VSim Questions - Exam 1

What information will the nurse provide to a patient to best assure minimizing the risk of side effects associated with sulfamethoxazole-trimethoprim therapy? 1.Increase fluid intake in order to remain well hydrated 2.Notify health care provider immediately if experiencing palpitations 3.Increase dietary consumption of dairy products 4.Arrange for a yearly flu vaccine

1.Increase fluid intake in order to remain well hydrated

A nurse is assessing an adolescent patient. Which of the following questions best represents therapeutic communication techniques? 1.What do you hope happens here today? 2.Are you feeling well? 3.Do you know what to do to stay healthy? 4.You don't smoke, do you?

1.What do you hope happens here today?

Hyponatremia is associated with a decrease of which electrolyte? 1.Phosphorus 2.Potassium 3.Sodium 4.Chloride

3.Sodium

As the nurse administered Mona's prescribed medication, guiafenesin, the pt states: " I don't like this medication. It makes me cough too much." How should the nurse respond? A. the med is given to you because of your pneumonia B. this med will help make your breathing easier C. when you cough you secretions, oxygenation is more effective D. I will let your provider know you have question about your meds

C

Upon entering the room, the nurse observes Mona slumped over in semi-fowlers position, struggling to catch her breath. What is the priority nursing action at this time? A. obtain VS B. trirate her o2 so that her oxygen is greater than or equal to 05% C. assist the pt into a high fowler psotions D. obtain an oxygen saturation level

C elevated HOB first, then assess o2 and VS then oxygen may need to be titrated

Provider orders ABCs for Mona Hernandez, who has pneumonia. What is the best explanation for this order? A. pt has fever and malaise B. pt has productive cough and rust colored sputum C. pt has a history of smoking 1/2 pack of ciggs a day D/ pt has shallow, ineffective breathing

D. Pt has shallow, ineffective breathing. Rationale: respiratory acidosis can be caused by inadequate ventilation, and this ABGs are performed to evaluate respiratory acidosis. the pts smoking prob contribute to her shallow, ineffective breathing, but they are not primary reasons for obtain ABGs. The pt's fever and malaise are symptoms of her current illness and not of acid-base imbalance.

patient demonstrate correct use of the incentive spirometer when the patient places the mouthpiece in the mouth and does which of the following? exhales quickly and forcefully inhales quickly and forcefully inhales slowly and deeply exhales slowly and deeply

inhales slowly and deeply The patient should then hold the breath for 5 seconds before exhaling.

A nurse is preparing to admit a patient with cystic fibrosis and altered nutrition status. The nurse plans to implement which precautions to be used in the patient's care? 1.Standard precautions 2.Contact precautions 3.Airborne precautions 4.Droplet precautions

1 standard

A patient with a low body mass index (BMI) is found to have low albumin and prealbumin levels. Which of the following nursing actions should be considered? (Select all that apply.) 1.Assess gastrointestinal function 2.Assess for signs and symptoms of infection 3.Monitor input and output for the patient 4.Request a nutrition consult 5.Encourage oral intake of foods and fluids as ordered

1.Assess gastrointestinal function 3.Monitor input and output for the patient 4.Request a nutrition consult 5.Encourage oral intake of foods and fluids as ordered

A nurse has just finished placing a nasogastric tube into a patient for the purposes of administering feedings. What should the nurse do first? 1.Confirm the placement of the nasogastric tube per facility policy. 2.Assess how much of the tube was inserted into the patient to verify placement. 3.Irrigate the nasogastric tube with 30 to 60 mL of water. 4.Administer the tube feeding as ordered.

1.Confirm the placement of the nasogastric tube per facility policy.

A nurse is creating a care plan for a young adult patient with a chronic illness. Which of the following nursing diagnoses might be included in the care plan? (Select all that apply.) 1.Ineffective health maintenance 2.Social isolation 3.Risk-prone health behavior 4.Caregiver role strain 5.Activity intolerance

1.Ineffective health maintenance 2.Social isolation 3.Risk-prone health behavior 5.Activity intolerance

Christopher Parrish has a low body mass index and has lost 12 pounds over the past two weeks. Which method could the nurse use to assess his overall dietary intake in order to provide nutrition education? 1.Obtain a food frequency assessment 2.Ask the patient to keep a food diary log 3.Ask the patient if he has a healthy diet. 4.Track the percentage of food eaten at each meal while in the hospital

1.Obtain a food frequency assessment

Which statement concerning the measurement of intake and output is true? 1.When possible, intake and output should be measured rather than estimated. 2.Health care agencies have adopted standard volumes for common beverage containers 3.Only foods that are consumed as liquids are included in intake calculations 4.Liquid medications are not considered when calculating intake

1.When possible, intake and output should be measured rather than estimated.

Calculate the IV infusion rate using the following provider's order: 1000 mL of NS over 8 hours. Infusion set has a drip rate of 10drops/mL. 1.41 2.21 3.10 4.30

2.21

What is the initial step in assessing a patient for orthostatic hypotension? 1.Encourage the patient to drink eight ounces of fluid, then take and record blood pressure and pulse 2.After having the patient lie in a supine position for three to 10 minutes, take and record blood pressure and pulse 3.After having the patient sit upright with legs dangling for one to three minutes, take and record blood pressure and pulse 4.Assist patient into a standing position lasting two to three minutes, then take and record blood pressure and pulse

2.After having the patient lie in a supine position for three to 10 minutes, take and record blood pressure and pulse

What information should be included when documenting a change in the infusion rate of an IV solution? (Select all that apply.) 1.Original flow rate 2.Change made to flow rate 3.Date and time change was made 4.Nurse's initials 5.Patient's response to IV therapy

2.Change made to flow rate 3.Date and time change was made 4.Nurse's initials 5.Patient's response to IV therapy

A nurse is assessing a patient with cystic fibrosis. Based on a diagnosis of cystic fibrosis, the nurse expects to find which of the following common physical symptoms upon assessment? 1.Increased activity, diaphoresis, and tachycardia 2.Cyanosis or pallor, dyspnea, and arrhythmias 3.Nausea, vomiting, and hyperreflexia 4.Shortness of breath, headache, and vision changes

2.Cyanosis or pallor, dyspnea, and arrhythmias

A provider orders a high-fat, high-protein, high-carbohydrate diet for a patient with cystic fibrosis. What is the best rationale for this diet order? 1.Cystic fibrosis is a chronic disease characterized by altered electrolytes. 2.Cystic fibrosis interferes with the digestions of food and absorption of nutrients. 3.Thickened mucus secretions predispose the patient to anemia. 4.The diet was ordered according to the patient's preferred food intake. 2.Cystic fibrosis interferes with the digestions of food and absorption of nutrients.

2.Cystic fibrosis interferes with the digestions of food and absorption of nutrients.

A patient complains of nausea after a tube feeding. What is the priority action of the nurse at this time? 1.Position the patient on left side. 2.Ensure the head of the bed remains elevated. 3.Aspirate the tube feeding contents from the patient's stomach. 4.Flush the tube with 30 to 60 mL water

2.Ensure the head of the bed remains elevated.

A nurse is planning patient education about a prescribed medication for a patient. What should the nurse do first? 1.Education the patient about potential allergic reactions to the medication. 2.Find out what the patient already knows about the medication. 3.Review the signs and symptoms of drug toxicity with the patient. 4.Educate the patient about potential drug interactions.

2.Find out what the patient already knows about the medication.

Considering Mr. Ahmed's diagnosis of dehydration and the possibility of neurological impairment, which nursing intervention is directed toward minimizing his risk for possible injury? 1.Educating the patient on the use of a calibrated urinal 2.Implementing falls precaution 3.Administrating ondansetron with a full glass of water 4.Assessing for orthostatic hypertension daily

2.Implementing falls precaution

Reduced skin turgor is characteristically altered among which population? 1.Smokers 2.Older adults 3.Infants 4.Premenstrual females

2.Older adults

A nurse plans on assessing the patient's gastrointestinal system. Which statement below reflects the best prioritization of this assessment? 1.The nurse should percuss and then auscultate the abdomen 2.The nurse should auscultate and then palpate the abdomen 3.The nurse should palpate and then auscultate the abdomen 4.The nurse should percuss and then inspect the abdomen

2.The nurse should auscultate and then palpate the abdomen

A patient has just completed a tube feeding that has run throughout the night. What is the best education the nurse can provide to the patient at this time? 1.You should wear your pneumatic compression device when you are in bed. 2.You should remain upright for the next hour. 3.You should lie down to get some sleep. 4.It is important that you ambulate three times today.

2.You should remain upright for the next hour.

A nurse is caring for an 18-year-old patient who has recently started living on his own and has experienced a greater than 5% weight loss over two weeks. He has a low body mass index (BMI) and complains of feeling fatigued. According to Maslow's hierarchy of needs, the nurse identifies which of the following as the patient's priority need at this time? 1.Safety and security needs 2.Self-esteem needs 3.Physiological needs 4.Love and belonging needs

3. physiological needs

Which diagnostic test serves as the basis for determining acid-base imbalances? 1.Specific gravity of urine 2.Blood urea nitrogen (BUN) 3.Arterial blood gas (ABG) 4.Serum potassium

3.Arterial blood gas (ABG)

A nurse is planning on administering a tube feeding to a patient with a nasogastric tube. The patient appears asleep flat in bed. What should the nurse do first? 1.Carefully connect the nasogastric tube to the tube feeding 2.Administer the feeding quietly without waking the patient 3.Assist the patient to a semi-Fowler's position or higher 4.Flush the nasogastric tube with 30 to 60 mL water

3.Assist the patient to a semi-Fowler's position or higher

Which statement by Mr. Ahmed best reflects his ability to assume some responsibility in tracking his urinary output? 1.I understand that it is important to measure my urine with the calibrated urinal 2.I listened as you discussed the instructions about the calibrated urinal 3.I will always use the calibrated urinal to measure my urine 4.I will notify staff when I need to use the calibrated urinal

3.I will always use the calibrated urinal to measure my urine

A patient is concerned about a medication the nurse is administering. The patient states that the medication is not normally something that is administered. What is the best response by the nurse? 1.The provider has ordered it for you. 2.It is probably a generic medication for something you normally get. 3.I will hold the medication and find out for you. 4.We should probably update your medical reconciliation forms.

3.I will hold the medication and find out for you.

In addition to regular monitoring of serum potassium level, which intervention will the nurse implement to address the safety needs of a patient prescribed intravenous potassium chloride? 1.Shading windows to minimize sun exposure 2.Delivering the medication by slow IC push 3.Securing electrocardiograms (ECG) regularly 4.Monitoring for hyperactivity

3.Securing electrocardiograms (ECG) regularly

What determines the acidity of a substance like body fluids? 1.The body's ability to trigger chemical reactions 2.The fluid's pH measurement 3.The number of existing H+ ions 4.The amounts of available HCO3

3.The number of existing H+ ions

In preparation for calculating the infusion rate for a newly ordered intravenous (IV) solution, the nurse must first secure what information? 1.When the IV is to be started 2.The status of the patient's IV site 3.Patient's history of allergies 4.The infusion set's drop factor 4.The infusion set's drop factor

4. the infusion is set to the drop factor

A patient with cystic fibrosis has five capsules of pancrelipase (amylase, lipase, and protease) ordered to be administered now with his breakfast. The patient is currently experiencing nausea and intermittent vomiting. What should the nurse do with this medication? 1.Crush the medication to administer to the patient 2.Administer the medication as ordered 3.Call the provider immediately 4.Hold the medication until the patient is able to eat again

4.Hold the medication until the patient is able to eat again

Hypokalemia is confirmed by what serum blood result? 1.Potassium 5.5 2.Sodium 146 3.Sodium 133 4.Potassium 3.0

4.Potassium 3.0

Which of Mr. Ahmed's lab results best supports his diagnosis of dehydration? 1.Creatinine 1.1 2.WBC 21 x 10^9 3.HgB 16.7 4.Sodium 130

4.Sodium 130

Which statement by the nurse indicates a need for further education on the role of water as a body fluid? 1.Tissue lubrication is facilitated by water 2.Water helps maintain normal body temperature 3.Waste products are removed from the cells by water 4.Water is transported to cells when it is attached to electrolytes

4.Water is transported to cells when it is attached to electrolytes

Which statement concerning fluid balance demonstrated a need for additional instruction concerning fluid intake and output? 1.A desirable amount of fluid intake and output in adults ranges from 1,500 to 3,500 mL daily 2.It is recommended that a healthy adult consume 1.5 quarts of water daily 3.Fluid output is comprised of feces, sweat, and exhaled air 4.The balance between fluid intake and output must be achieved each day to maintain homeostasis

4The balance between fluid intake and output must be achieved each day to maintain homeostasis

Mona complains of SOB with activity and does not want to exacerbate her condition by moving to the chair or ambulating three times a day as ordered. How should the nurse respond? A. even short activities as moving to the chair will help you cough mucous out of your lungs. B. You really need to walk as much as possible in order to prevent your pneumonia from getting worse. C. pneumonia cases thick secretions in your lungs, making it difficult to breathe D. you should wait until your breathing improves to try to get out of bed again, because it makes you SOB

A

Mona asks the nurse why is it necessary to use the incentive spirometer when she is already having difficulty breathing. What is the best response by the nurse? A. helps prevent atelectasis or collapsing of the alveoli in the lungs B. it increases the oxygen taken in by the lungs when you inhale C. it decreases cardiac workload during inspiration D. It was ordered by your provider

A spirometer helps deeps breathing, coughing, which prevents collapsing of alveoli in the lungs. the nurse should explain why an intervention should be done and not simply that is was ordered

ID the following potential problems or actual problems that the nurse should include when planning care for the pt diagnosed with pneumonia? (select all that apply) A. not able to tolerate activity B. ineffective respiratory gas exchange C. Difficulty breathing D. Metabolic acidosis E. Acute pain

A, B, C, E pt w/ pneumonia has potential for acute pain, ineffective ABGs in lungs, difficulty breathing, activity intolerance. Metabolic acidosis is not caused by impaired respiratory status

Mona's ABG;s indicate respiratory acidosis. Her o2 saturation is 95% per the pulse oximeter. Which interventions should the nurse provide? Select all that apply. A. promote voluntary coughing activities to clear secretions B. provide supplemental oxygen as ordered C. none; the pt has a 95% o2 D. ensure the pt is well hydrated E. assist the pt with adequate ventilation

A, B, D, E

A pt states he does not want to use the incentive spirometer because it makes the patient cough up too much sputum, and it is difficult to breathe. What is the correct information to teach the pt about the use of incentive spirometer? A. You should wait to use it until you are not coughing so much sputum B. You have to use your incentive spirometer because your provider has ordered it for you C. It helps you maximize lung function and minimize risk of atelectasis D. It will cause you to cough less because you are moving more air through the lungs

C Rationale: Using it will likely cause the patient to cough up sputum because the pt is breathing deeply. It WILL NOT decrease amount fo sputum. Informing pt has to do it will not teach the pt. Pt should should it to maximize lung function, preventing complications of atelectasis.

A nurse rounding on a patient with pneumonia notices the patient is more confused than at the beginning of the shift. What is the best response by the nurse? A. ensure the sitter is available to watch the pt B. Notify the provider C. check o2 saturation level D. document findings in the medical record

C decreased o2 can lead to confusion and changes in mental status. document AFTER assess o2 level and interventions.

Mona's lab work shows an elevated WBC with a lest shift in the differential. The nurse interprets this to mean which of the following? A. there is a high number of WBC to fight the infection, and the RBC are compensating B. the left shift in the differential means that there is no infection present C. there is a high number of WBC and immature WBC present to fight the infection D. there is a high number of WBC, but NOT immature WBC, present in circulation

C. WBC are elevated in response to infection or stress. a left shift in the differential means that there are more than normal number of immature WBCs in circulation that have been release to respond to the infection. the other answer choices do not explain labs or elevated WBC with left shift.

The nurse is caring for an adolescent patient who appears withdrawn and isolated. What strategy should the nurse use to work with this patient? 1.Develop a therapeutic, trusting relationship with the patient. 2.Leave the patient alone as much as possible. 3.Talk to the patient's parents about what is going on with the patient. 4.Tell the patient what the patient needs to do in order to get better.

Develop a therapeutic, trusting relationship with the patient.

The nurse titrates the pt's o2 to 3L per nasal cannula in order to maintain an oxygen saturation of at least 94%, per the provider's orders. What is the rationale for this order? Select all that apply. A. prevents atelectasis in pt with pneumonia B. allows the pt to receive 100% o2 C. Allows the body to meet metabolic demands D. Promotes a decrease in myocardial workload E. Promotes a decrease in respiratory effort

E, D, C Rationale: o2 administered decreases respiratory AND cardiac workload and offers increased oxygenation to meet metabolic demands. Oxygen per nasal cannula does NOT provide 100% oxygen. Deep breathing exercises help prevent atelectasis in a patient with pneumonia not maintaining oxygen saturation greater than 94%

Patient with newly diagnosed pneumonia has an oxygen saturation of 94% room air, an increased respiratory rate, and an increased pulse. The pt is pale, anxious. The nurse questions the o2 saturation results and looks up which of the following lab results? WBC count hemoglobin Chest X-ray Gram Stain

Hemoglobin Rationale: Pulse Ox measures hemoglobin. Gram stain determines type of bacteria causing the illness. WBC shows infection. X-ray is used to diagnose pneumonia.

Expected assessment findings of a patient with pneumonia may included which of the following? select all that apply tachypena malasie enuresis use of accessory muscles fever

fever, malaise, tachy, use of accessory muscles Rationale: Enuresis is not an assessment finding associated with pneumonia

A patient is semi-fowler's position is having difficulty breathing. What is the priority action of the nurse? conduct a pain assessment raise the head of the bed auscultate the lung call respiratory therapy

raise HOB rationale: other answer may be appropriate AFTER HOB has been raised

What pathology is responsible for metabolic acidosis? 1.A decrease in bicarbonate or an increase in hydrogen icons 2.A decrease of carbonic acid 3.An excess of HCO3 and/or a decrease in H+ ions 4.An increase of CO2

1.A decrease in bicarbonate or an increase in hydrogen icons

A nurse is teaching a patient with cystic fibrosis about nutrition in the high-fat, high-carbohydrate diet that has been recommended. Which of the following should be included in this education? 1.It is important to focus on eating calorie-dense foods 2.It is not necessary to monitor dietary intake 3.It is important to only eat high-fat, high-protein and high- carbohydrate foods 4.It is important to select a variety of nutrient-dense foods

4.It is important to select a variety of nutrient-dense foods

Which physical finding poses the greatest safety risk for a patient diagnosed with hyponatremia? 1.Cold, clammy skin 2.Dry mucous membranes 3.Anxiety 4.Orthostatic hypotension

4.Orthostatic hypotension

While completing discharge instructions with a patient, the nurse notices the pt is SOB. What is the priority nursing action at this time? A. determine if pt has questions B. listen to the pt lungs C. reassure the pt D. ask if pt has a support at home

B

The nurse is preparing to discharge mona from the hospital. Which of the following instructions should the nurse include in the discharge education? Select all that apply A. stop taking your antibiotics once you are feeling better B. quitting smoking will improve your recover C. use the incentive spirometer every one to two hours to move secretions out of your lungs D. take your antibiotics as directed, even if you are feeling better E. continue to focus on ambulating several times per day

B, C, D, E