Med Surg Exam #3 - Book NCLEX Questions

When caring for the patient with kidney failure, the nurse teaches the patient to manage his diet by avoiding which foods? a.) Green leafy vegetables and citrus b.) Apples and pears c.) Proteins of high biologic value d.) Oat, wheat, and rye-containing products

Answer A Rationale: Patients should avoid potassium-containing foods such as greens, citrus, banana, tomato, and cantaloupe. Apples and pears are permitted on a renal diet as are proteins of high biologic value and carbohydrates such as grains.

During the conversation about a patient, a new nurse states to the charge nurse, "His BP is 92/50, so he can't be in shock." Which response by the charge nurse indicates that the new nurse does not completely understand the symptoms of shock? a.) Patients can have a near-normal BP, yet still have inadequate tissue perfusion b.) The cutoff for shock is a systolic pressure of 100 mm HG c.) Shock is determined by mean arterial pressure d.) Shock is determined by a heart rate of over 100

Answer A Rationale: The definition of shock is inadequate tissue perfusion and is not based on specific criteria for vital signs.

A cast was applied to a patient's fractured leg 4 hours ago. Which finding is associated with neurovascular compromise? a.) Capillary refill of 5 seconds b.) Ability to move the toes without limitation c.) Full sensation d.) Toes warm to touch

Answer A Rationale: Capillary refill should be less than 2 seconds; a delay in capillary refill indicates impaired arterial perfusion.

A nurse would suspect an inhalation injury with which of the following findings? Select all that apply. a.) History of burn occurring in an enclosed space b.) Carbonaceous sputum c.) Egophony d.) Stridor e.) Singing of nasal hair

Answer A, B, D and E Rationale: An enclosed space is a classic history of inhalation injury and carbon is a common smoke byproduct, inhalation injury causes edema of the airways and stridor. Singing of facial or nasal hair is suspicious of smoke inhalation injury. There is no cause for bloody sputum.

What food would the nurse recommend for bone health? a.) Herbal tea b.) Yogurt c.) Liver d.) Eggs

Answer B Rationale: Sources of calcium include milk, cheese, yogurt, calcium fortified foods, sardines, oysters, clams, canned salmon with bones and dark leafy vegetables. To reduce the risk of osteoporosis, calcium intake should be the highest during adolescence and after 50 years of age.

A 73-year-old patient is placed in skeletal traction prior to surgery for an ORIF of fractured femur. She develops chest pain, tachypnea, and tachycardia the second day in traction. What additional symptom would indicate her symptoms are related to a fat emboli rather than a pulmonary thromboembolic event? a.) Hypotension b.) Restlessness c.) Petechia of the anterior chest wall d.) Warm, reddened areas in her leg

Answer C Rationale: Specific symptoms associated with fat emboli are pulmonary distress, mental status changes, and a petechial rash that develops from 6 to 72 hours after injury. Common symptoms of pulmonary emboli (PE) are shortness of breath, chest pain, increased respiratory rate, cough, apprehension and tachycardia.

A 12-year-old girl complained to the school nurse about back pain. The nurse's assessment revealed a deviation of the vertebrae to the right, with a raised shoulder and hip. What is the terminology for this finding? a.) Kyphosis b.) Lordosis c.) Osteoporosis d.) Scoliosis

Answer D Rationale: Scoliosis is an abnormal lateral curvature of the spine.

Mrs. Andersen has an indwelling catheter after an open cholecystectomy. She develops cramping in the supra-pubic area and urinary leakage. What is the nurse's first intervention? a.) Make certain the catheter is not kinked b.) Evaluate for incisional pain c.) Explain that her symptoms are due to peristalsis d.) Irrigate the urinary catheter to assess for blockage of flow e.) Provide an antispasmodic medication

Answer A Rationale: A kinked tube will prevent draining and can contribute to bladder spasms.

There has been a natural gas explosion in a mutli-story office building in the city. Initial reports indicate that the ED will be receiving a large number of victims that will overwhelm current resources. What need will the nurse working in the ED anticipate? a.) Initiate the hospital emergency operation plan b.) Call off-duty staff to come in and assist c.) Request burn packs from central supply d.) Take a meal break quickly before patients arrive

Answer A Rationale: Activation of the hospital emergency plan is indicated when resources will be overwhelmed. This ensures that resources and personnel are mobilized in a logical sequence to support the victims and multiple hospital areas that will be impacted.

The nurse is assisting with a lumbar puncture. What is the most common complication for which the nurse should monitor the patient following the procedure? a.) Post-lumbar puncture headache b.) Herniation of intracranial contents c.) Spinal epidural abscess d.) Meningitis

Answer A Rationale: Common complications following a lumbar puncture include: Post--lumbar puncture headache, voiding difficulties, slight elevation of temperature, backache or spasms, and stiffness of neck. Rare complications include: herniation of intracranial contents, spinal epidural abscess, spinal epidural hematoma, and meningitis.

A patient has returned to the room postoperatively. The nurse examines the patient's nail beds to asses for what condition? a.) Cyanosis b.) Respiratory rate c.) Edema d.) Cellulitis

Answer A Rationale: Cyanosis is the bluish discoloration that results from lack of oxygen in the blood. It appears with shock or with respiratory or circulatory compromise. A brief inspection of the nails includes observation of configuration, color, and consistency. An alteration of the nail or nail bed can reflect local or systemic abnormalities in progress.

What is reasonable option for pain management for a 50-year-old man who has just sustained 20% partial-thickness burns to his right leg and abdomen? a.) Fentanyl 50 ug intravenously b.) Morphine sulfate 10 mg IM into the left deltoid c.) Calm, reassuring words to help relax him d.) Oxycodone 10 mg PO

Answer A Rationale: Fentanyl is a useful opioid and medications must be given intravenously.

During assessment, what does the nurse recognize as a normal function of the skin? a.) Thermal regulation b.) Vitamin E production c.) Vitamin C production d.) Releasing of carbon dioxide

Answer A Rationale: Heat is dissipated primarily through the skin.

A 78-year-old woman in complaining of neck and upper back pain. The nurse's assessment reveals an abnormal convex curvature of the cervical and thoracic area. What is the terminology for this finding? a.) Kyphosis b.) Lordosis c.) Kyphoscoliosis d.) Scoliosis

Answer A Rationale: Kyphosis is an abnormal convex curvature (causes the back to bow) of the thoracic spine. It may also be noted in the thoracolumbar or sacral level.

The nurse is caring for a 32-year-old with circumferential full-thickness burns to the right arm and trunk. Which nursing intervention has the highest priority in the plan of care? a.) Assess radial pulses several times a day b.) Enforce airborne infection control procedures c.) Perform range-of-motion exercises several times per day d.) Remove blisters from the burn area

Answer A Rationale: The circumferential full thickness injury can quickly turn into a tourniquet effect that will require escharotomies that will be limb saving. Thus, assessment of the circulation of the extremity will be a priority nursing action.

A patient is undergoing a cerebral angiography to rule out an aneurysm. When preparing the patient for the procedure, what would the nurse include in the instructions? a.) Expect a metallic taste when the contrast agent is injected. b.) You will need a full bladder prior to the procedure c.) Maintain an NPO status d.) General sedation will be given prior to procedure

Answer A Rationale: The patient is instructed to remain immobile during the angiogram process and is told to expect a brief feeling of warmth in the face, behind the eyes, or in the jaw, teeth, tongue, and lips, and a metallic taste when the contrast agent is injected. The patient is instructed to void before going to the x-ray department. The patient should be well hydrated, and clear liquids are usually permitted up to the time of a regular arteriogram. After the groin is shaved and prepared, a local anesthetic is administered to prevent pain at the insertion site of the catheter and to reduce arterial spasm.

What places the patient at risk for impaired wound healing after surgery for a primary bone cancer? Select all that apply. a.) Radiation therapy b.) Prealbumin level is 28 mg/dL c.) Weight loss of 18% over the previous 3 months d.) Anorexia e.) Satisfactory vitamin C levels

Answer A, C, D Rationale: The purpose of radiation therapy is to disrupt cell mitosis and has lasting effects on wound healing. A normal prealbumin level is 19 to 38 mg/dL. An unintentional weight loss of 10% of usual body weight in three months is a risk factor for malnutrition. Anorexia is associated with inadequate nutrition that is necessary for healing. Vitamin C contributes to the body's resistance to infection and increases wound tensile strength.

A male patient is concerned about changes to his urinary stream. Which of the following are associated with lower urinary tract symptoms? Select all that apply. a.) Urgency b.) Incontinence c.) Frequency d.) Dribbling e.) Costovertebral angle (CVA) tenderness

Answer A, C, D Rationale: Urgency, frequency, and dribbling describe symptoms that are the results of changes to the structure or function of the lower urinary tract. CVA tenderness is associated with upper kidney diseases.

What does the nurse look for when assessing the characteristics of a lesion? Select all that apply. a.) Heat b.) Claudication c.) Size d.) Erythema e.) Pattern

Answer A, C, D, E Rationale: When assessing a lesion, it is important to describe clearly and in detail the color, any redness, heat, pain or swelling, size and location, pattern of eruption, and distribution of the lesion.

The nurse assesses the LOC of a patient who suffered a head injury and determines that the patient's GCS score is 15. Which of the following responses did the nurse assess to determine the GCS score? Select all that apply. a.) Spontaneous eye opening b.) Tachycardia, hypotension, bradycardia c.) Ability to follow commands d.) Unequal pupil size e.) Orientation to person, place, and time

Answer A, C, E Rationale: The Glascow Coma Scale (GCS) includes assessment of eye opening (E), verbal response (V), and motor response (M). The patient's responses are rated on a scale from 3 (deep coma) to 15 (normal). Vital signs should also be assessed, but they are not a part of the GCS. Pupillary response is included in the neurologic examination, but also is not part of the GCS.

A client is diagnosed with osteoporosis. Which statements should the nurse include when teaching the client about the disease? Select all that apply. a.) Osteoporosis is common in females after menopause b.) Osteoporosis is a degenerative disease characterized by an increase in bone density c.) Osteoporosis can increase the risk for fractures d.) The recommended daily calcium dose should be taken as a single dose, and the patient should be instructed not to lie down for 30 minutes e.) Weight-bearing exercise should be avoided f.) The patient's T score is at least 2.5 SD below the young adult mean value on the BMD scan

Answer A, C, F Rationale: It is estimated that one in two women over the age of 50 years will suffer a fracture due to osteoporosis. Characteristics of osteoporosis include a reduction of bone density. The bones become progressively porous, brittle, and fragile; they fracture easily under stresses that would not break normal bone. The calcium dose should be split and not taken as a single dose. Bone formation is enhanced by the stress of weight and muscle activity. Resistance and impact exercises are most beneficial in developing and maintaining bone mass. Osteoporosis is present when the T-score is at least 2.5 SD below the young adult mean value on BMD scan (NIH, 2015).

A patient with Parkinson disease is seen in the neurology clinic for treatment. The nurse identifies this disorder as being caused by a lack of which neurotransmitters? a.) Acetylcholine b.) Dopamine c.) Seratonin d.) Gamma-aminobutyric acid (GABA)

Answer B Rationale: A lack of the neurotransmitter dopamine leads to Parkinson's disease. Lack of actylcholine, serotonin, and GABA do not lead to the development of Parkinson's disease.

The nurse notices clear fluid draining from the nose of a patient who sustained a head injury 2 hours ago. This may indicate the presence of what condition? a.) Cerebral concussion b.) Basal skull fracture c.) Brain tumor d.) Sinus infection

Answer B Rationale: Basal skull fractures are usually open, creating the potential for a cerebral spinal fluid (CSF) leak. A sinus infection could produce fluid draining from the nose, though this is likely to be thick, and yellow or green. Concussion does not produce nasal drainage. Symptoms of concussion include headache, nausea, vomiting, blurry vision, and disorientation. A brain tumor also would not produce clear nasal drainage. Presenting symptoms for a brain tumor vary depending on the type and location of the tumor.

A 55-year-old woman reports stress incontinence when sneezing and playing tennis. She asks what she can do to prevent this from happening. Which of the following is the nurse's best response? a.) Start an anticholinergic medication b.) Void immediately prior to playing tennis to try and decrease urine loss while playing c.) Decrease overall fluid intake so this is unlikely to happen at any time d.) Restrict intake of calcium-containing foods e.) Choose more supportive undergarments

Answer B Rationale: Behavioral modifications such as emptying the bladder can often successfully address mild stress incontinence. While many patients may follow option C, this can impact medication and kidney function long-term. A and D would require additional input from a provider, and D does not impact urinary function.

A patient with severe burn injuries to the abdomen and legs become combative when it is time to change the dressings. What nursing intervention will be most helpful to this patient? a.) Allow the patient to determine the time of dressing change b.) Pre-medicate the patient with pain and anxiety medications before dressing change c.) Tell the patient it is OK to cry during dressing change d.) Explain the importance of dressing changes

Answer B Rationale: Burn patients often become very anxious during dressing changes. Patients who are adequately medicated with pain and anxiety medications often do better having a role in the dressing change. Although all other options for this question are reasonable, premedicating the patient is the priority as dressing changes are painful.

Which assessment finding may indicate to the nurse an acute peripheral neurovascular dysfunction for the patient recovering from surgery of the foot? a.) Pale skin, atrophy of the limb, with capillary refill of 2 seconds b.) Absence of feeling, capillary refill of 4 to 5 seconds, and cool skin c.) Atrophy of limb, increased motion, and thickened toe nails d.) Pale skin, weakness in motion, and loss of toe hairs

Answer B Rationale: Delayed capillary refill, pale cool skin, paresthesia, and weakness are associated with acute neurovascular dysfuntion. Atrophy of a limb, thickened toe nails, and loss of toe hairs are associated with chronic ischemia.

An MRI has been ordered for a patient with low back pain. What should be included in the teaching plan for this patient? a.) The patient will need to lie still for 3 to 4 hours. b.) A rhythmic rocking sound will be heard during the procedure. c.) There is no risk of claustrophobia. d.) It is an invasive technique.

Answer B Rationale: During the MRI, that patient needs to lie still for 30 to 60 minutes and hears a rhythmic knocking sound. Patients who experience claustrophobia may be able to tolerate the confinement of closed MRI equipment with sedation. The MRI is a noninvasive imaging technique that uses magnetic fields, radiowaves, and computers to demonstrate abnormalities.

In the immediate postoperative period, which measure would best prevent a DVT? a.) Adding a multivitamin to the patient's medication b.) Early ambulation c.) Measuring intake and output d.) Lowering the legs below the level of the heart

Answer B Rationale: Early ambulation enhances venous return and is an appropriate intervention to prevent problems related to inactivity such as a DVT.

A patient develops low BP and tachycardia and is very agitated. The nurse remembers that a central line was placed 3 hours ago. The patient's lung sounds are decreased on one side, and tracheal deviation is present. The nurse realizes that this patient is most likely experiencing which type of shock? a.) Hypovolemic b.) Obstructive c.) Anaphylactic d.) Neurogenic

Answer B Rationale: Given the history and findings, the patient most likely is experiencing obstructive shock due to a tension pneumothorax. A pneumothorax is a known complication of central line placement.

When entering a patient's room, the nurse notices blood clots in the IV line. What is the most appropriate nursing intervention at this time? a.) Milk the tubing b.) Discontinue the infusion c.) Irrigate the tubing and catheter d.) Aspirate the clot from the tubing

Answer B Rationale: If blood clots occur in the IV line, the infusion must be discontinued and restarted in another site with a new cannula and administration set. The tubing should not be irrigated or milked. The clot should not be aspirated from the tubing.

Which assessment finding would the nurse expect to find in a patient diagnosed with acute osteomyelitis? a.) Leukopenia and localized bone pain b.) Leukocytosis and elevated sedimentation (SED) rate c.) Leukopenia and elevated fever d.) Petechiae over the chest and abnormal arterial blood gas (ABG) results

Answer B Rationale: Leukocytosis or elevated white blood cells and increased sedimentation rate are seen in acute osteomyelitis.

A 25-year-old woman experienced an open fracture of the right fibula with major soft tissue damage of her lower leg in a motor vehicle accident. Surgical reduction and fixation of the fibula were performed with debridement of nonviable tissue and drain placement in the damaged soft tissue. Which complication is this patient at risk for? a.) Osteoporosis b.) Osteomyelitis c.) Fat emboli d.) Compartment syndrome

Answer B Rationale: Osteomyelitis is an acute or chronic infection of the bone or bone marrow. This patient is at risk for this bone infection because of direct contamination with an open fracture, and direct bone contamination from the Open Reduction and Internal Fixation (ORIF) of the right fibula fracture.

A patient who has been diagnosed with a small kidney stone has been told to increase fluid intake. The patient wants to know why this is necessary. What is the nurse's best response? a.) "This will decrease your pain." b.) "This will increase urine production and help move the stone from your system." c.) "This will help pain medications work more quickly." d.) "This will help prevent any nausea you are having."

Answer B Rationale: Production of urine will stimulate the peristaltic motion of the ureters, which in turn will aid in the movement of small stones.

During assessment of a patient admitted to the emergency room after a motor vehicle collision, he becomes semi-conscious and continues moaning with pain. His blood pressure has now decreased to 100/42, and his pulse has increased to 122. What is the most immediate life-threatening problem for this patient? a.) Arrhythmias due to hypokalemia b.) Hypovolemia c.) Respiratory depression from pain medication d.) Fat embolus to the lung

Answer B Rationale: Tachycardia and hypotension are associated with hypovolemia. Any patient with multitrauma is at risk for hypovolemia. Refer to Box 42-2 in the text for signs and symptoms of hypovolemic shock.

A patient is diagnosed with SIADH. What disturbance should the nurse be aware of related to this diagnosis? a.) Excess water loss b.) Dilutional hyponatremia c.) Serum sodium level of 148 mg/dL d.) Decreased urine osmolality

Answer B Rationale: The basic physiologic disturbances in SIADH are excessive ADH activity, with water retention and dilutional hyponatremia, and inappropriate urinary excretion of sodium in the presence of hyponatremia. Serum sodium levels are decreased. Urine osmolality is increased in SIADH.

A 23-year-old patient, experienced an open fracture of the left tibia with major soft tissue damage of his lower leg in a bicycle accident. Surgical reduction and fixation of the tibia were performed with debridement of nonviable tissue and drain placement in the damaged soft tissue. Which finding by the nurse would most likely indicate the development of the osteomyelitis? a.) Tachycardia b.) Elevated ESR c.) Numbness in the left leg and toes d.) Muscle spasms around the affected bone

Answer B Rationale: The erythrocyte sedimentation rate (ESR), is over 90% for patients who have confirmed osteomyelitis. However, a normal or slightly elevated ESR does not eliminate the diagnosis. In addition, the nurse assesses for pain over the affected bone.

A 90-year-old patient with multiple medical problems is admitted to the hospital's geriatric care unit. The nursing assessment reveals weight loss, poor capillary perfusion, and delayed skin turgor. These findings should alert the gerontologic nurse to which condition? a.) Aspiration b.) Fluid volume deficit c.) Pressure ulcers d.) Contractures

Answer B Rationale: The turgor (elasticity) of the skin, which decreases in normal aging, may be a factor in assessing the hydration status of a patient.

The nurse is testing the cranial nerves of a patient diagnosed with myasthenia gravis. The nurse asks the patient to clench his jaw while she palpates the temporal and masseter muscles. The nurse is correctly testing which cranial nerve? a.) Abducens b.) Trigeminal c.) Acoustic d.) Hypoglossal

Answer B Rationale: To assess chewing, the patient is asked to clench his jaw while the nurse palpates the temporal and master muscles. This tests the trigeminal nerve which is cranial nerve V. The abducens nerve is tested with EOMs. The acoustic nerve tests hearing. When assessing tongue movement, the nurse is testing cranial nerve XII or the hypoglossal nerve.

When planning care for the patient with kidney trauma, the nurse notifies the physician immediately for which of these findings? a.) Laboratory reports microscopic hematuria b.) Tachycardia and hypotension c.) Patient is upset and crying d.) Scar noted on patient's left flank

Answer B Rationale: While hematuria may be present in renal trauma, tachycardia and hypotension are clear symptoms of hemorrhagic shock and must be addressed immediately. The professional nurse has the skills to assist a patient who is upset. A scar on the flank represents an old wound; this is not an immediate concern.

The nurse recognizes the patient comprehends the signs and symptoms of renal transplant rejection when the patient states he will monitor for which of these signs and symptoms? Select all that apply. a.) Thrill and bruit over the fistula b.) Weight gain and fever c.) Palpitations and thirst d.) Flank pain and pyuria e.) Swelling of the ankles and around the eyes

Answer B and E Rationale: Symptoms of transplant rejection include fever, edema, weight gain, leukocytosis, tenderness over the graft site, and returning symptoms of uremia. Thrill and bruit over the fistula indicate a positive outcome for the fistula. Palpitations and thirst may be symptoms of fluid volume deficit, which is not found in the renal failure patient. Flank pain and pyuria are symptoms of pyelonephritis.

A 55-year-old patient with leukemia is being seen in the clinic for complaints of burning pain in the back. The patient has been diagnosed with shingles. The nurse would expect which medication classification to be ordered to reduce pain and halt the progression of the disease? a.) Anti-inflammatory b.) Antiviral c.) Antibiotic d.) Antifungal

Answer B. Rationale: IV acyclovir, if started early, is effective in significantly reducing the pain and halting the progression of the disease. Anti-inflammatory, antibiotics, and antifungals would not halt the progression of the disease. Shingles is a reactivated varicella-zoster virus. There is an increased frequency of herpes zoster infections among patients with weakened immune systems and cancers, such as leukemias and lymphomas.

A 20-year-old patient is being seen in the dermatology clinic for a basal cell carcinoma on her eye. The nurse would expect the physician to complete which intervention? a.) Electrosurgery b.) Mohs' micrographic surgery c.) Cryosurgery d.) Radiation

Answer B. Rationale: Mohs' micrographic surgery is the treatment of choice and the most effective for tumors around the eyes, nose, upper lip, and auricular and periauricular areas. Electrosurgery is destruction or removal of tissue by electrical surgery. Cryosurgery destroys the tumor by deep-freezing the tissue. Radiation therapy is frequently performed for cancer of the eyelid, the tip of the nose, and areas in or near vital structures. It is reserved for older patients, because x-ray changes may be seen after 5 to 10 years, and malignant changes in scars may be induced by irradiation 15 to 30 years later.

A patient sustained a C6 SCI 4 hours ago. What nursing diagnosis is a priority? a.) Urinary retention b.) Risk for impaired skin integrity c.) Ineffective breathing pattern d.) Powerlessness

Answer C Rationale: All of the options should be assessed in a patient with a spinal cord injury. However, the priority should be to assess for respiratory difficulty. Ascending cord edema can quickly compromise innervation of the diaphragm, and the patient may go into respiratory arrest. Urinary retention and impaired skin integrity are common problems in patients with spinal cord injury (SCI), but their assessment does not take priority over assessing for a patent airway. Powelessness is also common in the spinal cord patient population, but assessing for this is not an acute intervention.

The nurse is receiving report on a client with AKI. What should the nurse follow up on first? a.) Potassium value of 5.0 mEq/L b.) Patient refused fingerstick blood glucose c.) Crackles throughout lung fields d.) Patient reports itching skin

Answer C Rationale: Crackles in the lungs is suggestive of heart failure or pulmonary edema, a life threatening complication of fluid overload from oliguria or anuria of kidney failure. This requires immediate evaluation. Potassium of 5.0 mEq/L is a normal value. The client who refuses a fingerstick is not unstable in this situation and will not require immediate attention. Uremic waste products on the skin causing itching is an expected finding in patients with kidney failure; this does not require immediate follow up.

When being instructed on methods for managing the mucus in their urinary diversion, patients should be reminded to do which of the following? a.) Increase fiber intake b.) Consume high levels of citrus fruits and juices c.) Increase consumption of cranberry juice d.) Avoid caffeine consumption e.) Increase intake of dairy products

Answer C Rationale: Cranberry juice helps to acidify the urine and manage mucous production.

The nurse recognized that a patient with chronic kidney disease will need which hormone replaced? a.) Anterior pituitary b.) Parathyroid c.) Erythropoietin d.) Corticotropin-releasing

Answer C Rationale: Erythropoietin production declines as a result of chronic kidney disease.

A sexually active, 23-year-old woman presents with a history of three UTIs in the past 12 months. What is the first step in her evaluation? a.) A urine culture b.) An intravenous pyelogram to look for an anatomic abnormality c.) A history and physical examination d.) A 3-day course of antibiotics e.) A pregnancy test

Answer C Rationale: History and physical exam is always the first step, to confirm present complaint and history and guide evaluation.

A patient with a GI bleed arrives at the emergency department with the following vital signs: Temperature = 37.4 Celsius, HR = 112, RR = 26, BP = 88/44. The nurse recognizes that this patient is most likely experiencing or at risk for which type of shock? a.) Anaphylactic b.) Neurogenic c.) Hypovolemic d.) Septic

Answer C Rationale: In the setting of active bleeding and low blood pressure, hypovolemic shock due to hemorrhage is the most likely cause.

Topical corticosteroid therapy has been ordered for a patient with pruritus. What information should be incorporated into the plan of care for this patient? a.) Apply liberally in the prescribed area. b.) Absorption is enhanced when skin is dry c.) Local side effects may include skin atrophy and thinning d.) Absorption is decreased when covered with an occlusive dressing

Answer C Rationale: Local side effects may include skin atrophy and thinning, striae, and telangiectasia. The patient is taught to apply the medication sparingly and rub it into the prescribed area thoroughly. Absorption of topical corticosteroid is enhanced when the skin is hydrated or when the affected area is covered by an occlusive or moisture-retentive dressing.

What changes in the older adult best describe why aging process increases risk for impairment in skin integrity? a.) Epidermal cells thicken b.) Dermal thickness increases c.) Decreased elastin, collagen, and fat d.) Maceration

Answer C Rationale: Loss of subcutaneous tissue substances of elastin, collagen and fat diminishes the protection and cushioning of organs, decreases muscle tone, and results in the loss of the insulating properties of fat.

Traci, a 29-year-old married woman, frequently experiences a UTI after sexual intercourse. In addition to instruction regarding voiding after intercourse, her initial management may include which of the following? a.) A recommendation for abstinence b.) Testing for anatomic abnormalities c.) A prescription for antibiotics to be used post-coitus d.) Boric acid suppositories e.) Wipe the vagina from back to front after voiding

Answer C Rationale: Many women will be placed on antibiotics. A single dose post-coitus is often successful at preventing ascending infections.

A nurse working on a trauma unit is initiating IV fluids for a patient. For what condition would the nurse administer normal saline? a.) Renal impairment b.) Pulmonary edema c.) Burns d.) Heart failure

Answer C Rationale: Normal saline (0.9% sodium chloride) is used with blood transfusions and to replace large sodium losses, as in burn injuries. It is not used for heart failure, pulmonary edema, renal impairment, or sodium retention.

A nurse is analyzing her patient's ABG values. Which result is inconsistent with the diagnosis of respiratory acidosis? a.) pH 7.3 b.) PaCO2 50 c.) Hyperventilation (PaCO2 25) d.) Hypoventilation (PaCO2 60)

Answer C Rationale: Respiratory acidosis is always due to inadequate excretion of CO2 with inadequate ventilation, resulting in elevated plasma CO2. Any condition that causes hypoventilation is associated with an elevated PaCO2. Hyperventilation, causes a decrease in CO2 and is associated with respiratory alkalosis.

A patient who was burned at 10:00 a.m. reports a pre-burn weight of 154 lb (70kg). The estimated total body surface area (TBSA) burned is 60%. Using the Parkland/Baxter formula, the nurse verifies that the total amount of intravenous lactated Ringer solution to be infused by 6:00 p.m. on the day of the burn is which of the following? a.) 5,200 mL b.) 7,470 mL c.) 8,400 mL d.) 16,800 mL

Answer C Rationale: The formula for Parkland formula is 4 mL/kg/percentage TBSA over 24 hours, using LR. Thus 4mL/70/60%, equals 16,800 mL of IV fluid in 24 hours. Half of the volume is administered over the first 8 hours postburn and the remaining half is administered over the next 16 hours; 50% of 16,800 mL is 8,400 mL which is administered over 8 hours.

A 25-year-old patient is transported by paramedics to the ED following a fall from a second-story balcony during a party. During the primary survey, respirations are noted to be snoring with a heavy alcohol odor to the breath. The patient is receiving 100% O2 via face mask, and oxygen saturation is 91%. The patient withdraws from painful stimuli but is not speaking or responding appropriately to commands. What are the immediate priorities for care? a.) Open airway with head tilt-chin lift maneuver and obtain chest x-ray to assess pneumothorax b.) Draw labs for toxicology screen and administer 0.5 mg Ativan to prevent withdrawal seizures c.) Perform jaw-thrust maneuver and reassess ventilation effort d.) Rapidly transport patient to CT for brain CT to evaluate for neurologic injury

Answer C Rationale: The immediate priority in any patient presenting to the ED is to establish a patent airway. Snoring respirations and low oxygen saturation indicate a compromised airway. The patient is at risk for cervical spine injury due to his fall and the only initial safe method to establish an airway with suspected spinal cord injury is with the jaw-thrust maneuver. Performing the jaw-thrust maneuver and reassessing the adequacy of the airway and ventilation effort is the immediate priority. The patient may need airway support with other devices such as an endotracheal tube if the jaw-thrust maneuver does not adequately support a patent airway.

A 50-year-old patient presents to the ED with complaints of a fever and chills for the past 72 hours, body aches, and appears to be acutely ill. The nurse notes lesions on the patient's arms and face that have appear to be spreading quickly. What are immediate priorities for care? a.) An assessment of recent travel b.) Administer an antipyretic to reduce fever and body aches c.) Isolate from other patients and ensure all staff follow isolation precautions d.) Assist patient into a hospital gown for an immediate examination and give clothing to family members

Answer C Rationale: These symptoms are indicators of possible smallpox infection. While an assessment of recent travel may indicate a source of infection, it is not the immediate priority. After lesions develop this disease is highly communicable and isolation is the immediate priority. Clothing must not be given to the family and, if smallpox is confirmed, clothing must be autoclaved before being washed with water and bleach. If smallpox is confirmed, the public health department must be notified. Smallpox vaccine should be offered within 4 days to family members and staff who have had unprotected contact with the patient after the fever started.

Which interventions should the nurse's plan of care include to help prevent autonomic dysreflexia in a patient with SCI? Select all that apply. a.) Check for fecal impactions b.) Monitor blood pressure for hypotension c.) Check the urinary drainage system for any obstruction d.) Monitor bowel movements e.) Instruct the patient to wear a medic alert bracelet

Answer C, D Rationale: The nurse should ensure that the urinary drainage system does not become blocked, as this is the most common cause of autonomic dysreflexia. Having a fecal impaction can also cause autonomic dysreflexia, so the nurse should carefully monitor the patient for regular bowel movements. However, checking for fecal impactions can cause autonomic dysreflexia because of the resulting stimulation of the rectum. Checking for fecal impactions should only be done if the patient is having an episode of autonomic dysreflexia and other more common causes have been ruled out. Prior to this procedure being performed, the patient may receive an anesthetic agent. Instructing the patient to wear a medic alert bracelet should be done, but this will not prevent autonomic dysreflexia.

A 22-year-old man is admitted to the emergency department with a crush injury to both lower legs. He was pinned under a car fro 3 hours. On admission, his vital signs are stable; he is alert and oriented and complaining of extreme pain in his legs. Popliteal pulses are strong; pedal and posterior tibial pulses are weak. The ankle and feet appear dusky; the skin is tense, but the skin envelope is not broken. X-rays show no broken bones. Based upon these data, what interventions are most appropriate? a.) Notify the provider and anticipate that a stat V/Q scan will be performed to rule out fat emboli. b.) Notify the provider and prepare to set up skin traction to decrease the pressure on the calf muscle. c.) Notify the provider and anticipate that the provider will measure the pressure in the compartment and possibly perform a fasciotomy if elevated pressure is noted. d.) Notify the provider and prepare to give IV antibiotics stat to decrease the risk of osteomyelitis

Answer C. Rationale: Fat emboli would present with signs and symptoms of pulmonary distress, mental status changes, and a petechial rash that develops from 6 to 72 hours after injury. Skin traction is not appropriate in this situation; skin traction is used to treat fractures, dislocations, and long-duration muscle spasms. Compartment syndrome is defined as increasing pressure between bone and fascia of the limb and often presents with complaints of extreme pain unrelieved by pain medication, pain on passive extension, paresthesis and pulselessness. However, pulselessness presents late in this disorder. The patient symptoms suggest compartment syndrome. The provider should be notified immediately as a delay in diagnosis and treatment of compartment syndrome can lead to permanent nerve and muscle damage. Compartment pressure monitoring is useful in diagnosing this complication. Osteomyelitis presents with fever, pain, swelling, redness, drainage, and leukocytosis and typically occurs after several days or weeks.

The healthcare provider has ordered Collagenase for a patient with a left leg necrotic ulcer. What does the nurse understand about the use of collagenase? a.) Removes necrotic tissue and absorbs small to large amounts of exudates b.) Uses the body's own digestive enzymes to break down necrotic tissue c.) Speeds the rate at which necrotic tissue is removed d.) Uses a high moisture-vapor transmission rate to remove exudate

Answer C. Rationale: Santyl is an enzymatic debriding agent that speeds the rate at which necrotic tissue is removed. Wet to dry dressings remove necrotic tissues and absorbs small to large amounts of exudates. Autolytic debridement is a process that uses the body's own digestive enzymes to break down necrotic tissue. Commercially produced moisture-retentive dressings can perform the same functions as wet dressings but are more efficient at removing exudates because of their higher moisture-vapor transmission rate.

When assessing a trauma patient presenting in the ED, what is the most important priority for the nurse? a.) Controlling hemorrhage b.) Inserting two large-gauge IV catheters for fluid resuscitation c.) Obtaining name and phone numbers of nearest relative to inform them that the patient is in the hospital d.) Establishing a patent airway

Answer D Rationale: During the initial primary survey circulation, airway, breathing, and disability are assessed. Ensuring a patent airway is a critical step followed by ensuring adequate ventilation.

A city has been hit by a tornado, and reports indicate significant numbers of casualties and injuries. The hospital has not been affected, and all systems are operational at this time. As patients arrive, they have been tagged by field responders using the NATO color coding for severity. What does the nurse working in the ED know about this system? a.) Patients tagged with a green tag require immediate and extensive use of resources for survival b.) Patients with a red tag have minor injuries and can wait for care c.) Children always receive a red tag d.) Patients with a black tag are not a priority for treatment under MCI standards

Answer D Rationale: Patients with a black tag have injuries that are non-survivable or death appears to be imminent. Under the triage system, these patients are provided with comfort measures and separated from other casualties but extensive use of limited resources is futile and may compromise existing resources if resuscitative care is attempted. Patients presenting with red tags indicate significant injuries that are potentially survivable with appropriate resource utilization. The tagging system does not change based on age and is driven by injury. Patients with a green tag have minor injuries and can wait for care.

A patient is seen in the wound clinic for a pressure ulcer on his left leg. There is full-thickness tissue loss with the bone exposed. The nurse would correctly document this wound as being in which stage? a.) I b.) II c.) III d.) IV

Answer D Rationale: Stage IV pressure ulcers are described as a full-thickness tissue loss with exposed bone, tendon, or muscle. These ulcers often include undermining and tunneling. Stage I ulcer appears as intact skin with nonblanchable, erythema of a localized area usually over a bony prominence. Stage II pressure ulcers appear as a partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. Stage III causes full-thickness tissue loss. The depth of a Stage III pressure ulcer varies by anatomical location.

When caring for the patient with nephrotic syndrome, what is appropriate to include in the patient teaching plan to prevent long-term? a.) Observe for dark urine and clay-colored stool b.) Void every 2 hours on schedule c.) Avoid driving at night d.) Minimize the intake of saturated fat

Answer D Rationale: The patient with nephrotic syndrome has hyperlipidemia and risk for cardiovascular disease as part of the constellation of symptoms. Minimizing saturated fats is a prudent means to prevent cardiovascular disease. Dark urine and clay colored stools are symptoms of gallbladder or hepatic disease. Voiding every 2 hours on a schedule is useful to prevent incontinence. There are no ocular complications of nephrotic syndrome that will prevent the client from driving at night.

A patient comes in to the urgent care center complaining of shortness of breath and dizziness after being stung by a bee. The patient loses consciousness in the waiting room. The receptionist has called 911. The nurse anticipates that which medication will be considered first? a.) Diphenhydramine (Benadryl) b.) Phenytoin (Dilantin) c.) Epinephrine IV d.) Epinephrine IM

Answer D Rationale: This patient is experiencing anaphylactic shock. Epinephrine is the treatment for anaphylactic shock. Diphenhydramine is an antihistamine that should also be considered, but epinephrine should be given first. Epinephrine IV would work, but the IM route is the quickest and best choice in this situation. Dilantin is an antiseizure medication.

A patient is scheduled for an EEG tomorrow. Which piece of information should the nurse provide to the patient prior to the procedure? a.) Anti-seizure medications need to be taken prior to procedure b.) Sedation will be given during the procedure c.) There is a slight chance of electric shock d.) Maintain a sleep-deprived state the night before the procedure

Answer D Rationale: To increase the chances of recording seizure activity, it is sometimes recommended that the patient be deprived of sleep on the night before the EEG. Antiseizure agents, tranquilizers, stimulants, and depressants should be withheld 24 to 48 hours before an EEG because these medications can alter the EEG wave patterns or mask the abnormal wave patterns of seizure disorders. The patient is reassured that the procedure does not cause an electric shock.

The nurse knows that a frequent cause of white blood cells (WBCs) in the patient's urine is which condition? a.) Prostate enlargement b.) Hypertension c.) Bladder cancer d.) Genitourinary infection

Answer D Rationale: WBCs are an indicator of either infection or inflammation at some point in the GU tract. The nurse recognizes that urinary tract infections (UTIs) are some of the most common bacterial infections annually worldwide.5. Answer B. This collection of symptoms is consistent with pain from irritation of the kidney.

What does the nurse expect to see on the ECG reading when serum potassium levels rise to greater than 6 mEq/L? a.) Peaked, widened T waves b.) ST-segment elevation c.) Lengthened QT interval d.) ST-segment depression

Answer D Rationale: When potassium levels are greater than 6 mEq/L, the earliest ECG changes are a peaked, narrow T wave, ST-segment depression, and a shortened QT interval. If the serum potassium level continues to increase, the PR interval becomes prolonged and is followed by disappearance of the P waves.

A patient is admitted with a closed head injury that was sustained in a motorcycle accident. The patient has been showing an upward trend in ICP measurements. What is the first priority action that the nurse should take with this patient? a.) Administer 100 mg of IV pentobarbital as ordered b.) Increase the ventilator settings to a respiratory rate of 20 breaths/min c.) Administer 20 g of IV mannitol as ordered d.) Reposition the patient to avoid neck flexion

Answer D Rationale: While all of the above may be appropriate interventions for a patient with increased intracranial pressure (ICP), repositioning the patient to avoid neck flexion is the only nursing intervention and it should be first. If repositioning the neck does not decrease ICP, then mannitol or pentobarbital may be administered as ordered. Increasing the settings on the ventilator (hyperventilation) should only be used as last resort in patients with refractory increased ICP.

In early goal-directed therapy for shock, the nurse knows that which parameter is the highest priority when evaluating effectiveness of therapy? a.) Heart rate and BP b.) SvO2 and O2 saturation c.) Base deficit and hematocrit d.) SvO2 and CVP

Answer D Rationale: While the nurse must monitor heart rate, blood pressure, and oxygen saturation in the setting of shock, early goal-directed therapy refers to fluid resuscitation guided by the goal of SvO2 greater than 70% and CVP greater than 8.