stoma.

ANS: C Because the perineal wound is at high risk for infection, the initial care is focused on assessment and care of this wound. Teaching about diet is best done closer to discharge from the hospital. There will be very little drainage into the colostomy until peristalsis returns. The patient will be encouraged to assist with the colostomy, but this is not the highest priority in the immediate postoperative period.

Which information about a patient with Goodpasture syndrome requires the most rapid action by the nurse? a. Blood urea nitrogen level is 70 mg/dL. b. Urine output over the last 2 hours is 30 mL. c. Audible crackles bilaterally over the posterior chest to the midscapular level. d. Elevated level of antiglomerular basement membrane (anti-GBM) antibodies.

ANS: C Crackles heard to a high level indicate a need for rapid actions such as assessment of O2 saturation, reporting the findings to the health care provider, initiating O2 therapy, and dialysis. The other findings will be reported but are typical of Goodpasture syndrome and do not require immediate nursing action.

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. Hypoactive bowel sounds c. Maroon-colored liquid stool d. Abdominal pain with palpation

ANS: C Loose, bloody (maroon-colored) 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.

Which information will the nurse include when teaching the patient with a urinary tract infection (UTI) about the use of phenazopyridine? a. Take phenazopyridine for at least 7 days. b. Phenazopyridine may cause photosensitivity. c. Phenazopyridine may change the urine color. d. Take phenazopyridine before sexual intercourse.

ANS: C Patients should be taught that phenazopyridine will color the urine deep orange. Urinary analgesics should be needed for only a few days until the prescribed antibiotics decrease the bacterial count. Phenazopyridine does not cause photosensitivity. Taking phenazopyridine before intercourse will not be helpful in reducing the risk for UTI.

A young adult patient tells the health care provider about experiencing cold, numb fingers and Raynaud's phenomenon is suspected. What type of testing should the nurse anticipate explaining to the patient? 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.

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 of 138/88 mm Hg d. 25 mL of urine output over the past 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 -blockers or other antihypertensive drugs can be prescribed. The other findings are typical with aortic dissection and should also be reported but do not require immediate action.

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.

Which intervention is most effective for measuring the patient's fluid balance over time? a. Measure daily intake and output. b. Figure the patient's body mass index. c. Record daily weights before breakfast. d. Calculate the patient's ideal body weight.

ANS: C Daily weights before breakfast provide information about fluid retention and diuresis. Daily intake and output are not as effective for assessing fluid balance over time. Calculation of ideal body weight and BMI do not accurately measure the patient's fluid balance over time.

Which food item contains the most calories? a. 1 g of cane sugar b. 1 g of lean meat c. 1 g of butter d. 1 g of banana

ANS: C Fats contain 9 kilocalories per gram (kcalorie/g) while carbohydrates and protein provide 4 kcalorie/g. Therefore 1 g of butter would have more calories than 1 g of lean meat, sugar, or banana.

Which is the best menu option for a patient with celiac disease? a. Baked chicken breast with roll and butter b. Spaghetti with meat sauce and tossed salad c. Oatmeal with raisins, brown sugar, and milk d. Pizza with tomato sauce, cheese, and mushrooms

ANS: C Oatmeal is gluten-free so it will not worsen symptoms of celiac disease. Pizza crust, roll, and pasta all contain gluten and should be avoided by patients with celiac disease.

Which action of the nurse is best to reduce abdominal discomfort when administering intermittent gravity feedings through a gastrostomy tube? a. Chill the formula. b. Dilute the formula. c. Infuse the formula slowly. d. Lower the head of the bed.

ANS: C Slowly infusing the formula reduces risk for abdominal discomfort, vomiting, or diarrhea induced by bolus or too-rapid infusion of tube feedings. It is the patient's meal and should be delivered in the amount of the time a well-tolerated meal is eaten. Feedings should be at room temperature. Cold formula causes gastric cramping and discomfort. The nurse should not dilute the formula. Always administer feedings as prescribed to ensure that the patient is receiving the ordered nutrients.

A 26-yr-old woman is being evaluated for vomiting and abdominal pain. Which question from the nurse will be most useful in determining the cause of the patient's symptoms? a. "What type of foods do you eat?" b. "Is it possible that you are pregnant?" c. "Can you tell me more about the pain?" d. "What is your usual elimination pattern?"

ANS: C A complete description of the pain provides clues about the cause of the problem. Although the nurse should ask whether the patient is pregnant to determine whether the patient might have an ectopic pregnancy and before any radiology studies are done, this information is not the most useful in determining the cause of the pain. The usual diet and elimination patterns are less helpful in determining the reason for the patient's symptoms

What should the nurse ask the patient about to determine possible causes of acute glomerulonephritis? a. Recent bladder infection b. History of kidney stones c. Recent sore throat and fever d. History of high blood pressure

ANS: C Acute glomerulonephritis frequently occurs after a streptococcal infection such as strep throat. It is not caused by kidney stones, hypertension, or urinary tract infection.

Which action for a patient with neutropenia is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/VN)? 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/VN education and scope of practice. Patient teaching, assessment, and developing the plan of care require RN level education and scope of practice.

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

ANS: C 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 have symptoms of potentially life-threatening problems.

An older Asian patient seen at the health clinic is diagnosed with protein malnutrition. What action should the nurse plan to implement first? a. Suggest the use of liquid supplements as a way to increase protein intake. b. Encourage the patient to increase the dietary intake of meat, cheese, and milk. c. Ask the patient to record the intake of all foods and beverages for a 3-day period. d. Focus on the use of combinations of beans and rice to improve daily protein intake.

ANS: C Assessment is the first step in assisting a patient with health changes. The other answers may be appropriate for the patient, but the nurse will not be able to determine this until the assessment of the patient is complete.

Which action will the nurse include in the plan of care for a patient who is being admitted with Clostridium difficile? a. Teach the patient about proper food storage. b. Order a diet without dairy products for the patient. c. Place the patient in a private room on contact isolation. d. Teach the patient about why antibiotics will not be used

ANS: C Because C. difficile is highly contagious, the patient should be placed in a private room, and contact precautions should be used. There is no need to restrict dairy products for this type of diarrhea. Metronidazole (Flagyl) is frequently used to treat C. difficile infections. Improper food handling and storage do not cause C. difficile.

A 28-yr-old male patient has just been diagnosed with polycystic kidney disease. Which information should the nurse include in teaching during the first teaching session? a. Complications of renal transplantation b. Methods for treating severe chronic pain c. Options to consider for genetic counseling d. Differences between hemodialysis and peritoneal dialysis

ANS: C Because a 28-yr-old patient may be considering having children, the nurse should include information about genetic counseling when teaching the patient. A well-managed patient will not need to choose between hemodialysis and peritoneal dialysis or know about the effects of transplantation for many years. There is no indication that the patient has chronic pain.

The nurse plans to teach a patient and the caregiver how to manage high blood pressure. Which action should the nurse take first? a. Teach the caregiver how to use a manual blood pressure cuff. b. Give written information about hypertension to the patient and caregiver. c. Ask the patient to select information from a list of hypertension teaching topics. d. Have the dietitian meet with the patient and caregiver to discuss a low-sodium diet

ANS: C Because adults learn best when given information that they view as being needed immediately, asking the caregiver and patient to prioritize learning needs is likely to be the most successful approach to home management of health problems. The other actions may also be appropriate, depending on what learning needs the caregiver and patient have, but the initial action should be to assess what the learners feel is important.

A patient in the emergency department has just been diagnosed with peritonitis from a ruptured diverticulum. Which prescribed intervention will the nurse implement first? a. Send the patient for a CT scan. b. Insert a urinary catheter to drainage. c. Infuse metronidazole (Flagyl) 500 mg IV. d. Place a nasogastric tube to intermittent low suction.

ANS: C Because peritonitis can be fatal if treatment is delayed, the initial action should be to start antibiotic therapy (after any ordered cultures are obtained). The other actions can be done after antibiotic therapy is initiated.

Which patient statement to the nurse indicates that the patient understands self-care for pernicious anemia? 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.

After a patient has had a hemorrhoidectomy at an outpatient surgical center, which instructions will the nurse include in discharge teaching? a. Maintain a low-residue diet until the surgical area is healed.b. Use ice packs on the perianal area to relieve pain and swelling. c. Take prescribed pain medications before you expect a bowel movement. d. Delay having a bowel movement for several days until you are well healed.

ANS: C Bowel movements may be very painful, and patients may avoid defecation unless pain medication is taken before the bowel movement. A high-residue diet will increase stool bulk and prevent constipation. Delay of bowel movements is likely to lead to constipation. Warm Sitz baths rather than ice packs are used to relieve pain and keep the surgical area clean.

A patient has chronic peripheral artery disease (PAD) of the legs and an ulcer on the right second toe. What should the nurse expect to find on assessment?a. Dilated superficial veins. b. Swollen, dry, scaly ankles. c. Prolonged capillary refill in all the toes. d. 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.

Which information from a patient who had a transurethral resection with fulguration for bladder cancer 3 days ago is most important to report to the health care provider? a. The patient is voiding every 4 hours. b. The patient is using opioids for pain. c. The patient has seen clots in the urine. d. The patient is anxious about the cancer

ANS: C Clots in the urine are not expected and require further follow-up. Voiding every 4 hours, use of opioids for pain, and anxiety are typical after this procedure.

Which activity in the care of a patient with a new colostomy could the nurse delegate to unlicensed assistive personnel (UAP)? a. Document the appearance of the stoma. b. Place a pouching system over the ostomy. c. Drain and measure the output from the ostomy. d. Check the skin around the stoma for breakdown.

ANS: C Draining and measuring the output from the ostomy is included in UAP education and scope of practice. The other actions should be implemented by LPNs or RNs.

Which diet choice by the patient with an acute exacerbation of inflammatory bowel disease (IBD) indicates a need for more teaching? a. Scrambled eggs b. White toast and jam c. Oatmeal with cream d. Pancakes with syrup

ANS: C During acute exacerbations of IBD, the patient should avoid high-fiber foods such as whole grains. High-fat foods also may cause diarrhea in some patients. The other choices are low residue and would be appropriate for this patient.

A 46-yr-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 a patient who had just had sclerotherapy.

The nurse will anticipate teaching a patient with nephrotic syndrome who develops flank pain about treatment with: a. antibiotics. b. antifungals. c. anticoagulants. d. antihypertensives.

ANS: C Flank pain in a patient with nephrotic syndrome suggests a renal vein thrombosis and anticoagulation is needed. Antibiotics are used to treat a patient with flank pain caused by pyelonephritis. Fungal pyelonephritis is uncommon and is treated with antifungals. Antihypertensives are used if the patient has high blood pressure.

Which statement by a patient with interstitial cystitis indicates to the nurse that further instruction is needed? a. "I should stop having coffee and orange juice for breakfast." b. "I will buy calcium glycerophosphate (Prelief) at the pharmacy." c. "I will start taking high potency multiple vitamins every morning." d. "I should call the doctor about increased bladder pain or foul urine."

ANS: C High-potency multiple vitamins may irritate the bladder and increase symptoms. The other patient statements indicate good understanding of the teaching.

Which topic should the nurse include when planning a teaching session for a patient with benign nephrosclerosis? a. Preventing bleeding with anticoagulants b. Obtaining and documenting daily weight c. Monitoring and recording blood pressure d. Measuring daily intake and output volumes

ANS: C Hypertension is the major manifestation of nephrosclerosis. Measurements of intake and output and daily weights are not necessary unless the patient develops renal insufficiency. Anticoagulants are not used to treat nephrosclerosis.

A 68-yr-old patient admitted to the hospital with dehydration is confused and incontinent of urine. Which nursing action should be included in the plan of care? a. Restrict fluids between meals and after the evening meal. b. Insert an indwelling catheter until the symptoms have resolved. c. Assist the patient to the bathroom every 2 hours during the day. d. Apply absorbent adult incontinence diapers and pads over the bed linens.

ANS: C In older or confused patients, incontinence may be avoided by using scheduled toileting times. Indwelling catheters increase the risk for urinary tract infection. Incontinent pads and diapers increase the risk for skin breakdown. Restricting fluids is not appropriate in a patient with dehydration.

The health care provider prescribes an infusion of heparin and daily partial thromboplastin time (PTT) testing for a patient with venous thromboembolism (VTE). Which action should the nurse include in the plan of care? a. Obtain a Doppler for monitoring bilateral pedal pulses. b. Decrease the infusion when the PTT value is 65 seconds. c. Avoid giving IM medications to prevent localized bleeding. d. Have vitamin K available in case reversal of the heparin is needed.

ANS: C Intramuscular injections are avoided in patients receiving anticoagulation to prevent hematoma formation and bleeding from the site. 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 patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate? a. "I could take a stool softener if I feel constipated." b. "I can take the iron with orange juice before eating." c. "I should notify my health care provider if my stools turn black." d. "I will increase my fluid and fiber intake while I am taking iron."

ANS: C 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.

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

ANS: C 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.

A patient admitted to the hospital with pneumonia has a history of functional urinary incontinence. Which nursing action will be included in the plan of care? a. Demonstrate the use of the Credé maneuver. b. Teach exercises to strengthen the pelvic floor. c. Place a bedside commode close to the patient's bed. d. Use an ultrasound scanner to check postvoiding residuals.

ANS: C Modifications in the environment make it easier to avoid functional incontinence. Checking for residual urine and performing the Credé maneuver are interventions for overflow incontinence. Kegel exercises are useful for stress incontinence.

Which assessment finding for a patient who has been admitted with a right calf venous thromboembolism (VTE) requires immediate action by the nurse? a. Report of right calf pain b. Erythema of right lower leg 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 O2 administration and notification of the health care provider. The other findings are typical of VTE.

Which is an appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia? a. Provide a diet high in vitamin K. b. Teach the patient how to avoid injury. c. Encourage alternating rest and activity. d. Place the patient on protective isolation.

ANS: C Nursing care for patients with anemia should alternate periods of rest and activity to avoid 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.

The home health nurse teaches a patient with a neurogenic bladder how to use intermittent catheterization for bladder emptying. Which patient statement indicates that the teaching has been effective? a. "I will buy seven new catheters weekly and use a new one every day."b. "I will use a sterile catheter and gloves for each time I self-catheterize." c. "I will clean the catheter carefully before and after each catheterization." d. "I will take prophylactic antibiotics to prevent any urinary tract infections."

ANS: C Patients who are at home can use a clean technique for intermittent self-catheterization and change the catheter every 7 days. There is no need to use a new catheter every day, to use sterile catheters, or to take prophylactic antibiotics.

Four hours after a bowel resection, a 74-yr-old male patient with a nasogastric tube to suction reports nausea and abdominal distention. What should be the nurse's first action? a. Auscultate for hypotonic bowel sounds. b. Notify the patient's health care provider. c. Check for tube placement and reposition it. d. Remove the tube and replace it with a new one.

ANS: C Repositioning the tube will frequently facilitate drainage. Because this is a common occurrence, it is not appropriate to notify the health care provider unless other interventions do not resolve the problem. Information about the presence or absence of bowel sounds will not be helpful in improving drainage. Removing the tube and replacing it are unnecessarily traumatic to the patient, so that would only be done if the tube was completely occluded.

A 68-yr-old male patient who has bladder cancer had a cystectomy with creation of an Indiana pouch. Which topic will be included in patient teaching? a. Application of ostomy appliances b. Barrier products for skin protection c. Catheterization technique and schedule d. Analgesic use before emptying the pouch

ANS: C The Indiana pouch enables the patient to self-catheterize every 4 to 6 hours. There is no need for an ostomy device or barrier products. Catheterization of the pouch is not painful.

Which action by a nurse who is giving fondaparinux (Arixtra) to a patient with a lower leg venous thromboembolism (VTE) indicates that the nurse needs further education about the drug? a. The nurse avoids rubbing the site after giving the injection. b. The nurse injects the drug into the abdominal subcutaneous tissue. c. The nurse ejects the air bubble from the syringe before giving the drug. d. The nurse does not check partial thromboplastin time (PTT) before giving the drug.

ANS: C The air bubble is not ejected before giving fondaparinux to avoid loss of drug. The other actions by the nurse are appropriate for subcutaneous administration of a low-molecular-weight heparin (LMWH). LMWHs typically do not require ongoing PTT monitoring and dose adjustment.

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

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.

. The nurse observes unlicensed assistive personnel (UAP) taking the following actions when caring for a female patient with a urethral catheter. Which action requires that the nurse intervene? a. Securing the catheter to the patient's upper inner thigh b. Cleaning around the patient's urinary meatus with soap and water c. Disconnecting the catheter from the drainage tube to obtain a specimen d. Using an alcohol-based gel hand cleaner before performing catheter care

ANS: C The catheter should not be disconnected from the drainage tube because this increases the risk for urinary tract infection. The other actions are appropriate and do not require any intervention.

After ureterolithotomy, a patient has a left ureteral catheter and a urethral catheter in place. Which action will the nurse include in the plan of care? a. Provide teaching about home care for both catheters. b. Apply continuous steady tension to the ureteral catheter. c. Call the health care provider if the ureteral catheter output drops suddenly. d. Clamp the ureteral catheter off when output from the urethral catheter stops.

ANS: C The health care provider should be notified if the ureteral catheter output decreases because obstruction of this catheter may result in an increase in pressure in the renal pelvis. Tension on the ureteral catheter should be avoided to prevent catheter displacement. To avoid pressure in the renal pelvis, the catheter is not clamped. Because the patient is not usually discharged with a ureteral catheter in place, patient teaching about both catheters is not needed.

A 76-yr-old patient with obstipation has a fecal impaction and is incontinent of liquid stool. Which action should the nurse take first? a. Administer bulk-forming laxatives. b. Assist the patient to sit on the toilet. c. Manually remove the impacted stool. d. Increase the patient's oral fluid intake.

ANS: C The initial action with a fecal impaction is manual disimpaction. The other actions will be used to prevent future constipation and impactions.

A 19-yr-old woman is brought to the emergency department with a knife handle protruding from her abdomen. What should the nurse do during the initial assessment of the patient? a. Remove the knife and assess the wound. b. Determine the presence of Rovsing sign. c. Check for circulation and tissue perfusion. d. Insert a urinary catheter and assess for hematuria.

ANS: C The initial assessment is focused on determining whether the patient has hypovolemic shock. The knife should not be removed until the patient is in surgery, where bleeding can be controlled. Rovsing sign is assessed in the patient with suspected appendicitis. Assessment for bladder trauma is not part of the initial assessment.

A 25-yr-old male patient calls the clinic reporting diarrhea for 24 hours. Which action should the nurse take first? a. Inform the patient that testing of blood and stools will be needed. b. Suggest that the patient drink clear liquid fluids with electrolytes. c. Ask the patient to describe the stools and any associated symptoms. d. Advise the patient to use over-the-counter antidiarrheal medication.

ANS: C The initial response by the nurse should be further assessment of the patient. The other responses may be appropriate, depending on what is learned in the assessment.

What should the nurse will teach about when preparing a patient with bladder cancer for intravesical chemotherapy? a. Coping with hair loss b. Premedicating to prevent nausea c. Emptying the bladder before the instillation d. Maintaining oral care during the treatments

ANS: C The patient will be asked to empty the bladder before instillation of the chemotherapy. Systemic side effects are not usually experienced with intravesical chemotherapy.

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.

A young adult patient is admitted to the hospital for evaluation of right lower quadrant abdominal pain with nausea and vomiting. Which action should the nurse take? a. Assist the patient to cough and deep breathe. b. Palpate the abdomen for rebound tenderness. c. Suggest the patient lie on the side, flexing the right leg. d. Encourage the patient to sip clear, noncarbonated liquids.

ANS: C The patient's clinical manifestations are consistent with appendicitis. Lying still with the right leg flexed is often the most comfortable position. Checking for rebound tenderness frequently is unnecessary and uncomfortable for the patient. The patient should be NPO in case immediate surgery is needed. The patient will need to know how to cough and deep breathe postoperatively, but coughing will increase pain at this time.

Following rectal surgery, a patient voids about 50 mL of urine every 30 to 60 minutes for the first 4 hours. Which nursing action is the priority? a. Encourage the patient to drink more fluids. b. Plan to monitor the patient's intake and output. c. Use an ultrasound scanner to check the postvoiding residual volume. d. Reassure the patient that urinary problems are common after rectal surgery.

ANS: C The patient's history and clinical manifestations are consistent with overflow incontinence, so an ultrasound scanner can be used to check for residual urine after the patient voids. The other interventions may also be useful, but the priority patient problem is the potentially overfilled bladder.

A 72-yr-old male patient with dehydration caused by an exacerbation of ulcerative colitis is receiving 5% dextrose in normal saline at 125 mL/hour. Which assessment finding by the nurse is most important to report to the health care provider? a. Skin is dry with tenting and poor turgor. b. Patient has not voided for the last 2 hours. c. Crackles are heard halfway up the posterior chest. d. Patient has had 5 loose stools over the previous 6 hours.

ANS: C The presence of crackles in an older patient receiving IV fluids at a high rate suggests volume overload and a need to reduce the rate of the IV infusion. The other data will be reported but are consistent with the patient's age and diagnosis and do not require a change in the prescribed treatment.

A patient is admitted to the emergency department with severe abdominal pain and rebound tenderness. Vital signs include temperature 102° F (38.3° C), pulse 120 beats/min, respirations 32 breaths/min, and blood pressure (BP) 82/54 mm Hg. Which prescribed intervention should the nurse implement first? a. Administer IV ketorolac 15 mg for pain relief. b. Send a blood sample for a complete blood count (CBC). c. Infuse a liter of lactated Ringer's solution over 30 minutes. d. Send the patient for an abdominal computed tomography (CT) scan.

ANS: C The priority for this patient is to treat the patient's hypovolemic shock with fluid infusion. The other actions should be implemented after starting the fluid infusion.

Which actions for a patient at risk for venous thromboembolism could the nurse delegate to unlicensed assistive personnel (UAP)? a. Monitor for any bleeding after anticoagulation therapy is started. b. Tell the patient to call immediately if any shortness of breath occurs. c. Apply sequential compression devices whenever the patient is in bed. d. Ask the patient about use of any herbal medicines or dietary supplements.

ANS: C 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).

The nurse plans to provide instructions about diabetes to a patient who has a low literacy level. Which teaching strategies should the nurse use? (Select all that apply.) a. Discourage use of the Internet as a source of health information. b. Avoid asking the patient about reading abilities and level of education. c. Provide illustrations and photographs showing various types of insulin. d. Schedule one-to-one teaching sessions to practice insulin administration. e. Obtain CDs and DVDs that illustrate how to perform blood glucose testing.

ANS: C, D, E For patients with low literacy, visual and hands-on learning techniques are most appropriate. The nurse will need to obtain as much information as possible about the patient's reading level in order to provide appropriate learning materials. The nurse should guide the patient to Internet sites established by reputable heath care organizations such as the American Diabetes Association.

A patient who has chronic constipation asks the nurse about the use of psyllium (Metamucil). Which information will the nurse include in the response? a. Fiber-containing laxatives may reduce the absorption of fat-soluble vitamins. b. Dietary sources of fiber should be eliminated to prevent excessive gas formation. c. Use of this type of laxative to prevent constipation does not cause adverse effects. d. Large amounts of fluid should be taken to prevent impaction or bowel obstruction.

ANS: D A high fluid intake is needed when patients are using bulk-forming laxatives to avoid worsening constipation. Although bulk-forming laxatives are generally safe, the nurse should emphasize the possibility of constipation or obstipation if inadequate fluid intake occurs. Although increased gas formation is likely to occur with increased dietary fiber, the patient should gradually increase dietary fiber and eventually may not need the psyllium. Fat-soluble vitamin absorption is blocked by stool softeners and lubricants, not by bulk-forming laxatives.

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

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.

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

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

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 b. Vomiting c. Oral ulcers 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.

A patient is diagnosed with heart failure after being admitted to the hospital for shortness of breath and fatigue. Which teaching strategy, if implemented by the nurse, is most likely to be effective? a. Assure the patient that the nurse is an expert on management of heart failure. b. Delay teaching until the patient is seen by a home health nurse after discharge. c. Discuss the importance of medication control to avoid long-term complications. d. Explain to the patient at each meal about the amounts of sodium in various foods

ANS: D Principles of adult education indicate that readiness and motivation to learn are high when facing new tasks (e.g., learning about the sodium amounts in various food items) and when demonstration and practice of skills are available. Although a home health referral may be needed for this patient, teaching should not be postponed until discharge. Adult learners are independent. The nurse should act as a facilitator for learning, rather than as the expert. Adults learn best when the topic is of immediate usefulness. Long-term goals may not be very motivating.

Which menu item should be removed from the tray of a patient on a full liquid diet? a. Cup of chicken bouillon b. Cup of tomato cream soup c. Cup of orange frozen yogurt d. Cup of strawberry applesauce

ANS: D Applesauce is not considered a liquid and should be removed from the full liquid diet tray. Soup and frozen yogurts are considered liquids.

The nurse is caring for a pediatric patient with the nursing diagnosis constipation related to side effects of medications. Which menu option will the nurse recommend to the patient? a. Baked chicken nuggets and canned peaches b. Pancakes with sausage, butter, and maple syrup c. Peanut butter and jelly sandwich on white bread d. Snack mix with dried apricots, raisins, and almonds

ANS: D Dried fruits and nuts are good sources of fiber to help relieve constipation. Meats, peanut butter, white bread, and pancakes will not relieve constipation.

Which is the first action of the nurse when administering intermittent enteral tube feedings to the patient? a. Irrigate the tube with sterile saline. b. Place the patient in a supine position. c. Make sure that the feeding solution is chilled. d. Check to see that the tube is in the proper position.

ANS: D The first step is to verify tube placement; feedings instilled into a misplaced tube can cause serious injury or death. The nurse will place the patient in Fowler's or high-Fowler's position, not supine, before starting the feeding. After checking for residual, flush the feeding tube with 30 mL of water rather than sterile saline. The feeding solution should be warmed or at room temperature as chilled feeding solution can cause abdominal cramping.

Which is the most appropriate nursing diagnosis for a patient with a BMI of 46? a. Risk for imbalanced fluid volume related to rapid intravascular fluid shift b. Risk for imbalanced body temperature related to impaired thermoregulation c. Risk for compromised human dignity related to loss of control of body functions d. Imbalanced nutrition: more than body requirements related to chronic overeating

ANS: D The patient with a BMI of 46 is obese so the appropriate nursing diagnosis is imbalanced nutrition: more than body requirements related to chronic overeating. BMI of 46 does not put the patient at risk for rapid intravascular fluid shift, impaired thermoregulation, or loss of control of body functions.

Which is the appropriate intervention for a patient with the nursing diagnosis feeding self-care deficit related to neuromuscular hand and arm weakness? a. Provide meticulous oral hygiene before and after meals. b. Consult a speech-language pathologist for swallow precautions. c. Provide the patient with a pleasant, quiet environment for meals. d. Teach the patient how to use adaptive utensils to facilitate independence.

ANS: D The patient's self-care deficit is due to hand and arm weakness so the nurse should teach the patient how to use adaptive utensils to facilitate independence. Oral hygiene, swallow precautions, and quiet environment do not address the patient's hand and arm weakness.

A 40-yr-old male patient has had a herniorrhaphy to repair an incarcerated inguinal hernia. Which patient teaching will the nurse provide before discharge? a. Soak in Sitz baths several times each day. b. Cough 5 times each hour for the next 48 hours. c. Avoid using acetaminophen (Tylenol) for pain. d. Apply a scrotal support and ice to reduce swelling.

ANS: D A scrotal support and ice are used to reduce edema and pain. Coughing will increase pressure on the incision. Sitz baths will not relieve pain and would not be of use after this surgery. Acetaminophen can be used for postoperative pain

The nurse is providing preoperative teaching for a patient scheduled for an abdominal-perineal resection. Which information will the nurse include? a. The patient will need to remain on bedrest for three days after surgery. b. An additional surgery in 8 to 12 weeks will be done to create an ileal-anal reservoir. c. IV antibiotics will be started at least 24 hours before surgery to reduce the bowel bacteria. d. The site where the stoma will be located will be marked on the abdomen preoperatively.

ANS: D A wound, ostomy, continence nurse (WOCN) should select the site where the ostomy will be positioned and mark the abdomen preoperatively. The site should be within the rectus muscle, on a flat surface, and in a place that the patient is able to see. A permanent colostomy is created with this surgery. The patient will be encouraged to walk the day after surgery. Oral antibiotics (rather than IV antibiotics) are given to reduce colonic and rectal bacteria.

What is a likely finding in the nurse's assessment of a patient who has a large bowel obstruction? a. Referred back pain b. Metabolic alkalosis c. Projectile vomiting d. Abdominal distention

ANS: D Abdominal distention is seen in lower intestinal obstruction. Referred back pain is not a common clinical manifestation of intestinal obstruction. Metabolic alkalosis is common in high intestinal obstruction because of the loss of HCl acid from vomiting. Projectile vomiting is associated with higher intestinal obstruction.

Which risk factor should the nurse focus on when teaching a patient who has a 5-cm abdominal aortic aneurysm? a. Male gender b. Turner syndrome c. Abdominal trauma history d. Uncontrolled hypertension

ANS: D All 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

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.

Which breakfast choice indicates a patient's good understanding of information about a diet for celiac disease? a. Wheat toast with butter b. Oatmeal with nonfat milk c. Bagel with low-fat cream cheese d. Corn tortilla with scrambled eggs

ANS: D Avoidance of gluten-containing foods is the only treatment for celiac disease. Corn does not contain gluten, but oatmeal and wheat do.

Which finding for a patient admitted with glomerulonephritis indicates to the nurse that treatment has been effective? a. The urine dipstick is negative for nitrites. b. The patient denies pain or burning with voiding. c. The antistreptolysin-O (ASO) titer has decreased. d. The periorbital and peripheral edema are resolved.

ANS: D Because edema is a common clinical manifestation of glomerulonephritis, resolution of the edema indicates that the prescribed therapies have been effective. Nitrites will be negative, and the patient will not experience dysuria because the patient does not have a urinary tract infection. Antibodies to streptococcus will persist after a streptococcal infection.

Which statement by a patient indicates good understanding of the nurse's teaching about preventing 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 opioids 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.

Which assessment finding is most important to report to the health care provider regarding a patient who has had left-sided extracorporeal shock wave lithotripsy? a. Blood in urine b. Left flank bruisingc. Left flank discomfort d. Decreased urine output

ANS: D Because lithotripsy breaks the stone into small sand, which could cause obstruction, it is important to report a drop in urine output. Left flank pain, bruising, and hematuria are common after lithotripsy.

A patient is being evaluated for postthrombotic 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. Inspect for presence of lipodermatosclerosis.

ANS: D Clinical signs of postthrombotic 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.

Which topic should the nurse include in teaching for a patient with a venous stasis ulcer on the 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.

Which finding by the nurse will be most helpful in determining whether a 67-yr-old patient with benign prostatic hyperplasia has an upper urinary tract infection (UTI)? a. Bladder distention b. Foul-smelling urine c. Suprapubic discomfort d. Costovertebral tenderness

ANS: D Costovertebral tenderness is characteristic of pyelonephritis. Bladder distention, foul-smelling urine, and suprapubic discomfort are characteristic of a lower UTI and are likely to be present if the patient also has an upper UTI.

What should the nurse plan to teach about to a patient with Crohn's disease who has megaloblastic anemia? a. Iron dextran infusions b. Oral ferrous sulfate tablets c. Routine blood transfusions d. Cobalamin (B12) supplements

ANS: D Crohn's disease frequently affects the ileum, where absorption of cobalamin occurs. Cobalamin must be administered regularly by nasal spray or IM to correct the anemia. Iron deficiency does not cause megaloblastic anemia. The patient may need occasional transfusions but not regularly scheduled transfusions.

A patient needs to learn how to instill eyedrops. Which teaching strategy, if implemented by the nurse, would be most effective? a. Peer teaching b. Lecture-discussion c. Printed instructions d. Return demonstration

ANS: D Demonstration with return demonstration (show back) is best used to teach a patient how to learn to perform a skill. Lecture-discussion, peer teaching, and printed materials are more useful for other learning needs.

A 58-yr-old male patient who is diagnosed with nephrotic syndrome has ascites and 4+ leg edema. Which patient problem is present, based on these findings? a. Poor perfusion b. Inadequate nutrition c. Activity intolerance d. Excess fluid volume

ANS: D Edema and ascites are evidence of the excess fluid volume. There are no data provided to support the other problems.

A 55-yr-old woman admitted for shoulder surgery asks the nurse for a perineal pad, stating that laughing or coughing causes leakage of urine. Which intervention is appropriate to include in the care plan? a. Assist the patient to the bathroom q3hr. b. Place a commode at the patient's bedside. c. Demonstrate how to perform the Credé maneuver. d. Teach the patient how to perform Kegel exercises.

ANS: D Kegel exercises to strengthen the pelvic floor muscles will help reduce stress incontinence. The Credé maneuver is used to help empty the bladder for patients with overflow incontinence. Placing the commode close to the bedside and assisting the patient to the bathroom are helpful for functional incontinence

What action is expected by the nurse caring for a patient who has an acute exacerbation of polycythemia vera? a. Place the patient on bed rest. b. Administer iron supplements. c. Avoid use of aspirin products. 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.

Which question from the nurse would help determine if a patient's abdominal pain might indicate irritable bowel syndrome (IBS)? a. "Have you been passing a lot of gas?" b. "What foods affect your bowel patterns?" c. "Do you have any abdominal distention?" d. "How long have you had abdominal pain?"

ANS: D One criterion for the diagnosis of irritable bowel syndrome is the presence of abdominal discomfort or pain for at least 3 months. Abdominal distention, flatulence, and food intolerance are associated with IBS but are not diagnostic criteria.

Which assessment data reported by a patient is consistent with a lower urinary tract infection (UTI)? a. Low urine output b. Bilateral flank pain c. Nausea and vomiting d. Burning on urination

ANS: D Pain with urination is a common symptom of a lower UTI. Urine output does not decrease, but frequency may occur. Flank pain and nausea are associated with an upper UTI.

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.

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. Chemotherapy will not impact the fertility of a 55-yr-old woman. Maintenance chemotherapy is not used for Hodgkin's lymphoma. Pruritus is a clinical manifestation of lymphoma but should not be a concern after treatment.

While admitting a patient to the medical unit, the nurse determines that the patient has a hearing impairment. How should the nurse use this information to plan teaching and learning strategies?a. Motivation and readiness to learn will be affected. b. The family must be included in the teaching process. c. The patient will have problems understanding information. d. Written materials should be provided with verbal instructions.

ANS: D The information that the patient has a hearing impairment indicates that the nurse should use written and verbal materials in teaching along with other strategies. The patient does not indicate a lack of motivation or an inability to understand new information. The patient's decreased hearing does not necessarily imply that the family must be included in the teaching process.

A patient at the clinic says, "I always walk after dinner, but lately my leg cramps and hurts after just a few minutes. The pain goes away after I stop walking, though." What focused assessment should the nurse make? a. Look 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. Palpate for the presence of 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.

An older patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the right leg. After the nurse notifies the health care provider, what should the nurse do next? 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. Resting the leg will decrease the O2 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.

After several days of antibiotic therapy for pneumonia, an older hospitalized patient develops watery diarrhea. Which action should the nurse take first? a. Notify the health care provider. b. Obtain a stool specimen for analysis. c. Teach the patient about hand washing. d. Place the patient on contact precautions.

ANS: D The patient's history and new onset diarrhea suggest a C. difficile infection, which requires implementation of contact precautions to prevent spread of the infection to other patients. The other actions are also appropriate but can be accomplished after contact precautions are implemented.

A patient in the emergency department reports back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. What should the nurse's first action be? a. Administer oxygen therapy at a high flowrate. 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.

An adult male with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. Which laboratory data would the nurse identify as consistent with these symptoms? a. RBC count of 4,500,000/L b. Hematocrit (Hct) value of 38% c. Normal red blood cell (RBC) indices d. Hemoglobin (Hgb) of 8.6 g/dL (86 g/L)

ANS: D The patient's symptoms 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.

The health care provider has prescribed bed rest with the feet elevated for a patient admitted to the hospital with venous thromboembolism of the left lower leg. Which action by the nurse is best? a. The patient's bed is placed in the Trendelenburg position. b. Two pillows are positioned under the calf of the affected leg. c. The bed is elevated at the knee and pillows are placed under both feet. d. One pillow is placed under the thighs and 2 pillows are 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 2 pillows under the feet and another under the thighs. Placing the patient in the Trendelenburg position will lower the head below heart level, which is not indicated for this patient. Placing pillows under the calf or elevating the bed at the knee may cause blood stasis at the calf level.

A patient is transferred from the recovery room to a surgical unit after a transverse colostomy. The nurse observes the stoma to be deep pink with edema and a small amount of sanguineous drainage. What action should the nurse take? a. Place ice packs around the stoma. b. Notify the surgeon about the stoma. c. Monitor the stoma every 30 minutes. d. Document stoma assessment findings.

ANS: D The stoma appearance indicates good circulation to the stoma. There is no indication that surgical intervention is needed or that frequent stoma monitoring is required. Swelling of the stoma is normal for 2 to 3 weeks after surgery. An ice pack is not needed.

Which statement by a 22-yr-old female patient with cystitis indicates to the nurse that instruction regarding prevention of future urinary tract infections (UTIs) has been effective? a. "I can use vaginal antiseptic sprays to reduce bacteria." b. "I will drink a quart of water or other fluids every day." c. "I will wash with soap and water before sexual intercourse." d. "I will empty my bladder every 3 to 4 hours during the day."

ANS: D Voiding every 3 to 4 hours is recommended to prevent UTIs. Use of vaginal sprays is discouraged. The bladder should be emptied before and after intercourse, but cleaning with soap and water is not necessary to prevent UTI. A quart of fluids is insufficient to provide adequate urine output to decrease risk for UTI.