Complex final

A patient calls the clinic to report exposure to poison ivy and an itchy rash that is not helped with over-the-counter antihistamines. What response by the nurse is most appropriate?

"Antihistamines do not help poison ivy."

A nurse is teaching a patient with psoriatic arthritis about the medication golimumab (Simponi). What information is most important to include?

"Avoid large crowds or people who are ill."

A nurse is giving a patient instructions for showering with special antimicrobial soap the night before surgery. What instruction is most appropriate?

"Be sure to wash the area where you will have surgery very thoroughly."

A nurse has educated a patient on an epinephrine auto-injector (EpiPen). What statement by the patient indicates additional instruction is needed?

"I don't need to go to the hospital after using it."

A nurse has taught a patient about safety related to an automatic epinephrine injector and the indicators for obtaining replacements. Which statements by the patient indicate good understanding of this teaching? (SATA)

"I need a new pen if the fluid is discolored," "I should get a new injector every 2 years," "I will obtain a new pen if the cap comes off," "if the drug has expired, I will get a new pen," "I only need a new injector if I use the one i have."

A nurse is giving a preoperative patient a dose of ranitidine (Zantac). The patient asks why the nurse is giving this drug when the patient has no history of ulcers. What response by the nurse is best?

"It helps prevent ulcers from the stress of the surgery."

A patient with HIV/AIDS asks the nurse why gabapentin (Neurontin) is part of the drug regimen when the patient does not have a history of seizures. What response by the nurse is best?

"This drug helps treat the pain from nerve irritation."

A nurse is caring for four patients. Which patient does the nurse assess first for impaired Cognition?

88-year-old patient 3 days post-hemorrhagic stroke

A nurse in the family clinic is teaching a patient newly diagnosed with osteoarthritis (OA) about drugs used to treat the disease. For which medication does the nurse plan primary teaching?

Acetaminophen (Tylenol)

A patient in the operating room has developed malignant hyperthermia. The patient's potassium is 6.5 mEq/L (6.5 mmol/L). What action by the nurse takes priority?

Administer 10 units of regular insulin

A postoperative patient has just been admitted to the post-anesthesia care unit (PACU). What assessment by the PACU nurse takes priority?

Airway

A nurse is admitting an older patient for surgery to the inpatient surgical unit. The patient related a prior history of acute confusion after a precious operation. What interventions does the nurse include on the patient's plan of care to minimize the potential for this occurring? (SATA)

Allow family and friends to visit as the patient desires, ask the patient about coping techniques frequently used, instruct the nursing assistant to ensure the patient is bathed, place the patient in a room secluded at the end of the hall and provide the patient with uninterrupted periods of sleep.

A nurse working in the preoperative holding area performs which functions to ensure patient safety? (SATA)

Allow small sips of plain water, check the consent is on the chart, ensure that the patient has an armband on, have the patient help mark the surgical site and allow the patient to use the toilet before giving sedation

A circulating nurse has transferred an older patient to the operating room. What action by the nurse is most important for this patient?

Allow the patient to keep hearing aids in until anesthesia begins.

After teaching a patient about advance directives, a nurse assesses the patient's understanding. Which statement indicates that the patient correctly understands the Teaching?

An advance directive will specify what I want done when I can no longer make decisions about health care

A postoperative patient is reluctant to participate in physical therapy. Which action by the nurse is best?

Ask the patient about pain goals and if they are being met

A nurse is concerned that a preoperative patient has a great deal of anxiety about the upcoming procedure. What action by the nurse is best?

Ask the patient to describe current feelings

Which action by the nurse working with a patient best demonstrates respect for Autonomy

Asks if the patient has questions before signing a consent

A clinical nurse is teaching a patient prior to surgery. The patient does not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best?

Assess the patient for anxiety

A nurse is assessing an older patient for the presence of infection. The patient's temperature is 97.6 F (36.4 C). What response by the nurse is best?

Assess the patient for more specific signs

The UAP reports to the registered nurse that a postoperative patient has a pulse of 132 beats/minute and a blood pressure of 168/90 mm Hg. What response by the nurse is most appropriate?

Assess the patient for pain

A patient has just been diagnosed with human immune deficiency virus (HIV). The patient is distraught and does not know what to do. What intervention by the nurse is best?

Assess the patient for support systems

A nurse is monitoring a patient after moderate sedation. The provider has prewritten discharge orders and the patient's spouse is asking if they can leave. What action by the nurse is best?

Assess the patient using the modified Aldrete scale

A nurse is talking with a patient about a negative enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) antibodies. The test is negative and the patient states "Whew! I was really worried about that result." What action by the nurse is most important?

Assess the patient's sexual activity and patterns

A nurse wishes to provide patient-centered care in all interactions. Which action by the nurse best demonstrates this concept?

Assesses for cultural influences affecting health care

A patient is having shoulder surgery with regional anesthesia. What actions by the nurse are most important to enhance patient safety related to this anesthesia? (SATA)

Assessing distal circulation to the operative arm after positioning, keeping the patient warm during the operative procedure, padding the patient's shoulder and arm on the operating table, preparing to suction the patient's airway in the patient vomits, and speaking in a low, quiet voice as anesthesia is administered.

A clinic nurse is working with an older patient. What assessment is most important for preventing infections in this patient?

Assessing vaccination records for booster shot needs

A nurse is caring for a postoperative patient who reports discomfort, but denies serious pain and does not want medication. What action by the nurse is best to promote comfort?

Assist the patient into a position of comfort.

A patient has received an opioid analgesic for pain. The nurse assesses that the patient has a Pasero Scale score of 3 and a respiratory rate of 7 shallow breaths/min. The patient's oxygen saturation is 87%. Which action would the nurse perform first?

Attempt to arouse the patient

A nurse student about antibody-mediated immunity learns that the cell with the most direct role in this process begins development in which tissue or organ?

Bone marrow

A patient is going to be admitted for a scheduled surgical procedure. Which action does the nurse explain is the most important thing the patient can do to protect against errors?

Bring a list of all medications and what they are for

The nurse in the ED is caring for four patients. Which patient does the nurse assess for gas exchange abnormalities as a priority?

Brought in by roommate after opioid overdose

A home health care nurse is visiting a patient discharged home after a hip replacement. The patient is still on partial weight bearing and using a walker. What safety precautions can the nurse recommend to the patient? (SATA)

Buy and install an elevated toilet seat, install grab bars in the shower and by the toilet, step into the bathtub with the affected leg first, remove all throw rugs throughout the house, use a shower chair while taking a shower

A nurse is caring for a postoperative patient on the surgical unit. The patient's blood pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse is best?

Call the Rapid Response Team

. A patient is being discharged from the hospital after surgery on hydrocodone and acetaminophen (Lorcet). Which discharge instruction is most important for this patient?

Check an over-the-counter medications for acetaminophen

A nurse works in an allergy clinic. What task performed by the nurse takes priority?

Checking emergency equipment each morning

A nurse works on a unit that has admitted its first patient with acquired immune deficiency syndrome. The nurse overhears other staff members talking about the "AIDS guys'' and wondering how the patient contracted the disease. What action by the nurse is the best?

Confront the staff members about unethical behavior

A nurse assesses a patient in the preoperative holding area and finds brittle nails and hair, dry skin turgor and muscle wasting. What action by the nurse is best?

Consult the surgeon about a postoperative dietician referral.

A patient has been hospitalized with an opportunistic infection secondary to acquired immune deficiency syndrome. The patient's partner is listed as the emergency contact, but the patient's mother insists that she should be listed instead. What action by the nurse is best.

Contact the social worker to assist the patient with advance directives.

A nurse is assessing a patient for acute rejection of a kidney transplant. What assessment finding requires the most rapid communication with the provider?

Creatinine of 3.9 mg/dL (345 mcmol/L)

A nurse suspects a patient has serum sickness. What laboratory result would the nurse correlate with this condition?

Creatinine: 3.2 mg/dL (283 mcmol/L)

A nurse is caring for a patient with systemic sclerosis. The patient's facial skin is very taut, limiting the patient's ability to open the mouth. After consulting with a registered dietician for appropriate nutrition, what other consultation would the nurse facilitate?

Dentist

An older adult is brought to the ED because of a sudden onset of confusion. After the patient is stabilized and comfortable, what assessment by the nurse is most important?

Determine if there are new medications

A patient has been on dialysis for many years and now is receiving a kidney transplant. The patient experiences hyperacute rejection. What treatment does the nurse prepare to facilitate?

Dialysis

A nurse plans care for a patient who is nearing end of life. Which question will the nurse ask when developing this patient's plan of care?

Do you want to be at home at the end of your life?

Apatient is having robotic surgery. The circulating nurse observes the instruments being inserted, and then the surgeon appears to "break scrub" when going to the console and sitting down. What action by the nurse is best?

Document the time the robotic portion of the procedure begins.

An older adult has diabetic neuropathy and often reports unbearable foot pain. About which medication would the nurse plan to educate the patient?

Duloxetine (Cymbalta)

The nurse assesses patients for the cardinal signs of inflammation. Which signs/symptoms does this include?

Edema, pulselessness, pallor, redness and warmth

A nurse is orienting a new patient and family to the inpatient unit. What information does the nurse provide to help the patient promote his or her own safety?

Encourage the patient and family to be active partners

A patient is in the hospital and receiving IV antibiotics. When the nurse answers the patient's call light, the patient presents an appearance as shown below: What action by the nurse takes priority?

Ensure a patent airways while calling the Rapid Response Team

A new nurse is working with a preceptor on an inpatient medical-surgical unit. The preceptor advises the student that which is the priority when working as a professional Nurse?

Ensuring patient Safety

A nurse working with older adults in the community plans programming to improve morale and emotional health in this population. Which activity would best meet this Goal?

Exercise program to improve physical function

A postoperative patient has respiratory depression after receiving midazolam (Versed) for sedation. Which IV-push medication and dose does the nurse prepare to administer?

Flumazenil (Romazicon) 0.2 to 1 mg

A patient had a recent thromboembolic event and must resume work which requires frequent car and plane travel. What self-care measure does the nurse teach to reduce the risk of impaired clotting in this patient?

Get up and walk around at least every 2 hours while traveling

A patient with HIV wasting syndrome has inadequate nutrition. What assessment finding by the nurse best indicates that goals have been met for this patient problem?

Has a weight of 2 lbs (1 kg)/1 month

A nurse is caring for a patient on an epidural patient-controlled analgesia (PCA) pump. Which action by the nurse is most important to ensure patient safety?

Have another nurse double check the pump settings

A rehabilitation nurse cares for a patient who is wheelchair bound. Which intervention would the nurse implement to prevent skin breakdown?

Have the patient do wheelchair push-ups

An intensive care nurse discusses withdrawal of care with a patient's family. The family expresses concerns related to discontinuation of therapy. How will the nurse respond?

I realize this is a difficult decision. Discontinuation of therapy will allow the patient to die a natural death

A nurse is discharging a patient after a total hip replacement. What statement by the patient indicated good potential for self management?

I will not sit with my legs crossed."

A patient is typed and crossmatched for a unit of blood. Which statement by the nurse indicates a need for further genetic education?

If the patient's blood type is AB, then the patient is homozygous for that trait

A new perioperative nurse is receiving orientation to the surgical area and learns about the Surgical Care Improvement Project (SCIP) goals. What major areas do these measures focus on preventing? (SATA)

Infection, serious cardiac event and thromboembolism, hemorrhage and stroke

A home healthcare nurse has conducted a home safety assessment for an older adult. There are five concrete steps leading out from the front door. Which intervention would be most helpful in keeping the older adult safe on the steps?

Install contrasting color strips at the edge of ear

A patient having severe allergy symptoms has received several doses of IV antihistamines. What action by the nurse is most important?

Instruct the patient not to get up without help.

A nurse cares for a patient who has a genetic mutation that increases the risk for colon cancer. The patient states that he does not want any family to know about this result. How would the nurse respond?

It is not required that you tell anyone about this result. However, your siblings and children may also be at risk for colon cancer and this information might help them

An older patient is in the hospital. The patient is ambulatory and independent. What intervention by the nurse would be most helpful in preventing falls in this patient?

Keep the light on in the bathroom at night

A nurse is caring for a patient who is terminally ill. The patient's spouse states, "I am concerned because he does not want to eat." How does the nurse respond?

Let him know that food is available if he wants it, but do not insist that he eat

A patient had a surgical procedure with spinal anesthesia. The nurse raises the head of the patient's bed. The patient's blood pressure changes from 122/78 mmHg to 102/50 mmHg. What action by the nurse is best?

Lower the head of the bed

A nurse obtains health histories when admitting patients to a medical-surgical unit. With which patient would the nurse discuss predisposition genetic testing?

Middle-aged woman whose mother died at age 48 of breast cancer

A nurse is caring for a patient who has lung cancer and is dying. Which prescription does the nurse question

Morphine 10 mg sublingual every 6 hours PRN for pain level greater than 5

A nurse plans care for a patient who is bedridden. Which assessment would the nurse complete to ensure to prevent pressure ulcer formation?

Nutritional intake and serum albumin levels

A nursing faculty member working with students explains that the fastest growing subset of the older population is which group?

Old Old

A nurse cares for a dying patient. Which manifestation of dying does the nurse treat First?

Pain

A patient has arrived in the postoperative unit. What action by the circulating nurse takes priority?

Participating in hand-off report

. A nurse caring for an older patient on a medical-surgical unit notices the patient reports frequent constipation and only wants to eat softer foods such as rice, bread, and puddings. What assessment should the nurse perform first?

Perform an oral assessment

A nurse answers a call light on the postoperative nursing unit. The patient states there was a sudden gush of blood from the incision, and the nurse sees a blood spot on the sheet. What action does the nurse take first?

Perform hand hygiene and apply gloves

A patient is hospitalized with Pneumocystis jiroveci pneumonia. The patient reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort?

Place activities, allowing for adequate rest.

A patient has received intravenous anesthesia during an operation. What action by the postanesthesia care nurse is most important when the patient arrives in the PACU?

Place the patient on a cardiac monitor and pulse oximeter

A nurse cares for a pregnant patient who has a family history of sickle cell disease. The patient is unsure if she wants to participate in genetic testing. What action would the nurse take?

Provide information about the risks and benefits of genetic testing

A nurse is discharging a patient to a short-term rehabilitation center after a joint replacement. Which action by the nurse is most important?

Providing a verbal hand-off report to the facility

A patient has a leg wound that is in the second stage of the inflammatory response. For what manifestation does the nurse assess?

Purulent drainage

An older adult patient takes medication three times a day and becomes confused about which medication should be taken at which time. The patient refuses to use a pill sorter with slots for different times, saying "those are for old people." What action by the nurse would be most helpful?

Put color-coded stickers on the bottle caps

A circulating nurse wishes to provide emotional support to a patient who was just transferred to the operating room. What action by the nurse would be best?

Remain with the patient

A hospitalized patient uses a transdermal fentanyl (Duragesic) patch for chronic pain. Which action by the nurse is most important for patient safety?

Remove the old patch when applying the new one

A nurse delegates the ambulation of an older adult patent to a UAP. Which statement would the nurse include when delegating this task?

Sit the patient on the edge of the bed with legs dangling before ambulating

A nurse is educating a patient about genetic screening. The patient asks why red-green color blindness, an X-linked recessive disorder noted in some of her family members, is expressed more frequently in males that females. How would the nurse respond?

The incidence of X-linked recessive disorders is higher in males because they do not have a second X-chromosome to balance expression of the gene

A student nurse is caring for a patient whose pH 7.24. The student asks the registered nurse why the patient is breathing rapidly. What response by the RN is best?

The patient is trying to get rid of excess body acids

A patient who tests positive for a mutation in the BRCA1 gene allele asks a nurse to be present when she discloses this information to her adult daughter. How would the nurse Respond?

This conversation may be difficult for both of you; I will be there to provide support

A nurse is caring for a patient after joint replacement surgery. What action by the nurse is most important to prevent wound infection?

Use aseptic technique for dressing changes

A nurse is caring for a patient who has a spinal cord injury at level T3. Which intervention would the nurse implement to assist with bladder dysfunction?

Use the Crede maneuver every 3 hours

A rehabilitation nurse prepares to move a patient who has new bilateral leg amputations. Which is the best approach?

Utilize the facility's mechanical lift to move the patient

A nurse teaches a patient who has a flaccid bladder. Which bladder training technique would the nurse teach?

Valsalva maneuver

A nurse is preparing a patient for discharge after surgery. The patient needs to change a large dressing and manage a drain at home. What instruction by the nurse is most important?

Wash your hands before touching the drain or dressing"

A patient tells the nurse that even though it has been 4 months since her sister's death, she frequently finds herself crying uncontrollably. How does the nurse respond?

Your feelings are completely normal and may continue for a long time

A nurse collaborates with an occupational therapist when providing care for a rehabilitation patient. With which activities would the occupational therapist assist the patient? (SATA)

a. Attaining independence with dressing** b. Performing activities of daily living (ADLs)** c. Achieving mobility d. Using a walker in public e. Learning techniques for transferring f. Completing job training

A nurse teaches patients about patterns of inheritance for genetic disorders among adults. Which disorders have an autosomal dominant pattern of inheritance? (SATA)

a. Breast cancer** b. Huntington disease** c. Marfan syndrome** d. Alzheimer's disease e. Hemophilia f. Cystic Fibrosis

A nurse manager wishes to ensure that the nurses on the unit are practicing at their highest levels of competency. Which areas should the manager assess to determine if the nursing staff demonstrate competency according to the Institute of Medicine (IOM) report Health Professions Education: A Bridge to Quality? (SATA)

a. Collaborating with an interdisciplinary team ** b. Implementing evidence-based care ** c. Routinely using informatics in practice ** d. Using quality improvement in patient care** e. Providing family-focused care

A patient with a broken arm has had ice placed on it for 20 minutes. A short time after the ice was removed, the patient reports that the effect has worn off and requests pain medication, which cannot be given yet. Which actions by the nurse are most appropriate? (SATA)

a. Educate the patient on cold therapy** b. Repeat the ice application** c. Teach the patient relaxation techniques** d. Ask for a physical therapy consult e. Offer to provide a heating pad

. A nurse is caring for patients on an inpatient surgical unit. Which patients does the nurse identify as having a risk for impaired immunity? (SATA)

a. Patient who is 86 years old ** b. Patient with type 2 diabetes** c. Patient taking prednisone** d. Patient with many allergies e. Patient who drinks a beer a day

A hospice nurse is caring for a dying patient and her family members. Which interventions does the nurse implement? (SATA)

a. Teach family members about physical signs of impending death** b. Encourage the management of adverse symptoms** c. Encourage reminiscence by both patient and family members** d. Assist family members by offering an explanation for their loss e. Avoid spirituality because the patient's and the nurse's beliefs may not be congruent

. The nurse caring for a patient with malnutrition assesses which laboratory value as the Priority

prealbumin