ATI/Evolve Practice CAHA 2

A 33-yr-old patient has recently been diagnosed with stage II cervical cancer. Which statement by the nurse best explains the diagnosis? a. "The cancer is found at the point of origin only." b. "Tumor cells have been identified in the cervical region." c. "The cancer has been identified in the cervix and the liver." d. "Your cancer was identified in the cervix and has limited local spread."

"Your cancer was identified in the cervix and has limited local spread." (Stage II cancer is associated with limited local spread. Stage 0 denotes cancer in situ or at the point of origin only; stage I denotes tumor limited to the tissue of origin with localized tumor growth. Stage III denotes extensive local and regional spread. Stage IV denotes metastasis such as to the liver.)

A nurse has administered propranolol by IV bolus to a client who is having thyroid storm. Which of the following findings indicates that the client is having a therapeutic response? a. reduction in the effects of thyroid hormone on the heart b. blockage of the release of thyroid hormone from the thyroid gland c. increase in the heart's sensitivity to the thyroid hormone d. increase in the uptake of thyroid hormone by thyroid gland

a. reduction of the effects of thyroid hormone on the heart

The patient is receiving an IV vesicant chemotherapy drug. The nurse notices swelling and redness at the site. What should the nurse do first? a. Ask the patient if the site hurts. b. Turn off the chemotherapy infusion. c. Call the ordering health care provider. d. Administer sterile saline to the reddened area.

b. turn off the chemotherapy infusion

A nurse is assessing a client who has a new diagnosis of Cushing's disease. Which of the following finds should the nurse expect? a. decreased blood pressure b. weight loss c. hirsutism d. increased skin thickness

c. hirsutism (elevated BP, weight gain, and skin thinness)

A nurse is admitting a client who has hyperthyroidism. When assessing the client, the nurse should expect which of the following findings? a. cold intolerance b. lethargy c. tremors d. sunken eyes

c. tremors (diaphoresis, insomnia, weight loss)

The patient with type 1 diabetes mellitus eats a large meal but does not take his insulin as prescribed. In what order do the following physiologic events occur in the development of a hyperglycemic emergency? a. Fat metabolism leads to ketonemia. b. Insufficient insulin in the blood stream c. Fat is mobilized for energy from the adipose tissue. d. Potassium and water are excreted with H+ and ketones in the urine. e. Organic acid accumulation in the blood causes metabolic acidosis.

B, C, A, E, D

A patient has multiple myeloma and will be treated with autologous hematopoietic stem cell transplantation because a suitable donor has not been found. In which order will the following procedures occur? (Answer with a letter followed by a comma and a space (e.g. A, B, C, D).) a. Myeloablative chemotherapy is administered. b. Stem cells are infused after chemotherapy has been eliminated from the body. c. Peripheral stem cells are obtained from the peripheral blood in an outpatient procedure. d. Filgrastim, a granulocyte colony-stimulating factor, is administered with plerixafor (Mozobil). e. Stem cells are treated to remove undetected cancer cells then cryopreserved and stored until needed.

D, C, E, A, B (When the patient donates the stem cells for the autologous hematopoietic stem cell transplantation, first filgrastim or another granulocyte colony-stimulating factor is given along with plerixafor to increase the number of stem cells released from the bone marrow into the bloodstream. Peripheral stem cells are collected at an outpatient center, treated to remove undetected cancer cells, and cryopreserved to be stored for later use. Then the patient is treated with myeloablative chemotherapy to destroy the bone marrow. The preserved stem cells are then infused after the chemotherapy has been eliminated from the patient's body, approximately 24 to 48 hours after the last dose of chemotherapy.)

A nurse is teaching a client who has an autoimmune disease about the adverse effects of long-term corticosteroid therapy. Which of the following effects should the nurse include? a. osteoporosis b. moon-shaped face c. increased risk of infection d. hearing loss e. weight loss

a, b, c

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.)? Select all that apply. a. The level may be increased as a result of dehydration that accompanies hyperglycemia. b. The level may be raised as a result of metabolic ketoacidosis caused by hyperglycemia. c. The level is consistent with renal insufficiency that can develop with renal nephropathy. d. The patient may be excreting extra sodium and retaining potassium because of malnutrition. e. This level demonstrates adequate treatment of the cellulitis and effective serum glucose control.

a, b, c

Patients may reduce the risk of developing cancer using health promotion strategies.Identify strategies which can reduce the risk of developing cancer (select all that apply.). Select all that apply. a. Control weight b. Genetic testing c. Immunizations d. Use sunscreen e. Stop smoking f. Limit alcohol intake

a, b, c, d, e f

The patient and his family are upset that the patient is going through procedures to diagnose cancer. What nursing actions should the nurse use first to facilitate their coping with this situation (select all that apply.)? Select all that apply. a. Maintain hope. b. Exhibit a caring attitude. c. Plan realistic long-term goals. d. Give them antianxiety medications. e. Be available to listen to fears and concerns. f. Teach them about the types of cancer that could be diagnosed.

a, b, d (Maintaining hope, exhibiting a caring attitude, and being available to actively listen to fears and concerns would be the first nursing interventions to use as well as assessing factors affecting coping during the diagnostic period. Providing relief from distressing symptoms for the patient and teaching them about the diagnostic procedures would also be important. Realistic long-term goals and teaching about the type of cancer cannot be done until the cancer is diagnosed. Giving the family antianxiety medications would not be appropriate.)

The patient has anemia and has had laboratory tests done to diagnose the cause. Which results does the nurse know indicates a lack of nutrients needed to produce new red blood cells (RBCs) (select all that apply.)? Select all that apply. a. Increased homocysteine b. Decreased reticulocyte count c. Decreased cobalamin (vitamin B12) d. Increased methylmalonic acid (MMA) e. Elevated erythrocyte sedimentation rate (ESR)

a, c, d, (Increased homocysteine and MMA along with decreased cobalamin (vitamin B12) indicate cobalamin deficiency, which is a nutrient needed for RBC production. Decreased reticulocytes indicate low bone marrow activity in producing RBCs, not available nutrients. Elevated ESR is related to an increased inflammatory process, not anemia.)

When caring for elderly patients with hypertension, which information should the nurse consider when planning care (select all that apply.)? Select all that apply. a. Systolic blood pressure increases with aging. b. Blood pressures should be maintained near 120/80 mm Hg. c. White coat syndrome is prevalent in elderly patients. d. Volume depletion contributes to orthostatic hypotension. e. Blood pressure drops 1 hour postprandially in many older patients. f. Older patients will require higher doses of antihypertensive medications.

a, c, d, e (Systolic blood pressure increases with age and patients older than age 60 years should be maintained below 150/90 mm Hg. Older patients have significantly higher blood pressure readings when taken by health care providers (white coat syndrome). Older patients experience orthostatic hypotension related to dehydration, reduced compensatory mechanisms, and medications. One hour after eating, many older patients experience a drop in blood pressure. Lower doses of medications may be needed to control blood pressures in older adults related to decreased absorption rates and excretion ability.)

What medications should the nurse expect to include in the teaching plan to decrease the risk of cardiovascular events and death for PAD patients (select all that apply.)? Select all that apply. a. Ramipril (Altace) b. Cilostazol (Pletal) c. Simvastatin (Zocor) d. Clopidogrel (Plavix) e. Warfarin (Coumadin) f. Aspirin (acetylsalicylic acid)

a, c, f (Angiotensin-converting enzyme inhibitors (e.g., ramipril [Altace]) are used to control hypertension. Statins (e.g., simvastatin [Zocor]) are used for lipid management. Aspirin is used as an antiplatelet agent. Cilostazol (Pletal) is used for intermittent claudication, but it does not reduce CVD morbidity and mortality risks. Clopidogrel may be used if the patient cannot tolerate aspirin. Anticoagulants (e.g., warfarin [Coumadin]) are not recommended to prevent cardiovascular disease events in PAD patients.)

The nurse assesses a 76-yr-old man with chronic myeloid leukemia receiving chemotherapy using a kinase inhibitor medication. Which question is most important for the nurse to ask? a. "Have you had a fever?" b. "Have you lost any weight?" c. "Has diarrhea been a problem?" d. "Have you noticed any hair loss?"

a. "Have you had a fever?" (An adverse effect of kinase inhibitors is neutropenia. Infection is common in neutropenic patients and is the primary cause of death in cancer patients. Patients should report a temperature of 100.4° F or higher. The other options are possible while undergoing chemotherapy but do not represent the highest priority for assessment.)

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? a. "I will discard any insulin bottle that is cloudy in appearance." b. "The best injection site for insulin administration is in my abdomen." c. "I can wash the site with soap and water before insulin administration." d. "I may keep my insulin at room temperature (75oF) for up to 1 month."

a. "I will discard any insulin bottle that is cloudy in appearance." (Intermediate-acting insulin and combination-premixed insulin will be cloudy in appearance. Routine hygiene such as washing with soap and rinsing with water is adequate for skin preparation for the patient during self-injections. Insulin vials that the patient is currently using may be left at room temperature for up to 4 weeks unless the room temperature is higher than 86°F (30°C) or below freezing (<32°F [0°C]). Rotating sites to different anatomic sites is no longer recommended. Patients should rotate the injection within one particular site, such as the abdomen.)

A nurse is developing a teaching plan for a client who had a thyroidectomy and takes a thyroid replacement. Which of the following instructions should the nurse plan to include? a. "Take this medication on an empty stomach." b. "Take this medication with an antacid." c. "Change position slowly while taking this medication." d. "Limit your fluid intake while taking this medication."

a. "take this medication on an empty stomach."

A nurse is reviewing laboratory values for a client who has DKA. Which of the following results should the nurse expect? a, pH 7.32, PaCO2 36 mm Hg, HCO3- 14 mEq/L b. pH 7.38, PaCO2 55 mm Hg, HCO3- 22 mEq/L c. pH 7.44, PaCO2 40 mm Hg, HCO3- 24 mEq/L d. pH 7.50, PaCO2 42 mm Hg, HCO3- 30 mEq/L

a. (pH should be low, CO2 within normal range, and bicarb should be low)

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

a. A 48-yr-old woman with a hemoglobin A1C of 8.4% (Criteria for a diagnosis of diabetes mellitus include a hemoglobin A1C of 6.5% or greater, fasting plasma glucose level of 126 mg/dL or greater, 2-hour plasma glucose level of 200 mg/dL or greater during an oral glucose tolerance test, or classic symptoms of hyperglycemia or hyperglycemic crisis with a random plasma glucose of 200 mg/dL or greater.)

Which person should the nurse identify as having the highest risk for abdominal aortic aneurysm? a. A 70-yr-old man with high cholesterol and hypertension b. A 40-yr-old woman with obesity and metabolic syndrome c. A 60-yr-old man with renal insufficiency who is physically inactive d. A 65-yr-old woman with hyperhomocysteinemia and substance abuse

a. A 70-yr-old man with high cholesterol and hypertension (The most common etiology of descending abdominal aortic aneurysm (AAA) is atherosclerosis. Male gender, age 65 years or older, and tobacco use are the major risk factors for AAAs of atherosclerotic origin. Other risk factors include the presence of coronary or peripheral artery disease, high blood pressure, and high cholesterol.)

Previous administrations of chemotherapy agents to a cancer patient have resulted in diarrhea. Which dietary modification should the nurse recommend? a. A bland, low-fiber diet b. A high-protein, high-calorie diet c. A diet high in fresh fruits and vegetables d. A diet emphasizing whole and organic foods

a. A bland, low-fiber diet (Patients experiencing diarrhea secondary to chemotherapy or radiation therapy often benefit from a diet low in seasonings and roughage before the treatment. Foods should be easy to digest and low in fat. Fresh fruits and vegetables are high in fiber and should be minimized during treatment. Whole and organic foods do not prevent diarrhea)

Which patient has the highest risk of developing malignant melanoma? a. A fair-skinned woman who uses a tanning booth regularly b. An African American patient with a family history of cancer c. An adult who required phototherapy as an infant for the treatment of hyperbilirubinemia d. A Hispanic man with a history of psoriasis and eczema that responded poorly to treatment

a. A fair-skinned woman who uses a tanning booth regularly (Risk factors for malignant melanoma include a fair complexion and exposure to ultraviolet light. Psoriasis, eczema, short-duration phototherapy, and a family history of other cancers are less likely to be linked to malignant melanoma.)

The nurse should recognize that which patient is likely to have the poorest prognosis? a. A patient who is being treated for stage IV malignant melanoma b. A patient diagnosed with nodular ulcerative basal cell carcinoma c. A patient who has been diagnosed with late squamous cell carcinoma d. A patient whose biopsy has revealed superficial squamous cell carcinoma

a. A patient who is being treated for stage IV malignant melanoma (Late detection of malignant melanoma is associated with a poor outcome. Basal cell carcinomas often have very effective treatment success rates. Although late squamous cell carcinoma (SCC) has worse outcomes than superficial SCC, these are both exceeded in mortality rates by late-stage malignant melanoma.)

A nurse is managing care of a client who is postoperative and experiencing acute adrenal insufficiency. Which of the following actions should the nurse take? a. Administer IV hydrocortisone sodium. b. Give oral spironolactone. c. Infuse 1 unit of platelets. d. Restrict daily fluid intake.

a. Administer IV hydrocortisone sodium

Despite a high dosage, a male patient who is taking nifedipine (Procardia XL) for antihypertensive therapy continues to have blood pressures over 140/90 mm Hg. What should the nurse do next? a. Assess his adherence to therapy. b. Ask him to make an exercise plan. c. Instruct him to use the DASH diet. d. Request a prescription for a thiazide diuretic.

a. Assess his adherence to therapy. (A long-acting calcium-channel blocker such as nifedipine causes vascular smooth muscle relaxation, resulting in decreased systemic vascular resistance and arterial blood pressure and related side effects. The patient data the nurse has about this patient is very limited, so the nurse needs to begin by assessing adherence to therapy.)

The nurse is teaching a wellness class to a group of women at their workplace. Which findings represent the highest risk for developing cancer? a. Body mass index of 35 kg/m2 and smoking cigarettes for 20 years b. Family history of colorectal cancer and consumes a high-fiber diet c. Limits fat consumption and has regular mammography and Pap screenings d. Exercises five times every week and does not consume alcoholic beverages

a. Body mass index of 35 kg/m2 and smoking cigarettes for 20 years (Cancer prevention and early detection are associated with the following behaviors: limited alcohol use, regular physical activity, maintaining a normal body weight, obtaining regular cancer screenings, avoiding cigarette smoking and other tobacco use, using sunscreen with SPF 15 or higher, and practicing healthy dietary habits (e.g., reduced fat and increased fruits and vegetables).)

The laboratory reports that the cells from the patient's tumor biopsy are grade II. What should the nurse know about this histologic grading? a. Cells are abnormal and moderately differentiated. b. Cells are very abnormal and poorly differentiated. c. Cells are immature, primitive, and undifferentiated. d. Cells differ slightly from normal cells and are well-differentiated.

a. Cells are abnormal and moderately differentiated. (Grade II cells are more abnormal than grade I and moderately differentiated. Grade I cells differ slightly from normal cells and are well-differentiated. Grade III cells are very abnormal and poorly differentiated. Grade IV cells are immature, primitive, and undifferentiated; the cell origin is difficult to determine.)

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? a. Chooses a puncture site in the center of the finger pad b. Washes hands with soap and water to cleanse the site to be used c. Warms the finger before puncturing the finger to obtain a drop of blood d. Tells the nurse that the result of 110 mg/dL indicates good control of diabetes

a. Chooses a puncture site in the center of the finger pad (The patient should select a site on the sides of the fingertips, not on the center of the finger pad because this area contains many nerve endings and would be unnecessarily painful. Washing hands, warming the finger, and knowing the results that indicate good control all show understanding of the teaching.)

The nurse supervises an unlicensed assistant personnel (UAP) who is taking the blood pressure of 58-yr-old obese female patient admitted with heart failure. Which action by the UAP will require the nurse to intervene? a. Waiting 2 minutes after position changes to take orthostatic pressures b. Deflating the blood pressure cuff at a rate of 8 to 10 mm Hg per second c. Taking the blood pressure with the patient's arm at the level of the heart d. Taking a forearm blood pressure because the largest cuff will not fit the patient's upper arm

a. Deflating the blood pressure cuff at a rate of 8 to 10 mm Hg per second (The cuff should be deflated at a rate of 2 to 3 mm Hg per second. The arm should be supported at the level of the heart for accurate blood pressure measurements. Using a cuff that is too small causes a falsely high reading and too large causes a falsely low reading. If the maximum size blood pressure cuff does not fit the upper arm, the forearm may be used. Orthostatic blood pressures should be taken within 1 to 2 minutes of repositioning the patient.)

A nurse is monitoring the lab values of a client who has diabetes mellitus and is taking insulin. Which of the following results indicates a therapeutic outcome of insulin therapy? a. Fasting blood glucose 96 mg/dL b. Postprandial blood glucose 195 mg/dL c. Casual blood glucose 210 mg/dL d. Preprandial blood glucose 60 mg/dL

a. Fasting blood glucose 96 mg/dL

The nurse teaches a patient with hypertension that uncontrolled hypertension may damage organs in the body primarily by which mechanism? a. Hypertension promotes atherosclerosis and damage to the walls of the arteries. b. Hypertension causes direct pressure on organs, resulting in necrosis and replacement of cells with scar tissue. c. Hypertension causes thickening of the capillary membranes, leading to hypoxia of organ systems. d. Hypertension increases blood viscosity, which contributes to intravascular coagulation and tissue necrosis distal to occlusions.

a. Hypertension promotes atherosclerosis and damage to the walls of the arteries. (Hypertension is a major risk factor for the development of atherosclerosis by mechanisms not yet fully known. However, when atherosclerosis develops, it damages the walls of arteries and reduces circulation to target organs and tissues.)

Results of a patient's most recent blood work indicate an elevated neutrophil level. The nurse recognizes that this diagnostic finding most likely suggests which problem? a. Infection b. Hypoxemia c. Acute thrombotic event d. Risk of hypocoagulation

a. Infection (An increase in the neutrophil count most commonly occurs in response to infection or inflammation. Hypoxemia and coagulation do not directly affect neutrophil production).

A nurse is monitoring a client's status 24 hours after a total thyroidectomy. Which of the following findings should the nurse report to the provider? a. Laryngeal stridor b. Productive cough c. Pain with hyperextension of the neck d. Hoarse, weak voice

a. Laryngeal stridor (Laryngeal stridor is a harsh, high-pitched sound with inspiration that indicates respiratory obstruction. The nurse should take immediate action to preserve the client's airway.)

The patient has chronic venous insufficiency and a venous ulcer. The unlicensed assistive personnel (UAP) decides to apply compression stockings because that is what patients 'always' have ordered. Which assessment finding would indicate the application of compression stockings could harm the patient? a. Rest pain b. High blood pressure c. Elevated blood sugar d. Dry, itchy, flaky skin

a. Rest pain (Rest pain occurs as peripheral artery disease (PAD) progresses and involves multiple arterial segments. Compression stockings should not be used on patients with PAD. Elevated blood glucose, possibly indicating uncontrolled diabetes mellitus, and hypertension may or may not indicate arterial problems. Dry, itchy, flaky skin indicates venous insufficiency. The RN should be the one to obtain the order and instruct the UAP to apply compression stockings if they are ordered.)

A nurse is teaching a client about glycosylated hemoglobin (HbA1c) testing. Which of the following statements should the nurse identify as an indication that the client understands the information about this test? a. "I need to fast after midnight the night before the test." b. "This test's result is a good indicator of my average blood glucose levels." c. "A level of eight to ten percent suggests adequate blood glucose control." d. "I will use my hemoglobin A1c level to adjust my daily insulin doses."

b. "This test's result is a good indicator of my average blood glucose levels."

The nurse is admitting a 68-yr-old preoperative patient with a suspected abdominal aortic aneurysm (AAA). The medication history reveals that the patient has been taking warfarin (Coumadin) on a daily basis. Based on this history and the patient's admission diagnosis, the nurse should prepare to administer which medication? a. Vitamin K b. Cobalamin c. Heparin sodium d. Protamine sulfate

a. Vitamin K (Coumadin is a vitamin K antagonist anticoagulant that could cause excessive bleeding during surgery if clotting times are not corrected before surgery. For this reason, vitamin K is given as the antidote for warfarin (Coumadin).)

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? a. Assess patient's perception of what it means to have diabetes. b. Ask the patient to write down current knowledge about diabetes. c. Set goals for the patient to actively participate in managing his diabetes. d. Assume responsibility for all of the patient's care to decrease stress level.

a. assess patient's perception of what it means to have diabetes (For teaching to be effective, the first step is to assess the patient. Teaching can be individualized after the nurse is aware of what a diagnosis of diabetes means to the patient. After the initial assessment, current knowledge can be assessed, and goals should be set with the patient. Assuming responsibility for all of the patient's care will not facilitate the patient's health.)

A nurse is caring for a client who has pheochromocytoma. Which of the following actions should the nurse take? a. elevate the head of the client's bed b. palpate the client's abdomen c. monitor the client for hypotension d. check the client's urine specific gravity

a. elevate the head of the bed (to reduce blood pressure and abdominal pressure)

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

a. excessive thirst

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? a. Increased triglyceride levels b. Increased high-density lipoproteins (HDL) c. Decreased low-density lipoproteins (LDL) d. Decreased very-low-density lipoproteins (VLDL)

a. increased triglycerides (Macrovascular complications of diabetes include changes to large- and medium-sized blood vessels. They include cerebrovascular, cardiovascular, and peripheral vascular disease. Increased triglyceride levels are associated with these macrovascular changes. Increased HDL, decreased LDL, and decreased VLDL are positive in relation to atherosclerosis development.)

A nurse is assessing a client who has a syndrome of inappropriate ADH. Which of the following findings should the nurse report to the provider? a. Sodium 110 mEq/L b. 2+ deep-tendon reflexes c. Potassium 3.7 mEq/L d. Urine specific gravity 1.025

a. sodium 110 (a client with SIADH retains fluids, which causes dilutional hyponatremia)

Which assessment findings of the left lower extremity will the nurse identify as consistent with arterial occlusion (select all that apply.)? Select all that apply. a. Edematous b. Cold and mottled c. Complaints of paresthesia d. Pulse not palpable with Doppler e. Capillary refill less than three seconds f. Erythema and warmer than right lower extremity

b, c, d (Arterial occlusion may result in loss of limb if not timely revascularized. When an artery is occluded, perfusion to the extremity is impaired or absent. On assessment, the nurse would note a cold, mottled extremity with impaired sensation or numbness. The pulse would not be identified, even with a Doppler. In contrast, the nurse would find edema, erythema, and increased warmth in the presence of a venous occlusion (deep vein thrombosis). Capillary refill would be greater than 3 seconds in an arterial occlusion and less than 3 seconds with a venous occlusion.)

A nurse is providing discharge teaching for a client who has diabetes insipidus and has a new prescription for desmopressing nasal spray. Which of the following instructions should the nurse include in the teaching? a. "Depress the pump once before using the nasal spray for the first time." b. "Blow your nose gently prior to using the nasal spray." c. "Administer the nasal spray while in a side-lying position." d. "Instill the medication four times per day."

b. "Blow your nose gently prior to using the nasal spray."

Which statement by the nurse most facilitates patient cancer prevention during the promotion stage of cancer development? a. "Exercise every day for 30 minutes." b. "Follow smoking cessation recommendations." c. "Following a vitamin regime is highly recommended." d. "I recommend excision of the cancer as soon as possible."

b. "Follow smoking cessation recommendations." (The promotion stage of cancer is characterized by the reversible proliferation of the altered cells. Changing the lifestyle to avoid promoting factors (dietary fat, obesity, cigarette smoking, and alcohol consumption) can reduce the chance of cancer development. Cigarette smoking is a promoting factor and a carcinogen. Daily exercise and vitamins alone will not prevent cancer. Surgery at this stage may not be possible without a critical mass of cells, and this advice would not be consistent with the nurse's role.)

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. "Smokeless tobacco products decrease the risk of kidney damage." b. "I can help control my blood pressure by avoiding foods high in salt." c. "I should have yearly dilated eye examinations by an ophthalmologist." d. "I will avoid hypoglycemia by keeping my blood sugar above 180 mg/dL."

b. "I can help control my blood pressure by avoiding foods high in salt." (Diabetic nephropathy is a microvascular complication associated with damage to the small blood vessels that supply the glomeruli of the kidney. Risk factors for the development of diabetic nephropathy include hypertension, genetic predisposition, smoking, and chronic hyperglycemia. Patients with diabetes are screened for nephropathy annually with a measurement of the albumin-to-creatinine ratio in urine; a serum creatinine is also needed.)

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

b. "I may have a hypoglycemic reaction if I drink alcohol on an empty stomach." (Eating carbohydrates when drinking alcohol reduces the risk for alcohol-induced hypoglycemia. Intensified insulin therapy, such as the use of an insulin pump, allows considerable flexibility in food selection and can be adjusted for alterations from usual eating and exercise habits. However, saturated fat intake should still be limited to less than 7% of total daily calories. Daily fiber intake of 14 g/1000 kcal is recommended for the general population and for patients with diabetes mellitus. High-protein diets are not recommended for weight loss.)

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? a. "I should only walk barefoot in nice dry weather." b. "I should look at the condition of my feet every day." c. "I am lucky my shoes fit so nice and tight because they give me firm support." d. "When I am allowed up out of bed, I should check the shower water with my toes."

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

A patient with varicose veins has been prescribed compression stockings. Which nursing instruction would be most appropriate? a. "Try to keep your stockings on 24 hours a day, as much as possible." b. "While you're still lying in bed in the morning, put on your stockings." c. "Dangle your feet at your bedside for 5 minutes before putting on your stockings." d. "Your stockings will be most effective if you can remove them for a few minutes several times a day."

b. "While you're still lying in bed in the morning, put on your stockings." (The patient with varicose veins should apply stockings in bed before rising in the morning. Stockings should not be worn continuously and should not be removed several times daily. Dangling at the bedside before application is likely to decrease their effectiveness.)

Which patient is statistically and medically at the highest risk of developing cancer? a. A 68-yr-old white woman who has BRCA-1 gene and is obese b. A 56-yr-old African American man with hepatitis C who drinks alcohol daily c. An 18-yr-old Hispanic man who eats fast food once per week and drink alcohol d. An 80-yr-old Asian woman with coronary artery disease on blood pressure medication.

b. A 56-yr-old African American man with hepatitis C who drinks alcohol daily (The combination of statistically identified risk factors in addition to current liver disease (hepatitis C that is linked to the development of liver cancer) and the added promotor of alcohol makes this patient at the highest risk. Second is the white woman with the gene for breast cancer and the added promotor of obesity. The majority of cancer cases are diagnosed in individuals older than 55 years of age. The overall incidence of cancer is higher in men than women. Cancer incidence is higher in African Americans, then whites, and then people from other cultures.)

A patient with critical limb ischemia had peripheral artery bypass surgery to improve circulation. What nursing care should be provided on postoperative day 1? a. Keep patient on bed rest. b. Assist patient to walk several times. c. Have patient sit in the chair several times. d. Place patient on their side with knees flexed.

b. Assist patient to walk several times. (To avoid blockage of the graft or stent, the patient should walk several times on postoperative day 1 and subsequent days. Having the patient's knees flexed for sitting in a chair or in bed increase the risk of venous thrombosis and may place stress on the suture lines.)

The nurse is caring for a patient admitted with a history of hypertension. The patient's medication history includes hydrochlorothiazide daily for the past 10 years. Which parameter would indicate the optimal intended effect of this drug therapy? a. Weight loss of 2 lb b. BP 128/86 mm Hg c. Absence of ankle edema d. Output of 600 mL per 8 hours

b. BP 128/86 mm Hg (Hydrochlorothiazide may be used alone as monotherapy to manage hypertension or in combination with other medications if not effective alone. After the first few weeks of therapy, the diuretic effect diminishes, but the antihypertensive effect remains. Because the patient has been taking this medication for 10 years, the most direct measurement of its intended effect would be the blood pressure.)

The nurse admits a 73-yr-old male patient with dementia for treatment of uncontrolled hypertension. The nurse will closely monitor for hypokalemia if the patient receives which medication? a. Clonidine (Catapres) b. Bumetanide (Bumex) c. Amiloride (Midamor) d. Spironolactone (Aldactone)

b. Bumetanide (Bumex) (Bumetanide is a loop diuretic. Hypokalemia is a common adverse effect of this medication. Amiloride is a potassium-sparing diuretic. Spironolactone is an aldosterone-receptor blocker. Hyperkalemia is an adverse effect of both amiloride and spironolactone. Clonidine is a central-acting α-adrenergic antagonist and does not cause electrolyte abnormalities.)

The nurse is providing care for older adults on a subacute, geriatric medical unit. What effect does aging have on hematologic function of older adults? a. Thrombocytosis b. Decreased hemoglobin c. Decreased WBC count d. Decreased blood volume

b. Decreased hemoglobin (Older adults frequently experience decreased hemoglobin levels as a result of changes in erythropoiesis. Decreased blood volume, decreased WBCs, and alterations in platelet number are not considered to be normal, age-related hematologic changes.)

A 73-yr-old man with dementia has a venous ulcer related to chronic venous insufficiency. The nurse should provide teaching on which type of diet for this patient and his caregiver? a. Low-fat diet b. High-protein diet c. Calorie-restricted diet d. High-carbohydrate diet

b. High-protein diet (A patient with a venous ulcer should have a balanced diet with adequate protein, calories, and micronutrients; this type of diet is essential for healing. Nutrients most important for healing include protein, vitamins A and C, and zinc. Foods high in protein (e.g., meat, beans, cheese, tofu), vitamin A (green leafy vegetables), vitamin C (citrus fruits, tomatoes, cantaloupe), and zinc (meat, seafood) must be provided. Restricting fat or calories is not helpful for wound healing or in patients of normal weight. For overweight individuals with no active venous ulcer, a weight-loss diet should be considered.)

The nurse is caring for a patient receiving an initial dose of chemotherapy to treat a rapidly growing metastatic colon cancer. The nurse is aware that the patient is at risk for tumor lysis syndrome (TLS) and will monitor for which abnormality associated with this oncologic emergency? a. Hypokalemia b. Hypocalcemia c. Hypouricemia d. Hypophosphatemia

b. Hypocalcemia (TLS is a metabolic complication characterized by rapid release of intracellular components in response to chemotherapy. This can rapidly lead to acute renal injury. The hallmark signs of TLS are hyperuricemia, hyperphosphatemia, hyperkalemia, and hypocalcemia.)

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

b. Microangiopathy is specific to diabetes and most commonly affects the capillary membranes of the eyes, kidneys, and skin. (Microangiopathy occurs in diabetes mellitus. When it affects the eyes, it is called diabetic retinopathy. When the kidneys are affected, the patient has nephropathy. When the skin is affected, it can lead to diabetic foot ulcers. Macroangiopathy can occur in either type 1 or type 2 diabetes and contributes to cerebrovascular, cardiovascular, and peripheral vascular disease. Sexual impotency and slowed gastric emptying result from microangiopathy and neuropathy.)

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? a. 6:00 PM on the evening before the test b. Midnight before the test c. 4:00 AM on the day of the test d. 7:00 AM on the day of the test

b. Midnight before the test (Typically, a patient is ordered to be NPO for 8 hours before a fasting blood glucose level. For this reason, the patient who has a lab draw at 8:00 AM should not have any food or beverages containing any calories after midnight.)

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? a. Avoid sick people and wash hands. b. Obtain comprehensive dental care. c. Maintain hemoglobin A1C below 7%. d. Coughing and deep breathing with splinting

b. Obtain comprehensive dental care. (A person with diabetes is at high risk for postoperative infections. The most important preoperative teaching to prevent a postoperative infection in the heart is to have the patient obtain comprehensive dental care because the risk of septicemia and infective endocarditis increases with poor dental health. Avoiding sick people, hand washing, maintaining hemoglobin A1C below 7%, and coughing and deep breathing with splinting would be important for any type of surgery but are not the priority for this patient with mitral valve replacement.)

A patient was just diagnosed with acute arterial ischemia in the left leg secondary to atrial fibrillation. Which early clinical manifestation must be reported to the physician immediately to save the patient's limb? a. Paralysis b. Paresthesia c. Cramping d. Referred pain

b. Paresthesia (The physician must be notified immediately if any of the six Ps of acute arterial ischemia occur to prevent ischemia from quickly progressing to tissue necrosis and gangrene. The six Ps are paresthesia, pain, pallor, pulselessness, and poikilothermia, with paralysis being a very late sign indicating the death of nerves to the extremity. Crampy leg sensation is more common with varicose veins. The pain is not referred.)

A 67-yr-old man with peripheral artery disease is seen in the primary care clinic. Which symptom reported by the patient would indicate to the nurse that the patient is experiencing intermittent claudication? a. Patient complains of chest pain with strenuous activity. b. Patient says muscle leg pain occurs with continued exercise. c. Patient has numbness and tingling of all his toes and both feet. d. Patient states the feet become red if he puts them in a dependent position.

b. Patient says muscle leg pain occurs with continued exercise. (Intermittent claudication is an ischemic muscle ache or pain that is precipitated by a consistent level of exercise, resolves within 10 minutes or less with rest, and is reproducible. Angina is the term used to describe chest pain with exertion. Paresthesia is the term used to describe numbness or tingling in the toes or feet. Reactive hyperemia is the term used to describe redness of the foot; if the limb is in a dependent position the term is dependent rubor.)

The nurse is caring for a patient with hypertension who is scheduled to receive a dose of metoprolol (Lopressor). The nurse should withhold the dose and consult the prescribing physician for which vital sign taken just before administration? a. O2 saturation 93% b. Pulse 48 beats/min c. Respirations 24 breaths/min d. Blood pressure 118/74 mm Hg

b. Pulse 48 beats/min (Because metoprolol is a β1-adrenergic blocking agent, it can cause hypotension and bradycardia as adverse effects. The nurse should withhold the dose and consult with the health care provider for parameters regarding pulse rate limits.)

When teaching a patient about dietary management of stage 1 hypertension, which instruction is most appropriate? a. Increase water intake. b. Restrict sodium intake. c. Increase protein intake. d. Use calcium supplements.

b. Restrict sodium intake. (The patient should decrease intake of sodium. This will help to control hypertension, which can be aggravated by excessive salt intake, which in turn leads to fluid retention. Protein intake does not affect hypertension. Calcium supplements are not recommended to lower blood pressure.)

When providing dietary instruction to a patient with hypertension, the nurse would advise the patient to restrict intake of which meat? a. Broiled fish b. Roasted duck c. Roasted turkey d. Baked chicken breast

b. Roasted duck (Roasted duck is high in fat, which should be avoided by the patient with hypertension. Weight loss may slow the progress of atherosclerosis and overall cardiovascular disease risk. The other meats are lower in fat and are therefore acceptable in the diet.)

In caring for a patient admitted with poorly controlled hypertension, which laboratory test result should the nurse understand as indicating the presence of target organ damage? a. Serum uric acid of 3.8 mg/dL b. Serum creatinine of 2.6 mg/dL c. Serum potassium of 3.5 mEq/L d. Blood urea nitrogen of 15 mg/dL

b. Serum creatinine of 2.6 mg/dL (The normal serum creatinine level is 0.6 to 1.3 mg/dL. This elevated level indicates target organ damage to the kidneys. The other laboratory results are within normal limits.)

The patient had aortic aneurysm repair 6 hours ago. What priority nursing action will maintain graft patency? a. Assess output for renal dysfunction. b. Use IV fluids to maintain adequate BP. c. Use oral antihypertensives to maintain cardiac output. d. Maintain a low BP to prevent pressure on surgical site.

b. Use IV fluids to maintain adequate BP. (The priority is to maintain an adequate blood pressure (BP) (determined by the surgeon) to maintain graft patency. A prolonged low BP may result in graft thrombosis, and hypertension may cause undue stress on arterial anastomoses resulting in leakage of blood or rupture at the suture lines, which is when IV antihypertensives may be used. Renal output will be assessed when the aneurysm repair is above the renal arteries to assess graft patency, not maintain it.)

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

b. a 73-year-old patient who takes propranolol

A nurse is caring for a client following a thyroidectomy. The nurse should assess for which of the following as an indication of hypocalcemia? a. Strong, bounding pulse b. Decreased bowel sounds c, Tingling and numbness of the hands and feet d. Diminished deep-tendon reflexes

c. tingling and numbness of the hands and feet (hypocalcemia causes paresthesias which start in the hands and feet. also causes hyperactive deep tendon reflexes)

A nurse is assessing a client who has diabetes mellitus and reports feeling anxious. Which of the following findings should the nurse expect if the client is hypoglycemic? a. rapid, deep respirations b. cool, clammy skin c. abdominal cramping d. orthostatic hypotension

b. cool, clammy skin (plus anxiety, nervousness, tachycardia, and confusion)

A nurse is assessing a client who has diabetes insipidus. The nurse should expect which of the following findings? a. decreased heart rate b. increased hematocrit c. high urine specific gravity d. low BUN

b. increased hematocrit (dehydration)

A nurse is providing teaching for a client who has type I diabetes mellitus. Which of the following instructions should the nurse include? a. Consume no more than three servings of alcohol per day. b. Ingest alcohol with food to reduce alcohol-induced hypoglycemia. c. Increase insulin dosage before planned exercise. d. Rest for 3 days between periods of vigorous exercise.

b. ingest alcohol with food to reduce alcohol-induced hypoglycemia

A nurse is caring for a client who has diabetes mellitus and has developed periopheral neuropathy. Which of the following measures should the nurse recommend to prevent injuries to the client's feet? a. examine the skin and feet weekly b. monitor the temperature of bath water with a thermometer c. shop for shoes earlier in the day d. round the edges of toenails when trimming them

b. monitor the temperature of bath water with a thermometer

A 62-yr-old Hispanic male patient with diabetes mellitus has been diagnosed with peripheral artery disease (PAD). The patient is a smoker with a history of gout. To prevent complications, which factor is priority in patient teaching? a. Gender b. Smoking c. Ethnicity d. Comorbidities

b. smoking

The nurse is teaching a women's group about prevention of hypertension. What information should be included in the teaching for all the women (select all that apply.)? Select all that apply. a. Lose weight. b. Limit nuts and seeds. c. Limit sodium and fat intake. d. Increase fruits and vegetables. e. Exercise 30 minutes most days.

c, d, e (Primary prevention of hypertension is to make lifestyle modifications that prevent or delay the increase in BP. Along with exercise for 30 minutes on most days, the DASH eating plan is a healthy way to lower BP by limiting sodium and fat intake, increasing fruits and vegetables, and increasing nutrients that are associated with lowering BP. Nuts and seeds and dried beans are used for protein intake. Weight loss may or may not be necessary for the individual.)

The nurse teaches a 28-yr-old man newly diagnosed with hypertension about lifestyle modifications to reduce his blood pressure. Which patient statement requires reinforcement of teaching? a. "I will avoid adding salt to my food during or after cooking." b. "If I lose weight, I might not need to continue taking medications." c. "I can lower my blood pressure by switching to smokeless tobacco." d. "Diet changes can be as effective as taking blood pressure medications."

c. "I can lower my blood pressure by switching to smokeless tobacco." (Nicotine contained in tobacco products (smoking and chew) cause vasoconstriction and increase blood pressure. Persons with hypertension should restrict sodium to 1500 mg/day by avoiding foods high in sodium and not adding salt in preparation of food or at meals. Weight loss can decrease blood pressure between 5 to 20 mm Hg. Following dietary recommendations (e.g., the DASH diet) lowers blood pressure, and these decreases compare with those achieved with blood pressure-lowering medication.)

A nurse is teaching a patient with type I diabetes mellitus how to prevent complications during illness. Which of the following statements should the nurse identify as an indication that the client understands the teaching? a. "I should stop taking my insulin if I feel nauseous." b. "I will test my urine for protein when I start to feel ill." c. "I will call my doctor if my blood sugar is more than 250 milligrams per deciliter." d. "I should check my blood glucose level every 8 hours."

c. "I will call my doctor if my blood sugar is more than 250 milligrams per deciliter." (check every 4 hours and check for ketones, not protein)

The patient has osteosarcoma of the right leg. The unlicensed assistive personnel (UAP) reports that the patient's vital signs are normal, but the patient says he still has pain in his leg and it is getting worse. Which question would best determine treatment measures for the patient's pain? a. "Where is the pain?" b. "Is the pain getting worse?" c. "What does the pain feel like?" d. "Do you use medications to relieve the pain?"

c. "What does the pain feel like?" (The UAP told the nurse the location of the patient's pain and the patient reports worsening of pain (pattern). Asking about the quality of the pain will help in planning further treatment. The nurse should already know if the patient is using medication to relieve the pain or can check the patient's medication administration record to see if analgesics have been administered. The intensity of pain using a pain scale should also be assessed.)

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

c. "With type 2 diabetes, insulin secretion is decreased, and insulin resistance is increased." (In type 2 diabetes mellitus, the secretion of insulin by the pancreas is reduced and/or the cells of the body become resistant to insulin. The pancreas becomes inflamed with pancreatitis. The patient is totally dependent on exogenous insulin and may have had autoantibodies destroy the β-cells in the pancreas with type 1 diabetes mellitus.)

A female patient is having chemotherapy for brain metastasis. She is concerned about how she will look when she loses her hair. What is the best response by the nurse to this patient? a. "When your hair grows back, it will be patchy." b. "Don't use your curling iron, and that will slow down the loss." c. "You can get a wig now to match your hair so you will not look different." d. "You should contact "Look Good, Feel Better" to figure out what to do about this."

c. "You can get a wig now to match your hair so you will not look different." (The best response by the nurse is to suggest getting a wig before she loses her hair so she will not look or feel so different. Although hair loss with chemotherapy is usually reversible, hair loss with radiation is usually permanent in the areas radiation was administered. When hair grows back it could be a different color or texture. Avoiding use of electric hair dryers, curlers, and curling irons may slow the hair loss but will not answer the patient's concern. The American Cancer Society's "Look Good, Feel Better" program will be helpful, but this response is avoiding the patient's immediate concern.)

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? a. 8:40 PM to 9:00 PM b. 9:00 PM to 11:30 PM c. 10:30 PM to 1:30 AM d. 12:30 AM to 8:30 AM

c. 10:30-1:30 (Regular insulin exerts peak action in 2 to 5 hours, making the patient most at risk for hypoglycemia between 10:30 PM and 1:30 AM. Rapid-acting insulin's onset is between 10 and 30 minutes with peak action and hypoglycemia most likely to occur between 9:00 PM and 11:30 PM. With intermediate acting insulin, hypoglycemia may occur from 12:30 AM to 8:30 AM.)

The nurse is teaching about skin cancer prevention at the community center. Which person is most at risk for developing skin cancer? a. A 67-yr-old bald-headed man with psoriasis and type 2 diabetes mellitus b. A 76-yr-old Hispanic man who has a latex allergy and numerous acrochordons c. A 55-yr-old woman with fair skin and red hair who has a family history of skin cancer d. A 62-yr-old woman with chronic kidney disease who has blond hair with dry, pale skin

c. A 55-yr-old woman with fair skin and red hair who has a family history of skin cancer (Risk factors for skin cancer include having fair skin (with red hair) and a family history of skin cancer. Allergies, acrochordons (skin tags), psoriasis, type 2 diabetes mellitus, and chronic kidney disease are not risk factors associated with the development of skin cancer.)

A nurse is caring for a client who is taking propylthiouracil. The nurse should identify that the client has met the treatment goals when she reports an increase in which of the following manifestations? a. sweating b. stools c. weight d. appetite

c. weight

The patient was told that he would have intraperitoneal chemotherapy. He asks the nurse when the IV will be started for the chemotherapy. What should the nurse teach the patient about this type of chemotherapy delivery? a. It is delivered via an Ommaya reservoir and extension catheter. b. It is instilled in the bladder via a urinary catheter and retained for 1 to 3 hours. c. A Silastic catheter will be percutaneously placed in the abdomen for chemotherapy administration. d. The arteries supplying the tumor are accessed with surgical placement of a catheter connected to an infusion pump.

c. A Silastic catheter will be percutaneously placed in the abdomen for chemotherapy administration. (Intraperitoneal chemotherapy is delivered to the peritoneal cavity via a temporary percutaneously inserted Silastic catheter and drained from this catheter after the dwell time in the peritoneum. The Ommaya reservoir is used for intraventricular chemotherapy. Intravesical bladder chemotherapy is delivered via a urinary catheter. Intraarterial chemotherapy is delivered via a surgically placed catheter that delivers chemotherapy via an external or internal infusion pump.)

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? a. Routine insulin therapy and exercise b. Administer a different antibiotic for the UTI. c. Cardiac monitoring to detect potassium changes d. Administer IV fluids rapidly to correct dehydration.

c. Cardiac monitoring to detect potassium changes (This patient has manifestations of hyperosmolar hyperglycemic syndrome (HHS). Cardiac monitoring will be needed because of the changes in the potassium level related to fluid and insulin therapy and the osmotic diuresis from the elevated serum glucose level. Routine insulin would not be enough, and exercise could be dangerous for this patient. Extra insulin will be needed. The type of antibiotic will not affect HHS. There will be a large amount of IV fluid administered, but it will be given slowly because this patient is older and may have cardiac or renal compromise, requiring hemodynamic monitoring to avoid fluid overload during fluid replacement.)

A patient with a history of chronic hypertension is being evaluated in the emergency department for a blood pressure of 200/140 mm Hg. Which patient assessment question is the priority? a. Is the patient pregnant? b. Does the patient need to urinate? c. Does the patient have a headache or confusion? d. Is the patient taking antiseizure medications as prescribed?

c. Does the patient have a headache or confusion? (The nurse's priority assessments include neurologic deficits, retinal damage, heart failure, pulmonary edema, and renal failure. The headache or confusion could be seen with hypertensive encephalopathy from increased cerebral capillary permeability leading to cerebral edema. In addition, headache or confusion could represent signs and symptoms of a hemorrhagic stroke. Pregnancy can lead to secondary hypertension. Needing to urinate and taking antiseizure medication do not support a hypertensive emergency.)

A nurse is teaching a client who has diabetes mellitus about insulin injections. The cleitn's prescription includes evening doses of insulin glargine and regular insulin. Which of the following instructions should the nurse include? a. Inject the insulins intramuscularly. b. Shake the insulins vigorously prior to administration. c. Draw up the insulins into separate syringes. d. Expect the insulins to appear cloudy.

c. Draw up the insulins into separate syringes

When teaching how lisinopril (Zestril) will help lower the patient's blood pressure, which mechanism of action should the nurse explain? a. Blocks β-adrenergic effects b. Relaxes arterial and venous smooth muscle c. Inhibits conversion of angiotensin I to angiotensin II d. Reduces sympathetic outflow from central nervous system

c. Inhibits conversion of angiotensin I to angiotensin II

The patient is told that her adenoma tumor is not encapsulated but has normally differentiated cells and surgery will be needed. The patient asks the nurse what this means. What should the nurse tell the patient? a. It will recur. b. It has metastasized. c. It is probably benign. d. It is probably malignant.

c. It is probably benign. (Benign tumors are usually encapsulated, have normally differentiated cells, and do not metastasize. Malignant tumors are rarely encapsulated, have poorly differentiated cells, and are capable of metastasis.)

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? a. Central apnea b. Hypoventilation c. Kussmaul respirations d. Cheyne-Stokes respirations

c. Kussmaul respirations

The nurse is planning health promotion teaching for a group of healthy older adults in a residential community. Which statement accurately describes expected hematologic effects of aging? a. "Platelet production increases with age and leads to easy bruising." b. "Anemia is common with aging because iron absorption is impaired." c. "Older adults with infections may have only a mild white blood cell count elevation." d. "Older adults often have poor immune function with a decreased number of lymphocytes"

c. Older adults with infections may have only a mild white blood cell count elevation." (During an infection, the older adult may have only a minimal elevation in the total white blood cell count and may not have a fever. Presentation of infection can initially be nonspecific with disorientation, anorexia, and weakness. Platelets are unaffected by the aging process. However, changes in vascular integrity from aging can manifest as easy bruising. Iron absorption is not impaired in the older patient, but adequate nutritional intake of iron may be decreased. The total white blood cell count and differential are generally not affected by aging. However, a decrease in humoral antibody response and decrease in T-cell function may occur.)

A 62-yr-old male patient with disseminated intravascular coagulation (DIC) after urosepsis has a platelet count of 48,000/μL. The nurse should assess the patient for which abnormality? a. Pallor b. Purpura c. Pruritus d. Palpitation

c. Purpura (The normal range for a platelet count is 150,000 to 400,000/μL. Purpura is caused by decreased platelets or clotting factors, resulting in small hemorrhages into the skin or mucous membranes. Pallor is decreased or absent coloration in the conjunctiva or skin. Pruritus is an intense itching sensation. Palpitation is a sensation of feeling the heart beat, flutter, or pound in the chest.)

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? a. Increases insulin production from the pancreas b. Slows the absorption of carbohydrate in the small intestine c. Reduces glucose production by the liver and enhances insulin sensitivity d. Increases insulin release from the pancreas, inhibits glucagon secretion, and decreases gastric emptying

c. Reduces glucose production by the liver and enhances insulin sensitivity (Metformin is a biguanide that reduces glucose production by the liver and enhances the tissue's insulin sensitivity. Sulfonylureas and meglitinides increase insulin production from the pancreas. α-Glucosidase inhibitors slow the absorption of carbohydrate in the intestine. Glucagon-like peptide receptor agonists increase insulin synthesis and release from the pancreas, inhibit glucagon secretion, and decrease gastric emptying.)

The UAP is taking orthostatic vital signs. In the supine position, the blood pressure (BP) is 130/80 mm Hg, and the heart rate (HR) is 80 beats/min. In the sitting position, the BP is 140/80, and the HR is 90 beats/min. Which action should the nurse instruct the UAP to take next? a. Repeat BP and HR in this position. b. Record the BP and HR measurements. c. Take BP and HR with patient standing. d. Return the patient to the supine position

c. Take BP and HR with patient standing. (The vital signs taken do not reflect orthostatic changes, so the UAP will continue with the measurements while the patient is standing. There is no need to repeat or delay the readings. The patient does not need to return to the supine positon. When assessing for orthostatic changes, the UAP will take the BP and pulse in the supine position, then place the patient in a sitting position for 1 to 2 minutes and repeat the readings, and then reposition to the standing position for 1 to 2 minutes and repeat the readings. Results consistent with orthostatic changes would have a decrease of 20 mm Hg or more in systolic BP, a decrease of 10 mm Hg or more in diastolic BP, and/or an increase in HR of greater than or equal to 20 beats/min with position changes.)

The nurse is performing a skin assessment for an older adult patient. What finding should the nurse immediately report to the health care provider? a. The presence of wrinkles on the face and hands b. The patient's report of dry skin that is frequently itchy c. The presence of an irregularly shaped mole that the patient states is new d. The presence of veins on the back of the patient's leg that are blue and tortuous

c. The presence of an irregularly shaped mole that the patient states is new (The presence of an irregular mole that is new is suggestive of a neoplasm and warrants immediate reporting and follow-up. Age-related changes may occur that involve the decrease in skin oils that may cause dry skin that itches. Blue and tortuous veins may be unsightly for the patient but are a normal age-related change. Wrinkles are a normal age related change.)

A patient with breast cancer is having teletherapy radiation treatments after her surgery. What should the nurse teach the patient about the care of her skin? a. Use Dial soap to feel clean and fresh. b. Scented lotion can be used on the area. c. Avoid heat and cold to the treatment area. d. Wear the new bra to comfort and support the area.

c. avoid heat and cold to treatment area

The nurse is caring for a patient admitted with chronic obstructive pulmonary disease (COPD), angina, and hypertension. Before administering the prescribed daily dose of atenolol 100 mg PO, the nurse assesses the patient carefully. Which adverse effect is this patient at risk for given the patient's health history? a. Hypocapnia b. Tachycardia c. Bronchospasm d. Nausea and vomiting

c. bronchospasm

A nurse is assessing a client who has adrenal insufficiency. Which of the following findings should the nurse expect? a. Moon face b. Weight gain c. Calcium 12.8 mg/dL d. Sodium 150 mEq/L

c. calcium 12.8 mg/dL (a client with adrenal insufficiency has a high calcium level and a low sodium level)

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? a. Eat a piece of pizza. b. Drink some diet pop. c. Eat 15 g of simple carbohydrates. d. Take an extra dose of rapid-acting insulin.

c. eat 15 g of simple carbohydrates (When the patient with type 1 diabetes is unsure about the meaning of the symptoms she is experiencing, she should treat herself for hypoglycemia to prevent seizures and coma from occurring. She should also be advised to check her blood glucose as soon as possible. The fat in the pizza and the diet pop would not allow the blood glucose to increase to eliminate the symptoms. The extra dose of rapid-acting insulin would further decrease her blood glucose.)

A nurse in an outpatient clinic is teaching a client who has a diabetic foot ulcer about foot care. Which of the following statements should the nurse identify as an indication that the client understands the teaching? a. "I will let my feet air dry after washing." b. "I will wear sandals to allow air to circulate around my feet." c. "I will buy over-the-counter medicine to treat the calluses on my feet." d. "I will apply lotion to the dry areas of my feet, but not between my toes."

d. "I will apply lotion to the dry areas of my feet, but not between my toes."

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? a. "I want to go fishing for 30 minutes each day; I will drink fluids and wear sunscreen." b. "I will go running each day when my blood sugar is too high to bring it back to normal." c. "I will plan to keep my job as a teacher because I get a lot of exercise every school day." d. "I will take a brisk 30-minute walk 5 days per week and do resistance training three times a week."

d. "I will take a brisk 30-minute walk 5 days per week and do resistance training three times a week." (The best exercise plan for the person with type 2 diabetes is for 30 minutes of moderate activity 5 days per week and resistance training three times a week. Brisk walking is moderate activity. Fishing and teaching are light activity, and running is considered vigorous activity.)

A 44-yr-old man is diagnosed with hypertension and receives a prescription for benazepril (Lotensin). After providing instruction, which statement by the patient indicates correct understanding? a. "If I take this medication, I will not need to follow a special diet." b. "It is normal to have some swelling in my face while taking this medication." c. "I will need to eat foods such as bananas and potatoes that are high in potassium." d. "If I develop a dry cough while taking this medication, I should notify my doctor."

d. "If I develop a dry cough while taking this medication, I should notify my doctor." (Benazepril is an angiotensin-converting enzyme inhibitor. The medication inhibits breakdown of bradykinin, which may cause a dry, hacking cough. Other adverse effects include hyperkalemia. Swelling in the face could indicate angioedema and should be reported immediately to the prescriber. Patients taking drug therapy for hypertension should also attempt lifestyle modifications to lower blood pressure such as a reduced-sodium diet.)

Which item would be most beneficial when providing oral care to a patient with metastatic cancer who is at risk for oral tissue injury secondary to chemotherapy? a. Firm-bristle toothbrush b. Hydrogen peroxide rinse c. Alcohol-based mouthwash d. 1 tsp salt in 1 L water mouth rinse

d. 1 tsp salt in 1 L water mouth rinse (A salt-water mouth rinse will not cause further irritation to oral tissue that is fragile because of mucositis, which is a side effect of chemotherapy. A soft-bristle toothbrush will be used. One teaspoon of sodium bicarbonate may be added to the salt-water solution to decrease odor, alleviate pain, and dissolve mucin. Hydrogen peroxide and alcohol-based mouthwash are not used because they would damage the oral tissue.)

The patient is receiving immunotherapy and targeted therapy for ovarian cancer. What medication should the nurse expect to administer before therapy to combat the most common side effects of these medications? a. Morphine sulfate b. Ibuprofen (Advil) c. Ondansetron (Zofran) d. Acetaminophen (Tylenol)

d. Acetaminophen (Tylenol) (Acetaminophen is administered before therapy and every 4 hours to prevent or decrease the intensity of the severe flu-like symptoms, especially with interferon which is frequently used for ovarian cancer. Morphine sulfate and ibuprofen will not decrease flu-like symptoms. Ondansetron is an antiemetic but is not used first to combat flu-like symptoms of headache, fever, chills, myalgias, and so on.)

A 70-yr-old man who has end-stage lung cancer is admitted to the hospital with confusion and oliguria for 2 days. Which finding would the nurse report immediately to the health care provider? a. Weight gain of 6 lb b. Nausea and vomiting c. Urine specific gravity of 1.004 d. Serum sodium level of 118 mEq/L

d. sodium level of 118 mEq/L (Lung cancer cells are able to manufacture and release antidiuretic hormone (ADH) with resultant water retention and hyponatremia. Hyponatremia (serum sodium levels less than 135 mEq/L) may lead to central nervous system symptoms such as confusion, seizures, coma, and death. The other options listed are also symptoms of hyponatremia but are not as critical to report to the health care provider.)

The nurse is caring for a patient suffering from anorexia secondary to chemotherapy. Which strategy would be most appropriate to increase the patient's nutritional intake? a. Increase intake of liquids at mealtime to stimulate the appetite. b. Serve three large meals per day plus snacks between each meal. c. Avoid the use of liquid protein supplements to encourage eating at mealtimes. d. Add items such as skim milk powder, cheese, honey, or peanut butter to selected foods.

d. Add items such as skim milk powder, cheese, honey, or peanut butter to selected foods. (The nurse can increase the nutritional density of foods by adding items high in protein and/or calories (e.g., peanut butter, skim milk powder, cheese, honey, brown sugar) to foods the patient will eat. Increasing fluid intake at mealtime fills the stomach with fluid and decreases the desire to eat. Small frequent meals are best tolerated. Supplements can be helpful.)

A nurse is teaching a client about the adrenocorticotropic hormone (ACTH) stimulation test. The nurse should explain that the purpose of this test is to assess for which of the following disorders? a. DIabetes insipidus b. Hyperthyroidism c. PHeochromocytoma D. Addison's disease

d. Addison's disease (The nurse should instruct the client that the ACTH stimulation test is the standard test for Addison's disease. It measures the cortisol response to ACTH. The response is absent or very decreased in clients who have primary adrenal insufficiency.)

A patient was admitted for possible ruptured aortic aneurysm. No back pain was reported. Ten minutes later, the nurse notes sinus tachycardia 138 beats/min, blood pressure is palpable at 65 mm Hg, increasing waist circumference, and no urine output. How should the nurse interpret the findings? a. Tamponade will soon occur. b. The renal arteries are involved. c. Perfusion to the legs is impaired. d. Bleeding into the abdomen is likely.

d. Bleeding into the abdomen is likely. (The lack of back pain indicates the patient is most likely exsanguinating into the abdominal space, and the bleeding is likely to continue without surgical repair. A blockade of the blood flow will not occur in the abdominal space as it would in the retroperitoneal space, where surrounding anatomic structures may control the bleeding. The lack of urine output does not indicate renal artery involvement but that the bleeding is occurring above the renal arteries, which decreases the blood flow to the kidneys. There are no assessment data indicating decreased perfusion to the legs.)

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? a. Prealbumin level b. Urine ketone level c. Fasting glucose level d. Glycosylated hemoglobin level

d. Glycosylated hemoglobin level

When caring for the patient with cancer, what does the nurse understand as the response of the immune system to antigens of the malignant cells? a. Metastasis b. Tumor angiogenesis c. Immunologic escape d. Immunologic surveillance

d. Immunologic surveillance (Immunologic surveillance is the process in which lymphocytes check cell surface antigens and detect and destroy cells with abnormal or altered antigenic determinants to prevent these cells from developing into clinically detectable tumors. Metastasis is increased growth rate of the tumor, increased invasiveness, and spread of the cancer to a distant site in the progression stage of cancer development. Tumor angiogenesis is the process of blood vessels forming within the tumor itself. Immunologic escape is the cancer cells' evasion of immunologic surveillance that allows the cancer cells to reproduce.)

When assessing laboratory values on a patient admitted with septicemia, what does the nurse expect to find? a. Increased platelets b. Decreased red blood cells c. Decreased erythrocyte sedimentation rate (ESR) d. Increased bands in the white blood cell (WBC) differential

d. Increased bands in the white blood cell (WBC) differential (When infections are severe, such as in septicemia, more granulocytes are released from the bone marrow as a compensatory mechanism. To meet the increased demand, many young, immature polymorphonuclear neutrophils (bands) are released into circulation. WBCs are usually reported in order of maturity (initially with the less mature forms on the left side of a written report). Hence, the term "shift to the left" is used to denote an increase in the number of bands. Thrombocytosis occurs with inflammation and some malignant disorders. Decreased red blood cells indicate anemia. Decreased ESR is not indicative of septicemia.)

A 64-yr-old male patient who is receiving radiation to the head and neck as treatment for an invasive malignant tumor complains of mouth sores and pain. Which intervention should the nurse add to the plan of care? a. Provide ice chips to soothe the irritation. b. Weigh the patient every month to monitor for weight loss. c. Cleanse the mouth every 2 to 4 hours with hydrogen peroxide. d. Provide high-protein and high-calorie, soft foods every 2 hours.

d. Provide high-protein and high-calorie, soft foods every 2 hours. (A patient with stomatitis should have soft, nonirritating foods offered frequently. The diet should be high in protein and high in calories to aid healing. Extremes of temperature are to be avoided. Saline or water should be used to cleanse the mouth (not hydrogen peroxide). Patients should be weighed at least twice each week to monitor for weight loss.)

A nurse is preparing a teaching plan for a client who has diabetes insipidus and requires intranasal desmorpressin. Which of the following information should the nurse include in the treatment plan? a. Drink at least 3 L of fluid per day. b. Weigh yourself weekly while wearing similar clothing at the same time of day. c. Notify the provider of a weight loss of 0.45 kg (1 lb) or more per week. d. Report nocturia because it requires a dosage adjustment.

d. Report nocturia because it requires a dosage adjustment

A 67-yr-old woman with hypertension is admitted to the emergency department with a blood pressure of 234/148 mm Hg and was started on nitroprusside (Nitropress). After one hour of treatment, the mean arterial blood pressure (MAP) is 55 mm Hg. Which nursing action is a priority? a. Start an infusion of 0.9% normal saline at 100 mL/hr. b. Maintain the current administration rate of the nitroprusside. c. Request insertion of an arterial line for accurate blood pressure monitoring. d. Stop the nitroprusside infusion and assess the patient for potential complications.

d. Stop the nitroprusside infusion and assess the patient for potential complications. (Nitroprusside is a potent vasodilator medication. A blood pressure of 234/118 mm Hg would have a calculated MAP of 177 mm Hg. Subtracting 25% (or 44 mm Hg) = 133 mm Hg. The initial treatment goal is to decrease MAP by no more than 25% within minutes to 1 hour. For this patient, the goal MAP would be approximately 133 mm Hg. Minimal MAP required to perfuse organs is around 60 to 65 mm Hg. Lowering the blood pressure too rapidly may decrease cerebral, coronary, or renal perfusion and could precipitate a stroke, myocardial infarction, or renal failure. The priority is to stop the nitroprusside infusion and then use fluids only if necessary to support restoration of MAP.)

What is a priority nursing intervention in the care of a patient with a diagnosis of chronic venous insufficiency (CVI)? a. Application of topical antibiotics to venous ulcers b. Maintaining the patient's legs in a dependent position c. Administration of oral and/or subcutaneous anticoagulants d. Teaching the patient the correct use of compression stockings

d. Teaching the patient the correct use of compression stockings (CVI requires conscientious and consistent application of compression stockings. Anticoagulants are not necessarily indicated and antibiotics, if required, are typically oral or IV, not topical. The patient should avoid prolonged positioning with the limb in a dependent position.)

The patient is being treated with brachytherapy for cervical cancer. What factors must the nurse be aware of to protect herself when caring for this patient? a. The medications the patient is taking b. The nutritional supplements that will help the patient c. How much time is needed to provide the patient's care d. The time the nurse spends at what distance from the patient

d. The time the nurse spends at what distance from the patient (The principles of ALARA (as low as reasonably achievable) and time, distance, and shielding are essential to maintain the nurse's safety when the patient is a source of internal radiation. The patient's medications, nutritional supplements, and time needed to complete care will not protect the nurse caring for a patient with brachytherapy for cervical cancer.)

A nurse is teaching a client who has diabetes mellitus. Which of the following should the nurse include as an expected finding of DKA? a. decreased urine output b. weight gain of 1 lb in 24 hours c. rapid, shallow respirations d. blood glucose levels above 300 mg/dL

d. blood glucose levels above 300 mg/dL

A nurse is caring for a client undergoing screening for primary Cushing's disease. The nurse should expect an elevation in which of the following laboratory findings? a. lymphocyte b. potassium c. calcium d. glucose

d. glucose (Lympohocyte - low; potassium - low; calcium - low)

A home health nurse is assessing a client who requires lifelong hormone replacement therapy for the treatment of hypothyroidism. The client has not been taking his medication regularly. Which of the following findings should the nurse expect? a. increased urine output b. persistent diarrhea c. tachycardia d. hypotension

d. hypotension (along with bradypnea, dysrhythmias, cold intolerance, cool, and dry skin)

To screen a client for pheochromocytoma, a nurse schedules a vanillylmandelic acid test. When teaching the client about this test, which of the following instructions should the nurse include? a. "Start fasting at midnight prior to the day of the test." b. "Begin the 24-hour urine collection with the first morning urination." c. "Take low-dose aspirin for pain during the testing period." d. "Restrict coffee intake 2 to 3 days prior to the test."

d. restrict coffee intake 2-3 days prior to the test (avoid tea, coffee, bananas, chocolate, and vanilla)

Which nursing diagnosis is most appropriate for a patient experiencing myelosuppression secondary to chemotherapy for cancer treatment? a. Acute pain b. Hypothermia c. Powerlessness d. Risk for infection

d. risk for infection (Myelosuppression is accompanied by a high risk of infection and sepsis. Hypothermia, powerlessness, and acute pain are also possible nursing diagnoses for patients undergoing chemotherapy, but the threat of infection is paramount.)

A nurse is caring for a client who has type II diabetes mellitus and has hyperglycemic-hyperosmolar state (HHS). Which of the following laboratory findings should the nurse expect? a. serum pH of 7.32 b. blood glucose of 250 mg/dL c. blood glucose of 425 mg/dL d. serum pH of 7.45

d. serum pH of 7.45 (A client who has HHS produces enough insulin to prevent ketosis, but not enough to prevent hyperglycemia. Therefore, the serum pH is within the expected reference range. Glucose levels will be above 600 mg/dL.)