Adults Test 2

The triage nurse at an ambulatory clinic receives a call from an individual with possible metal fragments in both eyes. Which instructions would the nurse provide for emergency care of this possible eye injury? "Remove any visible metal fragments." "Apply a loose dressing over your eyes." "Rinse your eyes immediately with water." "Keep your eyes open to allow tears to form."

"Apply a loose dressing over your eyes."

The nurse is teaching a senior citizen's group about signs and symptoms of a stroke. Which statement by the nurse would provide accurate information? "Take the person to the hospital if a headache lasts for more than 24 hours." "Stroke symptoms usually start when the person is awake and physically active." "A person with a transient ischemic attack has mild symptoms that will go away." "Call 911 immediately if a person develops slurred speech or difficulty speaking."

"Call 911 immediately if a person develops slurred speech or difficulty speaking."

The nurse provides dietary instructions to the in-home caregiver of a 45-yr-old man with Huntington's disease. The nurse is most concerned if the caregiver makes which statement? "Depression is common and may cause a decrease in appetite." "If swallowing becomes difficult, a feeding tube may be needed." "Calories should be restricted to prevent unnecessary weight gain." "Muscles in the face are affected, and chewing may become impossible."

"Calories should be restricted to prevent unnecessary weight gain."

The patient informs the nurse that he has a "sty" that has been present for some time on the upper eyelid and reports using warm moist compresses with no improvement. What is the best response by the nurse? "Go to the pharmacy to get some eye drops." "Come in so the ophthalmologist can assess the lesion." "The health care provider will need to inject it with an antibiotic." "Wash the eyelid margins with baby shampoo to remove the crusting."

"Come in so the ophthalmologist can assess the lesion."

A nurse provides teaching for a patient with a newly diagnosed partial complex seizure disorder who is about to begin therapy with antiepileptic drugs (AEDs). Which statement by the patient indicates understanding of the teaching? "Even with an accurate diagnosis of my seizures, it may be difficult to find an effective drug." "I will soon know that the drugs are effective by being seizure free for several months." "Serious side effects may occur, and if they do, I should stop taking the medication." "When drug levels are maintained at therapeutic levels, I can expect to be seizure free."

"Even with an accurate diagnosis of my seizures, it may be difficult to find an effective drug."

The nurse has given medication instructions to a pt receiving phenytoin. Which statement indicates that the pt has an adequate understanding of the instructions? "Alcohol is not contraindicated while taking this medication." "Good oral hygiene is needed, including brushing and flossing." "The medication dose may be self-adjusted depending on side effects." "The morning dose of the medication should be taken before a serum medication level is drawn."

"Good oral hygiene is needed, including brushing and flossing."

The nurse is teaching a patient with type 2 diabetes mellitus how to prevent diabetic nephropathy. Which statement made by the patient indicates that teaching has been successful? "Smokeless tobacco products decrease the risk of kidney damage." "I can help control my blood pressure by avoiding foods high in salt." "I should have yearly dilated eye examinations by an ophthalmologist." "I will avoid hypoglycemia by keeping my blood sugar above 180 mg/dL."

"I can help control my blood pressure by avoiding foods high in salt."

The nurse is instructing a pt with Parkinson's disease about preventing falls. Which pt statement reflects a need for further teaching? "I can sit down to put on my pants and shoes." "I try to exercise every day and rest when I'm tired." "My son removed all loose rugs from my bedroom." "I don't need to use my walker to get to the bathroom."

"I don't need to use my walker to get to the bathroom."

The nurse is preparing to administer timolol eye drops for treatment of glaucoma. What statement made by the patient would cause the nurse to hold the medication and report to the health care provider? "I have sinusitis." "I have migraine headaches a lot." "I have chronic obstructive pulmonary disease." "I have a history of chronic urinary tract infections."

"I have chronic obstructive pulmonary disease."

The nurse instructs a patient with diabetes mellitus about a healthy eating plan. Which statement made by the patient indicates that teaching was successful? "I plan to lose 25 lb this year by following a high-protein diet." "I may have a hypoglycemic reaction if I drink alcohol on an empty stomach." "I should include more fiber in my diet than a person who does not have diabetes." "If I use an insulin pump, I will not need to limit the amount of saturated fat in my diet."

"I may have a hypoglycemic reaction if I drink alcohol on an empty stomach."

The nurse is teaching a patient about timolol eye drops for the treatment of glaucoma. What statement made by the patient demonstrates that teaching was effective? "I may feel some palpitations after instilling these eye drops." "I should withhold this medication if my blood pressure becomes elevated." "I should keep my eyes closed for 15 minutes after instilling these eye drops." "I may have some temporary blurring of vision after instilling these eye drops."

"I may have some temporary blurring of vision after instilling these eye drops."

The nurse is providing discharge teaching for a pt newly diagnosed with DM Type II who has been prescribed metformin. Which client statement indicates the need for further teaching? "It's okay if I skip meals now and then." "I need to constantly watch for signs of low blood sugar." "I need to let my HCP know if I get unusually tired." "I will be sure to not drink alcohol excessively while on this medication."

"I need to constantly watch for signs of low blood sugar."

The home health nurse visits a pt with a diagnosis of DM Type I. The pt relates a history of vomiting and diarrhea & tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the pt indicates a need for further teaching? "I need to stop my insulin." "I need to increase my fluid intake." "I need to monitor my blood glucose every 3-4 hours." "I need to call the HCP because of these symptoms."

"I need to stop my insulin."

The nurse is providing discharge teaching to a patient with type 2 diabetes after a scleral buckling procedure. Which statement, if made by the patient, indicates that the discharge teaching is effective? "I doubt my other eye will ever be affected." "I can expect severe pain after this procedure." "I should avoid lifting heavy objects and straining." "The procedure will correct my vision immediately."

"I should avoid lifting heavy objects and straining."

The nurse provides information to the caregiver of a 68-yr-old man with epilepsy who has tonic-clonic seizures. Which statement by the caregiver indicates a need for further teaching? "It is normal for a person to be sleepy after a seizure." "I should call 911 if breathing stops during the seizure." "The jerking movements may last for 30 to 40 seconds." "Objects should not be placed in the mouth during a seizure."

"I should call 911 if breathing stops during the seizure."

The nurse has taught a patient admitted with diabetes principles of foot care. The nurse evaluates that the patient understands the principles of foot care if the patient makes what statement? "I should only walk barefoot in nice dry weather." "I should look at the condition of my feet every day." "I am lucky my shoes fit so nice and tight because they give me firm support." "When I am allowed up out of bed, I should check the shower water with my toes."

"I should look at the condition of my feet every day."

The nurse instructs a patient prescribed dipivefrin eye drops to manage chronic open-angle glaucoma. Which statement, if made by the patient to the nurse, indicates that further teaching is needed? "The eye drops could cause a fast heart rate and high blood pressure." "I will need to take the eye drops twice a day for at least 2 to 3 months." "I may experience eye discomfort and redness from the use of these eye drops." "I will apply gentle pressure on the inside corner of my eye after each eye drop."

"I will apply gentle pressure on the inside corner of my eye after each eye drop."

When evaluating the patient's understanding about the care of the ileostomy, which statement by the patient indicates the patient needs more teaching? "I will be able to regulate when I have stools." "I will be able to wear the pouch until it leaks." "The drainage from my stoma can damage my skin." "Dried fruit and popcorn must be chewed very well."

"I will be able to regulate when I have stools."

The nurse teaches a patient recently diagnosed with type 1 diabetes mellitus about insulin administration. Which statement by the patient requires an intervention by the nurse? "I will discard any insulin bottle that is cloudy in appearance." "The best injection site for insulin administration is in my abdomen." "I can wash the site with soap and water before insulin administration." "I may keep my insulin at room temperature (75oF) for up to 1 month."

"I will discard any insulin bottle that is cloudy in appearance."

The nurse provides instructions to a pt newly diagnosed with DM Type I. The nurse recognizes accurate understanding of measures to prevent DKA when the pt makes which statement? "I will stop taking my insulin if I'm too sick to eat." "I will decrease my insulin dose during times of illness." "I will adjust my insulin dose according to the level of glucose in my urine." "I will notify my HCP if my BGL is higher than 250 mg/dL."

"I will notify my HCP if my BGL is higher than 250 mg/dL."

The nurse is teaching a patient with type 2 diabetes mellitus about exercise to help control blood glucose. The nurse knows the patient understands when the patient elicits which exercise plan? "I want to go fishing for 30 minutes each day; I will drink fluids and wear sunscreen." "I will go running each day when my blood sugar is too high to bring it back to normal." "I will plan to keep my job as a teacher because I get a lot of exercise every school day." "I will take a brisk 30-minute walk 5 days per week and do resistance training three times a week."

"I will take a brisk 30-minute walk 5 days per week and do resistance training three times a week."

A 21-yr-old female patient came to the clinic for instruction to prevent recurrence of urinary tract infections. Which patient statement indicates that teaching was effective? "I will urinate before and after having intercourse." "I will use vinegar as a vaginal douche every week." "I should drink three 8-oz glasses of water daily." "I can stop the antibiotics when symptoms disappear."

"I will urinate before and after having intercourse."

The nurse is teaching a patient with glaucoma about administration of pilocarpine. What statement is important for the nurse to include during the instructions? "Prolonged eye irritation is an expected adverse effect of this medication." "This medication will help to raise intraocular pressure to a near normal level." "This medication needs to be continued for at least 5 years after your initial diagnosis." "It is important not to do activities requiring visual acuity immediately after administration."

"It is important not to do activities requiring visual acuity immediately after administration."

The nurse is preparing to administer a dose of bisacodyl to a patient with constipation and the patient asks how it will work. What is the best response by the nurse? "It will increase bulk in the stool." "It will lubricate the intestinal tract to soften feces." "It will increase fluid retention in the intestinal tract." "It will increase peristalsis by stimulating nerves in the colon wall."

"It will increase peristalsis by stimulating nerves in the colon wall."

The nurse is preparing to administer famotidine to a postoperative patient with a colostomy. The patient states they do not have heartburn. What response by the nurse would be the most appropriate? "It will reduce the amount of acid in the stomach." "It will prevent air from accumulating in the stomach, causing gas pains." "It will prevent the heartburn that occurs as a side effect of general anesthesia." "The stress of surgery is likely to cause stomach bleeding if you do not receive it."

"It will reduce the amount of acid in the stomach."

The nurse is providing care for a patient with loss of hearing acuity over the past several years. Which statement by the nurse is most accurate? "This is often due to an infection that will resolve on its own." "Many people experience an age-related decline in their hearing." "This is likely an effect of your medications. Try stopping them for a few days." "You can likely accommodate for your hearing loss with a few small changes in your routine."

"Many people experience an age-related decline in their hearing."

The nurse is caring for a 62-yr-old woman taking tolterodine (Detrol) to treat urinary urgency and incontinence. Which instruction should be included in the discharge plan? "Stop smoking for 2 to 3 weeks before starting to take this medication." "Suck on sugarless candy or chew sugarless gum if you develop a dry mouth." "Have your vision checked every 6 months because this drug can cause cataracts." "Ask your physician to prescribe an extended-release form if you have loose stools."

"Suck on sugarless candy or chew sugarless gum if you develop a dry mouth."

The nurse is providing instructions to the pt newly diagnosed with DM who has been prescribed pramlintide. Which instructions should the nurse include in the discharge teaching? "Inject the pramlintide at the same time you take your other medications." "Take your prescribed pills 1 hour before or 2 hours after the injection." "Be sure to take the pramlintide with food so you don't upset your stomach." "Make sure you take you pramlintide immediately after you eat so you don't experience a low blood sugar."

"Take your prescribed pills 1 hour before or 2 hours after the injection."

A patient aged 20, who developed seizures after a head injury, tells the nurse he or she feels like he or she has lost control over his or her life since the seizures. Initially, what is the most appropriate response by the nurse? "With medications and your health care provider's assistance, I am sure you will be able to achieve your life goals." "Tell me about what you would like to do and how the seizures affect you." "New treatments come out every year, so don't give up." "You are young and can still heal from the injury. It has only been a few months."

"Tell me about what you would like to do and how the seizures affect you."

A pt with DM Type I calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the pt indicates an adequate understanding of the peak action of NPH insulin & exercise? "The best time for me to exercise is after breakfast." "The best time for my to exercise is mid to late afternoon." "I should not exercise since I am taking insulin." "NPH is a basal insulin, so I should exercise in the evening."

"The best time for me to exercise is after breakfast."

A miotic medication has been prescribed for a pt with glaucoma and the pt asks the nurse about the purpose of the medication. Which response should the nurse provide to the pt? "The medication will help dilate the eye to prevent pressure from occurring." "The medication will relax the muscles of the eyes and prevent blurred vision." "The medication causes the pupil to constrict and will lower the pressure in the eye." "The medication will help block the responses that are sent to the muscles in the eye."

"The medication causes the pupil to constrict and will lower the pressure in the eye."

The nurse is preparing to insert a nasogastric (NG) tube into a patient with a suspected small intestinal obstruction that is vomiting. The patient asks the nurse why this procedure is necessary. What response by the nurse is most appropriate? "The tube will help to drain the stomach contents and prevent further vomiting." "The tube will push past the area that is blocked and thus help to stop the vomiting." "The tube is just a standard procedure before many types of surgery to the abdomen." "The tube will let us measure your stomach contents so we can give you the right IV fluid replacement."

"The tube will help to drain the stomach contents and prevent further vomiting."

When teaching a patient about the pathophysiology related to open-angle glaucoma, which statement is most appropriate? "The retinal nerve is damaged by an abnormal increase in the production of aqueous humor." "There is decreased draining of aqueous humor in the eye, causing pressure damage to the optic nerve." "The lens enlarges with normal aging, pushing the iris forward, which then covers the outflow channels of the eye." "There is a decreased flow of aqueous humor into the anterior chamber by the lens of the eye blocking the papillary opening."

"There is decreased draining of aqueous humor in the eye, causing pressure damage to the optic nerve."

The nurse teaches a 38-yr-old woman who has migraine headaches about sumatriptan (Imitrex). Which statement by the patient requires clarification by the nurse? "The injection might feel like a bee sting." "This medicine will prevent a migraine headache." "I can take another dose if the first does not work." "This drug for migraine headaches could cause birth defects."

"This medicine will prevent a migraine headache."

After a vasectomy, what instruction should be included in discharge teaching? "Some secondary sexual characteristics may be lost after the surgery." "Use an alternative form of contraception until your semen is sperm free." "Erectile dysfunction may be present for several months after this surgery." "You will be uncomfortable, but you may safely have sexual intercourse today."

"Use an alternative form of contraception until your semen is sperm free."

The nurse has instructed the family of a pt with a stroke who has homonymous hemianopsia about measures to help the pt overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the pt? "We need to discourage him from wearing eyeglasses." "We need to place objects in his impaired field of vision." "We need to approach him from the impaired field of vision." "We need to remind him to turn his head to scan the lost visual field."

"We need to remind him to turn his head to scan the lost visual field."

A patient admitted with type 2 diabetes asks the nurse what "type 2" means. What is the most appropriate response by the nurse? "With type 2 diabetes, the body of the pancreas becomes inflamed." "With type 2 diabetes, the patient is totally dependent on an outside source of insulin." "With type 2 diabetes, insulin secretion is decreased, and insulin resistance is increased." "With type 2 diabetes, the body produces autoantibodies that destroy β-cells in the pancreas."

"With type 2 diabetes, insulin secretion is decreased, and insulin resistance is increased."

A patient is scheduled to receive "Colace 100 mg PO." The patient asks to take the medication in liquid form, and the nurse obtains an order for the change. The available syrup contains 150 mg/15 mL. Calculate how many milliliters the nurse should administer.

10 mL

The patient received regular insulin 10 units subcutaneously at 8:30 PM for a blood glucose level of 253 mg/dL. The nurse plans to monitor this patient for signs of hypoglycemia at which time related to the insulin's peak action? 8:40 PM to 9:00 PM 9:00 PM to 11:30 PM 10:30 PM to 1:30 AM 12:30 AM to 8:30 AM

10:30 PM to 1:30 AM

A patient is given a bisacodyl suppository and asks the nurse how long it will take to work. What is the best response by the nurse? 2 to 5 minutes 15 to 60 minutes 2 to 4 hours 6 to 8 hours

15 to 60 minutes

The patient has an order for phenytoin (Dilantin) 100 mg q8hr IV. Available is a phenytoin injection containing 50 mg/mL. How many milliliters of solution should the nurse draw up for the dose?

2 mL

The nurse is teaching resident at the retirement village about prevention of UTIs. One person asks how much fluid she should drink each day. The nurse determines that she weighs 140 lb. Calculate how many ounces of fluid this person should drink each day.

56 oz

A patient with suspected bowel obstruction had a nasogastric tube inserted at 4:00 AM. The nurse shares in the morning report that the day shift staff should check the tube for patency at what times? 7:00 AM, 10:00 AM, and 1:00 PM 8:00 AM, 12:00 PM, and 4:00 PM 9:00 AM and 3:00 PM 9:00 AM, 12:00 PM, and 3:00 PM

8:00 AM, 12:00 PM, and 4:00 PM

The nurse is teaching clinic patients about risk factors for testicular cancer. Which individual is at highest risk for developing testicular cancer? A 30-yr-old white man with a history of cryptorchidism A 48-yr-old African American man with erectile dysfunction A 19-yr-old Asian man who had surgery for testicular torsion A 28-yr-old Hispanic man with infertility caused by a varicocele

A 30-yr-old white man with a history of cryptorchidism

The nurse identifies that which patient is at highest risk for developing colon cancer? A 28-yr-old man who has a body mass index of 27 kg/m2 A 32-yr-old woman with a 12-year history of ulcerative colitis A 52-yr-old man who has followed a vegetarian diet for 24 years A 58-yr-old woman taking prescribed estrogen replacement therapy

A 32-yr-old woman with a 12-year history of ulcerative colitis

The nurse is caring for a group of patients on a medical unit. After receiving report, which patient should the nurse see first? A 42-yr-old patient with multiple sclerosis who was admitted with sepsis A 72-yr-old patient with Parkinson's disease who has aspiration pneumonia A 38-yr-old patient with myasthenia gravis who declined prescribed medications A 45-yr-old patient with amyotrophic lateral sclerosis who refuses enteral feedings

A 38-yr-old patient with myasthenia gravis who declined prescribed medications

The nurse is reviewing laboratory results for the clinic patients to be seen today. Which patient meets the diagnostic criteria for diabetes mellitus? A 48-yr-old woman with a hemoglobin A1C of 8.4% A 58-yr-old man with a fasting blood glucose of 111 mg/dL A 68-yr-old woman with a random plasma glucose of 190 mg/dL A 78-yr-old man with a 2-hour glucose tolerance plasma glucose of 184 mg/dL

A 48-yr-old woman with a hemoglobin A1C of 8.4%

The nurse in a primary care provider's office is assessing several patients today. Which patient is most at risk for a stroke? A 92-yr-old female patient who takes warfarin (Coumadin) for atrial fibrillation A 28-yr-old male patient who uses marijuana after chemotherapy to control nausea A 42-yr-old female patient who takes oral contraceptives and has migraine headaches A 72-yr-old male patient who has hypertension and diabetes mellitus and smokes tobacco

A 72-yr-old male patient who has hypertension and diabetes mellitus and smokes tobacco

Which patient with type 1 diabetes mellitus would be at the highest risk for developing hypoglycemic unawareness? A 58-yr-old patient with diabetic retinopathy A 73-yr-old patient who takes propranolol (Inderal) A 19-yr-old patient who is on the school track team A 24-yr-old patient with a hemoglobin A1C of 8.9%

A 73-yr-old patient who takes propranolol (Inderal)

A patient is planned for discharge home today after ostomy surgery for colon cancer. The nurse should assign the patient to which staff member? A nursing assistant on the unit who also has hospice experience A licensed practical nurse that has worked on the unit for 10 years A registered nurse with 6 months of experience on the surgical unit A registered nurse who has floated to the surgical unit from pediatrics

A registered nurse with 6 months of experience on the surgical unit

A male patient complains of fever, dysuria, and cloudy urine. What additional information may indicate that these manifestations may be something other than a urinary tract infection (UTI)? E. coli bacteria in his urine A very tender prostate gland Complaints of chills and rectal pain Complaints of urgency and frequency

A very tender prostate gland

3. The nurse is caring for the nauseated patient with type 1 diabetes mellitus. During which time frame does the nurse closely monitor the patient for hypoglycemia when the patient is unable to consume breakfast after receiving the usual morning dose of regular Humulin insulin at 7 AM? A. 7:30 AM - 10:00 AM B. 11 AM - 1 PM C. 2 PM - 4 PM D. 7:30 PM - 10:00 PM

A. 7:30 AM - 10:00 AM

Which finding related to primary open-angle glaucoma would the nurse expect to find when reviewing a patient's history and physical examination report? Absence of pain or pressure Blurred vision in the morning Seeing colored halos around lights Eye pain accompanied with nausea and vomiting

Absence of pain or pressure

Which nursing diagnosis is a priority in the care of a patient with myasthenia gravis (MG)? Acute confusion Bowel incontinence Activity intolerance Disturbed sleep pattern

Activity intolerance

When using the otoscope, the nurse is unable to see the landmarks or light reflex of the tympanic membrane. The tympanic membrane is bulging and red. What does the nurse determine is most likely occurring in the patient's ear? Swimmer's ear Acute otitis media Impacted cerumen Chronic otitis media

Acute otitis media

Which nursing diagnosis is priority when caring for a patient with renal calculi? Acute pain Risk for constipation Deficient fluid volume Risk for powerlessness

Acute pain

The patient newly diagnosed with Parkinson disease is being discharged. Which instruction for the patient's spouse is best for the nurse to provide? Administer medications promptly on schedule to maintain therapeutic drug levels. Complete activities of daily living for the patient. Speak loudly for better understanding. Provide large, high-calorie meals to maintain the patient's weight.

Administer medications promptly on schedule to maintain therapeutic drug levels.

When providing care to the patient with an acute stroke, which duty can be delegated to the LPN/LVN? Screen patient for tPA eligibility. Assess the patient's ability to swallow. Administer scheduled anticoagulant medications. Place equipment needed for seizure precautions in room.

Administer scheduled anticoagulant medications.

A pt is prescribed an eye drop and an eye ointment for the right eye. How should the nurse best administer the medications? Administer the eye drop first followed by the ointment Administer the ointment first, followed by the eye drop Administer the eye drop, wait 15 min and administer the ointment Administer the ointment, wait 15 min and administer the eye drop

Administer the eye drop first followed by the ointment

A colectomy is scheduled for a patient with ulcerative colitis. The nurse should plan to include which prescribed measure in the preoperative preparation of this patient? Instruction on irrigating a colostomy Administration of a cleansing enema A high-fiber diet the day before surgery Administration of IV antibiotics for bowel preparation

Administration of a cleansing enema

When a patient is experiencing seizure activity, the most appropriate time to clear the airway is: Any time during the seizure. Throughout the ictal period. During the most intense period of the seizure. After the tonic-clonic movements stop.

After the tonic-clonic movements stop.

Effects of Food on Stoma Output Diarrhea Causing

Alcohol Beer Cabbage Spinach Green beans Coffee Spicy foods Raw fruit

Incontinence Collaborative Care Drug Therapy when Incontinence is related to BPH

Alpha-adrenergic antagonists-may cause orthostatic hypotension: doxazosin (Cardura); Tamsulosin (Flomax) 5-Alpha-Reductase Inhibitors-monitor liver function tests: finasteride (Proscar) & dutasteride (Avodart)

A female patient has left-sided hemiplegia after an ischemic stroke 4 days earlier. How should the nurse promote skin integrity? Position the patient on her weak side the majority of the time. Alternate the patient's positioning between supine and side-lying. Avoid the use of pillows in order to promote independence in positioning. Establish a schedule for the massage of areas where skin breakdown emerges.

Alternate the patient's positioning between supine and side-lying.

Cataract surgery postop care

Antibiotic and corticosteroid eye drops Prevent infection and decrease inflammation d/t surgery Avoid activities that increase IOP Bending, stooping, coughing, lifting

A 74-yr-old man who has right-sided extremity paralysis related to a thrombotic stroke develops constipation. Which action should the nurse take first? Assist the patient to the bathroom every 2 hours. Provide incontinence briefs to wear during the day. Administer a bisacodyl (Dulcolax) rectal suppository every day. Arrange for several servings per day of cooked fruits and vegetables.

Arrange for several servings per day of cooked fruits and vegetables.

A patient with poor visual acuity is diagnosed with age-related macular degeneration (AMD). Which nursing action should be the nurse's priority? Teach about visual enhancement techniques. Teach nutritional strategies to improve vision. Assess coping strategies and support systems. Assess impact of vision on normal functioning.

Assess impact of vision on normal functioning.

The nurse is assigned to the care of a patient diagnosed with type 2 diabetes. In formulating a teaching plan that encourages the patient to actively participate in management of the diabetes, what should be the nurse's initial intervention? Assess patient's perception of what it means to have diabetes. Ask the patient to write down current knowledge about diabetes. Set goals for the patient to actively participate in managing his diabetes. Assume responsibility for all of the patient's care to decrease stress level.

Assess patient's perception of what it means to have diabetes.

The nurse observes a student nurse assigned to initiate oral feedings for a 68-yr-old woman with an ischemic stroke. Which action by the student will require the nurse to intervene? Giving the patient 1 oz of water to swallow Telling the patient to perform a chin tuck before swallowing Assisting the patient to sit in a chair before feeding the patient Assessing cranial nerves III, IV, and VI before attempting feeding

Assessing cranial nerves III, IV, and VI before attempting feeding

Which medication, if prescribed for the pt with glaucoma should the nurse question? Betaxolol Pilocarpine Erythromycin Atropine sulfate

Atropine sulfate

A hospitalized older patient reports his foreskin is retracted and will not return to normal. Which action is the priority? Start antibiotics. Apply ice to reduce swelling. Attempt to move the foreskin over the glans. Call the physician to prepare for circumcision.

Attempt to move the foreskin over the glans.

The nurse is preparing a teaching plan for a pt who had a cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? Select all that apply. Avoid activities that require bending over Contact the surgeon if eye scratchiness occurs Take acetaminophen for minor eye discomfort Expect episodes of sudden severe pain in the eye Place an eye shield on the surgical eye at bedtime Contact the surgeon if a decrease in visual acuity occurs

Avoid activities that require bending over Take acetaminophen for minor eye discomfort Place an eye shield on the surgical eye at bedtime Contact the surgeon if a decrease in visual acuity occurs

The nurse is caring for a 62-yr-old man after a transurethral resection of the prostate (TURP). Which instructions should the nurse include in the teaching plan? Avoid straining during defecation. Restrict fluids to prevent incontinence. Sexual functioning will not be affected. Prostate examinations are not needed after surgery.

Avoid straining during defecation.

A patient with Ménière's disease had decompression of the endolymphatic sac to reduce the frequent and incapacitating attacks being experienced. What should the nurse include in the discharge teaching for this patient? Airplane travel will be more comfortable now. Avoid sudden head movements or position changes. Cough or blow the nose to keep the Eustachian tubes clear. Take antihistamines, antiemetics, and sedatives for recovery.

Avoid sudden head movements or position changes.

Drugs that may cause diabetic complications

B-adrenergic blockers: mask symptoms of hypoglycemia; prolong hypoglycemic effects of insulin Corticosteroids: can increase blood glucose levels in people who already have and people who don't have DM

The nurse is providing discharge teaching to the patient with newly diagnosed diabetes. Which statement by the patient indicates a correct understanding about the need to wear a medical alert bracelet? A. ''If I become hyperglycemic, it is a medical emergency.'' B. ''If I become hypoglycemic, I could become unconscious.'' C. ''Medical personnel may need confirmation of my insurance.'' D. ''I may need to be admitted to the hospital suddenly.''

B. ''If I become hypoglycemic, I could become unconscious.''

The nurse is teaching the patient with diabetes about proper foot care. Which statement by the patient indicates that teaching was effective? A.''I should go barefoot in my house so that my feet are exposed to air.'' B.''I must inspect my shoes for foreign objects before putting them on.'' C.''I will soak my feet in warm water to soften calluses before trying to remove them.'' D.''I must wear canvas shoes as much as possible to decrease pressure on my feet.''

B.''I must inspect my shoes for foreign objects before putting them on.''

The nurse teaches a 30-yr-old man with a family history of prostate cancer about dietary factors associated with prostate cancer. The nurse determines that teaching is successful if the patient selects which menu? Grilled steak, French fries, and vanilla shake Hamburger with cheese, pudding, and coffee Baked chicken, peas, apple slices, and skim milk Grilled cheese sandwich, onion rings, and hot tea

Baked chicken, peas, apple slices, and skim milk

Effects of Food on Stoma Output Gas Forming

Beans Cabbage family Onions Beer Carbonated beverages Cheese Sprouts

A 73-yr-old male patient admitted for total knee replacement states during the health history interview that he has no problems with urinary elimination except that the "stream is less than it used to be." The nurse should give anticipatory guidance regarding what condition? A tumor of the prostate Benign prostatic hyperplasia Bladder atony because of age Age-related altered innervation of the bladder

Benign prostatic hyperplasia

An older male patient visits his primary care provider because of burning on urination and production of foul-smelling urine. What contributing factor should the health care provider consider? High-purine diet Sedentary lifestyle Benign prostatic hyperplasia (BPH) Recent use of broad-spectrum antibiotics

Benign prostatic hyperplasia (BPH)

A pt is admitted to the hospital with a diagnosis of benign prostatic hyperplasia, and a transurethral resection of the prostate is performed. Four hours after surgery, the nurse takes the pt's vital signs & empties the urinary drainage bag. Which assessment finding indicates the need to notify the HCP? Red, bloody urine Pain rate as 2 on a 0-10 pain scale Urinary output of 200 mL higher than intake Blood pressure, 100/50; pulse 130

Blood pressure, 100/50; pulse 130

Which clinical manifestations of inflammatory bowel disease does the nurse determine are common to both patients with ulcerative colitis (UC) and Crohn's disease (select all that apply.)? Restricted to rectum Strictures are common Bloody, diarrhea stools Cramping abdominal pain Lesions penetrate intestine

Bloody, diarrhea stools Cramping abdominal pain

The nurse is performing an assessment on a pt with a suspected diagnosis of cataract. Which clinical manifestation should the nurse expect to note in the early stages of cataract formation? Diplopia Eye pain Floating spots Blurred vision

Blurred vision

A postoperative pt has been placed on a clear liquid diet. The nurse should provide the pt with which items that are allowed to be consumed on this diet? Select all that apply. Broth Coffee Gelatin Pudding Vegetable juice Pureed vegetables

Broth Coffee Gelatin

Constipation Meds may be taken daily

Bulk-forming laxatives: methylcellulose (Citrucel); psyllium (Metamucil) Stool softners: docusate (Colace) Saline & osmotic solutions: polyethylene glycol (Miralax) Stimulants: senna (Senokot)

The diabetic patient has a rising HbA1c level. What is the best response to the patient regarding this finding? A. ''Keep up the good work.'' B. ''This is not good at all.'' C. "Have you had any health changes or started any new medications?'' D. ''You need more insulin.''

C. "Have you had any health changes or started any new medications?''

The nurse instructs a patient with diabetes mellitus about a healthy eating plan. Which of statement made by the patient indicates that teaching was successful? A. "If I use an insulin pump, I will not need to limit the amount of saturated fat in my diet." B. "I should include more fiber in my diet than a person who does not have diabetes." C. "I may have a hypoglycemic reaction if I drink alcohol on an empty stomach." D. "I plan to lose 25 pounds this year by following a high-protein diet."

C. "I may have a hypoglycemic reaction if I drink alcohol on an empty stomach."

The patient expresses fear and anxiety over the life changes associated with diabetes stating, ''I am scared I can't do it all and I will get sick and be a burden on my family.'' What is the nurse's best response? A. ''It is overwhelming, isn't it?'' B. ''Let's see how much you can learn today, so you are less nervous.'' C. ''Let's tackle it piece by piece. What is most scary to you?'' D. ''Other people do it just fine.''

C. ''Let's tackle it piece by piece. What is most scary to you?''

When establishing a diagnosis of multiple sclerosis (MS), which diagnostic tests will the nurse expect (select all that apply.)? EEG ECG CT scan Carotid duplex scan Evoked response testing Cerebrospinal fluid analysis

CT scan Evoked response testing Cerebrospinal fluid analysis

During the early postoperative period, a pt who has undergone a cataract extraction complains of nausea & severe eye pain over the operative site. What should be the initial nursing action? Call the HCP Reassure the pt that this is normal Turn the pt onto their operative side Administer the prescribed pain medication & antiemetic

Call the HCP

A patient with type 2 diabetes has a urinary tract infection (UTI), is difficult to arouse, and has a blood glucose of 642 mg/dL. When the nurse assesses the urine, there are no ketones present. What nursing action is appropriate at this time? Routine insulin therapy and exercise Administer a different antibiotic for the UTI. Cardiac monitoring to detect potassium changes Administer IV fluids rapidly to correct dehydration

Cardiac monitoring to detect potassium changes

The nurse is preparing to administer a scheduled dose of docusate sodium when the patient reports an episode of loose stool and does not want to take the medication. What is the appropriate action by the nurse? Write an incident report about this untoward event. Attempt to have the family convince the patient to take the ordered dose. Withhold the medication at this time and try to administer it later in the day. Chart the dose as not given on the medical record and explain in the nursing progress notes.

Chart the dose as not given on the medical record and explain in the nursing progress notes.

The nurse is assisting a patient with newly diagnosed type 2 diabetes to learn dietary planning as part of the initial management of diabetes. The nurse would encourage the patient to limit intake of which foods to help reduce the percent of fat in the diet? Cheese Broccoli Chicken Oranges

Cheese

The nurse has been teaching a patient with diabetes mellitus how to perform self-monitoring of blood glucose (SMBG). During evaluation of the patient's technique, the nurse identifies a need for additional teaching when the patient does what? Chooses a puncture site in the center of the finger pad Washes hands with soap and water to cleanse the site to be used Warms the finger before puncturing the finger to obtain a drop of blood Tells the nurse that the result of 110 mg/dL indicates good control of diabetes

Chooses a puncture site in the center of the finger pad

A patient has scleroderma and hypertension. The nurse knows this could be related to which renal diagnoses? Obstructive uropathy Goodpasture syndrome Chronic glomerulonephritis Calcium oxalate urinary calculi

Chronic glomerulonephritis

A patient with type 2 diabetes is reporting a second urinary tract infections(UTI)within the past month. Which medication should the nurse expect to be ordered for the recurrent infection? Ciprofloxacin Fosfomycin Nitrofurantoin Trimethoprim-sulfamethoxazole

Ciprofloxacin

Diverticulosis Clinical Manifestations

Common to have NO symptoms Discovered during routine colonoscopy Other Sx: ab pain, bloating, flatulence, change in bowel habits, blood in stool

The nurse is assessing the adaptation of a pt to changes in functional status after a stroke. Which observation indicates to the nurse that the pt is adapting most successfully? Gets angry with family if they interrupt a task Experiences bouts of depression and irritability Has difficulty using modified feeding utensils Consistently uses adaptive equipment in dressing self

Consistently uses adaptive equipment in dressing self

In preparation for cataract surgery, the nurse is to administer cyclopentolate eye drops at 0900 for surgery that is scheduled for 0915. What initial action should the nurse take in relation to the characteristics of the medication action? Provide lubrication to the operative eye prior to giving the eye drops Call the surgeon, as this medication will further constrict the operative pupil Consult the surgeon, as there is not sufficient time for the dilative effects to occur Give the medication as prescribed; the surgeon needs optimal constriction of the pupil

Consult the surgeon, as there is not sufficient time for the dilative effects to occur

A patient is one day postoperative after a transurethral resection of the prostate (TURP). Which event is an unexpected finding? Requires two tablets of Tylenol #3 during the night Complains of fatigue and claims to have minimal appetite Continuous bladder irrigation (CBI) infusing, but output has decreased Expressed anxiety about his planned discharge home the following day

Continuous bladder irrigation (CBI) infusing, but output has decreased

Which instruction should the nurse provide when teaching a patient to exercise the pelvic floor? Tighten both buttocks together. Squeeze thighs together tightly. Contract muscles around rectum. Lie on back and lift the legs together.

Contract muscles around rectum.

A pt with DM demonstrates acute anxiety when admitted to the hospital for the treatment of hyperglycemia. What is the appropriate intervention to decrease the pt's anxiety? Administer a sedative Convey empathy, trust, and respect toward the pt Ignore the signs & symptoms of anxiety, anticipating that they will soon disappear make sure that the pt is familiar with the correct medical terms to promote understanding of what is happening

Convey empathy, trust, and respect toward the pt.

A pt who is recovering from surgery has been advanced from a clear liquid to a full liquid diet. The pt is looking forward to the diet change because he has been bored with the clear liquid diet. The nurse should offer which full liquid item to the pt? Tea Gelatin Custard Ice pop

Custard

The nurse is teaching a patient with type 2 diabetes mellitus how to prevent diabetic nephropathy. Which statement made by the patient indicates that teaching has been successful? A. "I should have yearly dilated eye examinations by an ophthalmologist." B. "Smokeless tobacco products decrease the risk of kidney damage." C. "I will avoid hypoglycemia by keeping my blood sugar above 180 mg/dL." D. "I will control my blood pressure by avoiding foods high in sodium."

D. "I will control my blood pressure by avoiding foods high in sodium."

The nurse is providing care for a patient admitted to the hospital for treatment of nephrotic syndrome. What are the priority nursing assessments? Assessment of pain and level of consciousness Assessment of serum calcium and phosphorus levels Blood pressure and assessment for orthostatic hypotension Daily weights and measurement of the patient's abdominal girth

Daily weights and measurement of the patient's abdominal girth

A pt who has a cold is seen in the ED with an inability to void. Because the pt has a history of benign prostatic hyperplasia, the nurse determines that the pt should be questioned about the use of which medication? Diuretics Antibiotics Antilipemics Decongestants

Decongestants

The nurse is collecting data from a pt. Which symptom described by the pt is characteristic of an early symptom of benign prostatic hyperplasia? Nocturia Scrotal edema Occasional constipation Decreased force in the stream of urine

Decreased force in the stream of urine

The nurse requests a patient scheduled for colectomy to sign the operative permit as directed in the physician's preoperative orders. The patient states that the physician has not really explained very well what is involved in the surgical procedure. What is the most appropriate action by the nurse? Ask family members whether they have discussed the surgical procedure with the physician. Have the patient sign the form and state the physician will visit to explain the procedure before surgery. Explain the planned surgical procedure as well as possible and have the patient sign the consent form. Delay the patient's signature on the consent and notify the physician about the conversation with the patient.

Delay the patient's signature on the consent and notify the physician about the conversation with the patient.

The home health nurse is visiting a pt who was recently diagnosed with DM Type II. The pt is prescribed repaglinide & metformin. The nurse should provide which instructions to the pt? Select all that apply. Diarrhea may occur secondary to the metformin. The repaglinide is not taken if a meal is skipped. The repaglinide is taken 30 minutes before eating. A simple sugar food item is carried & used to treat mild hypoglycemia episodes. Muscle pain is an expected effect of metformin & may be treated with acetaminophen. Metformin increases hepatic glucose production to prevent hypoglycemia associated with repaglinide.

Diarrhea may occur secondary to the metformin. The repaglinide is not taken if a meal is skipped. The repaglinide is taken 30 minutes before eating. A simple sugar food item is carried & used to treat mild hypoglycemia episodes.

Obstructive BPH Manifestations **due to urinary retention**

Difficulty initiating voiding Changes in size & force of urinary stream Dribbling at end of urination

o monitor the progression of decreased urinary stream, the nurse should encourage which type of regular screening? Uroflowmetry Transrectal ultrasound Digital rectal examination (DRE) Prostate-specific antigen (PSA) monitoring

Digital rectal examination (DRE)

The nurse is providing discharge instructions for a patient using contact lenses who is diagnosed with bacterial conjunctivitis. What is most important for the nurse to include in the instructions? Discard all opened or used lens care products. Disinfect contact lenses by soaking in a cleaning solution for 48 hours. Put all used cosmetics in a plastic bag for 1 week to kill any bacteria before reusing. Disinfect all lens care products with the prescribed antibiotic drops for 1 week after infection.

Discard all opened or used lens care products.

The nurse visits a patient who is being treated with phenytoin (Dilantin) for seizures. Which instruction is most important to prevent precipitation of seizures in this patient? Notify the health care provider about unusual hair growth. Practice good dental hygiene to control gingival hyperplasia. Do not stop the drug abruptly without consulting the health care provider. Maintain a healthy lifestyle with regular exercise and nutritious diet.

Do not stop the drug abruptly without consulting the health care provider.

The nurse observes a 74-yr-old man with Parkinson's disease rocking side to side while sitting in the chair. Which action by the nurse is most appropriate? Provide the patient with diversional activities. Document the activity in the patient's health record. Take the patient's blood pressure sitting and standing. Ask if the patient is feeling either anxious or depressed.

Document the activity in the patient's health record.

The nurse is admitting a patient with severe dehydration and frequent watery diarrhea. A 10-day outpatient course of antibiotic therapy for bacterial pneumonia has just been completed. What is the most important for the nurse to take which action? Wear a mask to prevent transmission of infection. Wipe equipment with ammonia-based disinfectant. Instruct visitors to use the alcohol-based hand sanitizer. Don gloves and gown before entering the patient's room.

Don gloves and gown before entering the patient's room.

When teaching the patient about the diet for diverticular disease, which foods should the nurse recommend? White bread, cheese, and green beans Fresh tomatoes, pears, and corn flakes Oranges, baked potatoes, and raw carrots Dried beans, All Bran (100%) cereal, and raspberries

Dried beans, All Bran (100%) cereal, and raspberries

A patient is newly diagnosed with type 1 diabetes and reports a headache, changes in vision, and being anxious but does not have a portable blood glucose monitor present. Which action should the nurse advise her to take? Eat a piece of pizza. Drink some diet pop. Eat 15 g of simple carbohydrates. Take an extra dose of rapid-acting insulin.

Eat 15 g of simple carbohydrates.

Effects of Food on Stoma Output Odor Producing

Eggs Garlic Onions Fish Asparagus Cabbage Broccoli Alcohol

After an exploratory laparotomy, a patient on a clear liquid diet reports severe gas pains and abdominal distention. Which action by the nurse is most appropriate? Return the patient to NPO status. Place cool compresses on the abdomen. Encourage the patient to ambulate as ordered. Administer an as-needed dose of IV morphine sulfate

Encourage the patient to ambulate as ordered.

When planning care for a patient with disturbed sensory perception related to increased intraocular pressure caused by primary open-angle glaucoma, what nursing action would be a priority? Recognizing that eye damage caused by glaucoma can be reversed in the early stages Giving anticipatory guidance about the eventual loss of central vision that will occur Encouraging compliance with drug therapy for the glaucoma to prevent loss of vision Managing the pain experienced by patients with glaucoma that persists until the optic nerve atrophies

Encouraging compliance with drug therapy for the glaucoma to prevent loss of vision

An acoustic neuroma is removed from a patient. The nurse instructs the patient about tumor recurrence. What should the nurse instruct the patient to monitor (select all that apply.)? Lack of coordination Episodes of dizziness Worsening of hearing Inability to close the eye Clear drainage from the nose

Episodes of dizziness Worsening of hearing Inability to close the eye

The nurse is evaluating a patient diagnosed with type 2 diabetes mellitus. Which symptom reported by the patient correlates with the diagnosis? Excessive thirst Gradual weight gain Overwhelming fatigue Recurrent blurred vision

Excessive thirst

The nurse is developing a teaching plan for a pt with glaucoma. Which instruction should the nurse include in the plan of care? Avoid overuse of the eyes Decrease the amount of salt in the diet Eye medications will need to be administered for life Decrease fluid intake to control the intraocular pressure

Eye medications will need to be administered for life

A patient after a stroke who primarily uses a wheelchair for mobility has developed diarrhea with fecal incontinence. What is a priority assessment by the nurse? Fecal impaction Perineal hygiene Dietary fiber intake Antidiarrheal agent use

Fecal impaction

A patient is admitted to the emergency department after a motor vehicle crash with suspected abdominal trauma. What assessment finding by the nurse is of highest priority? Nausea and vomiting Hyperactive bowel sounds Firmly distended abdomen Abrasions on all extremities

Firmly distended abdomen

A pt has just had surgery to create an ileostomy. The nurse assesses the pt in the immediate post-operative period for which most frequent complication of this type of surgery? Folate deficiency Malabsorption of fat Intestinal obstruction Fluid & electrolyte imbalance

Fluid & electrolyte imbalance

Sigmoid Colostomy Stool consistency Fluid requirement Bowel Regulation Pouch & skin barriers Irrigation

Formed No change Yes, if history of regular bowel pattern Depends on bowel regulation Possibly every 24-48 hours

The nurse caring for a patient hospitalized with diabetes mellitus would look for which laboratory test result to obtain information on the patient's past glucose control? Prealbumin level Urine ketone level Fasting glucose level Glycosylated hemoglobin level

Glycosylated hemoglobin level

When administering eye drops to a patient with glaucoma, which nursing measure is most appropriate to minimize systemic effects of the medication? Apply pressure to each eyeball for a few seconds after administration. Have the patient close the eyes and move them back and forth several times. Have the patient put pressure on the inner canthus of the eye after administration. Have the patient try to blink out excess medication immediately after administration.

Have the patient put pressure on the inner canthus of the eye after administration.

A patient is prescribed intravenous (IV) gentamicin after repair of an intestinal perforation. The nurse should assess for which adverse effect of this medication? Hearing loss Exophthalmos Conjunctivitis Recurrent fever

Hearing loss

A nurse is admitting a patient with advanced renal carcinoma. Which clinical manifestations represent the "classic triad" observed in patients with renal cancer? Fever, chills, and flank pain Hematuria, flank pain, and palpable mass Hematuria, proteinuria, and palpable mass Flank pain, palpable abdominal mass, and proteinuria

Hematuria, flank pain, and palpable mass

The nurse is caring for a patient admitted with a suspected bowel obstruction. The nurse auscultating the abdomen listens for which type of bowel sounds that are consistent with the patient's clinical picture? Low-pitched and rumbling above the area of obstruction High-pitched and hypoactive below the area of obstruction Low-pitched and hyperactive below the area of obstruction High-pitched and hyperactive above the area of obstruction

High-pitched and hyperactive above the area of obstruction

The nurse is developing a plan of care for a patient with an abdominal mass and suspected bowel obstruction. Which factor in the patient's history does the nurse recognize as increasing the patient's risk for colorectal cancer? Osteoarthritis History of colorectal polyps History of lactose intolerance Use of herbs as dietary supplements

History of colorectal polyps

What information would have the highest priority for the nurse to include in preoperative teaching for a patient scheduled for a colectomy? How to care for the wound How to deep breathe and cough The location and care of drains after surgery Which medications will be used during surgery

How to deep breathe and cough

Which modifiable risk factor for stroke would be most important for the nurse to include when planning a community education program? Hypertension Hyperlipidemia Alcohol consumption Oral contraceptive use

Hypertension

A pt is taking Humulin NPH insulin and regular insulin every morning. The nurse should provide which instructions to the pt. Select all that apply. Hypoglycemia may be experienced before dinnertime. The insulin dose should be decreased if illness occurs. The insulin should be administered at room temperature. The insulin vial needs to be vigorously shaken to break up precipitates. The NPH insulin should be drawn into the syringe first, then the regular insulin.

Hypoglycemia may be experienced before dinnertime. The insulin should be administered at room temperature.

Pts that experience frequent episodes of hypoglycemic, older pts, and pts taking Beta adrenergic blocking agents may not experience the warning signs of hypoglycemia until the BGL is dangerously low

Hypoglycemia unawareness

The patient with type 1 diabetes mellitus is having a seizure. Which medication should the nurse anticipate will be administered first? IV dextrose solution IV diazepam (Valium) IV phenytoin (Dilantin) Oral carbamazepine (Tegretol)

IV dextrose solution

Clostridium difficle (C. diff) treatment

IV or oral metronidazole (Flagyl) and/or oral Vancomycin

Legal Blindness

If the best visual acuity with corrective lenses in the better eye is 20/200 or less OR If the widest diameter of the visual field in that eye is no greater than 20 degrees

Two days after a colectomy for an abdominal mass, a patient reports gas pains and abdominal distention. The nurse plans care for the patient based on the knowledge that the symptoms are occurring as a result what event? Impaired peristalsis Irritation of the bowel Nasogastric suctioning Inflammation of the incision site

Impaired peristalsis

The nurse would expect to find what clinical manifestation in a patient admitted with a left-sided stroke? Impulsivity Impaired speech Left-side neglect Short attention span

Impaired speech

Carbidopa-levodopa is prescribed for a pt with Parkinson's disease. The nurse monitors the pt for side and adverse effects of the medication. Which finding indicates that the pt is experiencing an adverse effect? Pruritus Tachycardia Hypertension Impaired voluntary movements

Impaired voluntary movements

The nurse is preparing a plan of care for a pt with DM who has hyperglycemia. The nurse places priority on which pt problem? Lack of knowledge Inadequate fluid volume Compromised family coping Inadequate consumption of nutrients

Inadequate fluid volume

The nurse coordinates postoperative care for a 70-yr-old man with osteoarthritis after prostate surgery. Which task is appropriate for the nurse to delegate to a licensed practical/vocational nurse (LPN/LVN) (select all that apply.)? Clean around the catheter daily. Increase flow of irrigation solution. Teach the patient how to perform Kegel exercises. Provide instructions to the patient on catheter care. Administer oxybutynin (Ditropan) for bladder spasms. Manually irrigate the urinary catheter to restore catheter flow.

Increase flow of irrigation solution. Administer oxybutynin (Ditropan) for bladder spasms.

The nurse is reviewing laboratory results for a patient with a 15-year history of type 2 diabetes. Which result reflects the expected pattern accompanying macrovascular disease as a complication of diabetes? Increased triglyceride levels Increased high-density lipoproteins (HDL) Decreased low-density lipoproteins (LDL) Decreased very-low-density lipoproteins (VLDL)

Increased triglyceride levels

A hospitalized patient has just been diagnosed with diarrhea due to Clostridium difficile. Which nursing interventions should be included in the patient's plan of care (select all that apply.)? Initiate contact isolation precautions. Place the patient on a clear liquid diet. Disinfect the room with 10% bleach solution. Teach any visitors to wear gloves and gowns. Use hand sanitizer before and after patient or bodily fluid contact.

Initiate contact isolation precautions. Disinfect the room with 10% bleach solution. Teach any visitors to wear gloves and gowns.

Overflow Incontinence

Involuntary loss of urine associated with overdistention of the bladder when bladder capacity has reached its maximum due to urethral obstruction/spasm; bladder or urethral outlet obstruction

Urge Incontinence

Involuntary loss of urine during activities that increase abdominal and detrusor (bladder muscle) pressure; Overactive bladder

Reflex Incontinence

Involuntary loss of urine that occurs without warning Associated with CNS disorders

The patient with Parkinson disease is being discharged home with his wife. To promote compliance to the management plan, which discharge action is most effective? Involving the patient and his wife in developing a plan of care Setting up visitations by a home health nurse Telling his wife what the patient needs Writing up a detailed plan of care according to standards

Involving the patient and his wife in developing a plan of care

An external insulin pump is prescribed for a client with DM. When the pt asks the nurse about the functioning of the pump, the nurse bases the response on which information about the pump?

It administers a small continuous dose of short duration insulin subcutaneously. The pt can self-administer an additional bolus dose from the pump before each meal.

What is the nurse's priority when changing the appliance for a patient with an ileal conduit? Keep the skin free of urine. Inspect the peristomal area. Cleanse and dry the area gently. Affix the appliance to the faceplate.

Keep the skin free of urine.

Eight months after the delivery of her first child, a 31-yr-old woman sought care for occasional incontinence when sneezing or laughing. Which measure should the nurse recommend first? Kegel exercises Use of adult incontinence pads Intermittent self-catheterization Dietary changes including fluid restriction

Kegel exercises

A patient, admitted with diabetes mellitus, has a glucose level of 380 mg/dL and a moderate level of ketones in the urine. As the nurse assesses for signs of ketoacidosis, which respiratory pattern would the nurse expect to find? Central apnea Hypoventilation Kussmaul respirations Cheyne-Stokes respirations

Kussmaul respirations

Diverticulitis Clinical Manifestations

Left lower quadrant ab pain Elevated temp Leukocytosis Palpable ab mass

The nurse is caring for a pt who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply. Loosening restrictive clothing Restraining the pt's limbs Removing the pillow and raising padded side rails Positioning the pt to the side, if possible, with the head flexed forward Keeping the curtain around the pt and the room door open so when help arrives they can quickly enter to assist

Loosening restrictive clothing Removing the pillow and raising padded side rails Positioning the pt to the side, if possible, with the head flexed forward

Which medication will the nurse prepare to administer to the patient who is experiencing status epilepticus? Atropine by intravenous push Lorazepam (Ativan) by intravenous push Propranolol (Inderal) orally Phenytoin (Dilantin) orally

Lorazepam (Ativan) by intravenous push

Functional Incontinence

Loss of urine resulting from cognitive impairment/balance, functional, or environmental factors and mobility problems in older adults

When administering a scheduled dose of pilocarpine, in which area should the nurse place the drops? Inner canthus Outer canthus Center of the eyeball Lower conjunctival sac

Lower conjunctival sac

The nurse is administering a cathartic agent to a patient with renal insufficiency. Which order will the nurse question? Bisacodyl Lubiprostone Cascara sagrada Magnesium hydroxide

Magnesium hydroxide

The nurse is conducting discharge teaching for a patient with metastatic lung cancer who was admitted with a bowel impaction. Which instructions would be most helpful to prevent further episodes of constipation? Maintain a high intake of fluid and fiber in the diet. Discontinue intake of medications causing constipation. Eat several small meals per day to maintain bowel motility. Sit upright during meals to increase bowel motility by gravity.

Maintain a high intake of fluid and fiber in the diet.

A CT scan of a 68-yr-old male patient's head reveals that he has experienced a hemorrhagic stroke. What is the priority nursing intervention in the emergency department? Maintenance of the patient's airway Positioning to promote cerebral perfusion Control of fluid and electrolyte imbalances Administration of tissue plasminogen activator (tPA)

Maintenance of the patient's airway

The nurse is teaching a patient who has diabetes about vascular complications of diabetes. What information is appropriate for the nurse to include? Macroangiopathy does not occur in type 1 diabetes but rather in type 2 diabetics who have severe disease. Microangiopathy is specific to diabetes and most commonly affects the capillary membranes of the eyes, kidneys, and skin. Renal damage resulting from changes in large- and medium-sized blood vessels can be prevented by careful glucose control. Macroangiopathy causes slowed gastric emptying and the sexual impotency experienced by a majority of patients with diabetes.

Microangiopathy is specific to diabetes and most commonly affects the capillary membranes of the eyes, kidneys, and skin.

A patient with diabetes mellitus is scheduled for a fasting blood glucose level at 8:00 AM. The nurse instructs the patient to only drink water after what time? 6:00 PM on the evening before the test Midnight before the test 4:00 AM on the day of the test 7:00 AM on the day of the test

Midnight before the test

A female patient complains of a throbbing headache. The nurse learns the patient has experienced photophobia and headaches previously. Which diagnosis does the nurse suspect? Cluster headache Migraine headache Polycythemia vera Hemorrhagic stroke

Migraine headache

Characteristic of Stoma Edema

Mild to Moderate = normal in the initial postop period; trauma to stoma; any medical condition that results in edema Moderate to Severe = obstruction to stoma; allergic reaction to food; gastroenteritis

Betaxolol hydrochloride eye drops have been prescribed for a pt with glaucoma. Which nursing action is most appropriate related to monitoring for side and adverse effects of this medications? Assessing for edema Monitoring temperature Monitoring blood pressure Assessing blood glucose level

Monitoring blood pressure

Primary Open-Angle Glaucoma

Most common Usually bilateral Usually asymptomatic early** Reduced outflow of aqueous fluid through chamber angle Gradual increase in IOP

Incontinence: Collaborative Care Drug Therapy

Muscarinic Receptor Antagonists & Anticholinergics MOA: reduce overactive bladder Indications: urge/overactive Meds: oxybutynin (Ditropan); tolterodine (Detol); solifenacin (VESIcare); dicyclomine (Bentyl)

A patient admitted to the emergency department after a motor vehicle accident. Which urinalysis findings would the nurse expect if kidney trauma occurred (select all that apply.)? Casts Glucose Bilirubin Myoglobinuria Red blood cells White blood cells

Myoglobinuria Red blood cells

Intermediate Acting Insulin generic (Trade) Onset Peak Duration

NPH (Humulin N; Novolin N; ReliOn N Onset: 2-4 hours Peak: 4-10 hours Duration: 10-16 hours

The nurse is caring for a 73-yr-old male patient with a history of benign prostatic hyperplasia and symptoms of a urinary tract infection. Which diagnostic finding would support this diagnosis? White blood cell count is 7500 cells/µL. Antistreptolysin-O (ASO) titer is 106 Todd units/mL. Glucose, protein, and ketones are present in the urine. Nitrites and leukocyte esterase are present in the urine.

Nitrites and leukocyte esterase are present in the urine.

The nurse should administer an as-needed dose of magnesium hydroxide after noting what information when reviewing a patient's medical record? Abdominal pain and bloating No bowel movement for 3 days A decrease in appetite by 50% over 24 hours Muscle tremors and other signs of hypomagnesemia

No bowel movement for 3 days

Tonometry is performed on a pt with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure (IOP) value of 23. What should be the nurse's initial action? Apply normal saline drops Note the time of day the test was done Contact the HCP Instruct the pt to sleep with the head of the bed flat

Note the time of day the test was done

Effects of Food on Stoma Output Potential Obstruction in Ileostomy

Nuts Raisins Popcorn Seeds Vegetables (Raw) Celery Corn

A patient has been receiving scheduled doses of phenytoin (Dilantin) and begins to experience diplopia. Which additional findings would the nurse expect? An aura or focal seizure Nystagmus or confusion Abdominal pain or cramping Irregular pulse or palpitations

Nystagmus or confusion

The nurse provides nutritional counseling for a 45-yr-old man with nephrotic syndrome. The nurse determines teaching has been successful if the patient selects which breakfast menu? Scrambled eggs, milk, yogurt, and sliced ham Oatmeal, nondairy creamer, banana, and orange juice Cottage cheese, peanut butter, white bread, and coffee Waffle, bacon strips, tomato juice, and canned peaches

Oatmeal, nondairy creamer, banana, and orange juice

The patient has a history of cardiovascular disease and has developed erectile dysfunction. He is frustrated because he is taking nitrates and cannot take erectogenic medications. What should the nurse do first? Give the patient choices for penile implant surgery. Recommend counseling for the patient and his partner. Obtain a thorough sexual, health, and psychosocial history. Assess levels of testosterone, prolactin, luteinizing hormone, and thyroid hormones.

Obtain a thorough sexual, health, and psychosocial history.

A patient with diabetes mellitus who has multiple infections every year needs a mitral valve replacement. What is the most important preoperative teaching the nurse should provide to prevent a cardiac infection postoperatively? Avoid sick people and wash hands. Obtain comprehensive dental care. Maintain hemoglobin A1C below 7%. Coughing and deep breathing with splinting

Obtain comprehensive dental care.

The nurse is providing instructions to a pt who will be self-administering eye drops. To minimize systemic absorption of the eye drops, the nurse should instruct the pt to take which action? Eat before instilling the drops Swallow several times after instilling the drops Blink vigorously to encourage tearing after instilling the drops Occlude the nasolacrimal duct with a finger after instilling the drop

Occlude the nasolacrimal duct with a finger after instilling the drop

Biguanides MOA generic (Trade)

Oral Agent-NOT INSULIN Reduce glucose production by liver; enhance insulin sensitivity at tissues; improve glucose transport into cells metformin (Glucophage)

Sulfonylureas MOA generic (Trade)

Oral agent--NOT INSULIN Increase insulin production from pancreas glipizide (Glucotrol) glimepiride (Amaryl)

The nurse is instituting seizure precautions for a pt who is being admitted from the ED. Which measures should the nurse include in planning for the pt's safety? Select all that apply. Padding the side rails of the bed Placing an airway at the bedside Placing the bed in the high position Putting a padded tongue blade at the head of the bed Placing oxygen and suction equipment at the bedside Flushing the intravenous catheter to ensure that the site is patent

Padding the side rails of the bed Placing an airway at the bedside Placing oxygen and suction equipment at the bedside Flushing the intravenous catheter to ensure that the site is patent

The urinalysis of a patient reveals a high microorganism count. What data should the nurse use to determine which part of the urinary tract is infected (select all that apply.)? Pain location Fever and chills Mental confusion Urinary hesitancy Urethral discharge Postvoid dribbling

Pain location Urethral discharge

Cataracts

Patho: opacity of the lens = distorted image projected into the retina Slightly blurred vision can progress to blindness Decreased color perception Glare Lens cloudiness

A patient is diagnosed with severe myopia. Which type of correction is the patient planning to have if they state, "I can't wait to be able to see after they implant a contact lens over my lens"? Photorefractive keratectomy (PRK) Phakic intraocular lenses (phakic IOLs) Refractive intraocular lens (refractive IOL) Laser-assisted in situ keratomileusis (LASIK)

Phakic intraocular lenses (phakic IOLs)

Medication used for dysuria as a urinary analgesic

Phenazopyridine (Pyridium)

The nurse is monitoring a pt newly diagnosed with DM for signs of complications. Which sign or symptoms, if exhibited in the pt, indicates that the pt is at risk for chronic complications of diabetes if the BGL is not adequately managed? Polyuria Diaphoresis Pedal edema Decreased respiratory rate

Polyuria

A pt with DM visits a clinic. The pt's DM previously had been well controlled with glyburide daily, but recently the fasting BGL has been 180-200 mg/dL. Which medications, if added to the pt's regimen, may have contributed to the hyperglycemia? Prednisone Atenolol Phenelzine Allopurinol

Prednisone

A patient presents to the emergency department reporting a sudden onset of headache described as "the worse headache ever." The patient also reports nausea and visual disturbances. What collaborative intervention is a priority for the nurse? Prepare patient for transport to computed tomography (CT) scan. Obtain consent for lumbar puncture. Administer morphine sulfate 4 mg intravenous push (IVP). Administer Ondanestron (Zofran) 4 mg intravenous push (IVP) for nausea.

Prepare patient for transport to computed tomography (CT) scan.

A client with diabetes mellitus has a glycosylated hemoglobin A1C level of 9%. On the basis of this test result, the nurse plans to teach the client about the need for which measure? Avoiding infection Taking in adequate fluids Preventing & recognizing hypoglycemia Preventing & recognizing hyperglycemia

Preventing and recognizing hyperglycemia.

A 48-yr-old man was just diagnosed with Huntington's disease. His 20-yr-old son is upset about his father's diagnosis. What is the nurse's best response? Provide emotional and psychologic support. Encourage him to get diagnostic genetic testing. Explain that cognitive deterioration will be treated with counseling. Instruct that chorea and psychiatric disorders can be treated with haloperidol (Haldol).

Provide emotional and psychologic support.

A male patient with a diagnosis of Parkinson's disease (PD) is admitted to a long-term care facility. Which action should the health care team take to promote adequate nutrition for this patient? Provide multivitamins with each meal. Provide a diet that is low in complex carbohydrates and high in protein. Provide small, frequent meals throughout the day that are easy to chew and swallow. Provide the patient with a minced or pureed diet that is high in potassium and low in sodium.

Provide small, frequent meals throughout the day that are easy to chew and swallow.

The nurse is providing care for a pt with a recent transverse colostomy. Which observation requires immediate notification of the health care provider? Stoma is beefy red & red Purple discoloration of the stoma Skin excoriation around the stoma Semi-formed stool noted in the ostomy pouch

Purple discoloration of the stoma

Glimepiride is prescribed for a pt with DM. The nurse instructs the pt that which food items are most acceptable to consume while taking this medication? Select all that apply Alcohol Red meats Whole-grain cereals Low-calorie desserts Carbonated beverages

Red meats Whole-grain cereals Carbonated beverages

A 50-yr-old male patient has been diagnosed with amyotrophic lateral sclerosis (ALS). What strategy will prevent a common cause of death for patients with ALS? Reduce fat intake. Reduce the risk of aspiration. Decrease injury related to falls. Decrease pain secondary to muscle weakness.

Reduce the risk of aspiration.

The newly diagnosed patient with type 2 diabetes has been prescribed metformin. What should the nurse teach the patient to best explain how this medication works? Increases insulin production from the pancreas Slows the absorption of carbohydrate in the small intestine Reduces glucose production by the liver and enhances insulin sensitivity Increases insulin release from the pancreas, inhibits glucagon secretion, and decreases gastric emptying

Reduces glucose production by the liver and enhances insulin sensitivity

The home care nurse visits a pt recently diagnosed with DM who is taking Humulin NPH insulin daily. The pt asks the nurse how to store the unopened vials of insulin. The nurse should tell the pt to take which action? Freeze the insulin Refrigerate the insulin Store the insulin in a dark, dry place Keep the insulin at room temperature

Refrigerate the insulin

The nurse is planning psychosocial support for the family of the patient who suffered a stroke. What factor will have the greatest impact on family coping? Specific patient neurologic deficits The patient's ability to communicate Rehabilitation potential of the patient Presence of complications of a stroke

Rehabilitation potential of the patient

A 22-yr-old patient's blood pressure during a pre-employment physical examination was 110/68 mm Hg. During a health fair 2 months later, the blood pressure is 154/96 mm Hg. What renal problem could contribute to this rise in blood pressure? Renal trauma Renal artery stenosis Renal vein thrombosis Benign nephrosclerosis

Renal artery stenosis

Which task can the nurse delegate to an unlicensed assistive personnel (UAP) in the care of a patient who has recently undergone prostatectomy? Assessing the patient's incision Irrigating the patient's urinary catheter Reporting complaints of pain or bladder spasms Evaluating the patient's pain and selecting analgesia

Reporting complaints of pain or bladder spasms

A patient with an intestinal obstruction has a nasogastric (NG) tube to suction but complains of nausea and abdominal distention. The nurse irrigates the tube as necessary as ordered, but the irrigating fluid does not return. What should be the priority action by the nurse? Notify the physician. Auscultate for bowel sounds. Reposition the tube and check for placement. Remove the tube and replace it with a new one.

Reposition the tube and check for placement.

Oxybutynin chloride is prescribed for a pt with urge incontinence. Which sign would indicate a possible toxic effect related to this medication? Pallor Drowsiness Bradycardia Restlessness

Restlessness

A 71-yr-old patient with a diagnosis of benign prostatic hyperplasia (BPH) has been scheduled for a contact laser technique. What is the primary goal of this intervention? Resumption of normal urinary drainage Maintenance of normal sexual functioning Prevention of acute or chronic renal failure Prevention of fluid and electrolyte imbalances

Resumption of normal urinary drainage

Characteristics of Stoma Color

Rose to brick red = viable stoma mucosa Pale = may indicate anemia Blanching, dark red to purple = inadequate blood supply to stoma or bowel

The patient with diabetes mellitus had a right-sided stroke. Which nursing intervention should the nurse plan to provide for this patient? Safety measures Patience with communication Mobility assistance on the right side Place food in the left side of patient's mouth.

Safety measures

When caring for a patient with nephrotic syndrome, which food selection indicates the patient understands dietary teaching? Peanut butter and crackers One small grilled pork chop Salad made of fresh vegetables Spaghetti with canned spaghetti sauce

Salad made of fresh vegetables

Ascending Colostomy Stool consistency Fluid requirement Bowel Regulation Pouch & skin barriers Irrigation

Semiliquid Increased No Yes No

Transverse Colostomy Stool consistency Fluid requirement Bowel Regulation Pouch & skin barriers Irrigation

Semiliquid to semiformed Possibly increased No Yes No

The patient has a low-grade carcinoma on the left lateral aspect of the prostate gland and has been on "watchful waiting" status for 5 years. Six months ago, his last prostate-specific antigen (PSA) level was 5 ng/mL. Which manifestations indicate prostate cancer may be extending and require a change in the plan of care (select all that apply.)? Casts in his urine Presence of α-fetoprotein Serum PSA level 10 ng/mL Onset of erectile dysfunction Nodularity of the prostate gland Development of a urinary tract infection

Serum PSA level 10 ng/mL Nodularity of the prostate gland

The nurse teaches a pt with DM about differentiating between hypoglycemia & ketoacidosis. The pt demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptom or symptoms occur? Select all that apply Polyuria Shakiness Palpitations Blurred vision Lightheadedness Fruity breath odor

Shakiness Palpitations Lightheadedness

Which sensory-perceptual deficit is associated with left-sided stroke (right hemiplegia)? Overestimation of physical abilities Difficulty judging position and distance Slow and possibly fearful performance of tasks Impulsivity and impatience at performing tasks

Slow and possibly fearful performance of tasks

A pt is taking the prescribed dose of phenytoin to control seizures. Results of a phenytoin blood level study reveal a level of 35 mcg/mL. Which finding would be expected as a result of this laboratory result. Hypotension Tachycardia Slurred speech No abnormal finding

Slurred speech Normal is 10-20 mcg/mL

Characteristic of Stoma Bleeding

Small amount = oozing from stoma mucosa when touched is normal due to high vascularity Moderate to large amount = coagulation factor deficiency; varicies secondary to portal hypertension; lower GI bleeding

The nurse is caring for a hearing-impaired pt. Which approach will facilitate communication? Speak loudly Speak frequently Speak at a normal volume Speak directly into the impaired ear

Speak at a normal volume

The nurse notes that the HCP has documented a diagnosis of presbycusis on a pt's chart. Based on this information, what action should the nurse take? Speak loudly, but mumble or slur the words Speak loudly and clearly while facing the pt Speak at normal tone and pitch, slowly and clearly Speak loudly and directly into the pt's affected ear

Speak at normal tone and pitch, slowly and clearly

Constipation meds should only be taken as needed **Can cause dependence**

Stool lubricants: mineral oil enema (Fleet's) Saline & osmotic solutions: magnesium citrate, milk of magnesia; lactulose (Chronulac) Stimulants: bisacodyl (Dulcolax)

The female patient has been brought to the emergency department complaining of the most severe headache of her life. Which type of stroke should the nurse anticipate? TIA Embolic stroke Thrombotic stroke Subarachnoid hemorrhage

Subarachnoid hemorrhage

Which nursing intervention is most appropriate in providing care for an adult patient with newly diagnosed adult onset polycystic kidney disease (PKD)? Help the patient cope with the rapid progression of the disease. Suggest genetic counseling resources for the children of the patient. Expect the patient to have polyuria and poor concentration ability of the kidneys. Implement appropriate measures for the patient's deafness and blindness in addition to the renal problems.

Suggest genetic counseling resources for the children of the patient.

The nurse is preparing to administer a daily dose of docusate sodium to a patient that will continue taking it after discharge. What information should the nurse provide to the patient to optimize the outcome of the medication? Take a dose of mineral oil at the same time. Add extra salt to food on at least one meal tray. Ensure a dietary intake of 10 g of fiber each day. Take each dose with a full glass of water or other liquid.

Take each dose with a full glass of water or other liquid.

The nurse performs a physical assessment on a pt with DM Type II. Findings include a fasting BGL of 120, temp 101 F, P 102, RR 22, BP 142/72. Which finding would be the priority concern to the nurse? Pulse Respiration Temperature Blood pressure

Temperature

A patient is admitted with diabetes mellitus, malnutrition cellulitis, and a potassium level of 5.6 mEq/L. The nurse understands that what could be contributing factors for this laboratory result (select all that apply.)? The level may be increased as a result of dehydration that accompanies hyperglycemia. The level may be raised as a result of metabolic ketoacidosis caused by hyperglycemia. The level is consistent with renal insufficiency that can develop with renal nephropathy. The patient may be excreting extra sodium and retaining potassium because of malnutrition. This level demonstrates adequate treatment of the cellulitis and effective serum glucose control.

The level may be increased as a result of dehydration that accompanies hyperglycemia. The level may be raised as a result of metabolic ketoacidosis caused by hyperglycemia. The level is consistent with renal insufficiency that can develop with renal nephropathy.

The wound, ostomy, and continence nurse (WOCN) selects the site where the ostomy will be placed. What should be included in site consideration? The patient must be able to see the site. The site should be outside the rectus muscle area. It is easier to seal the drainage bag to a protruding area. A waistline site will allow using a belt to hold the appliance in place

The patient must be able to see the site.

The nurse is assigned to care of a pt with complete right sided hemiparesis from a stroke. Which characteristics are associated with this condition? Select all that apply. The pt is aphasic The pt has weakness on the right side of his body The pt has complete bilateral paralysis of the arms & legs The pt has weakness on the right side of the face & tongue The pt has lost the ability to move the right arm but is able to walk independently The pt has lost the ability to ambulate independently but is able to feed & bathe themselves without assistance

The pt is aphasic The pt has weakness on the right side of his body The pt has weakness on the right side of the face & tongue

Which characteristic will the nurse associate with a focal seizure? The patient lost consciousness during the seizure. The seizure involved both sides of the patient's brain. The seizure involved lip smacking and repetitive movements. The patient fell to the ground and became stiff for 20 seconds.

The seizure involved lip smacking and repetitive movements.

A patient is scheduled for a corneal transplant and is concerned regarding the difficulty with vision that may last for up to 12 months after the transplant. What is the best response by the nurse? If the transplant is done soon after the donor dies, there will not be as much trouble recovering vision. The astigmatism the patient is experiencing may be corrected with glasses or rigid contact lenses. Increasing the amount of light and using a magnifier to read will be helpful if a transplant is not wanted. There are newer procedures in which only the damaged cornea epithelial layer is replaced, and they have a faster recovery.

There are newer procedures in which only the damaged cornea epithelial layer is replaced, and they have a faster recovery.

The home health nurse visits a pt who is taking phenytoin for control of seizures. During the assessment, the nurse notes that the pt is taking birth control pills. Which information should the nurse include in the teaching plan? Pregnancy must be avoided while taking phenytoin The pt may stop the medication if it is causing severe GI effects There is the potential of decreased effectiveness of birth control pills while taking phenytoin There is the increased risk of thrombophlebitis while taking phenytoin & birth control pills together

There is the potential of decreased effectiveness of birth control pills while taking phenytoin

A pt had a new colostomy created 2 days earlier & is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? This is the normal, expected event. the pt is experiencing early signs of ischemic bowel. The pt should not have the NG tube removed. This indicates inadequate preoperative bowel preparation.

This is the normal, expected event.

The nurse is discharging a patient admitted with a transient ischemic attack (TIA). For which medications might the nurse expect to provide discharge instructions (select all that apply.)? Ticlopidine Clopidogrel Enoxaparin Dipyridamole Enteric-coated aspirin Tissue plasminogen activator (tPA)

Ticlopidine Clopidogrel Dipyridamole Enteric-coated aspirin

The nurse is monitoring a pt who was diagnosed with DM Type I and is being treated with NPH and regular insulin. Which manifestations would alert the nurse to the presence of possible hypoglycemic reaction? Select all that apply. Tremors Anorexia Irritability Nervousness Hot, dry, skin Muscle cramps

Tremors Irritability Nervousness

A nurse is caring for a patient with a history of epilepsy who suddenly begins to experience a tonic-clonic seizure and loses consciousness. Which is the nurse's priority action? Restraining the patient's extremities Turning the patient's head to the side Taking the patient's blood pressure Placing an airway into the patient's mouth

Turning the patient's head to the side

The nurse is examining a patient's ear in the clinic to determine if recent treatment for acute otitis media has been effective. Which assessment finding indicates resolution of the middle ear infection? Fenestrations are visible in the tympanic membrane. Tympanic membrane is gray, shiny, and translucent. Cone of light is not visible on the tympanic membrane. Tympanic membrane is blue and bulging with no landmarks.

Tympanic membrane is gray, shiny, and translucent.

A 33-yr-old patient noticed a painless lump and heaviness in his scrotum during testicular self-examination. The nurse should provide the patient information on which diagnostic test? Ultrasound Cremasteric reflex Doppler ultrasound Transillumination with a flashlight

Ultrasound

Irritative BPH Manifestations **associated w/inflammation & infection**

Urgency, frequency Nocturia Dysuria Incontinence

Phenazopyridine is prescribed for a pt with a UTI. The nurse evaluates that the medication is effective based on which observation? Urine is clear amber Urination is not painful Urge incontinence is not present A reddish-orange discoloration of the urine is present

Urination is not painful

The nurse is caring for a patient with a nephrostomy tube. The tube has stopped draining. After receiving orders, what should the nurse do? Keep the patient on bed rest. Use 5 mL of sterile saline to irrigate. Use 30 mL of water to gently irrigate. Have the patient turn from side to side.

Use 5 mL of sterile saline to irrigate.

Which intervention is most appropriate when communicating with a patient suffering from receptive and expressive aphasia following a stroke? Present several thoughts at once so that the patient can connect the ideas. Ask open-ended questions to provide the patient the opportunity to speak. Finish the patient's sentences to minimize frustration associated with slow speech. Use simple, short sentences accompanied by visual cues to enhance comprehension

Use simple, short sentences accompanied by visual cues to enhance comprehension

Which intervention is most appropriate when communicating with a patient with aphasia after a stroke? Present several thoughts at once so that the patient can connect the ideas. Ask open-ended questions to provide the patient the opportunity to speak. Finish the patient's sentences to minimize frustration associated with slow speech. Use simple, short sentences accompanied by visual cues to enhance comprehension.

Use simple, short sentences accompanied by visual cues to enhance comprehension.

A patient with septic shock is receiving multiple medications. Which intravenous (IV) medication is most likely to cause a hearing loss? Dopamine Ampicillin Aspirin Vancomycin

Vancomycin

The nurse counsels a 64-yr-old man on dietary restrictions to prevent recurrent uric acid renal calculi. Which foods should the patient avoid? Venison, crab, and liver Spinach, cabbage, and tea Milk, yogurt, and dried fruit Asparagus, lentils, and chocolate

Venison, crab, and liver

A patient is recovering from a motor vehicle crash that resulted in blindness. The patient is withdrawn and refuses to get out of bed. What is the nurse's priority goal for this patient? Use suitable coping strategies to reduce stress. Identify patient's strengths and support system. Verbalize feelings related to visual impairment. Transition successfully to the sudden vision loss.

Verbalize feelings related to visual impairment.

Which care measure is a priority for a patient with multiple sclerosis (MS)? Vigilant infection control and adherence to standard precautions Careful monitoring of neurologic assessment and frequent reorientation Maintenance of a calorie count and hourly assessment of intake and output Assessment of blood pressure and monitoring for signs of orthostatic hypotension

Vigilant infection control and adherence to standard precautions

The nurse is preparing to administer eye drops. Which intervention should the nurse take to administer the drops? Select all that apply. Wash hands Put gloves on Place the drop in the conjunctival sac Pull the lower lid down against the cheekbone Instruct the pt to squeeze the eyes shut after instilling the eye drop Instruct the pt to titl the head forward, open the eyes, and look down

Wash hands Put gloves on Place the drop in the conjunctival sac Pull the lower lid down against the cheekbone

The nurse is teaching the pt how to mix regular insulin and NPH in the same syringe. Which action, if performed by the pt, indicates the need for further teaching? Withdraws the NPH insulin first Withdraws the regular insulin first Injects air into the NPH insulin vial first Injects an amount of air equal to the desired dose of insulin into each vial

Withdraws the NPH insulin first

The HCP prescribes exenatide for a pt with DM Type I who takes insulin. The nurse should plan to take which most appropriate intervention? Withhold the medication & call the HCP, questioning the prescription for the pt. Administer the medication within 60 minutes before the morning and evening meal. Monitor the pt for gastrointestinal side effects after administering the medication. Withdraw the insulin from the prefilled pen into an insulin syringe to prepare for administration.

Withhold the medication & call the HCP, questioning the prescription for the pt.

Which manifestations would the nurse expect in patients with BPH? Select all that apply a. Hesitancy when starting the urine stream b. Decrease in the size and force of the urinary stream c. Frequent urination d. Scrotal tenderness and swelling e. Nocturia

a. Hesitancy when starting the urine stream b. Decrease in the size and force of the urinary stream c. Frequent urination e. Nocturia

The patient is also prescribed finasteride (Proscar). What information should the nurse provide? Select all that apply a. Liver function tests should be monitored b. Most patients see a significant improvement in BPH symptoms in two weeks c. This medication should not be handled by women or children d. Your libido should improve as your symptoms improve

a. Liver function tests should be monitored c. This medication should not be handled by women or children

It is two days later and the patient is preparing for discharge. What is the best analogy for the nurse to use when describing how to contract the pelvic floor muscles? a. Squeeze as if stopping the flow of urine b. Bear down as if having a bowel movement c. Tilt both hips and pelvis forward d. Pull the abdominal muscles toward the spine

a. Squeeze as if stopping the flow of urine

Medication used for glaucoma: Carbonic anhydrase inhibitors Action Adverse reaction Nursing Implications

acetazolamide, methazolamide, dorzolamide Decreases aqueous humor production Oral meds associated w/anaphylaxis, electrolyte loss, depression, impotence, GI upset, weight loss Don't administer to pts w/sulfa allergies; monitor electrolytes

Medication used for glaucoma: Alpha-adrenergic agonist Action Adverse reaction Nursing Implications

apraclonidine, brimonidine Decreases aqueous humor production eye redness, dry mouth teach pt punctal occlusion

Four hours later, the patient reports increased bladder discomfort. The urinary drainage output for the last two hours is minimal. What action should the nurse take? a. Apply gentle pressure over the bladder b. Stop the CBI and irrigate the catheter c. Gradually increase the flow rate of the CBI d. Continue the CBI and notify the surgeon

b. Stop the CBI and irrigate the catheter

Medication used for glaucoma: Beta blockers Action Adverse reaction Nursing Implications

betaxolol, timolol decreases aqueous humor production can have systemic effects--bradycardia, exacerbation of pulmonary disease, hypotension Contraindicated in pts with COPD, heart blocks, HF teach pts punctal occlusion to reduce systemic effects

The patient is prescribed Tamsulosin (Flomax). What information should the nurse provide? a. "Avoid dairy products within two hours of taking this medication." b. "Remain in an upright position for 30 minutes after taking this medication." c. "Change positions slowly, especially when standing up." d. "Wear long-sleeved clothing when going out in direct sunlight."

c. "Change positions slowly, especially when standing up."

The patient states that he is thinking about cutting back on drinking fluids to reduce his symptoms. How should the nurse respond? a. "Restrict fluid intake until you are able to have surgery." b. "Increase your intake of diuretic type fluids, such as coffee or tea, to increase urine flow." c. "Add citrus juice to your daily fluid intake to boost immune defenses against infection." d. "Decreasing fluid intake my increase your risk of developing a urinary tract infection."

d. "Decreasing fluid intake my increase your risk of developing a urinary tract infection."

The provider orders a blood urea nitrogen and serum creatinine test. The patient asks why these tests are necessary since he has already had a prostate exam. How should the nurse respond? a. "If these kidney test results are normal, then your symptoms are not due to prostate enlargement." b. "If these kidney tests are elevated, dehydration, not prostate enlargement, may be the cause of your symptoms." c. "Prostate enlargement may be caused by altered or decreased urine production in the kidneys, which these results will evaluate." d. "If your prostate gland is blocking the flow of your urine, you may have some degree of kidney damage that can be detected with these tests."

d. "If your prostate gland is blocking the flow of your urine, you may have some degree of kidney damage that can be detected with these tests."

The patient asks if he still needs yearly prostate exams. How should the nurse respond? a. "You no longer need rectal exams or prostate specific antigen (PSA) tests." b. "Yearly PSA screenings need to be performed but not rectal exams." c. "You will only need rectal exams but not PSA screenings." d. "You still need yearly rectal exams and PSA screenings."

d. "You still need yearly rectal exams and PSA screenings."

Which assessment finding indicates that the patient is experiencing urinary retention? a. Presence of a bruit auscultated over the renal artery b. Reports of flank pain on gentle palpation c. Presence of frank hematuria d. Bladder distention on palpation

d. Bladder distention on palpation

The patient's symptoms worsen over the next year and the patient undergoes a transurethral resection of the prostate (TURP). After surgery, the patient has a continuous bladder irrigation (CBI) infusing with normal saline. Eight hours postoperatively, the urinary drainage is reddish pink. What action should the nurse take? a. Notify the surgeon of the drainage b. Stop the CBI and irrigate the catheter c. Increase the rate of flow of the CBI d. Document that the CBI is infusing without difficulty

d. Document that the CBI is infusing without difficulty

Medication used for glaucoma: Adrenergic agonist Action Adverse reaction Nursing Implications

dipiverfin, epinephrine reduces production of aqueous humor & increases blood flow eye redness/burning, systemic effects->BP, palpitations, HA teach pts punctal occlusion to reduce systemic effects

Long Acting Insulin generic (Trade) Onset Peak Duration

glargine (Lantus) detemir (Levemir) Onset: 1-2 hours Peak: no pronounced peak Duration: 24+hours

Glaucoma Patho

increased intraocular pressure (IOP) due to decrease in outflow of aqueous fluid through the anterior chamber IOP due to overproduction of aqueous fluid IOP inhibits blood supply to optic nerve & retina

Medication used for glaucoma: Prostoglandin analogues Action Adverse reaction Nursing Implications

latanoprost Increases uveoscleral outflow Darkening of the iris, conjunctival redness, possible rash Instruct pt to report adverse reactions

Ileostomy Stool consistency Fluid requirement Bowel Regulation Pouch & skin barriers Irrigation

liquid to semiliquid incrased No Yes No

Rapid Acting Insulin: generic (Trade) Onset Peak Duration

lispro (Humalog) aspart (Novolog) glulisine (Apidra) Onset: 15 min Peak: 60-90 min Duration: 3-4 hours

Primary medications for seizure disorders

phenytoin (Dilantin)--<Na influx carbamazepine (Tegretol)--<Na influx phenobarbital divalproex (Depakote) lamotrigine (Lamictal)--<Na influx topiramate (Topamax) tiagabine (Gabitril) levetiracetam (Keppra)--<Na influx zonisamide (Zonegran)--<Ca influx gabapentin (Neurontin)**used as add on-->increase effects of GABA

Short Acting Insulin generic (Trade) Onset Peak Duration

regular (Humulin R; Novolin R; ReliOn R) Onset: 30 min-1 hour Peak: 2-3 hours Duration: 3-6 hours

Stress Incontinence

weakened pelvic floor muscles