Adult 1 Final Review

A school nurse is caring for a 10-year-old girl who is having an asthma attack. What is the preferred intervention to alleviate this clients airflow obstruction?

Administer inhaled beta-adrenergic agonist

The nurse is caring for a 78-year-old female patient who is scheduled for surgery to remove her brain tumor. The patient is very apprehensive and keeps asking when she will get her preoperative medicine. The medicine is ordered to be given on call to OR. When would be the best time to give this medication?

After being notified by the OR and before the preoperative preparations

A diabetic nurse is working for the summer at a camp for adolescents with diabetes. When providing information on the prevention and management of hypoglycemia, what action should the nurse promote?

Always carry a form of fast-acting sugar.

The nurse is performing a respiratory assessment of a patient who has been experiencing episodes of hypoxia. The nurse is aware that this is ultimately attributable to impaired gas exchange. On what factor does adequate gas exchange primarily depend?

An adequate ventilation perfusion ratio

The OR nurse is providing care for a 25-year-old major trauma patient who has been involved in a motorcycle accident. The nurse should know that the patient is at increased risk for what complication of surgery?

Anesthesia awareness

The nurse is planning patient teaching for a patient who is scheduled for an open hemicolectomy. The nurse intends to address the topics of incision splinting and leg exercises during this teaching session. When is the best time for the nurse to provide teaching?

As soon as possible before the surgical procedure

A patient has received a diagnosis of type 2 diabetes. The diabetes nurse has made contact with the patient and will implement a program of health education. What is the nurses priority action?

Assess the patients readiness to learn.

A nurse is caring for a patient who has been admitted for the treatment of advanced cirrhosis. What assessment should the nurse prioritize in this patients plan of care?

Assessment for variceal bleeding

A patients plan of care specifies postural drainage. What action should the nurse perform when providing this noninvasive therapy?

Assist the patient into a position that will allow gravity to move secretions.

A nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease?

Asterixis

While planning a patients care, the nurse identifies nursing actions to minimize the patients pleuritic pain. Which intervention should the nurse include in the plan of care?

Avoid actions that will cause the patient to breathe deeply / give analgesic for pain

An elderly patient comes to the clinic with her daughter. The patient is a diabetic and is concerned about foot care. The nurse goes over foot care with the patient and her daughter as the nurse realizes that foot care is extremely important. Why would the nurse feel that foot care is so important to this patient?

Avoiding foot ulcers may mean the difference between institutionalization and continued independent living

A patient has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The patients current medication regimen includes lactulose (Cephulac) four times daily. What desired outcome should the nurse relate to this pharmacologic intervention?

2-3 soft bowel movements daily

The OR nurse is setting up a water-seal chest drainage system for a patient who has just had a thoracotomy. The nurse knows that the amount of suction in the system is determined by the water level. At what suction level should the nurse set the system?

20 cm H2O

2. 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 patient has just been diagnosed with type 2 diabetes. The physician has prescribed an oral antidiabetic agent that will inhibit the production of glucose by the liver and thereby aid in the control of blood glucose. What type of oral antidiabetic agent did the physician prescribe for this patient?

A biguanide

Which of the following patients with type 1 diabetes is most likely to experience adequate glucose control?

A patient who adheres closely to a meal plan and meal schedule

A nurse is caring for a patient following knee surgery that was performed under a spinal anesthetic. What intervention should the nurse implement to prevent a spinal headache?

Keep the patient positioned supine

An occupational health nurse is screening a group of workers for diabetes. What statement should the nurse interpret as suggestive of diabetes?

Lately, I drink and drink and cant seem to quench my thirst

The nurse is assessing a patient who has a 35 pack-year history of cigarette smoking. In light of this known risk factor for lung cancer, what statement should prompt the nurse to refer the patient for further assessment?

Lately, I have this cough that just never seems to go away

A nurse is providing preoperative teaching to a patient who will soon undergo a cardiac bypass. The nurses teaching plan includes exercises of the extremities. What is the purpose of teaching a patient leg exercises prior to surgery?

Leg exercises improve circulation and prevent venous thrombosis

A previously healthy adults sudden and precipitous decline in health has been attributed to fulminant hepatic failure, and the patient has been admitted to the intensive care unit. The nurse should be aware that the treatment of choice for this patient is what?

Liver transplantation

A school nurse is teaching a group of high school students about risk factors for diabetes. Which of the following actions has the greatest potential to reduce an individuals risk for developing diabetes?

Lose weight, if obese.

A patient is undergoing testing to see if he has a pleural effusion. Which of the nurses respiratory assessment findings would be most consistent with this diagnosis?

Lung fields dull to percussion, absent breath sounds, and a pleural friction rub

A patient is being treated on the acute medical unit for acute pancreatitis. The nurse has identified a diagnosis of Ineffective Breathing Pattern Related to Pain. What intervention should the nurse perform in order to best address this diagnosis?

Maintain the patient in a semi-Fowlers position whenever possible.

A patient with a history of type 1 diabetes has just been admitted to the critical care unit (CCU) for diabetic ketoacidosis. The CCU nurse should prioritize what assessment during the patients initial phase of treatment?

Maintaining and monitoring the patients fluid balance

The nurse is caring for a patient with lung metastases who just underwent a mediastinotomy. What should be the focus of the nurses postprocedure care?

Maintaining the patient's chest tube

A home health nurse is caring for a patient discharged home after pancreatic surgery. The nurse documents the nursing diagnosis Risk for Imbalanced Nutrition: Less than Body Requirements on the care plan based on the potential complications that may occur after surgery. What are the most likely complications for the patient who has had pancreatic surgery?

Malabsorption and hyperglycemia

You are caring for a 65-year-old male patient admitted to your medical unit 72 hours ago with pyloric stenosis. A nasogastric tube has been placed on low intermittent suction ever since. Upon review of the mornings blood work, you notice that the patient's potassium is below reference range. You should recognize that the patient may be at risk for what imbalance?

Metabolic alkalosis

A medical nurse is aware of the need to screen specific patients for their risk of hyperglycemic hyperosmolar syndrome (HHS). In what patient population does hyperosmolar nonketotic syndrome most often occur?

Middle-aged or older people with either type 2 diabetes or no known history of diabetes

A patient has questioned the nurses administration of IV normal saline., asking whether sterile water would be a more appropriate choice than saltwater. Under what circumstances would the nurse administer electrolyte-free water intravenously?

Never, because it rapidly enters red blood cells, causing them to rupture.

A patient is 2 hours postoperative with a Foley catheter in situ. The last hourly urine output recorded for this patient was 10 mL. The tubing of the Foley is patent. What should the nurse do?

Notify the physician and continue to monitor the hourly urine output closely

A nurse is caring for a patient with type 1 diabetes who is being discharged home tomorrow. What is the best way to assess the patients ability to prepare and self-administer insulin?

Observe the patient drawing up and administering the insulin.

During the care of a preoperative patient, the nurse has given the patient a preoperative benzodiazepine. The patient is now requesting to void. What action should the nurse take?

Offer the patient a bedpan or urinal.

A nurse is caring for a patient with a blocked bile duct from a tumor. What manifestation of obstructive jaundice should the nurse anticipate?

Orange and foamy urine

The PACU nurse is caring for a male patient who had a hernia repair. The patients blood pressure is now 164/92 mm Hg; he has no history of hypertension prior to surgery and his preoperative blood pressure was 112/68 mm Hg. The nurse should assess for what potential causes of hypertension following surgery?

Pain, hypoxia, or bladder distention

The nurse is caring for a hospice patient who is scheduled for a surgical procedure to reduce the size of his spinal tumor in an effort to relieve his pain. The nurse should plan this patient care with the knowledge that his surgical procedure is classified as which of the following?

Palliative

A nurse is performing an admission assessment of a patient with a diagnosis of cirrhosis. What technique should the nurse use to palpate the patients liver?

Place hand under right lower rib cage and press down lightly with the other hand.

The nurse is caring for an 82-year-old patient with a diagnosis of tracheobronchitis. The patient begins complaining of right-sided chest pain that gets worse when he coughs or breathes deeply. Vital signs are within normal limits. What would you expect the patient is experiencing?

Pleuritic pain

A nurse educator is reviewing the indications for chest drainage systems with a group of medical nurses. What indications should the nurses identify? Select all that apply.

Post thoracotomy Spontaneous pneumothorax Chest trauma resulting in pneumothorax Pleural effusion

The nurse is caring for an 88-year-old patient who is recovering from an ileac-femoral bypass graft. The patient is day 2 postoperative and has been mentally intact, as per baseline. When the nurse assesses the patient, it is clear that he is confused and has been experiencing disturbed sleep patterns and impaired psychomotor skills. What should the nurse suspect is the problem with the patient?

Postoperative delerium

A patient arrives in the emergency department with an attack of acute bronchiectasis. Chest auscultation reveals the presence of copious secretions. What intervention should the nurse prioritize in this patients care?

Postural chest drainage

The nurse is discharging a patient home from an outpatient surgery center. The nurse has reviewed all of the discharge instructions with the patient and her caregiver. What else should the nurse do before discharging the patient from the facility? Select all that apply.

Provide all discharge instructions in writing Provide the nurses or surgeons contact information Give prescriptions to the patient

A postoperative patient rapidly presents with hypotension; rapid, thready pulse; oliguria; and cold, pale skin. The nurse suspects that the patient is experiencing a hemorrhage. What should be the nurses first action?

Quickly attempt to determine the cause of the hemorrhage

The nurse has noted the emergence of a significant amount of fresh blood at the drain site of a patient who is postoperative day 1 following total laryngectomy. How should the nurse respond to this development?

Rapidly assess the patient and notify the surgeon about the patient's bleeding

A nurse is teaching basic survival skills to a patient newly diagnosed with type 1 diabetes. What topic should the nurse address?

Recognition of hypoglycemia and hyperglycemia

The nurse is caring for a patient on the medicalsurgical unit postoperative day 5. During each patient assessment, the nurse evaluates the patient for infection. Which of the following would be most indicative of infection?

Red, warm, tender incision

A nurse is caring for a patient with cirrhosis secondary to heavy alcohol use. The nurses most recent assessment reveals subtle changes in the patients cognition and behavior. What is the nurses most appropriate response?

Report this finding to the primary care provider due to the possibility of hepatic encephalopathy.

A patient who is being treated for pneumonia starts complaining of sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 24mm Hg. What does the ABG reflect?

Respiratory acidosis

A patient with along standing diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes, upon assessment, that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acid-base imbalance?

Respiratory alkalosis

The surgical patient is a 35-year-old woman who has been administered general anesthesia. The nurse recognizes that the patient is in stage II (the excitement stage) of anesthesia. Which intervention would be most appropriate for the nurse to implement during this stage?

Restrain the patient

A nurse is assessing a patient who has been diagnosed with cholecystitis, and is experiencing localized abdominal pain. When assessing the characteristics of the patients pain, the nurse should anticipate that it may radiate to what region?

Right shoulder

A 90-year-old female patient is scheduled to undergo a partial mastectomy for the treatment of breast cancer. What nursing diagnosis should the nurse prioritize when planning this patients postoperative care?

Risk for infection related to reduced immune function

You are developing a care plan for a patient with Cushing syndrome. What nursing diagnosis would have the highest priority in this care plan?

Risk for injury related to weakness

A patient has been admitted to the post-surgical unit following a thyroidectomy. To promote comfort and safety, how should the nurse best position the patient?

Semi-Fowlers with the head supported on two pillows

A 37-year-old male patient presents at the emergency department (ED) complaining of nausea and vomiting and severe abdominal pain. The patients abdomen is rigid, and there is bruising to the patients flank. The patients wife states that he was on a drinking binge for the past 2 days. The ED nurse should assist in assessing the patient for what health problem?

Severe pancreatitis with possible peritonitis

You are caring for a patient with a secondary diagnosis of hypermagnesemia. What assessment finding would be most consistent with this diagnosis?

Shallow respirations

A patient with emphysema is experiencing shortness of breath. To relieve this patients symptoms, the nurse should assist her into what position?

Sitting upright, leaning forward slightly

A 54-year-old man has just been diagnosed with small cell lung cancer. The patient asks the nurse why the doctor is not offering surgery as a treatment for his cancer. What fact about lung cancer treatment should inform the nurses response?

Small cell cancer of the lung grows rapidly and metastasizes early and extensively.

A surgical patient has been in the PACU for the past 3 hours. What are the determining factors for the patient to be discharged from the PACU? Select all that apply.

Stable blood pressure Sufficient oxygen saturation Adequate respiratory function

The nurse is caring for a 78-year-old man who has had an outpatient cholecystectomy. The nurse is getting him up for his first walk postoperatively. To decrease the potential for orthostatic hypotension and consequent falls, what should the nurse have the patient do?

Stand upright for 2-3 minutes prior to ambulating

A patient with type 2 diabetes achieves adequate glycemic control through diet and exercise. Upon being admitted to the hospital for a cholecystectomy, however, the patient has required insulin injections on two occasions. The nurse would identify what likely cause for this short-term change in treatment?

Stress has likely caused an increase in the patients blood sugar levels.

A patient is admitted to the unit with acute cholecystitis. The physician has noted that surgery will be scheduled in 4 days. The patient asks why the surgery is being put off for a week when he has a sick gallbladder. What rationale would underlie the nurses response?

Surgery is delayed until the acute symptoms subside

The nurse is caring for a 46-year-old patient recently diagnosed with the early stages of lung cancer. The nurse is aware that the preferred method of treating patients with nonsmall cell tumors is what?

Surgical resection

A 55-year-old man has been newly diagnosed with acute pancreatitis and admitted to the acute medical unit. How should the nurse most likely explain the pathophysiology of this patients health problem?

The enzymes that your pancreas produces have damaged the pancreas itself.

An adult patient has tested positive for tuberculosis (TB). While providing patient teaching, what information should the nurse prioritize?

The importance of adhering closely to prescribed medication regimen

A medical nurse educator is reviewing a patient's recent episode of metabolic acidosis with members of the nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis?

The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance.

An older adult patient has been diagnosed with COPD. What characteristic of the patients current health status would preclude the safe and effective use of a metered-dose inhaler (MDI)?

The patient has severe arthritis in her hands

A patient is prescribed corticosteroid therapy. What would be priority information for the nurse to give the patient who is prescribed long-term corticosteroid therapy?

The patient is at an increased risk for developing infection.

The OR nurse is taking the patient into the OR when the patient informs the operating nurse that his grandmother spiked a 104F temperature in the OR and nearly died 15 years ago. What relevance does this information have regarding the patient?

The patient may be at risk for malignant hyperthermia

A patient with type 1 diabetes has told the nurse that his most recent urine test for ketones was positive. What is the nurse's most plausible conclusion based on this assessment finding?

The patient's insulin levels are inadequate

The nurse is caring for a patient who has been in a motor vehicle accident and the care team suspects that the patient has developed pleurisy. Which of the nurses assessment findings would best corroborate this diagnosis?

The patient's pain intensifies when he coughs or takes a deep breath

A patient with suspected adrenal insufficiency has been ordered an adrenocorticotropic hormone (ACTH) stimulation test. Administration of ACTH caused a marked increase in cortisol levels. How should the nurse interpret this finding?

The patients pituitary function is compromised

The ED nurse is caring for an 11-year-old brought in by ambulance after having been hit by a car. The childs parents are thought to be en route to the hospital but have not yet arrived. No other family members are present and attempts to contact the parents have been unsuccessful. The child needs emergency surgery to save her life. How should the need for informed consent be addressed?

The surgery should be done without informed consent

While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of the patients closed chest-drainage system. What should the nurse conclude?

The system has an air leak

The nurse in the ED is caring for a man who has returned to the ED 4 days after receiving stitches for a knife wound on his hand. The wound is now infected, so the stitches were removed, and the wound is cleaned and packed with gauze. The ED doctor plans to have the man return tomorrow to remove the packing and resuture the wound. You are aware that the wound will now heal by what means?

Third intention

The nurse is providing preoperative teaching to a patient scheduled for surgery. The nurse is instructingthe patient on the use of deep breathing, coughing, and the use of incentive spirometry when the patientstates, I dont know why youre focusing on my breathing. My surgery is on my hip, not my chest. What rationale for these instructions should the nurse provide?

To promote optimal lung expansion

The PACU nurse is caring for a patient who has arrived from the OR. During the initial assessment, the nurse observes that the patients skin has become blue and dusky. The nurse looks, listens, and feels for breathing, and determines the patient is not breathing. What is the priority intervention?

Treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw

A diabetic patient calls the clinic complaining of having a flu bug. The nurse tells him to take his regular dose of insulin. What else should the nurse tell the patient?

Try to eat small amounts of carbs, if possible.

An adult patient is in the recovery room following a nephrectomy performed for the treatment of renal cell carcinoma. The patients vital signs and level of consciousness stabilized, but the patient then complains of severe nausea and begins to retch. What should the nurse do next?

Turn the patient completely to one side

A 15-year-old child is brought to the emergency department with symptoms of hyperglycemia and is subsequently diagnosed with diabetes. Based on the fact that the childs pancreatic beta cells are being destroyed, the patient would be diagnosed with what type of diabetes?

Type 1 diabetes

he nurse is performing a shift assessment of a patient with aldosteronism. What assessments should the nurse include? Select all that apply.

Urine output Blood pressure

The nurse is explaining the safe and effective administration of nasal spray to a patient with seasonal allergies. What information is most important to include in this teaching?

Use as prescribed to prevent rebound congestion

A patient with a severe exacerbation of COPD requires reliable and precise oxygen delivery. Which mask will the nurse expect the physician to order?

Venturi mask

A nurses assessment reveals that a client with COPD may be experiencing bronchospasm. What assessment finding would suggest that the patient is experiencing bronchospasm?

Wheezes or diminished breath sounds on auscultation

A patient is admitted to the ED complaining of abdominal pain, stating that he has been vomiting coffee-ground like emesis. The patient is diagnosed with a perforated gastric ulcer and is informed that he needs surgery. When can the patient most likely anticipate that the surgery will be scheduled?

Without delay because the bleed is emergent

A nurse is teaching a patient with asthma about Azmacort, an inhaled corticosteroid. Which adverse effects should the nurse be sure to address in patient teaching?

Cough and oral thrush

A student nurse is preparing to care for a patient with bronchiectasis. The student nurse should recognize that this patient is likely to experience respiratory difficulties related to what pathophysiologic process?

Dilation of the bronchi and bronchioles

You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patients most recent laboratory reports, you note that the patients magnesium levels are high. You should prioritize assessment for which of the following health problems?

Diminished deep tendon reflexes

The nurse is caring for a patient who is scheduled for a lobectomy for a diagnosis of lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes the clients oxygen saturation rapidly dropping. The patient complains of shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Further assessment findings supporting the presence of a pneumothorax include what?

Diminished or absent breath sounds on the affected side

A 30 year-old female patient has been diagnosed with Cushing syndrome. What psychosocial nursing diagnosis should the nurse most likely prioritize when planning the patients care?

Disturbed body image related to changes in physical appearance

A diabetes nurse educator is teaching a group of patients with type 1 diabetes about sick day rules. What guideline applies to periods of illness in a diabetic patient?

Do not eliminate insulin when nauseated and vomiting.

A patient with thyroid cancer has undergone surgery and a significant amount of parathyroid tissue has been removed. The nurse caring for the patient should prioritize what question when addressing

Do you feel any muscle twitches or spasms?

The nurse is assessing a patient who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the patients respirations. How should the nurse best respond to this assessment finding?

Document that the chest drainage system is operating as it is intended.

An admitting nurse is assessing a patient with COPD. The nurse auscultates diminished breath sounds, which signify changes in the airway. These changes indicate to the nurse to monitor the patient for what?

Dyspnea and hypoxemia

The nurse is admitting a patient to the medicalsurgical unit from the PACU. What should the nurse do to help the patient clear secretions and help prevent pneumonia?

Encourage the patient to use incentive spirometry every 2 hours

A client just returned to the surgical unit after a gastric bypass. What action by the nurse is the priority?

Ensure adequate airway

The OR nurse is participating in the appendectomy of a 20 year-old female patient who has a dangerously low body mass index. The nurse recognizes the patients consequent risk for hypothermia. What action should the nurse implement to prevent the development of hypothermia?

Ensure that the IV fluids are warmed to the patient's body temperature

A nurse in the preoperative holding area is admitting a woman prior to reduction mammoplasty. What should the nurse include in the care given to this patient? Select all that apply

Establishing an IV line Verifying the surgical site with the patient Taking measures to ensure the patient's comfort

A patient with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH) is being cared for on the critical care unit. The priority nursing diagnosis for a patient with this condition is what?

Excess fluid volume

You are the nurse caring for a patient who receives daunorubicin, a chemotherapeutic agent. You start the infusion and check the insertion site as per protocol. During your most recent check, you notice that the IV has infiltrated so you stop the infusion. What is your main concern with this infiltration?

Extravasation of the medication

The nurse is caring for a patient who is admitted to the ER with the diagnosis of acute appendicitis. The nurse notes during the assessment that the patient's ribs and xiphoid process are prominent. The patient states she exercises two to three times daily and her mother indicates that she is being treated for anorexia nervosa. How should the nurse best follow up these assessment data?

Facilitate a detailed analysis of the patient's electrolyte levels.

The nurse is assessing the respiratory status of a patient who is experiencing an exacerbation of her emphysema symptoms. When preparing to auscultate, what breath sounds should the nurse anticipate?

Faint breath sounds with prolonged expiration

A patient presents to the clinic complaining of symptoms that suggest diabetes. What criteria would support checking blood levels for the diagnosis of diabetes?

Fasting plasma glucose greater than or equal to 126 mg/dL

A sputum study has been ordered for a patient who has developed coarse chest crackles and a fever. At what time should the nurse best collect the sample?

First thing in the morning

A patients total laryngectomy has created a need for alaryngeal speech which will be achieved through the use of tracheoesophageal puncture. What action should the nurse describe to the patient when teaching him about this process?

Fitting for voice prosthesis

An older adult patient with type 2 diabetes is brought to the emergency department by his daughter. The patient is found to have a blood glucose level of 623 mg/dL. The patients daughter reports that the patient recently had a gastrointestinal virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made. What nursing action would be a priority?

Fluid and electrolyte replacement

You are caring for a patient who has a diagnosis of SIADH. Your patient's plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to assess what aspects of the patient's health?

Fluid volume status

During a health education session, a participant has asked about the hepatitis E virus. What prevention measure should the nurse recommend for preventing infection with this virus?

Following proper hand-washing techniques

The ED nurse is assessing a young gymnast who fell from a balance beam. The gymnast presents with a clear fluid leaking from her nose. What should the ED nurse suspect?

Fracture of the cribriform plate

A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a patient admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray?

Fried chicked

A student with diabetes tells the school nurse that he is feeling nervous and hungry. The nurse assesses the child and finds he has tachycardia and is diaphoretic with a blood glucose level of 50 mg/dL (2.8 mmol/L). What should the school nurse administer?

Half of a cup of juice, followed by cheese and crackers

One day after a patient is admitted to the medical unit, you note that the patient is oliguric. You notify the acute-care nurse practitioner who orders a fluid challenge of 200 mL of normal saline solution over 15 minutes. This intervention will achieve which of the following?

Help distinguish reduced renal blood flow from decreased renal function

An adult patient has just been admitted to the PACU following abdominal surgery. As the patient begins to awaken, he is uncharacteristically restless. The nurse checks his skin and it is cold, moist, and pale. The nurse concerned the patient may be at risk for what?

Hemorrhage and shock

An asthma educator is teaching a patient newly diagnosed with asthma and her family about the use of a peak flow meter. The educator should teach the patient that a peak flow meter measures what value?

Highest airflow during forced expiration

A nurse caring for a patient with diabetes insipidus is reviewing laboratory results. What is an expected urinalysis finding?

Highly dilute urine

The nurse is caring for a patient whose recent unexplained weight loss and history of smoking have prompted diagnostic testing for cancer. What symptom is most closely associated with the early stages of laryngeal cancer?

Hoarseness and low pitch

A patient has been diagnosed with pancreatic cancer and has been admitted for care. Following initial treatment, the nurse should be aware that the patient is most likely to require which of the following?

Hospice care

A triage nurse in the emergency department is assessing a patient who presented with complaints of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this patients presentation?

How many alcoholic drinks do you typically consume in a week?

You are caring for a patient who is being treated on the oncology unit with a diagnosis of lung cancer with bone metastases. During your assessment you note the patient complains of a new onset of weakness with abdominal pain. Further assessment suggests that the patient likely has a fluid volume deficit. You should recognize that the patient may be experiencing what electrolyte imbalances?

Hypercalcemia

While assisting with the surgical removal of an adrenal tumor, the OR nurse is aware that the patients vital signs may change upon manipulation of the tumor. What vital sign changes would the nurse expect to see?

Hypertension and heart rate changes

The perioperative nurse has completed the presurgical assessment of an 82-year-old female patient who is scheduled for a left total knee replacement. When planning this patients care, the nurse should address the consequences of the patients aging cardiovascular system. These include an increased risk of which of the following?

Hypervolemia

A patient has returned to the floor after having a thyroidectomy for thyroid cancer. The nurse knows that sometimes during thyroid surgery the parathyroid glands can be injured or removed. What laboratory finding may be an early indication of parathyroid gland injury or removal?

Hypocalcemia

The nurse is assessing the patient for the presence of a Chvosteks sign. What electrolyte imbalance would a positive Chvosteks sign indicate?

Hypocalcemia

You are the surgical nurse caring for a 65-year-old female patient who is postoperative day 1 following a thyroidectomy. During your shift assessment, the patient complains of tingling in her lips and fingers. She tells you that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should you first suspect?

Hypocalcemia

The nurse is preparing an elderly patient for a scheduled removal of orthopedic hardware, a procedure to be performed under general anesthetic. For which adverse effect should the nurse most closely monitor the patient?

Hypothermia

You are working on a burns unit and one of your acutely ill patients is exhibiting signs and symptoms of third spacing. Based on this change in status, you should expect the patient to exhibit signs and symptoms of what imbalance?

Hypovolemia

The nurse admits a patient to the PACU with a blood pressure of 132/90 mm Hg and a pulse of 68 beats per minute. After 30 minutes, the patients blood pressure is 94/47 mm Hg, and the pulse is 110. The nurse documents that the patients skin is cold, moist, and pale. Of what is the patient showing signs?

Hypovolemic shock

A patient has been brought to the emergency department by paramedics after being found unconscious. The patients Medic Alert bracelet indicates that the patient has type 1 diabetes and the patients blood glucose is 22 mg/dL (1.2 mmol/L). The nurse should anticipate what intervention?

IV administration of 50% dextrose in water

. The nurses assessment of a patient with thyroidectomy suggests tetany and a review of the most recent blood work corroborate this finding. The nurse should prepare to administer what intervention?

IV calcium gluconate

A patient with pheochromocytoma has been admitted for an adrenalectomy to be performed the following day. To prevent complications, the nurse should anticipate preoperative administration of which of the following?

IV corticosteroids

A patient has been diagnosed with acute pancreatitis. The nurse is addressing the diagnosis of Acute Pain Related to Pancreatitis. What pharmacologic intervention is most likely to be ordered for this patient?

IV hydromorphone (Dilaudid)

A nurse is conducting a class on how to self-manage insulin regimens. A patient asks how long a vial of insulin can be stored at room temperature before it goes bad. What would be the nurses best answer?

If you are going to use up the vial within 1 month it can be kept at room temperature.

A nurse educator is teaching a group of recent nursing graduates about their occupational risks for contracting hepatitis B. What preventative measures should the educator promote? Select all that apply.

Immunization Use of standard precautions

A nurse on a solid organ transplant unit is planning the care of a patient who will soon be admitted upon immediate recovery following liver transplantation. What aspect of nursing care is the nurses priority?

Implementation of infection control measures

A patients abdominal ultrasound indicates cholelithiasis. When the nurse is reviewing the patients laboratory studies, what finding is most closely associated with this diagnosis?

Increased bilirubin

A nurse is caring for a patient with COPD. The patients medication regimen has been recently changed and the nurse is assessing for therapeutic effect of a new bronchodilator. What assessment parameters suggest a consequent improvement in respiratory status? Select all that apply.

Increased expiratory flow rate Relief of dyspnea

You are the nurse evaluating a newly admitted patient's laboratory results, which include several values that are outside of reference ranges. Which of the following would cause the release of antidiuretic hormone (ADH)?

Increased serum sodium

A patient with a longstanding diagnosis of type 1 diabetes has a history of poor glycemic control. The nurse recognizes the need to assess the patient for signs and symptoms of peripheral neuropathy. Peripheral neuropathy constitutes a risk for what nursing diagnosis?

Infection

The clinic nurse is doing a preoperative assessment of a patient who will be undergoing outpatient cataract surgery with lens implantation in 1 week. While taking the patients medical history, the nurse notes that this patient had a kidney transplant 8 years ago and that the patient is taking immunosuppressive drugs. For what is this patient at increased risk when having surgery?

Infection

The nurse is providing care for an older adult patient whose current medication regimen includes levothyroxine (Synthroid). As a result, the nurse should be aware of the heightened risk of adverse effects when administering an IV dose of what medication?

A benzodiazepine

A nurse who provides care in a walk-in clinic assesses a wide range of individuals. The nurse should identify which of the following patients as having the highest risk for chronic pancreatitis?

A 39-year-old man with chronic alcoholism

The nurse is assessing a patient whose respiratory disease in characterized by chronic hyperinflation of the lungs. What would the nurse most likely assess in this patient?

A barrel chest

A student nurse is caring for a patient who has a diagnosis of acute pancreatitis and who is receiving parenteral nutrition. The student should prioritize which of the following assessments?

Blood glucose levels

A nurse is caring for a patient who has been hospitalized with an acute asthma exacerbation. What drugs should the nurse expect to be ordered for this patient to gain underlying control of persistent asthma?

Controlled inhaler., anti-inflammatory drugs

The nurse is preparing a patient for surgery. The patient states that she is very nervous and really does not understand what the surgical procedure is for or how it will be performed. What is the most appropriate nursing action for the nurse to take?

Call the physician to review the procedure with the patient

A patient with portal hypertension has been admitted to the medical floor. The nurse should prioritize which of the following assessments related to the manifestations of this health problem?

Daily weights and abdominal girth measurement