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A patient comes to the clinic complaining of pain in the epigastric region. What assessment question during the health interview would most help the nurse determine if the patient has a peptic ulcer? "Does your pain get worse if you get up and do some exercise?" "Do over-the-counter pain medications help your pain?" "Do you find that your pain is worse when you need to have a bowel movement?" "Does your pain resolve when you have something to eat?"
"Does your pain resolve when you have something to eat?"
The management of the patient's gastrostomy is an assessment priority for the home care nurse. What statement would indicate that the patient is managing the tube correctly? "I try to stay still most of the time to avoid dislodging my tube." "I flush my tube with water before and after each of my medications." "The only time I flush my tube is when I'm putting in medications." "I clean my stoma twice a day with alcohol."
"I flush my tube with water before and after each of my medications."
A patient on the medical unit has told the nurse that he is experiencing significant dyspnea, despite that he has not recently performed any physical activity. What assessment question should the nurse ask the patient while preparing to perform a physical assessment? "When was the last time you ate or drank anything?" "On a scale from 1 to 10, how bad would rate your shortness of breath?" "Do you think that some medication might help you catch your breath?" "Are you feeling any nausea along with your shortness of breath?"
"On a scale from 1 to 10, how bad would rate your shortness of breath?"
A patient has just been diagnosed with lung cancer. After the physician discusses treatment options and leaves the room, the patient asks the nurse how the treatment is decided upon. What would be the nurse's best response? "The type of treatment depends on the patient's age and health status." "The type of treatment depends on the discussion between the patient and the physician of which treatment is best." "The type of treatment depends on what the patient wants when given the options." "The type of treatment depends on the cell type of the cancer, the stage of the cancer, and the patient's health status."
"The type of treatment depends on the cell type of the cancer, the stage of the cancer, and the patient's health status."
The clinic nurse is caring for a 42-year-old male oncology patient. He complains of extreme fatigue and weakness after his first week of radiation therapy. Which response by the nurse would best reassure this patient? "These symptoms usually result from radiation therapy; however, we will continue to monitor your laboratory and x-ray studies." "Try not to be concerned about these symptoms. Every patient feels this way after having radiation therapy." "Even though it is uncomfortable, this is a good sign. It means that only the cancer cells are dying." "These symptoms are part of your disease and are an unfortunately inevitable part of living with cancer."
"These symptoms usually result from radiation therapy; however, we will continue to monitor your laboratory and x-ray studies."
A patient with a diagnosis of peptic ulcer disease has just been prescribed omeprazole (Prilosec). How should the nurse best describe this medication's therapeutic action? "This medication will make the lining of your stomach more resistant to damage." "This medication will reduce the amount of acid secreted in your stomach." "This medication will specifically address the pain that accompanies peptic ulcer disease." "This medication will help your stomach lining to repair itself."
"This medication will reduce the amount of acid secreted in your stomach."
A 58-year-old male patient has been hospitalized for a wedge resection of the left lower lung lobe after a routine chest x-ray shows carcinoma. The patient is anxious and asks if he can smoke. Which statement by the nurse would be most therapeutic? "You are anxious about the surgery. Do you see smoking as helping?" "Smoking is OK right now, but after your surgery it is contraindicated." "Smoking is the reason you are here." "The doctor left orders for you not to smoke."
"You are anxious about the surgery. Do you see smoking as helping?"
A nurse who provides care in an ambulatory clinic integrates basic cancer screening into admission assessments. What patient most likely faces the highest immediate risk of oral cancer? A 57-year-old man with GERD and dental caries A 32-year-old man who is obese and uses smokeless tobacco A 45-year-old woman who has type 1 diabetes and who wears dentures A 65-year-old man with alcoholism who smokes
A 32-year-old man who is obese and uses smokeless tobacco
The home care nurse is assessing the home environment of a patient who will be discharged from the hospital shortly after his laryngectomy. The nurse should inform the patient that he may need to arrange for the installation of which system in his home? An air conditioning system A water purification system A humidification system A radiant heating system
A humidification system
A nurse is caring for a patient who has been admitted to the hospital with diverticulitis. Which of the following would be appropriate nursing diagnoses for this patient? Select all that apply. Acute Pain Related to Increased Peristalsis and GI Inflammation Activity Intolerance Related to Generalized Weakness Impaired Urinary Elimination Related to GI Pressure on the Bladder Deficient Fluid Volume Related to Anorexia, Nausea, and Diarrhea Bowel Incontinence Related to Increased Intestinal Peristalsis
Acute Pain Related to Increased Peristalsis and GI inflammation Activity Intolerance Related to Generalized Weakness Deficient Fluid Volume Related to Anorexia, Nausea, and Diarrhea
The nurse is caring for a patient admitted with an acute exacerbation of chronic obstructive pulmonary disease. During assessment, the nurse finds that the patient is experiencing increased dyspnea. What is the most accurate measurement of the concentration of oxygen in the patient's blood? Pulse oximetry An arterial blood gas (ABG) study A capillary blood sample A complete blood count (CBC)
An arterial blood gas (ABG) study
A patient has been diagnosed with peptic ulcer disease and the nurse is reviewing his prescribed medication regimen with him. What is currently the most commonly used drug regimen for peptic ulcers? Antibiotics, proton pump inhibitors, and bismuth salts H2 antagonists, antibiotics, and bicarbonate salts Bicarbonate salts, antibiotics, and ZES Bismuth salts, antivirals, and histamine-2 (H2) antagonists
Antibiotics, proton pump inhibitors, and bismuth salts
A nurse is assessing a patient who has just been admitted to the postsurgical unit following surgical resection for the treatment of oropharyngeal cancer. What assessment should the nurse prioritize? Assess for signs of infection. Assess ability to clear oral secretions. Assess for ability to communicate. Assess for a patent airway.
Assess for a patent airway.
An older adult who resides in an assisted living facility has sought care from the nurse because of recurrent episodes of constipation. Which of the following actions should the nurse first perform? Assess the patient's food and fluid intake. Encourage the patient to take stool softener daily. Encourage the patient to take fiber supplements. Assess the patient's surgical history.
Assess the patient's food and fluid intake.
The nurse is caring for a patient who is receiving oxygen therapy for pneumonia. How should the nurse best assess whether the patient is hypoxemic? Assess the patient's oxygen saturation level. Review the patient's hemoglobin, hematocrit, and red blood cell levels. Assess the patient's level of consciousness (LOC). Assess the patient's extremities for signs of cyanosis.
Assess the patient's oxygen saturation level.
A patient has come to the outpatient radiology department for diagnostic testing. Which of the following diagnostic procedures will allow the care team to evaluate and remove polyps? Upper gastrointestinal fibroscopy Barium enema Colonoscopy ERCP
Colonoscopy
A nurse is working with a patient who has chronic constipation. What should be included in patient teaching to promote normal bowel function? Limit physical activity in order to promote bowel peristalsis. Use glycerin suppositories on a regular basis. Resist the urge to defecate until the urge becomes intense. Consume high-residue, high-fiber foods.
Consume high-residue, high-fiber foods.
A patient has been diagnosed with heart failure that has not yet responded to treatment. What breath sound should the nurse expect to assess on auscultation? Crackles Inspiratory wheezes Expiratory wheezes Rhonchi
Crackles
A 54-year-old has a diagnosis of breast cancer and is tearfully discussing her diagnosis with the nurse. The patient states, "They tell me my cancer is malignant, while my coworker's breast tumor was benign. I just don't understand at all." When preparing a response to this patient, the nurse should be cognizant of what characteristic that distinguishes malignant cells from benign cells of the same tissue type? Slow rate of mitosis of cancer cells Different proteins in the cell membrane Differing size of the cells Different molecular structure in the cells
Different proteins in the cell membrane
A patient's enteral feedings have been determined to be too concentrated based on the patient's development of dumping syndrome. What physiologic phenomenon caused this patient's complication of enteral feeding? Entry of large amounts of water into the small intestine because of osmotic pressure Acid-base imbalance resulting from the high volume of solutes in the feed Mucosal irritation of the stomach and small intestine by the high concentration of the feed Increased gastric secretion of HCl and gastrin because of high osmolality of feeds
Entry of large amounts of water into the small intestine because of osmotic pressure
A patient on the oncology unit is receiving carmustine, a chemotherapy agent, and the nurse is aware that a significant side effect of this medication is thrombocytopenia. Which symptom should the nurse assess for in patients at risk for thrombocytopenia? Interrupted sleep pattern Hot flashes Epistaxis (nose bleed) Increased weight
Epistaxis (nose bleed)
A nurse is caring for a patient who just has been diagnosed with a peptic ulcer. When teaching the patient about his new diagnosis, how should the nurse best describe a peptic ulcer? Erosion of the lining of the stomach or intestine Viral invasion of the stomach wall Inflammation of the lining of the stomach Bleeding from the mucosa in the stomach
Erosion of the lining of the stomach or intestine
The perioperative nurse has admitted a patient who has just underwent a tonsillectomy. The nurse's postoperative assessment should prioritize which of the following potential complications of this surgery? Hemorrhage Bradycardia Infrequent swallowing Difficulty ambulating
Hemorrhage
The nurse is caring for a patient whose recent unexplained weight loss and history of smoking have prompted diagnostic testing for cancer. What symptom is most closely associated with the early stages of laryngeal cancer? Dyspnea Hoarseness Dysphagia Frequent nosebleeds
Hoarseness
A nurse is caring for a patient who is acutely ill and has included vigilant oral care in the patient's plan of care. Why are patients who are ill at increased risk for developing dental caries? Hydration that is received intravenously lacks fluoride Hormonal changes brought on by the stress response cause an acidic oral environment Systemic infections frequently migrate to the teeth Inadequate nutrition and decreased saliva production can cause cavities
Inadequate nutrition and decreased saliva production can cause cavities
A critical-care nurse is caring for a patient diagnosed with pneumonia as a surgical complication. The nurse's assessment reveals that the patient has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the patient to do? Increase activity. Lie in a low Fowler's or supine position. Call the nurse for oral suctioning, as needed. Increase oral fluids unless contraindicated.
Increase oral fluids unless contraindicated.
An adult patient has been diagnosed with diverticular disease after ongoing challenges with constipation. The patient will be treated on an outpatient basis. What components of treatment should the nurse anticipate? Select all that apply. Increased fiber intake Anticholinergic medications Reduced fat intake Fluid reduction Enemas on alternating days
Increased fiber intake Reduced fat intake
The nurse is planning the care of a patient who is scheduled for a laryngectomy. The nurse should assign the highest priority to which postoperative nursing diagnosis? Impaired verbal communication related to removal of the larynx Anxiety related to diagnosis of cancer Altered nutrition related to swallowing difficulties Ineffective airway clearance related to airway alterations
Ineffective airway clearance related to airway alterations
A patient is brought to the ED by ambulance after a motor vehicle accident in which the patient received blunt trauma to the chest. The patient is in acute respiratory failure, is intubated, and is transferred to the ICU. What parameters of care should the nurse monitor most closely? Select all that apply. Level of consciousness Oral intake Arterial blood gases Coping Vital signs
Level of consciousness Arterial blood gases Vital signs
A nurse is creating a care plan for a patient who is receiving parenteral nutrition. The patient's care plan should include nursing actions relevant to what potential complications? Select all that apply. Line sepsis Pneumothorax Clotted or displaced catheter Hyperglycemia Dumping syndrome
Line sepsis Clotted or displaced catheter Pneumothorax Hyperglycemia
A patient has been discharged home on parenteral nutrition (PN). Much of the nurse's discharge education focused on coping. What must a patient on PN likely learn to cope with? Select all that apply. Loss of eating as a social behavior Chronic bowel incontinence from GI changes Stress of choosing the correct PN formulation Changes in lifestyle Sleep disturbances related to frequent urination during nighttime infusions
Loss of eating as a social behavior Stress of choosing the correct PN formulation Changes in lifestyle
A patient has been diagnosed with a small bowel obstruction and has been admitted to the medical unit. The nurse's care should prioritize which of the following outcomes? Maintaining skin and tissue integrity Maintaining fluid and electrolyte balance Preventing infection Preventing nausea and vomiting
Maintaining fluid and electrolyte balance
A patient has a gastrostomy tube that has been placed to drain stomach contents by low intermittent suction. What is the nurse's priority during this aspect of the patient's care? Monitor drainage for change in color. Feed the patient via the G tube as ordered. Titrate the suction every hour. Measure and record drainage.
Measure and record drainage.
A nurse in a stroke rehabilitation facility recognizes that the brain regulates swallowing. Damage to what area of the brain will most affect the patient's ability to swallow? Pons Medulla oblongata Cerebellum Temporal lob
Medulla oblongata
The ICU nurse is caring for a patient who experienced trauma in a workplace accident. The patient is complaining of having trouble breathing with abdominal pain. An ABG reveals the following results: pH 7.28, PaCO2 50 mm Hg, HCO3- 23 mEq/L. The nurse should recognize the likelihood of what acid-base disorder? Respiratory alkalosis Respiratory acidosis Metabolic alkalosis Mixed acid-base disorder
Mixed acid-base disorder
A community health nurse is preparing for an initial home visit to a patient discharged following a total gastrectomy for treatment of gastric cancer. What would the nurse anticipate that the plan of care is most likely to include? Gastrointestinal decompression by nasogastric tube Enteral feeding via gastrostomy tube (G tube) Periodic assessment for esophageal distension Monthly administration of injections of vitamin B12
Monthly administration of injections of vitamin B12
A patient newly diagnosed with cancer is scheduled to begin chemotherapy treatment and the nurse is providing anticipatory guidance about potential adverse effects. When addressing the most common adverse effect, what should the nurse describe? Altered glucose metabolism Confusion Pruritis (itching) Nausea and vomiting
Nausea and vomiting
A firefighter was trapped in a fire and is admitted to the ICU for smoke inhalation. After 12 hours, the firefighter is exhibiting signs of ARDS and is intubated. What other supportive measures are initiated in a patient with ARDS? Occupational therapy Nutritional support Psychological counseling High-protein oral diet
Nutritional support
An advanced practice nurse is assessing the size and density of a patient's abdominal organs. If the results of palpation are unclear to the nurse, what assessment technique should be implemented? Rectal examination Auscultation Inspection Percussion
Percussion
Diagnostic imaging and physical assessment have revealed that a patient with peptic ulcer disease has suffered a perforated ulcer. The nurse recognizes that emergency interventions must be performed as soon as possible in order to prevent the development of what complication? Acute pancreatitis Gastroesophageal reflux Gastritis Peritonitis
Peritonitis
The nurse is reviewing the electronic health record of a patient with an empyema. What health problem in the patient's history is most likely to have caused the empyema? Asbestosis Lung cancer Smoking Pneumonia
Pneumonia
A patient has been brought to the ED by the paramedics. The patient is suspected of having ARDS. What intervention should the nurse first anticipate? Setting up oxygen at 5 L/minute by nasal cannula Performing deep suctioning Setting up a nebulizer to administer corticosteroids Preparing to assist with intubating the patient
Preparing to assist with intubating the patient
The nurse is caring for a patient who has returned to the unit following a bronchoscopy. The patient is asking for something to drink. Which criterion will determine when the nurse should allow the patient to drink fluids? Presence of a cough and gag reflex Oxygen saturation of ≥92% Ability to demonstrate deep inspiration Absence of nausea
Presence of a cough and gag reflex
A nursing educator is reviewing the care of patients with feeding tubes and endotracheal tubes (ET). The educator has emphasized the need to check for tube placement in the stomach as well as residual volume. What is the main purpose of this nursing action? Prevent diarrhea Prevent abdominal distention Prevent aspiration Prevent gastric ulcers
Prevent aspiration
A nurse is creating a plan of care for an oncology patient and one of the identified nursing diagnoses is risk for infection related to myelosuppression. What intervention addresses the leading cause of infection-related death in oncology patients? Assist the patient with hygiene, as needed. Assess the integrity of the patient's oral mucosa regularly. Provide skin care to maintain skin integrity. Encourage several small meals daily.
Provide skin care to maintain skin integrity.
In addition to heart rate, blood pressure, respiratory rate, and temperature, the nurse needs to assess a patient's arterial oxygen saturation (SaO2). What procedure will best accomplish this? Incentive spirometry Pulse oximetry Arterial blood gas (ABG) measurement Peak flow measurement
Pulse oximetry
A nurse is caring for a patient who is postoperative day 1 following neck dissection surgery. The nurse is performing an assessment of the patient and notes the presence of high-pitched adventitious sounds over the patient's trachea on auscultation. The patient's oxygen saturation is 90% by pulse oximetry with a respiratory rate of 31 breaths per minute. What is the nurse's most appropriate action? Encourage the patient to perform deep breathing and coughing exercises hourly. Report this finding promptly to the physician and remain with the patient. Activate the emergency response system. Reposition the patient into a prone or semi-Fowler's position and apply supplementary oxygen by nasal cannula.
Report this finding promptly to the physician and remain with the patient.
A patient with cancer of the tongue has had a radical neck dissection. What nursing assessment would be a priority for this patient? Presence of acute pain and anxiety Respiratory status and airway clearance Self-esteem and body image Tissue integrity and color of the operative site
Respiratory status and airway clearance
A nursing student is discussing a patient with viral pharyngitis with the preceptor at the walk-in clinic. What should the preceptor tell the student about nursing care for patients with viral pharyngitis? The focus of care is resting the voice to prevent chronic hoarseness. Teaching focuses on safe and effective use of antibiotics. The patient should be preliminarily screened for surgery. Symptom management is the main focus of medical and nursing care.
Symptom management is the main focus of medical and nursing care
An adult patient has tested positive for tuberculosis (TB). While providing patient teaching, what information should the nurse prioritize? The fact that TB is self-limiting, but can take up to 2 years to resolve The fact that the disease is a lifelong, chronic condition that will affect ADLs The importance of adhering closely to the prescribed medication regimen The need to work closely with the occupational and physical therapists
The importance of adhering closely to the prescribed medication regimen
A medical nurse educator is reviewing a patient's recent episode of metabolic acidosis with members of the nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis? The kidneys regulate the bicarbonate level in the intracellular fluid. The kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance. The kidneys react rapidly to compensate for imbalances in the body. The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance.
The kidneys regulate the bicarbonate level in the intracellular fluid.
A patient has a diagnosis of multiple sclerosis. The nurse is aware that neuromuscular disorders such as multiple sclerosis may lead to a decreased vital capacity. What does vital capacity measure? The volume of air inhaled and exhaled with each breath The volume of air in the lungs after a maximal inspiration The maximal volume of air exhaled from the point of maximal inspiration The maximal volume of air inhaled after normal expiration
The maximal volume of air exhaled from the point of maximal inspiration
A 16-year-old female patient experiences alopecia resulting from chemotherapy, prompting the nursing diagnoses of disturbed body image and situational low self-esteem. What action by the patient would best indicate that she is meeting the goal of improved body image and self-esteem? The patient requests that her family bring her makeup and wig. The patient cries openly when discussing her disease. The patient reports less disruption from pain and discomfort. The patient begins to discuss the future with her family.
The patient requests that her family bring her makeup and wig.
A nurse is caring for a newly admitted patient with a suspected GI bleed. The nurse assesses the patient's stool after a bowel movement and notes it to be a tarry-black color. This finding is suggestive of bleeding from what location? Upper GI tract Anus or rectum Sigmoid colon Large intestine
Upper GI tract
A newly graduated nurse is admitting a patient with a long history of emphysema. The new nurse's preceptor is going over the patient's past lab reports with the new nurse. The nurse takes note that the patient's PaCO2 has been between 56 and 64 mm Hg for several months. The preceptor asks the new nurse why they will be cautious administering oxygen. What is the new nurse's best response? Oxygen may cause the patient to hyperventilate and become acidotic. Oxygen will increase the patient's intracranial pressure and create confusion. Using oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia. The patient's calcium will rise dramatically due to pituitary stimulation.
Using oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia.
A patient is being treated for bacterial pharyngitis. Which of the following should the nurse recommend when promoting the patient's nutrition during treatment? A liquid or soft diet A high-potassium, low-sodium diet A high-protein diet A 1.5 L/day fluid restriction
liquid or soft diet
A patient is undergoing diagnostic testing for a tumor of the small intestine. What are the most likely symptoms that prompted the patient to first seek care? Intermittent pain and bloody stool Abdominal bloating and recurrent constipation Unexplained bowel incontinence and fatty stools Hematemesis and persistent sensation of fullness
ntermittent pain and bloody stool
A patient presents to the ED stating she was in a boating accident about 3 hours ago. Now the patient has complaints of headache, fatigue, and the feeling that he "just can't breathe enough." The nurse notes that the patient is restless and tachycardic with an elevated blood pressure. This patient may be in the early stages of what respiratory problem? Acute respiratory failure Pleural effusion Pneumoconiosis Pneumonia
Acute respiratory failure
The public health nurse is administering Mantoux tests to children who are being registered for kindergarten in the community. How should the nurse administer this test? Administer intramuscular injections into each child's vastus lateralis. Administer intradermal injections into the children's inner forearms. Administer a subcutaneous injection into each child's umbilical area. Administer a subcutaneous injection at a 45-degree angle into each child's deltoid.
Administer intradermal injections into the children's inner forearms.
A hospital has been the site of an increased incidence of hospital-acquired pneumonia (HAP). What is an important measure for the prevention of HAP? Administration of pneumococcal vaccine to vulnerable individuals Administration of prophylactic antibiotics Obtaining culture and sensitivity swabs from all newly admitted patients Administration of antiretroviral medications to patients over age 65
Administration of pneumococcal vaccine to vulnerable individuals
A perioperative nurse is caring for a postoperative patient. The patient has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the patient's increased risk for what complication? Aspiration Acute respiratory distress syndrome (ARDS) Atelectasis Pulmonary embolism
Atelectasis
A nurse is providing care for a patient who is postoperative day 2 following gastric surgery. The nurse's assessment should be planned in light of the possibility of what potential complications? Select all that apply. Chronic gastritis Atelectasis Malignant hyperthermia Pneumonia Metabolic imbalances
Atelectasis Pneumonia Metabolic imbalances
An oncology nurse is caring for a patient who has developed erythema following radiation therapy. What should the nurse instruct the patient to do? Keep the area cleanly shaven. Avoid using soap on the treatment area. Apply petroleum jelly to the affected area. Periodically apply ice to the area.
Avoid using soap on the treatment area.
A nurse is assessing a patient's stoma on postoperative day 3. The nurse notes that the stoma has a shiny appearance and a bright red color. How should the nurse best respond to this assessment finding? Document a nursing diagnosis of Impaired Skin Integrity. Irrigate the ostomy to clear a possible obstruction. Document that the stoma appears healthy and well perfused. Contact the primary care provider to report this finding.
Document that the stoma appears healthy and well perfused.
A nurse is addressing the prevention of esophageal cancer in response to a question posed by a participant in a health promotion workshop. What action has the greatest potential to prevent esophageal cancer? Early diagnosis and treatment of gastroesophageal reflux disease Annual screening endoscopy for patients over 50 with a family history of esophageal cancer Adequate fluid intake and avoidance of spicy foods Promotion of a nutrient-dense, low-fat diet
Early diagnosis and treatment of gastroesophageal reflux disease
A nurse is performing the admission assessment of a patient whose high body mass index (BMI) corresponds to class III obesity. In order to ensure empathic and patient-centered care, the nurse should do which of the following? Elicit the patient's short-term and long-term goals for weight loss. Examine one's own attitudes towards obesity in general and the patient in particular. Dialogue with the patient about the lifestyle and psychosocial factors that resulted in obesity. Describe one's own struggles with weight gain and weight loss to the patient.
Examine one's own attitudes towards obesity in general and the patient in particular.
A nurse is providing care for a patient whose neck dissection surgery involved the use of a graft. When assessing the graft, the nurse should prioritize data related to what nursing diagnosis? Risk for Trauma Unilateral Neglect Ineffective Tissue Perfusion Risk for Disuse Syndrome
Ineffective Tissue Perfusion
A medical nurse has admitted a patient to the unit with a diagnosis of failure to thrive. The patient has developed a fever and cough, so a sputum specimen has been obtained. The nurse notes that the sputum is greenish and that there is a large quantity of it. The nurse notifies the patient's physician because these symptoms are suggestive of what? Lung tumors Pulmonary edema Pneumothorax Infection
Infection
A patient presents to the walk-in clinic complaining of vomiting and burning in her mid-epigastria. The nurse knows that in the process of confirming peptic ulcer disease, the physician is likely to order a diagnostic test to detect the presence of what? A metabolic acid-base imbalance Infection with Helicobacter pylori Excessive stomach acid secretion An incompetent pyloric sphincter
Infection with Helicobacter pylori
A 35-year-old male patient presents at the emergency department with symptoms of a small bowel obstruction. In collaboration with the primary care provider, what intervention should the nurse prioritize? Administration of a glycerin suppository and an oral laxative Administration of a mineral oil enema Insertion of a central venous catheter Insertion of a nasogastric tube
Insertion of a nasogastric tube
An oncology patient will begin a course of chemotherapy and radiation therapy for the treatment of bone metastases. What is one means by which malignant disease processes transfer cells from one place to another? Inducing mutation of cells of another organ Phagocytizing healthy cells Adhering to primary tumor cells Invading healthy host tissues
Invading healthy host tissues
A patient is scheduled to have excess pleural fluid aspirated with a needle in order to relieve her dyspnea. The patient inquires about the normal function of pleural fluid. What should the nurse describe? It allows for full expansion of the lungs within the thoracic cavity. It lubricates the movement of the thorax and lungs. It limits lung expansion within the thoracic cavity. It prevents the lungs from collapsing within the thoracic cavity.
It lubricates the movement of the thorax and lungs.
The nurse is assessing placement of a nasogastric tube that the patient has had in place for 2 days. The tube is draining green aspirate. What is the nurse's most appropriate action? Leave the tube in its present position. Withdraw the tube 2 to 4 cm. Advance the tube up to 8 cm. Inform the physician that the tube may be in the patient's pleural space.
Leave the tube in its present position.
A nurse is preparing to place a patient's ordered nasogastric tube. How should the nurse best determine the correct length of the nasogastric tube? Insert the tube into the patient's nose until secretions can be aspirated. Place distal tip to nose, then ear tip and end of xiphoid process. Instruct the patient to lie prone and measure tip of nose to umbilical area. Obtain an order from the physician for the length of tube to insert.
Place distal tip to nose, then ear tip and end of xiphoid process.
The nurse has noted the emergence of a significant amount of fresh blood at the drain site of a patient who is postoperative day 1 following total laryngectomy. How should the nurse respond to this development? Rapidly assess the patient and notify the surgeon about the patient's bleeding. Administer a STAT dose of vitamin K to aid coagulation. Remove the patient's drain and apply pressure with a sterile gauze. Assess the patient, reposition the patient supine, and apply wall suction to the drain.
Rapidly assess the patient and notify the surgeon about the patient's bleeding.
A nurse is caring for a patient with a nasogastric tube for feeding. During shift assessment, the nurse auscultates a new onset of bilateral lung crackles and notes a respiratory rate of 30 breaths per minute. The patient's oxygen saturation is 89% by pulse oximetry. After ensuring the patient's immediate safety, what is the nurse's most appropriate action? Perform chest physiotherapy. Report possible signs of aspiration pneumonia to the primary care provider. Reduce the height of the patient's bed and remove the NG tube. Liaise with the dietitian to obtain a feeding solution with lower osmolarity.
Report possible signs of aspiration pneumonia to the primary care provider.
A public health nurse has formed an interdisciplinary team that is developing an educational program entitled Cancer: The Risks and What You Can Do About Them. Participants will receive information, but the major focus will be screening for relevant cancers. This program is an example of what type of health promotion activity? Tertiary prevention Disease prophylaxis Risk reduction Secondary prevention
Secondary prevention
A patient has had a nasogastric tube in place for 6 days due to the development of paralytic ileus after surgery. In light of the prolonged presence of the nasogastric tube, the nurse should prioritize assessments related to what complication? Pharyngitis Laryngitis Sinus infections Esophageal strictures
Sinus infections
A patient with chronic lung disease is undergoing lung function testing. What test result denotes the volume of air inspired and expired with a normal breath? Total lung capacity Residual volume Tidal volume Forced vital capacity
Tidal volume
A nurse is preparing to provide care for a patient whose exacerbation of ulcerative colitis has required hospital admission. During an exacerbation of this health problem, the nurse would anticipate that the patient's stools will have what characteristics? Dry and streaked with blood Loose with visible fatty streaks Hard and black or tarry Watery with blood and mucus
Watery with blood and mucus
