5040 Final (questions)

The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action should the nurse include in the plan of care?

Avoid intramuscular injections

Postoperatively, the nurse should monitor the patient who received inhalation anesthesia for which complication?

Laryngospasm

A patient who is scheduled for a breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct?

Malignant tumors may spread to other tissues or organs

The nurse supervises the care of a patient with a temporary radioactive cervical implant. Which action by unlicensed assistive personnel (UAP), if observed by the nurse, would require an intervention?

The UAP stands by the patient's bed for 30 minutes talking with the patient.

Which patient requires the most rapid assessment and care by the emergency department nurse?

The patient with neutropenia who has a temperature of 101.8° F

The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia. The nurse will plan to check the laboratory results for the

bilirubin level.

A routine complete blood count for an active older man indicates possible myelodysplastic syndrome. The nurse will plan to teach the patient about

bone marrow biopsy.

When caring for a patient with a soft, silicone nasogastric tube in place for enteral feedings, the nurse will

flush the tubing after checking for residual volumes

A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of

folic acid

According to Piaget, one basic concept that a child will learn during the first year is that

he is separate from his parents

The nurse assesses a patient who has numerous petechiae on both arms. Which question should the nurse ask the patient?

Do you take medication containing salicylates?"

A patient's T-tube is draining dark green fluid after gallbladder surgery. What action by the nurse is the most appropriate?

Document the color and amount of drainage.

While caring for a child recovering from viral pneumonia, you examine his lungs for evidence of exudate and fluid. Which finding would suggest cause for concern

Dullness of his lower lobes heard on percussion

Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate?

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

A patient scheduled to undergo total knee replacement surgery under general anesthesia asks the nurse, "Will the doctor put me to sleep with a mask over my face?" Which response by the nurse is most appropriate?

I will check with the anesthesia care provider to find out what is planned."

Interleukin-2 (IL-2) is used as adjuvant therapy for a patient with metastatic renal cell carcinoma. Which information should the nurse include when explaining the purpose of this therapy to the patient

IL-2 enhances the body's immunologic response to tumor cells.

The nurse assesses a patient with non-Hodgkin's lymphoma who is receiving an infusion of rituximab (Rituxan). Which assessment finding would require the most rapid action by the nurse?

Shortness of breath

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

C

A patient with pancytopenia of unknown origin is scheduled for the following diagnostic tests. The nurse will provide a consent form to sign for which test?

Bone marrow biopsy

An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy twice a day. Which collaborative problem should the nurse identify as a priority for this patient?

Potential complication: venous thromboembolism

Which action will the perioperative nurse take after surgery is completed for a patient who received ketamine as an anesthetic agent?

Provide a quiet environment in the postanesthesia care unit.

Which action for a patient receiving tube feedings through a percutaneous endoscopic gastrostomy (PEG) may be delegated to a licensed practical/vocational nurse (LPN/LVN)?

Providing skin care to the area around the tube site

A patient who is diagnosed with cervical cancer classified as Tis, N0, M0 asks the nurse what the letters and numbers mean. Which response by the nurse is accurate?

The cancer involves only the cervix

When assessing children using a Snellen eye chart, you should be aware that the first number of the vision report (20/20) represents

the distance the child stands from the chart.

A patient who had a total hip replacement had an intraoperative hemorrhage 14 hours ago. Which laboratory test result would the nurse expect?

Elevated reticulocyte count

A patient has received atropine before surgery and complains of dry mouth. Which action by the nurse is most appropriate?

Explain that dry mouth is an expected side effect.

Which technique would you begin with to assess a child's abdomen?

Inspection

Which action in the perioperative patient plan of care can the charge nurse delegate to a surgical technologist?

Pass sterile instruments and supplies to the surgeon and scrub technician.

An older adult patient who has colorectal cancer is receiving IV fluids at 175 mL/hr in conjunction with the prescribed chemotherapy. Which finding by the nurse is most important to report to the health care provider?

Patient has crackles up to the midline posterior chest

A patient who is scheduled for a therapeutic abortion tells the nurse, "Having an abortion is wrong." Which functional health pattern should the nurse further assess?

Value-belief

Which information in this male patient's electronic health record as shown in the accompanying figure will the nurse use to confirm that the patient has metabolic syndrome

Waist size Blood glucose

The nurse is coaching a community group for individuals who are overweight. Which participant behavior is an example of the best exercise plan for weight loss?

Walking for 40 minutes 6 or 7 days/week

Which of the following factors would contribute least to the ultimate height that a child reaches?

Whether he enjoys active sports or not

To assess for abnormal eye alignment, you would observe a child while you

cover one eye and then remove the cover.

The nurse is caring for a patient with left-sided lung cancer. Which finding would be most important for the nurse to report to the health care provider? A. Hematocrit 32% B. Pain with deep inspiration C. Serum Sodium 126 mEq/L D. Decreased breath sounds on left side

C

The nurse assesses a patient on the second postoperative day after abdominal surgery to repair a perforated duodenal ulcer. Which finding is most important for the nurse to report to the surgeon?

200 mL sanguineous fluid in the wound drain

After change-of-shift report, which patient will the nurse assess first?

A 40-yr-old man with continuous enteral feedings who has developed pulmonary crackles

The nurse at the clinic is interviewing a 64-year-old woman who is 5 feet, 3 inches tall and weight 125 pound. The patient has not seen a health care provider for 20 years. She walks 5 miles most days and has a glass of wine 2 or 3 times a week. Which topics will the nurse plan to include in patient teaching about cancer screening and decreasing cancer risk? Select all that apply. A. Pap testing B. Tobacco use C. Sunscreen use D.Mammography E. Colorectal screening

A, C, D, E

A patient has been assigned the nursing diagnosis of imbalanced nutrition: less than body requirements related to painful oral ulcers. Which nursing action will be most effective in improving oral intake?

Apply prescribed anesthetic gel to oral lesions before meals.

A patient is being admitted for bariatric surgery. Which nursing action can the nurse delegate to unlicensed assistive personnel (UAP)?

Assist with IV insertion by holding adipose tissue out of the way

Which patient should the nurse assign as the roommate for a patient who has aplastic anemia?

A patient with chronic heart failure

While ambulating in the room, a patient complains of feeling dizzy. In what order will the nurse accomplish the following activities? a. Have the patient sit down in a chair. b. Give the patient something to drink. c. Take the patient's blood pressure (BP). d. Notify the patient's health care provider

A, C, B, D

Which action will the admitting nurse include in the care plan for a 30-year old woman who is neutropenic? a. Avoid any injections. b. Check temperature every 4 hours. c. Omit fruits or vegetables from the diet. d. Place a "No Visitors" sign on the door.

B

When teaching a patient about testing to diagnose metabolic syndrome, which topic would the nurse include?

Blood glucose test

The nurse assesses a patient with pernicious anemia. Which assessment finding would the nurse expect? A. Yellow-tinged sclerae B. Shiny, smooth tongue C. Numbness of the extremities D. Gum bleeding and tenderness

C

Which assessment action will help the nurse determine if an obese patient has metabolic syndrome?

Check the patient's blood pressure.

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?

Lip swelling

When a patient with splenomegaly is scheduled for splenectomy, which action will the nurse include in the preoperative plan of care?

Schedule immunization with the pneumococcal vaccine (e.g., Pneumovax

If a preschooler sees you pour his liquid medicine from a tall, thin glass into a short, wide one, he will probably reason that

the amount of medicine is less (the glass is not as full).

A 52-yr-old patient has a new diagnosis of pernicious anemia. The nurse determines that the patient understands the teaching about the disorder when the patient states,

"I could choose nasal spray rather than injections of vitamin B12."

Which statement, if made by a new circulating nurse, reflects understanding of the circulating nurse role?

"I will assist in preparing the operating room for the patient."

When caring for patient who is pancytopenic, which action by unlicensed assistive personnel (UAP) indicates a need for the nurse to intervene? A. The UAP assists the patient to use dental floss after eating B. The UAP adds baking soda to the patinet's saline oral rinses C. The UAP puts fluoride toothpaste on the patient's toothbrush D. The UAP has the patient rinse after meals with a saline solution

A

Which action will the nurse include in the plan of care for a 72-year-old woman 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.

A

A patient who has diabetes and uses insulin to control blood glucose has been NPO since midnight before having a knee replacement surgery. Which action should the nurse take? A. Withhold the usual scheduled insulin dose because the patient is NPO. B. Obtain a blood glucose measurement before any insulin administration C. Give the patient the usual insulin dose because stress will increase the blood glucose D. Administer a lower dose of insulin because there will be no oral intake before surgery

B

A patient who has never had any prior surgeries tells the nurse doing the preoperative assessment about an allergy to bananas and avocados. Which action is most important for the nurse to take? A.Notify the dietitian about the food allergies B. Alert the surgery center about a possible latex allergy C. Reassure the patient that all allergies are noted on the medical record D. Ask whether the patient uses antihistamines to reduce allergic reactions

B

A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of A. Iron B. Folic acid C. Vitamin B12 D. Vitamin C

B

Which information obtained by the nurse caring for patient with thrombocytopenia should be immediately communication to the health care provider? A. The platelet count is 52,000 B. The patient is difficult to arouse C. There are purpura on the oral mucosa D. There are large bruises on the patient's back

B

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

B

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

B

The nurse receives change-of-shift report on the oncology unit. Which patient should the nurse assess first? a. 35-year-old patient who has wet desquamation associated with abdominal radiation b. 42-year-old patient who is sobbing after receiving a new diagnosis of ovarian cancer c. 24-year-old patient who received neck radiation and has blood oozing from the neck d. 56-year-old patient who developed a new pericardial friction rub after chest radiation

C

External-beam radiation is planned for a patient with cervical cancer. What instructions should the nurse give to the patient to prevent complications from the effects of the radiation?

Clean the perianal area carefully after every bowel movement

The outpatient surgery nurse reviews the complete blood cell (CBC) count results for a patient who is scheduled for surgery. The results are white blood cell (WBC) count 10.2 ´ 103/µL; hemoglobin 15 g/dL; hematocrit 45%; platelets 150 ´ 103/µL. Which action should the nurse take?

Continue to prepare the patient for the surgical procedure

Which action should the nurse take when caring for a patient who is receiving chemotherapy and complains of problems with concentration? A. Teach the patient to rest the brain by avoiding new activities B. Teach that "chemo-brain" is a short-term effect of chemotherapy C. Report patient symptoms immediately to the health care provider D. Suggest use of a daily planner and encourage adequate rest and sleep

D

You meet a 3-year-old girl in a health maintenance setting. What is the first question you would ask her mother to obtain a health history?

Do you have any concerns about Sarah?"

A patient who has ovarian cancer is crying and tells the nurse, "My husband rarely visits. He just doesn't care." The husband indicates to the nurse that he does not know what to say to his wife. Which nursing diagnosis is appropriate for the nurse to add to the plan of care?

Dysfunctional family processes related to effect of illness on family members

The nurse is caring for a patient on the first postoperative day after a Roux-en- gastric bypass procedure. Which assessment finding should be reported immediately to the surgeon?

Emesis of bile-colored fluid past the nasogastric (NG) tube

During a routine health examination, a 40-yr-old patient tells the nurse about a family history of colon cancer. Which action should the nurse take next?

Obtain more information about the family history.

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)?

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

Five minutes after receiving the ordered preoperative midazolam by IV injection, the patient asks to get up to go to the bathroom to urinate. Which action by the nurse is most appropriate?

Offer the patient a urinal or bedpan.

The nurse is planning care for a patient who is chronically malnourished. Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?

Offer the patient the prescribed nutritional supplement between meals.

The health care provider's progress note for a patient states that the complete blood count (CBC) shows a "shift to the left." Which assessment finding will the nurse expect?

Pallor and weakness

Which action best describes the role of the certified registered nurse anesthetist (CRNA) on the surgical care team

Releases or discharges patients from the postanesthesia care area.

A patient receiving head and neck radiation for larynx cancer has ulcerations over the oral mucosa and tongue and thick, ropey saliva. Which instructions should the nurse give to this patient?

Rinse the mouth before and after each meal and at bedtime with a saline solution.

Which information obtained by the nurse assessing a patient admitted with multiple myeloma is most important to report to the health care provider?

Serum calcium level is 15 mg/dL.

A patient who has just been started on tube feedings of full-strength formula at 100 mL/hr has 6 diarrhea stools the first day. Which action should the nurse plan to take?

Slow the infusion rate of the tube feeding

When caring for a patient who is pancytopenic, which action by unlicensed assistive personnel (UAP) indicates a need for the nurse to intervene?

The UAP assists the patient to use dental floss after eating.

Which assessment finding should the nurse caring for a patient with thrombocytopenia communicate immediately to the health care provider?

The patient is difficult to arouse.

A 38-yr-old woman is admitted for an elective surgical procedure. Which information obtained by the nurse during the preoperative assessment is most important to communicate to the anesthesiologist and surgeon before surgery?

The patient's report that her last menstrual period was 8 weeks ago

After successfully losing 1 lb weekly for several months, a patient at the clinic has not lost any weight for the past month. The nurse should first

ask the patient whether there have been any changes in exercise or diet patterns.

A patient who has acute myelogenous leukemia (AML) is considering treatment with a hematopoietic stem cell transplant (HSCT). The best approach for the nurse to assist the patient with a treatment decision is to

ask whether there are questions or concerns about HSCT.

It is important for the nurse providing care for a patient with sickle cell crisis to

evaluate the effectiveness of opioid analgesics.

A child's temperament makes her easy to care for. Her characteristics probably include

long attention span, high level of persistence.

An expected action by the nurse caring for a patient who has an acute exacerbation of polycythemia vera is to

monitor fluid intake and output

You want to know how much time a preschooler's parents spend playing with her every day. The best way to obtain this kind of information is to ask the

parents for a day history

The nurse is caring for a patient diagnosed with stage I colon cancer. When assessing the need for psychologic support, which question by the nurse will provide the most information

Can you tell me what has been helpful to you in the past when coping with stressful events?"

Which action describes how the scrub nurse protects the patient with aseptic technique during surgery?

Changes gloves after touching the upper arm of the surgeon's gown

Which action will the admitting nurse include in the care plan for a patient who has neutropenia

Check temperature every 4 hours.

A postoperative patient has a nursing diagnosis of ineffective airway clearance. The nurse determines that interventions for this nursing diagnosis have been successful if which is observed?

Patient's breath sounds are clear to auscultation.

A nurse reviews the laboratory data for an older patient. The nurse would be most concerned about which finding?

White blood cell (WBC) count of 2800/µL

The nurse receives change-of-shift report on the oncology unit. Which patient should the nurse assess first?

A 24-yr-old patient who received neck radiation and has blood oozing from the neck

The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action should the nurse include in the plan of care? A. Avoid intramuscular injections B. Encourage increased oral fluids C. Check temperature every 4 hours D. Increase intake of iron-rich foods

A

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

A

Which statement by a patient schedule for surgery is most important to report to the health care provider? A. "I had a heart valve replacement last year" B. "I had bacterial pneumonia 3 months ago" C. "I have knee pain whenever I walk or jog" D. "I have a strong family history of breast cancer"

A

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

After receiving change-of-shift report for several patients with neutropenia, which patient should the nurse assess first?

A 33-yr-old with a fever of 100.8° F (38.2° C)

Which of the nurse's assigned patients should be referred to the dietitian for a complete nutritional assessment (select all that apply)?

A 48-yr-old patient with rheumatoid arthritis who takes prednisone daily A 23-yr-old patient who has a history of fluctuating weight gains and losses A 64-yr-old patient who is admitted for débridement of an infected surgical wound

A patient with metastatic cancer of the colon experiences severe vomiting after each administration of chemotherapy. Which action, if taken by the nurse, is appropriate

Administer prescribed antiemetics 1 hour before the treatments.

A patient who had knee surgery received IV ketorolac 30 minutes ago and continues to complain of pain at a level of 7 (0 to 10 scale). Which action is most effective for the nurse to take at this time?

Administer the prescribed PRN IV morphine sulfate.

A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse would indicate a need for further teaching? a. The patient ambulates several times a day in the room. b. The patient's visitors bring in some fresh peaches from home. c. The patient cleans with a warm washcloth after having a stool. d. The patient uses soap and shampoo to shower every other day.

B

A patient with Hodgkin's lymphoma who is undergoing external radiation therapy tells the nurse, "I am so tired I can hardly get out of bed in the morning." Which intervention should the nurse add to the plan of care? a. Minimize activity until the treatment is completed. b. Establish time to take a short walk almost every day. c. Consult with a psychiatrist for treatment of depression. d. Arrange for delivery of a hospital bed to the patient's home.

B

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

B

An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy twice a day. Which collaborative problem should the nurse identify as a priority for this patient? A. Potential complication: hypovolemic shock B. Potential complication: venous thromboembolism C. Potential complication: fluid and electrolyte imbalance D. Potential complication: impaired surgical wound healing

B

In the postanesthesia care unit (PACU), a patient's vital signs are blood pressure 116/72, pulse 74, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take? A. Place the patient in a side-lying position B. Encourage the patient to take deep breaths C. Prepare to transfer the patient to a clinical unit D. Increase the rate of the postoperative IV fluid

B

The nurse is planning to administer a transfusion of packed red blood cells to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to UAP A. Verify the patient indentification according to hospital policy B. Obtain the temperature, blood pressure, and pulse before the transfusion C. Double-check the product numbers on the pRBCs with the patient ID band D. Monitor the patient for shortness of breath or chest pain during the transfusion

B

The nurse is preparing to witness the patient signing the operative consent form when the patient says, "I do not really understand what the doctor said." Which action is best for the nurse to take? A. Provide an explanation of the planned surgical procedure B. Notify the surgeon that the informed consent process is not complete C. Administer the prescribed preoperative antibiotics and withhold any ordered sedative medications D. Notify the operating room staff that the surgeon needs to give a more complete explanation of the procedure

B

Which action could the postanesthesia care unit (PACU) nurse delegate to unlicensed assistive personnel (UAP) who help with the transfer of a patient to the clinical unit? a. Clarify the postoperative orders with the surgeon. b. Help with the transfer of the patient onto a stretcher. c. Document the appearance of the patient's incision in the chart. d. Provide hand off communication to the surgical unit charge nurse.

B

Which information in the preoperative patient's medication history is most important to communicate to the health care provider? A. The patient uses acetaminophen (Tylenol) occasionally for aches and pains. B. The patient takes garlic capsules daily but did not take any on the surgical day. C. The patient has a history of cocaine use but quit using the drug over 10 years ago D. The patient took a sedative medication the previous night to assist in falling asleep

B

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

B

A patient who has severe pain associated with terminal pancreatic cancer is being cared for at home by family members. Which finding by the nurse indicates that teaching regarding pain management has been effective? A. The patient uses the ordered opioid pain medication whenever the pain is greater than 5 (0 to 10 scale) B. The patient agrees to take the medications by the IV route in order to improve analgesic effectiveness C. The patient takes opioids around the clock on a regular schedule and uses additional doses when breakthrough pain occurs. D. The patient states that nonopioid analgesics may be used when the maximal dose of the opioid is reached without adequate pain relief

C

The nurse is caring for a patient who has been diagnosed with stage 1 cancer of the colon . When assessing the need for psychologic support, which question by the nurse will provide the most information? A. "How long ago where you diagnosed with this cancer? B. "Do you have any concerns about body images changes?" C. "Can you tell me what has been helpful to you in the past when coping with stressful events?" D. "Are you familiar with the stages of emotional adjustment to a diagnosis like cancer of the colon?"

C

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

C

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

D

A patient who takes a diuretic and a beta-blocker to control blood pressure is scheduled for breast reconstruction surgery. Which patient information is most important to communicate to the health care provider before surgery? A. Hematocrit 36% B. Blood pressure 144/82 C. Pulse 58 beats per min D. Serum potassium 3.2

D

An older adult patient who has colorectal cancer is receiving IV fluids at 175 mL/hour in conjunction with the prescribed chemotherapy. Which finding by the nurse is most important to report to the health care provider? a. Patient complains of severe fatigue. b. Patient needs to void every hour during the day. c. Patient takes only 50% of meals and refuses snacks. d. Patient has audible crackles to the midline posterior chest.

D

The nurse reviews the complete blood count (CBC) and white blood cell (WBC) differential of a patient admitted with abdominal pain. Which information will be most important for the nurse to communicate to the health care provider? a. Monocytes 4% b. Hemoglobin 13.6 g/dL c. Platelet count 168,000/µL d. White blood cells (WBCs) 15,500/µL

D

The nurse reviews the laboratory results of a patient who is receiving chemotherapy. Which laboratory result is most important to report to the health care provider? A. Hematocrit of 30% B. Platelets of 95,000 C. Hemoglobin of 10 D. White blood cell (WBC) count of 2700

D

A patient with a large stomach tumor attached to the liver is scheduled for a debulking procedure. Which information should the nurse teach the patient about the outcome of this procedure?

Decreasing the tumor size will improve the effects of other therapy

The nurse teaches a postmenopausal patient with stage III breast cancer about the expected outcomes of cancer treatment. Which patient statement indicates that the teaching has been effective? a. "After cancer has not recurred for 5 years, it is considered cured." b. "The cancer will be cured if the entire tumor is surgically removed." c. "Cancer is never considered cured, but the tumor can be controlled with surgery, chemotherapy, and radiation." d. "I will need to have follow-up examinations for many years after I have treatment before I can be considered cured."

D

The outpatient surgery nurse reviews the complete (CBC) count results for a patient who is scheduled for surgery in a few days. The results are white blood cell (WBC) count 10.2 x 10^3, hemoglobin 15g/dL; hematocrit 45%; platelets 150 x 10^3. Which action should the nurse take? A. Call the surgeon and anesthesiologist immediately B. Ask the patient about any symptoms of a recent infection C. Discuss the possibility of blood transfusion with the patient. D. Send the patient to the holding area when the operating room calls.

D

When assessing a newly admitted patient, the nurse notes pallor of the skin and nail beds. The nurse should ensure that which laboratory test has been ordered? A. Platelet count B. Neutrophil count C. White blood cell count D. Hemoglobin count

D

A patient undergoing external radiation has developed a dry desquamation of the skin in the treatment area. The nurse teaches the patient about the management of the skin reaction. Which statement, if made by the patient, indicates the teaching was effective?

I can buy aloe vera gel to use on my skin

Which statement by a patient scheduled for surgery is most important to report to the health care provider?

I had a heart valve replacement last year

Which adult will the nurse plan to teach about risks associated with obesity

Man with a 42 in waist and 44 in hips

After receiving change-of-shift report about these postoperative patients, which patient should the nurse assess first?

Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating

A patient who has diabetes and uses insulin to control blood glucose has been NPO since midnight before having a knee replacement surgery. Which action should the nurse take

Obtain a blood glucose measurement before any insulin administration.

Which collaborative problem will the nurse include in a care plan for a patient admitted to the hospital with idiopathic aplastic anemia?

Potential complication: infection

The nurse teaches a patient who is scheduled for a prostate needle biopsy about the procedure. Which statement, if made by the patient, indicates that teaching was effective?

The biopsy will help decide the treatment for my enlarged prostate."

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?

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

A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action should the nurse take first?

Check the oxygen (O2) saturation.

The home health nurse is caring for a patient who has been receiving interferon therapy for treatment of cancer. Which statement by the patient indicates a need for further assessment

"I rarely have the energy to get out of bed."

A patient scheduled for an elective hysterectomy tells the nurse, "I am afraid that I will die in surgery like my mother did!" Which initial response by the nurse is appropriate?

"Tell me more about what happened to your mother."

Which action will the nurse include in the plan of care for a patient admitted with multiple myeloma?

Monitor fluid intake and output.

A healthy adult woman who weighs 145 lb (66 kg) asks the clinic nurse about the minimum daily requirement for protein. How many grams of protein will the nurse recommend?

53

A patient arrives in the ambulatory surgery center for a scheduled laparacopy procedure in outpatient surgery. Which information is of most concern to the nurse? A. The patient is planning to drive home after surgery B. The patient had a sip of water 4 hours before arriving C. The patient's insurance does not cover outpatient surgery D. The patient has not had surgery suing general anesthesia before

A

After receiving change-of-shift report about these postoperative patients, which patient should the nurse assess first? A. Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating B. Patient who has 30mL of sanguineous drainage in the wound drain 10 hours after hip replacement sugery C. Patient who has bibasilar crackles and a temperature of 100 degrees F on the first postoperative day after chest surgery D. Patient who continues to have incisional pain 15 minutes after hydrocodone and acetaminophen (Vicodin) administration

A

The nurse examines the lymph nodes of a patient during a physical assessment. Which assessment finding would be of most concern to the nurse?

A 2-cm nontender supraclavicular node

A patient develops neutropenia after receiving chemotherapy. Which information about ways to prevent infection will the nurse include in the teaching plan? Select all that apply A. Cook food thoroughly before eating B. Choose low fiber, low residue foods C. Avoid public transportation such as buses D. Use rectal suppositories if needed for consitipation E. Talk to the oncologist before having any dental work done

A, C, E

To evaluate an obese patient for adverse effects of lorcaserin (Belviq), which action will the nurse take?

Ask about bowel movements

Which nursing action is appropriate when coaching obese adults enrolled in a behavior modification program?

Asking the adults about situations that tend to increase appetite

A patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU) is restless and shouting at the nurse. The patient's oxygen saturation is 96%, and recent laboratory results are all normal. Which action by the nurse is most appropriate?

Assess for bladder distention.

A patient who is being treated for stage IV lung cancer tells the nurse about new-onset back pain. Which action should the nurse take first?

Assess for sensation and strength in the legs.

On admission of a patient to the postanesthesia care unit (PACU), the blood pressure (BP) is 122/72. Thirty minutes after admission, the BP falls to 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate? a. Increase the IV fluid rate. b. Continue to take vital signs every 15 minutes. c. Administer oxygen therapy at 100% per mask. d. Notify the anesthesia care provider (ACP) immediately.

B

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

B

The home health nurse cares for a patient who has been receiving interferon therapy for treatment of cancer. Which statement by the patient indicates a need for further assessment? a. "I have frequent muscle aches and pains." b. "I rarely have the energy to get out of bed." c. "I experience chills after I inject the interferon." d. "I take acetaminophen (Tylenol) every 4 hours."

B

Which data identified during the preoperative assessment alerts the nurse that special protection techniques should be implemented during surgery

History of spinal and hip arthritis

A patient with leukemia is considering whether to have hematopoietic stem cell transplantation (HSCT). The nurse will include which information in the patient's teaching plan?

Hospitalization is required for several weeks after the stem cell transplant.

Which information shown in the table below about a patient who has just arrived in the emergency department is most urgent for the nurse to communicate to the health care provider?

Platelet count

After change-of-shift report on the oncology unit, which patient should the nurse assess first? a. Patient who has a platelet count of 82,000/µL after chemotherapy b. Patient who has xerostomia after receiving head and neck radiation c. Patient who is neutropenic and has a temperature of 100.5° F (38.1° C) d. Patient who is worried about getting the prescribed long-acting opioid on time

C

During a routine health examination, a 40-year-old patient tells the nurse about a family history of colon cancer. Which action should the nurse take next? a. Teach the patient about the need for a colonoscopy at age 50. b. Teach the patient how to do home testing for fecal occult blood. c. Obtain more information from the patient about the family history. d. Schedule a sigmoidoscopy to provide baseline data about the patient.

C

Which problem reported by a patient with hemophilia is most important for the nurse to communicate to the health care provider?

Tarry stools

Which finding about a patient with polycythemia vera is most important for the nurse to report to the health care provider?

Calf swelling and pain

A young adult with extensive facial injuries from a motor vehicle crash is receiving tube feedings through a percutaneous endoscopic gastrostomy (PEG). Which action will the nurse include in the plan of care?

Check the gastric residual volume every 4 to 6 hours.

A patient undergoing an emergency appendectomy has been using St. John's wort to prevent depression. Which complication would the nurse expect in the postanesthesia care unit?

Increased anesthesia recovery time

During the teaching session for a patient who has a new diagnosis of acute leukemia, the patient is restless and looks away without making eye contact. The patient asks the nurse to repeat the information about the complications associated with chemotherapy. Based on this assessment, which nursing diagnosis is appropriate for the patient?

Risk for ineffective health maintenance related to possible anxiety about leukemia diagnosis

A 40-yr-old obese woman reports that she wants to lose weight. Which question should the nurse ask first

What factors led to your obesity?"

The ability to think through hypotheses, or "what if" questions, is acquired during what stage of growth?

Adolescence

A patient with cancer has a nursing diagnosis of imbalanced nutrition: less than body requirements related to altered taste sensation. Which nursing action would address the cause of the patient problem?

Avoid giving the patient foods that are strongly disliked

The nurse will be teaching self-management to patients after gastric bypass surgery. Which information will the nurse plan to include?

Drink fluids between meals but not with meals

When giving directions on safety protection of a toddler's intravenous site, the nurse should

have the parents reinforce the information being given.

After the nurse teaches a patient about the recommended amounts of foods from animal and plant sources, which menu selections indicate that the initial instructions about diet have been understood?

3 oz of roasted pork, a cup of corn, and a cup of carrot sticks

A widowed mother of four school-age children is hospitalized with metastatic ovarian cancer. The patient is crying and tells the nurse that she does not know what will happen to her children when she dies. Which response by the nurse is the most appropriate?

A Why don't we talk about the options you have for the care of your children?"

Which action for a patient with neutropenia is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)?

Administering subcutaneous filgrastim (Neupogen) injection

Which of the following statements best explains the principle behind a Rinne test for determining hearing loss?

Air conduction of sound is normally better than bone conduction of sound.

Which finding would indicate to the nurse that a postoperative patient is at increased risk for poor wound healing?

Albumin level 2.2 g/dL

While in the holding area, a patient reveals to the nurse that his father had a high fever after surgery. What action by the nurse is a priority?

Alert the anesthesia care provider of the family member's reaction to surgery.

When assessing for bowel sounds, which of the following is true?

All four quadrants should be auscultated in a consistent pattern.

Which intervention will be included in the nursing care plan for a patient with immune thrombocytopenic purpura?

Avoid intramuscular (IM) injections.

The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia. The nurse will plan to check the laboratory results for the A. Schilling test B. Bilirubin level C. Stool occult blood test D. Gastric analysis testing

B

Which of the following assessments would you expect to introduce for the first time in the physical examination of a 3-year-old child?

Blood-pressure recording

The nurse working in the postanesthesia care unit (PACU) notes that a patient who has just been transported from the operating room is shivering and has a temperature of 96.5° F (35.8° C). Which action should the nurse take next?

Cover the patient with a warm blanket.

The nurse assesses a patient who is receiving interleukin-2. Which finding should the nurse report immediately to the health care provider?

Crackles heard at the lung bases

A 62-year old man with chronic anemia is experiencing increased fatigue and occasional palpitation at rest. The nurse would expect the patient's laboratory findings to include A. A hematocrit of 38% B. an RBC count of 4,500,000 C. Normal red blood cell indices D. A hemoglobin of 8.6

D

A nurse reviews the laboratory data for an older patient. The nurse would be most concerned about which finding? A. Hematocrit 35% B. Hemoglobin of 11.8 C. Platelet count of 400,000 D. White blood cell (WBC) count of 2800

D

A chemotherapy drug that causes alopecia is prescribed for a patient. Which action should the nurse take to support the patient's self-esteem?

Encourage the patient to purchase a wig or hat to wear when hair loss begins.

The nurse is reviewing laboratory results and notes a patient's activated partial thromboplastin time (aPTT) level of 28 seconds. The nurse should notify the health care provider in anticipation of adjusting which medication?

Heparin

The nurse teaches a postmenopausal patient with stage III breast cancer about the expected outcomes of cancer treatment. Which patient statement indicates that the teaching has been effective?

I will need follow-up examinations for many years after treatment before I can be considered cured."

A patient's blood pressure in the postanesthesia care unit (PACU) has dropped from an admission blood pressure of 140/86 to 102/60 mm Hg with a pulse change of 70 to 96 beats/min. SpO2 is 92% on 3 L of oxygen. In which order should the nurse take these actions?

Increase the IV infusion rate. Increase the oxygen flow rate Assess the patient's dressing. Check the patient's temperature

The nurse obtains information about a hospitalized patient who is receiving chemotherapy for colorectal cancer. Which information about the patient alerts the nurse to discuss a possible change in cancer therapy with the health care provider?

Increased carcinoembryonic antigen

A patient's peripheral parenteral nutrition (PN) bag is nearly empty, and a new PN bag has not arrived yet from the pharmacy. Which intervention by the nurse is appropriate?

Infuse 5% dextrose in water until a new PN bag is delivered.

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?

Infuse normal saline 500 mL over 30 minutes.

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?

Neutropenia

When caring for a patient who has received a general anesthetic, the circulating nurse notes red, raised wheals on the patient's arms. Which action should the nurse take?

Notify the anesthesia care practitioner (ACP).

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?

Notify the health care provider

The nurse is preparing to witness the patient signing the operative consent form when the patient says, "I don't understand what the doctor said about the surgery." Which action should the nurse take next?

Notify the surgeon that the informed consent process is not complete.

You watch a child arranging sugar packets from his meal trays in order of their weight. This activity of conservation is most typical of what age child?

School age

Which patient information is most important for the nurse to monitor when evaluating the effectiveness of deferoxamine (Desferal) for a patient with hemochromatosis?

Serum iron level

A patient who takes a diuretic and a b-blocker to control blood pressure is scheduled for breast reconstruction surgery. Which patient information is most important to communicate to the health care provider before surgery?

Serum potassium 3.2 mEq/L

The nurse is caring for a patient with left-sided lung cancer. Which finding would be most important for the nurse to report to the health care provider?

Serum sodium of 126 mEq/L

A patient hospitalized with chronic heart failure eats only about 50% of each meal and reports "feeling too tired to eat." Which action should the nurse take first?

Serve multiple small feedings of high-calorie, high-protein foods.

A patient who has acute myelogenous leukemia develops an absolute neutrophil count of 850/µL while receiving outpatient chemotherapy. Which action by the outpatient clinic nurse is most appropriate?

Teach the patient to administer filgrastim (Neupogen) injections.

After bariatric surgery, a patient who is being discharged tells the nurse, "I prefer to be independent. I am not interested in any support groups." Which response by the nurse is best?

Tell me what types of resources you think you might use after this surgery."

When caring for a child with a cognitive impairment, what is a primary factor for the nurse to consider regarding the approach for interaction with the child?

The developmental stage is based on developmental tasks achieved.

An experienced nurse orients a new nurse to the postanesthesia care unit (PACU). Which action by the new nurse, if observed by the experienced nurse, indicates that the orientation was successful?

The new nurse positions an unconscious patient on the side upon arrival in the PACU.

Which finding for a patient who has been taking orlistat (Xenical) is most important to report to the health care provider?

The patient is pale and has many bruises.

The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider?

The patient's calf is swollen, warm, and painful.

The nurse interviews a patient scheduled to undergo general anesthesia for a bilateral hernia repair. Which information is most important to communicate to the surgeon and anesthesiologist before surgery?

The patient's father died after general anesthesia for abdominal surgery.

A 20-yr-old woman is being admitted with electrolyte disorders of unknown etiology. Which assessment finding is most important to report to the health care provider?

The patient's serum potassium level is 2.9 mEq/L.

A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse would indicate a need for further teaching?

The patient's visitors bring in fresh peaches

Which statement by the nurse is most likely to help a 22-yr-old patient with extreme obesity in losing weight on a 1000-calorie diet?

You are likely to notice changes in how you feel after a few weeks of diet and exercise."

A 62-year old man with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patient's laboratory test findings to include

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

When you examine a toddler, you suggest to his mother that the activity that could most appropriately foster his developmental task according to Erikson would be to

allow him to pull a talking-duck toy

An appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia is to

alternate periods of rest and activity.

A severely malnourished patient reports that he is Jewish. The nurse's initial action to meet his nutritional needs will be to

ask the patient about food preferences

During their school-age years, children understand concepts best if they can see the concept illustrated. This type of thinking is termed

concrete thought.

A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurse's first action should be to

disconnect the transfusion and infuse normal saline.

The nurse is caring for a patient with type A hemophilia being admitted to the hospital with severe pain and swelling in the right knee. The nurse should

immobilize the knee joint.

All infants should have their head circumference measured at health-assessment visits. This measurement is made from

just above the eyebrows through the prominent part of the occiput.

An 8-month-old infant who cries when the parents leave the room has developed the concept of

permanence.

A patient has a body mass index (BMI) of 31 kg/m2, a normal C-reactive protein level, and low serum transferrin and albumin levels. The nurse will plan patient teaching to increase the patient's intake of foods that are high in

protein

A patient's capillary blood glucose level is 120 mg/dL 6 hours after the nurse initiated a parenteral nutrition (PN) infusion. The appropriate action by the nurse is to

recheck the capillary blood glucose level in 4 to 6 hours.

What information will the nurse include for an overweight 35-yr-old woman who is starting a weight-loss plan?

Low carbohydrate diets lead to rapid weight loss but are difficult to maintain.

The nurse assesses a patient with pernicious anemia. Which assessment finding would the nurse expect?

Numbness of the extremities

The nurse should suggest which food choice when providing dietary teaching for a patient scheduled to receive external-beam radiation for abdominal cancer?

baked chicken

A young adult who has von Willebrand disease is admitted to the hospital for minor knee surgery. The nurse will review the coagulation survey to check the

bleeding time.

The nurse teaches a patient with cancer of the liver about high-protein, high-calorie diet choices. Which snack choice by the patient indicates that the teaching has been effective?

Blueberry yogurt

A patient who has ovarian cancer is crying and tells the nurse, ""my husband rarely visits. He just doesn't care." The husband indicates to the nurse that he never knows what to say to help his wife. Which nursing diagnosis is most appropriate for the nurse to add to the plan of care?

D Dysfunctional family processes related to effect of illness on family members

Which topic is most important for the nurse to discuss preoperatively with a patient who is scheduled for an open cholecystectomy?

Deep breathing and coughing

An older patient is being discharged from the ambulatory surgical unit following left eye surgery. The patient tells the nurse, "I don't know if I can take care of myself once I'm home." Which action by the nurse is most appropriate?

Discuss specific concerns regarding self-care

A patient's complete blood count (CBC) shows a hemoglobin of 19 g/dL and a hematocrit of 54%. Which question should the nurse ask to determine possible causes of this finding?

Do you have any history of lung disease

A 19-yr-old woman admitted with anorexia nervosa is 5 ft, 6 in (163 cm) tall and weighs 88 lb (41 kg). Laboratory tests reveal hypokalemia and iron-deficiency anemia. Which patient problem has the highest priority?

Risk for electrolyte imbalance

A patient arrives at the outpatient surgical center for a scheduled laparoscopy under general anesthesia. Which information requires the nurse's preoperative intervention to maintain patient safety?

The patient is planning to drive home after surgery.

When auscultating bowel sounds, which of the following frequencies would you identify as normal?

Five to 10 per minute

The nurse is caring for a patient receiving intravesical bladder chemotherapy. The nurse should monitor for which adverse effect?

Hematuria

The nurse is caring for a patient the first postoperative day following a laparotomy for a small bowel obstruction. The nurse notices new bright-red drainage about 5 cm in diameter on the dressing. Which action should the nurse take first?

Take the patient's vital signs.

A patient scheduled for an elective hysterectomy tells the nurse, "I am afraid that I will die in surgery like my mother did!" Which response by the nurse is the most appropriate? A. "Tell me more about what happened to your mother" B. "You will receive medications to reduce your anxiety" C. You should talk to the doctor again about the surgery" D. "Surgical techniques have improved a lot in recent years"

A

The nurse is caring for a patient with colon cancer who is scheduled for external radiation therapy to the abdomen. Which information obtained by the nurse would indicate a need for patient teaching?

The patient swims several days each week.

Which information in the preoperative patient's medication history is most important to communicate to the health care provider?

The patient takes garlic capsules every day.

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?

Absolute neutrophil count

Which laboratory result will the nurse expect to show a decreased value if a patient develops heparin-induced thrombocytopenia (HIT)?

Activated partial thromboplastin time

A malnourished patient is receiving a parenteral nutrition (PN) infusion containing amino acids and dextrose from a bag that was hung with a new tubing and filter 24 hours ago. The nurse observes that about 50 mL remain in the PN container. Which action is best for the nurse to take?

Add a new container of PN using the current tubing and filter.

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?

Administer PRN acetaminophen (Tylenol

Which action will the nurse include in the plan of care for a patient who has thalassemia major?

Administer iron chelation therapy as needed.

Which action by the nurse will be most helpful to a patient who is expected to ambulate, deep breathe, and cough on the first postoperative day?

Administer prescribed analgesic medications before the activities.

A patient who has not had any prior surgeries tells the nurse doing the preoperative assessment about allergies to avocados and bananas. Which action is most important for the nurse to take?

Alert the surgery center about a possible latex allergy.

The health care provider orders a liver and spleen scan for a patient who has been in a motor vehicle crash. Which action should the nurse take before this procedure?

Assist the patient to a flat position.

The nasogastric (NG) tube is removed on the second postoperative day, and the patient is placed on a clear liquid diet. Four hours later, the patient complains of frequent, cramping gas pains. What action by the nurse is the most appropriate?

Assist the patient to ambulate.

The surgical unit nurse has just received a patient with a history of smoking from the postanesthesia care unit. Which action is most important at this time?

Auscultate for adventitious breath sounds

Which instruction will the nurse plan to include in discharge teaching for a patient admitted with a sickle cell crisis?

Avoid exposure to crowds when possible.

A 38-year-old female is admitted for an elective surgical procedure. Which information obtained by the nurse during the preoperative assessment is most important to report to the anesthesiologist before surgery? A. The patient's lack of knowledge about postoperative pain control measures B. The patient's statement that her last menstrual period was 8 weeks previously C. The patient's history of a postoperative infection following a prior cholecystectomy The patient's concern that she will be unable to care for her children postoperatively

B

A chemotherapy drug that causes alopecia is prescribed for a patient. Which action should the nurse take to maintain the patient's self-esteem? a. Tell the patient to limit social contacts until regrowth of the hair occurs. b. Encourage the patient to purchase a wig or hat and wear it once hair loss begins. c. Teach the patient to gently wash hair with a mild shampoo to minimize hair loss. d. Inform the patient that hair usually grows back once the chemotherapy is complete.

B

A patient is transferred from the postanesthesia care unit (PACU) to the clinical unit. Which action by the nurse on the clinical unit should be performed first? a. Assess the patient's pain. b. Orient the patient to the unit. c. Take the patient's vital signs. d. Read the postoperative orders.

C

A patient who is scheduled for a right breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct? A. Benign tumors do not cause damage to other tissues B. Benign tumors are likely to recur in the same location C. Malignant tumors may spread to other tissues or organs D. Malignant cells reproduce more rapidly than normal cells

C

A patient with cancer has a nursing diagnosis of imbalanced nutrition: less than body requirements related to altered taste sensation. Which nursing action is most appropriate? A. Add strained baby meats to foods such as casseroles B. Teach the patient about foods that are high in nutrition. C. Avoid giving the patient foods that are strongly disliked D. Add extra spice to enhance the flavor of foods that are served

C

A patient develops neutropenia after receiving chemotherapy. Which information about ways to prevent infection will the nurse include in the teaching plan (select all that apply)?

Cook food thoroughly before eating. Avoid public transportation such as buses Talk to the oncologist before having any dental work

During the teaching session for a patient who has a new diagnosis of acute leukemia the patient is restless and is looking away, never making eye contact. After teaching about the complications associated with chemotherapy, the patient asks the nurse to repeat all of the information. Based on this assessment, which nursing diagnosis is most appropriate for the patient? a. Risk for ineffective adherence to treatment related to denial of need for chemotherapy b. Acute confusion related to infiltration of leukemia cells into the central nervous system c. Risk for ineffective health maintenance related to anxiety about new leukemia diagnosis d. Deficient knowledge: chemotherapy related to a lack of interest in learning about treatment

C

The health care provider's progress note for a patient states that the complete blood count (CBC) shows "shift to the left." Which assessment finding will the nurse expect? A. Cool extremities B. Pallor and weakness C. Elevated temperature D. Low oxygen saturation

C

The nurse is caring for a patient who smokes 2 packs/day. To reduce the patient's risk of lung cancer, which action by the nurse is the best? A. Teach the patient about the seven warning signs of cancer B. Plan to monitor the patient's carcinoembryonic antigen (CEA) level C. Discuss the risks associated with cigarettes during every patient encounter D. Teach the patient about the use of annual chest x-rays for lung cancer screening

C

A few months after bariatric surgery, a 56-yr-old male patient tells the nurse, "My skin is hanging off of me. I think I might want to surgery to remove the skinfolds." Which response by the nurse is most appropriate?

Cosmetic surgery may be possible once your weight has stabilized

When caring for a preoperative patient on the day of surgery, which actions included in the plan of care can the nurse delegate to unlicensed assistive personnel (UAP)? Select all that apply. A. Teach incentive spirometer use B. Explain preoperative routine care C. Obtain and document baseline vitals signs D. Remove nail polish and apply pulse oximeter E. Transport the patient by stretcher to the operating room

C, D, E

The nurse notes pallor of the skin and nail beds in a newly admitted patient. The nurse should ensure that which laboratory test has been ordered

Hemoglobin level

On admission of a patient to the postanesthesia care unit (PACU), the blood pressure (BP) is 122/72 mm Hg. Thirty minutes after admission, the BP is 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate

Continue to take vital signs every 15 minutes.

Which information will the nurse prioritize in planning preoperative teaching for a patient undergoing a Roux-en- gastric bypass?

Instructing the patient on coughing and breathing techniques

The operating room nurse is providing orientation to a student nurse. Which action would the nurse list as a major responsibility of a scrub nurse?

Keep both hands above the operating table level.

Which nursing action should the operating room (OR) nurse manager delegate to the registered nurse first assistant (RNFA) when caring for a surgical patient?

Make surgical incisions and suture as needed.

Following successful treatment of Hodgkin's lymphoma for a 55-yr-old woman, which topic will the nurse include in patient teaching?

Need for follow-up appointments to screen for malignancy

A 6-month-old is admitted to the hospital because of a fever. When you obtain a health history, what data would you obtain first?

Details about the fever

Which action should the nurse take first when preparing to teach a frail 79-yr-old Hispanic man who lives with an adult daughter about ways to improve nutrition

Determine who shops for groceries and prepares the meals.

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?

Discontinue the heparin infusion.

The nurse is caring for a patient who smokes two packs/day. Which action by the nurse could help reduce the patient's risk of lung cancer?

Discuss risks associated with cigarette smoking during each patient encounter

The nurse obtains a health history from a patient who is scheduled for elective hip surgery in 1 week. The patient reports use of garlic and ginkgo biloba. Which action by the nurse is most appropriate?

Discuss the herb and supplement use with the patient's health care provider.

You are interviewing the parents of a 3-year-old. Which of the following is the best-worded example of a health history question?

Does Sarah have pain?"

In the postanesthesia care unit (PACU), a patient's vital signs are blood pressure 116/72 mm Hg, pulse 74 beats/min, respirations 12 breaths/min, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take first?

Encourage the patient to take deep breaths.

Which action should the perioperative nurse take to best protect the patient from burn injury during surgery?

Ensure correct placement of the grounding pad.

A patient with Hodgkin's lymphoma who is undergoing external radiation therapy tells the nurse, "I am so tired I can hardly get out of bed in the morning." Which intervention should the nurse add to the plan of care?

Establish time to take a short walk almost every day.

Which menu choice best indicates that the patient is implementing the nurse's suggestion to choose high-calorie, high-protein foods

Fried chicken with potatoes and gravy

When planning care for children, the nurse knows which of the following factors has the largest impact but is not able to be altered to influence the growth and development of children?

Genetics

A 60-yr-old man who is hospitalized with an abdominal wound infection has been eating very little and states, "Nothing on the menu sounds good." Which action by the nurse will be most effective in improving the patient's oral intake?

Have family members bring favorite foods.

A patient with pancytopenia has a bone marrow aspiration from the left posterior iliac crest. Which action would be important for the nurse to take after the procedure?

Have the patient lie on the left side for 1 hour.

While ambulating in the room, a patient complains of feeling dizzy. In what order will the nurse accomplish the following activities

Have the patient sit down in a chair Take the patient's blood pressure (BP) Give the patient something to drink Inform the patient's health care provider.

Which actions will the nurse include in the surgical time-out procedure before surgery

Have the patient state name and date of birth. Verify the patient identification band number. Ask the patient to state the surgical procedure.

When caring for a patient the second postoperative day after abdominal surgery for removal of a large pancreatic cyst, the nurse obtains an oral temperature of 100.8° F (38.2° C). Which action should the nurse take next?

Have the patient use the incentive spirometer.

Based on the principles of growth and development, which of the following assessment findings would lead you to determine that a child is developing normally?

He can throw a large but not a small ball.

The terms "growth" and "development" often are used interchangeably. To which of the following does "development" refer?

He learns to throw a ball overhand.

Which action could the postanesthesia care unit (PACU) nurse delegate to unlicensed assistive personnel (UAP) who help to transport a patient to the clinical unit?

Help with the transfer of the patient onto a stretcher.

When caring for a preoperative patient on the day of surgery, which actions included in the plan of care can the nurse delegate to unlicensed assistive personnel

Obtain and document baseline vital signs. Remove nail polish and apply pulse oximeter. Transport the patient by stretcher to the operating room.

Which menu choice indicates that the patient understands the nurse's teaching about recommended dietary choices for iron-deficiency anemia?

Omelet and whole wheat toast

The nurse at the clinic is interviewing a 64-yr-old woman who is 5 feet, 3 inches tall and weighs 125 lb (57 kg). The patient has not seen a health care provider for 20 years. She walks 5 miles most days and has a glass of wine two or three times a week. Which topics will the nurse plan to include in patient teaching about cancer screening and decreasing cancer risk (select all that apply)?

Pap testing Sunscreen use Mammography Colorectal screening

Which finding for a young adult who follows a vegan diet may indicate the need for cobalamin supplementation

Paresthesias

After change-of-shift report on the oncology unit, which patient should the nurse assess first

Patient who is neutropenic and has a temperature of 100.5° F (38.1° C)

A postoperative patient has not voided for 8 hours after return to the clinical unit. Which action should the nurse take first?

Perform a bladder scan

The nurse assesses that the oxygen saturation is 89% in an unconscious patient who was transferred from surgery to the postanesthesia care unit (PACU) 15 minutes ago. Which action should the nurse take first?

Perform the jaw-thrust maneuver.

A 76-yr-old woman with a body mass index (BMI) of 17 kg/m2 and a low serum albumin level is being admitted by the nurse. Which assessment finding will the nurse expect to find?

Pitting edema

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?

Platelet count is 42,000/mL.

The nurse plans to provide preoperative teaching to an alert older man who has hearing and vision deficits. His wife answers most questions that are directed to the patient. Which action should the nurse take when doing the teaching?

Provide additional time for the patient to understand preoperative instructions and carry out procedures.

Which of the following findings would you interpret as least significant when assessing a child's lungs?

Rhonchi

Which statement by a patient indicates good understanding of the nurse's teaching about prevention of sickle cell crisis?

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

A patient is receiving continuous enteral nutrition through a small-bore silicone feeding tube. What should the nurse plan for when this patient has a computed tomography (CT) scan ordered?

Shut the feeding off 30 to 60 minutes before the scan.

Monitored anesthesia care (MAC) is going to be used for a closed, manual reduction of a dislocated shoulder. What action does the nurse anticipate?

Starting an IV in the patient's unaffected arm

The nurse is caring for a 47-yr-old female patient who is comatose and is receiving continuous enteral nutrition through a soft nasogastric tube. The nurse notes the presence of new crackles in the patient's lungs. In which order will the nurse take action? (

Stop administering the continuous feeding. Check the patient's oxygen saturation. Measure the tube feeding residual volume. Notify the patient's health care provider.

The nurse administers an IV vesicant chemotherapeutic agent to a patient. Which action is most important for the nurse to take?

Stop the infusion if swelling is observed at the site.

The nurse is preparing a patient on the morning of surgery. The patient refuses to remove a wedding ring, saying, "I've never taken it off since the day I was married." Which response by the nurse is best?

Suggest that the patient give the ring to a family member to keep

Which action should the nurse take when caring for a patient who is receiving chemotherapy and complains of problems with concentration?

Suggest use of a daily planner and encourage adequate rest and sleep.

After sleeve gastrectomy, a 42-yr-old male patient returns to the surgical nursing unit with a nasogastric tube to low, intermittent suction and a patient-controlled analgesia (PCA) machine for pain control. Which nursing action should be included in the postoperative plan of care?

Support the surgical incision during patient coughing and turning in bed.

After abdominal surgery, a patient with protein calorie malnutrition is receiving parenteral nutrition (PN). Which is the best indicator that the patient is receiving adequate nutrition?

Surgical incision is healing normally

A patient is transferred from the postanesthesia care unit (PACU) to the clinical unit. Which action by the nurse on the clinical unit should be performed first?

Take the patient's vital signs

A patient who has severe pain associated with terminal pancreatic cancer is being cared for at home by family members. Which finding by the nurse indicates that teaching regarding pain management has been effective

The patient takes opioids around the clock on a regular schedule and uses additional doses when breakthrough pain occurs.

The nurse facilitates student clinical experiences in the surgical suite. Which action, if performed by a student, would require the nurse to intervene

The student wears street clothes in the semirestricted area.

You administer a Denver Developmental Screening Test to a preschooler. Which of the following statements is the best introduction to this test for her mother?

This test will identify different developmental skills your child can perform

At early school age, based on the rate of growth of different body tissues, which physical assessment finding would you categorize as normal?

Tonsillar tissue at the rear of the mouth is enlarged.

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?

Transfuse only leukocyte-reduced PRBCs.

A patient in the surgical holding area is being prepared for a spinal fusion. Which action by a member of the surgical team requires immediate intervention by the charge nurse?

Walking into the hallway outside the operating room with hair uncovered

The nurse is caring for a patient who is being discharged after an emergency splenectomy following a motor vehicle crash. Which instructions should the nurse include in the discharge teaching?

Wash hands and avoid persons who are ill.

A patient in surgery receives a neuromuscular blocking agent as an adjunct to general anesthesia. While in the postanesthesia care unit (PACU), what assessment finding is most important for the nurse to report?

Weak chest movement

The nurse reviews the laboratory test results of a patient admitted with abdominal pain. Which information will be most important for the nurse to communicate to the health care provider?

White blood cell (WBC) count 15,500/µL

The nurse reviews the laboratory results of a patient who is receiving chemotherapy. Which laboratory result is most important to report to the health care provider?

White blood cells (WBC) 2700/µL

A widowed mother of four school-age children is hospitalized with metastatic ovarian cancer. The patient is crying and tells the nurse that she does not know what will happen to her children when she dies. Which response by the nurse is most appropriate?

Would you like to talk about options for the care of your children

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

check all stools for occult blood.