med surg final

Which information about dietary management should the nurse include when teaching a patient with peptic ulcer disease (PUD)?

"Avoid foods that cause pain after you eat them."

A 26-yr-old woman is being evaluated for vomiting and abdominal pain. Which question from the nurse will be most useful in determining the cause of the patient's symptoms?

"Can you tell me more about the pain?"

A patient with newly diagnosed lung cancer tells the nurse, "I don't think I'm going to live to see my next birthday." Which is the best initial response by the nurse?

"Can you tell me what it is that makes you think you will die so soon?"

A patient with a right lower leg fracture will be discharged home with an external fixation device in place. Which information will the nurse teach?

"Check and clean the pin insertion sites daily."

A few months after bariatric surgery, a 56-yr-old male patient tells the nurse, "My skin is hanging off of me. I think I might want to surgery to remove the skinfolds." Which response by the nurse is most appropriate?

"Cosmetic surgery may be possible once your weight has stabilized."

The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is most important for the nurse to ask before the skin test?

"Did you receive the bacille Calmette-Guérin (BCG) vaccine for TB?"

A patient's complete blood count (CBC) shows a hemoglobin of 19 g/dL and a hematocrit of 54%. Which question should the nurse ask to determine possible causes of this finding?

"Do you have any history of lung disease?"

The nurse assesses a patient who has numerous petechiae on both arms. Which question should the nurse ask the patient?

"Do you take medication containing salicylates?"

A high school teacher who has been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse, "I cannot teach any more. It will be too upsetting if I have a seizure at work." Which response by the nurse specifically addresses the patient's concern?

"Epilepsy usually can be well controlled with medications."

The nurse is admitting a 67-yr-old patient with new-onset steatorrhea. Which question is most important for the nurse to ask?

"Have you noticed a recent weight loss?"

A 58-yr-old woman who was recently diagnosed with esophageal cancer tells the nurse, "I do not feel ready to die yet." Which response by the nurse is most appropriate?

"Having this new diagnosis must be very hard for you."

Which question from the nurse would help determine if a patient's abdominal pain might indicate irritable bowel syndrome (IBS)?

"How long have you had abdominal pain?"

A nurse obtains a health history from a patient who has a 35 pack-year smoking history. The patient complains of hoarseness and tightness in the throat and difficulty swallowing. Which question is important for the nurse to ask?

"How much alcohol do you drink in an average week?"

The nurse is caring for a patient who is to be discharged from the hospital 4 days after insertion of a femoral head prosthesis using a posterior approach. Which statement by the patient indicates a need for additional instruction?

"I can sleep in any position that is comfortable for me."

The nurse discusses management of upper respiratory infections (URIs) with a patient who has acute sinusitis. Which statement by the patient indicates that additional teaching is needed?

"I can use nasal decongestant spray until the congestion is gone."

A 52-yr-old patient has a new diagnosis of pernicious anemia. The nurse determines that the patient understands the teaching about the disorder when the patient states,

"I could choose nasal spray rather than injections of vitamin B12."

The nurse instructs a patient who has osteosarcoma of the tibia about a scheduled above-the-knee amputation. Which statement by a patient indicates additional patient teaching is needed?

"I did not have this bone cancer until my leg broke a week ago."

A patient who has gastroesophageal reflux disease (GERD) is experiencing increasing discomfort. Which patient statement to the nurse indicates that additional teaching about GERD is needed?

"I eat small meals during the day and have a bedtime snack."

The nurse completes discharge instructions for a patient with a total laryngectomy. Which statement by the patient indicates that additional instruction is needed?

"I must keep the stoma covered with an occlusive dressing."

Which statement by a patient who has had an above-the-knee amputation indicates the nurse's discharge teaching has been effective?

"I should lie flat on my abdomen for 30 minutes 3 or 4 times a day."

Which statement by the patient indicates a good understanding of the nurse's teaching about a new short-arm synthetic cast?

"I will apply an ice pack to the cast over the fracture site off and on for 24 hours."

A high school teacher with ulnar drift caused by rheumatoid arthritis (RA) is scheduled for arthroplasty of several joints in the left hand. Which patient statement to the nurse indicates a realistic expectation for the surgery?

"I will be able to use my fingers with more flexibility to grasp things."

A patient whose employment requires frequent lifting has a history of chronic back pain. After the nurse has taught the patient about correct body mechanics, which patient statement indicates the teaching has been effective?

"I will begin doing exercises to strengthen and support my back."

A patient with heart failure has a new order for captopril 12.5 mg PO. After giving the first dose and teaching the patient about the drug, which statement by the patient indicates that teaching has been effective?

"I will call for help when I need to get up to use the bathroom."

Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate?

"I will call my health care provider if my stools turn black."

The nurse completes discharge teaching for a patient who has had a lung transplant. Which patient statement indicates to the nurse that the teaching has been effective?

"I will call the health care provider right away if I develop a fever."

The home health nurse teaches a patient with a neurogenic bladder how to use intermittent catheterization for bladder emptying. Which patient statement indicates that the teaching has been effective?

"I will clean the catheter carefully before and after each catheterization."

The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement, if made by the patient, indicates a good understanding of the instructions?

"I will continue to do deep breathing and coughing exercises at home."

The nurse teaches a patient about discharge instructions after a rhinoplasty. Which statement, if made by the patient, indicates that the teaching was successful?

"I will elevate my head for 48 hours to minimize swelling."

The nurse determines that instruction regarding prevention of future urinary tract infections (UTIs) has been effective for a 22-yr-old female patient with cystitis when the patient states which of the following?

"I will empty my bladder every 3 to 4 hours during the day."

The nurse determines that teaching about management of migraine headaches has been effective when the patient says which of the following?

"I will lie down someplace dark and quiet when the headaches begin."

Which statement by a patient with stage 5 chronic kidney disease (CKD) indicates that the nurse's teaching about management of CKD has been effective?

"I will measure my urinary output each day to help calculate the amount I can drink."

Which statement by the patient indicates that teaching has been effective for a patient scheduled for radiation therapy of the larynx?

"I will need to buy a water bottle to carry with me."

Which patient statement indicates that the nurse's teaching about sulfasalazine (Azulfidine) for ulcerative colitis has been effective?

"I will need to use a sunscreen when I am outdoors."

The nurse determines that further instruction is needed for a patient with interstitial cystitis when the patient says which of the following?

"I will start taking high potency multiple vitamins every morning."

The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective?

"I will use the incentive spirometer every hour or two during the day."

Which information will the nurse include for a patient with newly diagnosed gastroesophageal reflux disease (GERD)?

"Keep the head of your bed elevated on blocks."

A woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. Which response by the nurse is accurate?

"MS symptoms may be worse after the pregnancy."

The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective?

"My spouse will sleep in another room."

Which information will the nurse include when teaching a patient with peptic ulcer disease about the effect of ranitidine (Zantac)?

"Ranitidine decreases gastric acid secretion."

Which statement by a patient indicates good understanding of the nurse's teaching about prevention of sickle cell crisis?

"Risk for a crisis is decreased by having an annual influenza vaccination."

A 74-yr-old patient who is progressing to stage 5 chronic kidney disease asks the nurse, "Do you think I should go on dialysis? Which initial response by the nurse is best?

"Tell me more about what you are thinking regarding dialysis."

After bariatric surgery, a patient who is being discharged tells the nurse, "I prefer to be independent. I am not interested in any support groups." Which response by the nurse is best?

"Tell me what types of resources you think you might use after this surgery."

A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The patient tells the nurse, "I would rather have chemotherapy than surgery." Which response by the nurse is most appropriate?

"Tell me what you know about the treatments available."

After the health care provider recommends amputation for a patient who has nonhealing ischemic foot ulcers, the patient tells the nurse that he would rather die than have an amputation. Which response by the nurse is best?

"Tell me what you know about your options for treatment."

The nurse determines that teaching regarding cobalamin injections has been effective when the patient with chronic atrophic gastritis states

"The cobalamin injections will prevent me from becoming anemic."

A patient who has acute myelogenous leukemia (AML) asks the nurse whether the planned chemotherapy will be worth undergoing. Which response by the nurse is appropriate?

"The side effects of chemotherapy are difficult, but AML frequently goes into remission with chemotherapy."

A 53-yr-old patient with stage D heart failure and type 2 diabetes asks the nurse whether heart transplant is a possible therapy. Which response by the nurse is most accurate?

"The suitability of a heart transplant for you depends on many factors."

Which patient statement indicates that the nurse's postoperative teaching after a gastroduodenostomy has been effective?

"Vitamin supplements may prevent anemia."

A 40-yr-old obese woman reports that she wants to lose weight. Which question should the nurse ask first?

"What factors led to your obesity?"

Which statement by the nurse is most likely to help a 22-yr-old patient with extreme obesity in losing weight on a 1000-calorie diet?

"You are likely to notice changes in how you feel after a few weeks of diet and exercise."

A tennis player has an arthroscopic repair of a rotator cuff injury performed in same-day surgery. When the nurse plans postoperative teaching for the patient, which information will be included?

"You will begin work with a physical therapist tomorrow."

A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, "Will I be able to talk normally after surgery?" What is the most accurate response by the nurse?

"You will have a permanent opening into your neck, and you will need rehabilitation for some type of voice restoration."

A patient with osteomyelitis is to receive vancomycin (Vancocin) 500 mg IV every 6 hours. The vancomycin is diluted in 100 mL of normal saline and needs to be administered over 1 hour. The nurse will set the IV pump for how many milliliters per minute? (Round to the nearest hundredth.)

1.67

Vasopressin 0.1 unit/min infusion is prescribed for a patient with acute arterial gastrointestinal (GI) bleeding. The vasopressin label states vasopressin 100 units/250 mL normal saline. How many mL/hr will the nurse infuse?

15ml/hr

A patient with a new ileostomy asks how much drainage to expect. The nurse explains that after the bowel adjusts to the ileostomy, the usual drainage will be about _____ cups daily.

2

A patient who is having an acute exacerbation of multiple sclerosis has a prescription for methylprednisolone (Solu-Medrol) 150 mg IV. The label on the vial reads: methylprednisolone 125 mg in 2 mL. How many mL will the nurse administer?

2.4

A patient is to receive an infusion of 250 mL of platelets over 2 hours through tubing that is labeled: 1 mL equals 10 drops. How many drops per minute will the nurse infuse?

21

After the nurse teaches a patient about the recommended amounts of foods from animal and plant sources, which menu selections indicate that the initial instructions about diet have been understood?

3 oz of roasted pork, a cup of corn, and a cup of carrot sticks

The nurse monitors a patient in the emergency department after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed?

400 mL of blood in the collection chamber

A patient in the oliguric phase after an acute kidney injury has had a 250-mL urine output and an emesis of 100 mL in the past 24 hours. What is the patient's fluid restriction for the next 24 hours?

950 mL

The nurse examines the lymph nodes of a patient during a physical assessment. Which assessment finding would be of most concern to the nurse?

A 2-cm nontender supraclavicular node

Several patients call the outpatient clinic and ask to make an appointment as soon as possible. Which patient should the nurse schedule to be seen first?

A 23-yr-old with no previous health problems who has a nontender lump in the axilla

After change-of-shift report, which patient should the nurse assess first?

A 30-yr-old female patient with a femoral hernia who has abdominal pain and vomiting

Which patient should the nurse assess first after receiving change-of-shift report?

A 30-yr-old patient who has abdominal distention and an apical heart rate of 136 beats/minute

After receiving change-of-shift report for several patients with neutropenia, which patient should the nurse assess first?

A 33-yr-old with a fever of 100.8° F (38.2° C)

The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first?

A 46-yr-old patient on bed rest who is complaining of sudden onset of shortness of breath

After change-of-shift report, which patient should the nurse assess first?

A 60-yr-old patient with nausea and vomiting who has dry mucosa and lethargy

After change-of-shift report, which patient should the nurse assess first?

A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter insertion

The nurse is reviewing the medical records for five patients who are scheduled for their yearly physical examinations in September. Which patients should receive the inactivated influenza vaccination (select all that apply)?

A 76-yr-old nursing home resident, 36-yr-old female patient who is pregnant, A 30-yr-old patient who takes corticosteroids for rheumatoid arthritis

A patient will need vascular access for hemodialysis. Which statement by the nurse accurately describes an advantage of a fistula over a graft?

A fistula is much less likely to clot

A 38-yr-old patient who had a kidney transplant 8 years ago is receiving the immunosuppressants tacrolimus (Prograf), cyclosporine (Sandimmune), and prednisone . Which assessment data will be of most concern to the nurse?

A nontender axillary lump.

Which patient in the ear, nose, and throat (ENT) clinic should the nurse assess first?

A patient who is complaining of a sore throat and has a muffled voice

After receiving change-of-shift report on four patients admitted to a heart failure unit, which patient should the nurse assess first?

A patient who is cool and clammy, with new-onset confusion and restlessness

Which patient should the nurse assign as the roommate for a patient who has aplastic anemia?

A patient with chronic heart failure

Which patient should the nurse assess first after receiving change-of-shift report?

A patient with esophageal varices who has a blood pressure of 92/58 mm Hg

The nurse supervises a student nurse who is assigned to take care of a patient with active tuberculosis (TB). Which action, if performed by the student nurse, would require an intervention by the nurse?

A surgical face mask is applied before visiting the patient.

In which order will the nurse implement these interprofessional interventions prescribed for a patient admitted with acute osteomyelitis with a temperature of 101.2° F? (Put a comma and a space between each answer choice [A, B, C, D].) a. Obtain blood cultures from two sites. b. Administer dose of gentamicin 60 mg IV. c. Send to radiology for computed tomography (CT) scan of right leg. d. Administer acetaminophen (Tylenol) now and every 4 hours PRN for fever.

ABDC

The nurse assumes care of a patient who just returned from surgery for a total laryngectomy and radical neck dissection and notes the following problems. In which order should the nurse address the problems? (Put a comma and a space between each answer choice [A, B, C, D].) a. The patient is in a side-lying position with the head of the bed flat. b. The patient is coughing blood-tinged secretions from the tracheostomy. c. The nasogastric (NG) tube is disconnected from suction and clamped off. d. The wound drain in the neck incision contains 200 mL of bloody drainage.

ABDC

The nurse notes new onset confusion in an older patient who is normally alert and oriented. In which order should the nurse take the following actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Obtain the O2 saturation. b. Check the patient's pulse rate. c. Document the change in status. d. Notify the health care provider.

ABDC

A patient with a complex pelvic fracture from a motor vehicle crash is on bed rest. Which nursing assessment finding indicates a potential complication of the fracture?

Abdomen is distended and bowel sounds are absent.

Which laboratory test will the nurse use to determine whether filgrastim (Neupogen) is effective for a patient with acute lymphocytic leukemia who is receiving chemotherapy?

Absolute neutrophil count

A hospitalized patient complains of a bilateral headache (4/10 on the pain scale) that radiates from the base of the skull. Which prescribed PRN medications should the nurse administer initially?

Acetaminophen (Tylenol)

Which laboratory result will the nurse expect to show a decreased value if a patient develops heparin-induced thrombocytopenia (HIT)?

Activated partial thromboplastin time

Which prescribed action will the nurse implement first for a patient who has vomited 1100 mL of blood?

Administer 1 L of lactated Ringer's solution.

A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take?

Administer PRN acetaminophen (Tylenol).

Which action will the nurse include in the plan of care for a patient who has thalassemia major?

Administer iron chelation therapy as needed.

An adult with Escherichia coli O157:H7 food poisoning is admitted to the hospital with bloody diarrhea and dehydration. Which prescribed action will the nurse question?

Administer loperamide (Imodium) after each stool.

Which prescribed intervention will the nurse implement first for a patient in the emergency department who is experiencing continuous tonic-clonic seizures?

Administer lorazepam (Ativan) 4 mg IV.

After being hospitalized for 3 days with a right femur fracture, a patient suddenly develops shortness of breath and tachypnea. The patient tells the nurse, "I feel like I am going to die!" Which action should the nurse take first?

Administer prescribed PRN O2 at 4 L/min.

The day after a having a right below-the-knee amputation, a patient complains of pain in the missing right foot. Which action is most important for the nurse to take?

Administer prescribed analgesics.

Which nursing action is of highest priority for a patient with renal calculi who is being admitted to the hospital with gross hematuria and severe colicky left flank pain?

Administer prescribed analgesics.

Before assisting a patient with ambulation 2 days after total hip arthroplasty, which action is most important for the nurse to take?

Administer prescribed pain medication.

A 53-yr-old male patient with deep partial-thickness burns from a chemical spill in the workplace experiences severe pain followed by nausea during dressing changes. Which action will be most useful in decreasing the patient's nausea?

Administer the prescribed morphine sulfate before dressing changes.

An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action should the nurse take?

Administer the prescribed morphine.

Which action for a patient with neutropenia is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)?

Administering subcutaneous filgrastim (Neupogen) injection

Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia (select all that apply)?

Age, BP, RR, presence of confusion, BUN level

A patient has peptic ulcer disease that has been associated with Helicobacter pylori. About which medications will the nurse plan to teach the patient?

Amoxicillin (Amoxil), clarithromycin (Biaxin), and omeprazole (Prilosec)

A 40-yr-old male patient has had a herniorrhaphy to repair an incarcerated inguinal hernia. Which patient teaching will the nurse provide before discharge?

Apply a scrotal support and ice to reduce swelling.

Which action will the urgent care nurse take for a patient with a possible knee meniscus injury?

Apply an immobilizer to the affected leg.

Which action should the nurse take first when a patient develops epistaxis?

Apply squeezing pressure to the nostrils for 10 minutes.

Which care activity for a patient with a paralytic ileus is appropriate for the registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)?

Applying petroleum jelly to the lips

A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan?

Appropriate use of cough suppressants

A patient diagnosed with active tuberculosis (TB) is homeless and has a history of alcohol abuse. Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen?

Arrange for a daily meal and drug administration at a community center.

To evaluate an obese patient for adverse effects of lorcaserin (Belviq), which action will the nurse take?

Ask about bowel movements.

Which action will the nurse take first when a patient is seen in the outpatient clinic with neck pain?

Ask about numbness or tingling of the hands and arms.

Which nursing intervention will be included in the plan of care after a patient with a right femur fracture has a hip spica cast applied?

Ask the patient about abdominal discomfort.

After a total proctocolectomy and permanent ileostomy, the patient tells the nurse, "I cannot manage all these changes. I don't want to look at the stoma." What is the best action by the nurse?

Ask the patient about the concerns with stoma management.

A 25-yr-old male patient calls the clinic complaining of diarrhea for 24 hours. Which action should the nurse take first?

Ask the patient to describe the character of the stools and any associated symptoms.

A 22-yr-old patient seen at the health clinic with a severe migraine headache tells the nurse about having similar headaches recently. Which initial action should the nurse take?

Ask the patient to keep a headache diary.

After 2 months of tuberculosis (TB) treatment with isoniazid, rifampin (Rifadin), pyrazinamide, and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next?

Ask the patient whether medications have been taken as directed.

Which nursing action is appropriate when coaching obese adults enrolled in a behavior modification program?

Asking the adults about situations that tend to increase appetite

Which action will the nurse take in order to evaluate the effectiveness of Buck's traction for a patient who has an intracapsular fracture of the right femur?

Assess for hip pain.

After a motorcycle accident, a patient arrives in the emergency department with severe swelling of the left lower leg. Which action will the nurse take first?

Assess leg pulses and sensation.

A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action should the nurse include in the plan of care in collaboration with the speech therapist?

Assess the ability to swallow before using the fenestrated tube.

A patient who slipped and fell in the shower at home has a proximal left humerus fracture immobilized with a long-arm cast and a sling. Which nursing intervention will be included in the plan of care?

Assess the left axilla and change absorbent dressings as needed.

A 71-yr-old patient had an abdominal-perineal resection for colon cancer. Which nursing action is most important to include in the plan of care for the day after surgery?

Assess the perineal drainage and incision.

The health care provider orders a liver and spleen scan for a patient who has been in a motor vehicle crash. Which action should the nurse take before this procedure?

Assist the patient to a flat position.

A patient is unable to void after having an open loop resection and fulguration of the bladder. Which nursing action should be implemented?

Assist the patient to soak in a 15-minute sitz bath.

A patient with bacterial pneumonia has coarse crackles and thick sputum. Which action should the nurse plan to promote airway clearance?

Assist the patient to splint the chest when coughing.

A 68-yr-old female patient admitted to the hospital with dehydration is confused and incontinent of urine. Which nursing action should be included in the plan of care?

Assist the patient to the bathroom every 2 hours during the day.

A patient with muscular dystrophy is hospitalized with pneumonia. Which nursing action will be included in the plan of care?

Assist the patient with ambulation.

A young adult been admitted to the emergency department with nausea and vomiting. Which action could the RN delegate to unlicensed assistive personnel (UAP)?

Assist the patient with oral care.

A patient is being admitted for bariatric surgery. Which nursing action can the nurse delegate to unlicensed assistive personnel (UAP)?

Assist with IV insertion by holding adipose tissue out of the way.

A patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care?

Assist with active range of motion (ROM).

After a laryngectomy, a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first?

Attempt to reinsert the tracheostomy tube with the obturator in place.

Which information about a patient with Goodpasture syndrome requires the most rapid action by the nurse?

Audible crackles bilaterally over the posterior chest to the midscapular level.

When caring for a patient with a left arm arteriovenous fistula, which action will the nurse include in the plan of care to maintain the patency of the fistula?

Auscultate for a bruit at the fistula site.

A patient who was admitted the previous day with pneumonia complains of a sharp pain of 7 (on 0 to 10 scale) "whenever I take a deep breath." Which action will the nurse take next?

Auscultate for breath sounds.

A patient with a history of chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. Which action should the nurse do first?

Auscultate the breath sounds.

Which information will be included when the nurse is teaching self-management to a patient who is receiving peritoneal dialysis (select all that apply)?

Avoid commercial salt substitutes, Take phosphate binders with each meal, Choose high-protein foods for most meals.

Which instruction will the nurse plan to include in discharge teaching for a patient admitted with a sickle cell crisis?

Avoid exposure to crowds when possible.

Which intervention will be included in the nursing care plan for a patient with immune thrombocytopenic purpura?

Avoid intramuscular (IM) injections.

The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action should the nurse include in the plan of care?

Avoid intramuscular injections.

Which information will the nurse include when teaching adults to decrease the risk for cancers of the tongue and buccal mucosa?

Avoid use of cigarettes and smokeless tobacco.

Nursing staff on a hospital unit are reviewing rates of health care-associated infections (HAI) of the urinary tract. Which nursing action will be most helpful in decreasing the risk for urinary HAI in patients admitted to the hospital?

Avoiding unnecessary urinary catheterizations

Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute shortness of breath has heart failure?

B-type natriuretic peptide

Which topic will the nurse plan to include in discharge teaching for a patient with heart failure with reduced ejection fraction (HFrEF)?

Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors

A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first?

Blood cultures from two sites

When teaching a patient about testing to diagnose metabolic syndrome, which topic would the nurse include?

Blood glucose test

Which information in this male patient's electronic health record as shown in the accompanying figure will the nurse use to confirm that the patient has metabolic syndrome (select all that apply)?

Blood glucose, waist size

An outpatient who has chronic heart failure returns to the clinic after 2 weeks of therapy with metoprolol (Toprol XL). Which assessment finding is most important for the nurse to report to the health care provider?

Blood pressure (BP) of 88/42 mm Hg

Which assessment finding for a patient who has just been admitted with acute pyelonephritis is most important for the nurse to report to the health care provider?

Blood pressure 90/48 mm Hg

A patient with pancytopenia of unknown origin is scheduled for the following diagnostic tests. The nurse will provide a consent form to sign for which test?

Bone marrow biopsy

Which information will the nurse include when teaching a patient how to avoid chronic constipation (select all that apply)?

Bulk-forming laxatives are an excellent source of fiber, Walking or cycling frequently will help bowel motility, A good time for a bowel movement may be after breakfast., Some over-the-counter (OTC) medications cause constipation.

Which assessment data reported by a patient is consistent with a lower urinary tract infection (UTI)?

Burning on urination

Which information will the nurse teach seniors at a community recreation center about ways to prevent fractures?

Buy shoes that provide good support and are comfortable to wear.

In which order will the nurse take these actions when caring for a patient in the emergency department with a right leg fracture after a motor vehicle crash? (Put a comma and a space between each answer choice [A, B, C, D, E, F].) a. Obtain x-rays. b. Check pedal pulses. c. Assess lung sounds. d. Take blood pressure. e. Apply splint to the leg. f. Administer tetanus prophylaxis.

CDBEAF

Which finding about a patient with polycythemia vera is most important for the nurse to report to the health care provider?

Calf swelling and pain

When giving home care instructions to a patient who has comminuted left forearm fractures and a long-arm cast, which information should the nurse include?

Call the health care provider for numbness of the hand.

After ureterolithotomy, a patient has a left ureteral catheter and a urethral catheter in place. Which action will the nurse include in the plan of care?

Call the health care provider if the ureteral catheter output drops suddenly.

Which finding in a patient with a Colles' fracture of the left wrist is most important to communicate immediately to the health care provider?

Capillary refill to the fingers is prolonged.

A patient who has acute glomerulonephritis is hospitalized with hyperkalemia. Which information will the nurse monitor to evaluate the effectiveness of the prescribed calcium gluconate IV?

Cardiac rhythm

A 68-yr-old male patient who has bladder cancer had a cystectomy with creation of an Indiana pouch. Which topic will be included in patient teaching?

Catheterization technique and schedule

The nurse is caring for a patient who has had an ileal conduit for several years. Which nursing action could be delegated to unlicensed assistive personnel (UAP)?

Change the ostomy appliance.

A patient is admitted to the emergency department with possible renal trauma after an automobile accident. Which prescribed intervention will the nurse implement first?

Check blood pressure and heart rate.

A patient has arrived for a scheduled hemodialysis session. Which nursing action is most appropriate for the registered nurse (RN) to delegate to a dialysis technician?

Check blood pressure before starting dialysis.

Which action will the admitting nurse include in the care plan for a patient who has neutropenia?

Check temperature every 4 hours.

The second day after admission with a fractured pelvis, a patient suddenly develops confusion. Which action should the nurse take first?

Check the O2 saturation.

During routine hemodialysis, a patient complains of nausea and dizziness. Which action should the nurse take first?

Check the blood pressure (BP).

A patient with acute kidney injury (AKI) has longer QRS intervals on the electrocardiogram (ECG) than were noted on the previous shift. Which action should the nurse take first?

Check the medical record for the most recent potassium level.

Based on the information in the accompanying figure obtained for a patient in the emergency room, which action will the nurse take first? History • Age 23 years • Right lower leg injury Physical Assessment • Reports severe right lower leg pain • Reports feeling short of breath • Bone protruding from right lower leg Diagnostic Exams • CBC: WBC 9400/µL; Hgb 11.6 g/dL • Right leg x-ray; right tibial fracture

Check the patient's O2 saturation using pulse oximetry.

Which assessment action will help the nurse determine if an obese patient has metabolic syndrome?

Check the patient's blood pressure.

A patient who has had open reduction and internal fixation (ORIF) of a hip fracture tells the nurse he is ready to get out of bed for the first time. Which action should the nurse take?

Check the patient's prescribed weight-bearing status.

A patient admitted with a peptic ulcer has a nasogastric (NG) tube in place. When the patient develops sudden, severe upper abdominal pain, diaphoresis, and a firm abdomen, which action should the nurse take?

Check the vital signs.

Which patient choice for a snack 3 hours before bedtime indicates that the nurse's teaching about gastroesophageal reflux disease (GERD) has been effective?

Cherry gelatin with fruit

When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient?

Chest tube connected to suction

After being hit by a baseball, a patient arrives in the emergency department with a possible nasal fracture. Which finding by the nurse is most important to report to the health care provider?

Clear nasal drainage

The nurse will plan to teach a patient with Crohn's disease who has megaloblastic anemia about the need for

Cobalamin supplements

A patient who has a right-sided chest tube after a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is appropriate?

Continue to monitor the collection device.

Which breakfast choice indicates a patient's good understanding of information about a diet for celiac disease?

Corn tortilla with scrambled eggs

Which finding by the nurse will be most helpful in determining whether a 67-yr-old patient with benign prostatic hyperplasia has an upper urinary tract infection (UTI)?

Costovertebral tenderness

A 72-yr-old male patient with dehydration caused by an exacerbation of ulcerative colitis is receiving 5% dextrose in normal saline at 125 mL/hour. Which assessment finding by the nurse is most important to report to the health care provider?

Crackles are heard halfway up the posterior chest.

The nurse is assessing a patient with abdominal pain. The nurse, who notes that there is ecchymosis around the area of umbilicus, will document this finding as

Cullen sign.

The nurse is caring for a patient who develops watery diarrhea and a fever after prolonged omeprazole (Prilosec) therapy. In which order will the nurse take actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Contact the health care provider. b. Assess blood pressure and heart rate. c. Give the PRN acetaminophen (Tylenol). d. Place the patient on contact precautions.

DBAC

The clinic nurse is teaching a patient with acute sinusitis. Which interventions should the nurse plan to include in the teaching session (select all that apply)?

Decongestants can be used to relieve swelling, Taking a hot shower will increase sinus drainage and decrease pain, Saline nasal spray can be made at home and used to wash out secretions, You will be more comfortable if you keep your head in an upright position

Which assessment finding is most important to report to the health care provider regarding a patient who has had left-sided extracorporeal shock wave lithotripsy?

Decreased urine output

The nurse obtains the following assessment data on an older patient who has influenza. Which information will be most important for the nurse to communicate to the health care provider?

Diffuse crackles in the lungs

Which medication taken by a patient with restless legs syndrome should the nurse discuss with the patient?

Diphenhydramine

The nurse observes unlicensed assistive personnel (UAP) taking the following actions when caring for a patient with a urethral catheter. Which action requires that the nurse intervene?

Disconnecting the catheter from the drainage tube to obtain a specimen

A patient who has been receiving IV heparin infusion and oral warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when the platelet level drops to 110,000/µL. Which action will the nurse include in the plan of care?

Discontinue the heparin infusion.

A patient tells the nurse about using acetaminophen (Tylenol) several times every day for recurrent bilateral headaches. Which action will the nurse plan to take first?

Discuss the need to stop taking the acetaminophen.

Which item should the nurse offer to the patient who is to restart oral intake after being NPO due to nausea and vomiting?

Dish of lemon gelatin

The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)?

Document the amount of drainage every 8 hours.

Which activity in the care of a patient with a new colostomy could the nurse delegate to unlicensed assistive personnel (UAP)?

Drain and measure the output from the ostomy.

The nurse will be teaching self-management to patients after gastric bypass surgery. Which information will the nurse plan to include?

Drink fluids between meals but not with meals.

A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, and respirations of 42 breaths/min. Which action should the nurse take first?

Elevate the head of the bed to a semi-Fowler's position.

Which nursing action should be included in the postoperative plan of care for a patient after a laparoscopic esophagectomy?

Elevate the head of the bed to at least 30 degrees.

A patient who had a total hip replacement had an intraoperative hemorrhage 14 hours ago. Which laboratory test result would the nurse expect?

Elevated reticulocyte count

The health care provider's progress note for a patient states that the complete blood count (CBC) shows a "shift to the left." Which assessment finding will the nurse expect?

Elevated temperature

The nurse is caring for a patient on the first postoperative day after a Roux-en- gastric bypass procedure. Which assessment finding should be reported immediately to the surgeon?

Emesis of bile-colored fluid past the nasogastric (NG) tube

A patient complains of gas pains and abdominal distention 2 days after a small bowel resection. Which nursing action should the nurse take?

Encourage the patient to ambulate.

Which nursing action will be included in the plan of care for a 25-yr-old male patient with a new diagnosis of irritable bowel syndrome (IBS)?

Encourage the patient to express concerns and ask questions about IBS.

When caring for a patient who is using Buck's traction after a hip fracture, which action can the nurse delegate to unlicensed assistive personnel (UAP)?

Ensure the weight for the traction is hanging freely.

A 58-yr-old male patient who is diagnosed with nephrotic syndrome has ascites and 4+ leg edema. Which patient problem is present based on these findings?

Excess fluid volume

Which information will the nurse include when teaching a patient with acute low back pain (select all that apply)?

Expect symptoms of acute low back pain to improve in a few weeks, Avoid activities that require twisting of the back or prolonged sitting, Use ibuprofen (Motrin, Advil) or acetaminophen (Tylenol) to relieve pain.

A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which response by the nurse reflects accurate knowledge about the medication and the patient's illness?

Explain that orange discolored urine and tears are normal while taking this medication.

A patient with Crohn's disease who is taking infliximab (Remicade) calls the nurse in the outpatient clinic about new symptoms. Which symptom is most important to communicate to the health care provider?

Fever

A young woman who has Crohn's disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, fecal-smelling urine. What information will the nurse add to a general teaching plan about UTIs in order to individualize the teaching for this patient?

Fistulas can form between the bowel and bladder.

A patient reports feeling numbness and tingling of the left arm before experiencing a seizure. The nurse determines that this history is consistent with what type of seizure?

Focal

A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of

Folic acid.

The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy. Which information should the nurse include about the patient's postoperative care?

Frequent use of an incentive spirometer

A patient with a history of polycystic kidney disease is admitted to the surgical unit after having shoulder surgery. Which of the routine postoperative orders is most important for the nurse to discuss with the health care provider?

Give ketorolac 10 mg PO PRN for pain.

A 37-yr-old female patient is hospitalized with acute kidney injury (AKI). Which information will be most useful to the nurse in evaluating improvement in kidney function?

Glomerular filtration rate (GFR)

A patient with pancytopenia has a bone marrow aspiration from the left posterior iliac crest. Which action would be important for the nurse to take after the procedure?

Have the patient lie on the left side for 1 hour.

A patient arrives in the ear, nose, and throat clinic complaining of a piece of tissue being "stuck up my nose" and with foul-smelling nasal drainage from the right nare. Which action should the nurse take first?

Have the patient occlude the left nare and blow the nose.

A patient had a cystectomy with an ileal conduit yesterday. Which new assessment data is most important for the nurse to communicate to the health care provider?

Heart rate 102 beats/minute

The nurse notes pallor of the skin and nail beds in a newly admitted patient. The nurse should ensure that which laboratory test has been ordered?

Hemoglobin level

A 55-yr-old patient with end-stage kidney disease (ESKD) is scheduled to receive a prescribed dose of epoetin alfa (Procrit). Which information should the nurse report to the health care provider before giving the medication?

Hemoglobin level 13 g/dL

The nurse is reviewing laboratory results and notes a patient's activated partial thromboplastin time (aPTT) level of 28 seconds. The nurse should notify the health care provider in anticipation of adjusting which medication?

Heparin

A 33-yr-old patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information will the nurse include in patient teaching?

How to draw up and administer injections of the medication

A patient is being discharged after 1 week of IV antibiotic therapy for acute osteomyelitis in the right leg. Which information will be included in the discharge teaching?

How to monitor and care for a long-term IV catheter

The nurse plans to teach a patient how to manage allergic rhinitis. Which information should the nurse include in the teaching plan?

Identifying and avoiding environmental triggers are the best way to prevent symptoms.

Which nursing diagnosis is of highest priority for a patient with Parkinson's disease who is unable to move the facial muscles?

Imbalanced nutrition: less than body requirements

A patient with acute osteomyelitis of the left femur is hospitalized for regional antibiotic irrigation. Which intervention will the nurse include in the initial plan of care?

Immobilization of the left leg

A patient with pneumonia has a fever of 101.4° F (38.6° C), a nonproductive cough, and an O2 saturation of 88%. The patient complains of weakness, fatigue, and needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as the priority?

Impaired gas exchange related to respiratory congestion

While assessing a 68-yr-old with ascites, the nurse also notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. The nurse knows this finding indicates

Increased right atrial pressure.

The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect?

Increased tactile fremitus

A patient is admitted to the emergency department with severe abdominal pain and rebound tenderness. Vital signs include temperature 102°F (38.3°C), pulse 120 beats/min, respirations 32 breaths/min, and blood pressure (BP) 82/54 mm Hg. Which prescribed intervention should the nurse implement first?

Infuse a liter of lactated Ringer's solution over 30 minutes.

A patient in the emergency department has just been diagnosed with peritonitis caused by a ruptured diverticulum. Which prescribed intervention will the nurse implement first?

Infuse metronidazole (Flagyl) 500 mg IV.

A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature of 102° F (38.9° C), and severe back pain. Which prescribed action will the nurse implement first?

Infuse normal saline 500 mL over 30 minutes.

A 49-yr-old man has been admitted with hypotension and dehydration after 3 days of nausea and vomiting. Which prescribed action will the nurse implement first?

Infuse normal saline at 250 mL/hr.

A 76-yr-old with benign prostatic hyperplasia (BPH) is agitated and confused, with a markedly distended bladder. Which intervention prescribed by the health care provider should the nurse implement first?

Insert a urinary retention catheter.

A 72-yr-old patient with a history of benign prostatic hyperplasia (BPH) is admitted with acute urinary retention and elevated blood urea nitrogen (BUN) and creatinine levels. Which prescribed therapy should the nurse implement first?

Insert urethral catheter.

A patient has been taking phenytoin (Dilantin) for 2 years. Which action will the nurse take when evaluating for adverse effects of the medication?

Inspect the oral mucosa.

Which information will the nurse prioritize in planning preoperative teaching for a patient undergoing a Roux-en- gastric bypass?

Instructing the patient on coughing and breathing techniques

A nurse is caring for a patient who has had a total laryngectomy and radical neck dissection. During the first 24 hours after surgery what is the priority nursing action?

Keep the patient in semi-Fowler's position.

Which assessment finding may indicate that a patient is experiencing adverse effects to a corticosteroid prescribed after kidney transplantation?

Knee and hip joint pain

A patient who has chronic constipation asks the nurse about the use of psyllium (Metamucil). Which information will the nurse include in the response?

Large amounts of fluid should be taken to prevent impaction or bowel obstruction.

A patient seen in the clinic for a bladder infection describes the following symptoms. Which information is most important for the nurse to report to the health care provider?

Left-sided flank pain

A patient who has non-Hodgkin's lymphoma is receiving combination treatment with rituximab (Rituxan) and chemotherapy. Which patient assessment finding requires the most rapid action by the nurse?

Lip swelling

Which information will the nurse teach a patient with lactose intolerance?

Live-culture yogurt is usually tolerated.

Which nursing action included in the care of a patient after laminectomy can the nurse delegate to experienced unlicensed assistive personnel (UAP)?

Log roll the patient from side to side every 2 hours.

What information will the nurse include for an overweight 35-yr-old woman who is starting a weight-loss plan?

Low carbohydrate diets lead to rapid weight loss but are difficult to maintain.

The nurse in the dialysis clinic is reviewing the home medications of a patient with chronic kidney disease (CKD). Which medication reported by the patient indicates that patient teaching is required?

Magnesium hydroxide

Which adult will the nurse plan to teach about risks associated with obesity?

Man with a 42 in waist and 44 in hips

A 76-yr-old patient with obstipation has a fecal impaction and is incontinent of liquid stool. Which action should the nurse take first?

Manually remove the impacted stool.

The nurse notes that a patient has incisional pain, a poor cough effort, and scattered coarse crackles after a thoracotomy. Which action should the nurse take first?

Medicate the patient with prescribed morphine.

An 80-yr-old patient who is hospitalized with peptic ulcer disease develops new-onset auditory hallucinations. Which prescribed medication will the nurse discuss with the health care provider before administration?

Metoclopramide (Reglan)

Which action should the nurse include in the plan of care when caring for a patient admitted with acute decompensated heart failure (ADHF) who is receiving nesiritide (Natrecor)?

Monitor blood pressure frequently.

Which action will the nurse include in the plan of care for a patient admitted with multiple myeloma?

Monitor fluid intake and output.

Which actions will the nurse include in the plan of care for a patient with metastatic bone cancer of the left femur (select all that apply)?

Monitor serum calcium., Support the left leg when repositioning the patient., Support family and patient as they discuss the prognosis.

Which nursing action will the nurse include in the plan of care for a 35-yr-old male patient admitted with an exacerbation of inflammatory bowel disease (IBD)?

Monitor stools for blood.

A patient who is receiving dobutamine for the treatment of acute decompensated heart failure (ADHF) has the following nursing interventions included in the plan of care. Which action will be most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)?

Monitor the patient's blood pressure and heart rate every hour.

A patient who has had progressive chronic kidney disease (CKD) for several years has just begun regular hemodialysis. Which information about diet will the nurse include in patient teaching?

More protein is allowed because urea and creatinine are removed by dialysis.

Which menu choice by the patient with diverticulosis is best for preventing diverticulitis?

Navy bean soup and vegetable salad

Following successful treatment of Hodgkin's lymphoma for a 55-yr-old woman, which topic will the nurse include in patient teaching?

Need for follow-up appointments to screen for malignancy

The nurse has obtained the health history, physical assessment data, and laboratory results shown in the accompanying figure for a patient admitted with aplastic anemia. Which information is most important to communicate to the health care provider? History • Fatigue, which has increased over last month • Frequent constipation Physical Assessment • Conjunctiva pale pink, moist • Multiple bruises • Clear lung sounds Laboratory Results • Hct 33% • WBC 1500/µL • Platelets 70,000/µL

Neutropenia

A patient who has had open reduction and internal fixation (ORIF) of left lower leg fractures continues to complain of severe pain in the leg 15 minutes after receiving the prescribed IV morphine. Pulses are faintly palpable and the foot is cool to the touch. Which action should the nurse take next?

Notify the health care provider.

A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which action is most important for the nurse to take?

Notify the health care provider.

After a thymectomy, a patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient complains of nausea and severe abdominal cramps. Which action should the nurse take first?

Notify the patient's health care provider.

The nurse assesses a patient with pernicious anemia. Which assessment finding would the nurse expect?

Numbness of the extremities

The nurse is caring for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider?

O2 saturation is 88%.

Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires the most immediate action by the nurse?

O2 saturation of 88%

Which diet choice by the patient with an acute exacerbation of inflammatory bowel disease (IBD) indicates a need for more teaching?

Oatmeal with cream

Which menu choice by a patient with osteoporosis indicates the nurse's teaching about appropriate diet has been effective?

Oatmeal with skim milk and fruit yogurt

The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment could be used to evaluate the effectiveness of the therapies?

Observe for distended neck veins.

A 46-yr-old female patient returns to the clinic with recurrent dysuria after being treated with trimethoprim and sulfamethoxazole for 3 days. Which action will the nurse plan to take?

Obtain a midstream urine specimen for culture and sensitivity testing.

Which action should the nurse in the emergency department anticipate for a young adult patient who has had several episodes of bloody diarrhea?

Obtain a stool specimen for culture.

The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to unlicensed assistive personnel (UAP)?

Obtain the temperature, blood pressure, and pulse before the transfusion.

A 73-yr-old patient is diagnosed with stomach cancer after an unintended 20-lb weight loss. Which nursing action will be included in the plan of care?

Offer supplemental feedings between meals.

Which menu choice indicates that the patient understands the nurse's teaching about recommended dietary choices for iron-deficiency anemia?

Omelet and whole wheat toast

A 28-yr-old male patient is diagnosed with polycystic kidney disease. Which information is most appropriate for the nurse to include in teaching at this time?

Options to consider for genetic counseling

A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department n

Paradoxical chest movement

Which information obtained by the nurse about a patient with a lumbar vertebral compression fracture requires an immediate report to the health care provider?

Patient has been incontinent of urine and stool.

Which information about a patient who has a new prescription for phenytoin (Dilantin) indicates that the nurse should consult with the health care provider before administration of the medication?

Patient has minor elevations in the liver function tests.

A patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving nifedipine (Procardia). Which assessment would best indicate to the nurse that the patient's condition is improving?

Patient reports a decrease in exertional dyspnea.

After the nurse has completed teaching a patient with newly diagnosed eosinophilic esophagitis about the management of the disease, which patient action indicates that the teaching has been effective?

Patient schedules an appointment for allergy testing.

After receiving change-of-shift report, which patient should the nurse assess first?

Patient who has just returned from having hemodialysis and has a heart rate of 124/min

A nurse who works on the orthopedic unit has just received change-of-shift report. Which patient should the nurse assess first?

Patient who has not voided 10 hours after a laminectomy

After receiving change-of-shift report on a heart failure unit, which patient should the nurse assess first?

Patient who is taking digoxin and has a potassium level of 3.1 mEq/L

After change-of-shift report, which patient should the nurse assess first?

Patient with a urethral stricture who has not voided for 12 hours

After change-of-shift report, which patient should the nurse assess first?

Patient with myasthenia gravis who is reporting increased muscle weakness

After change-of-shift report, which patient should the nurse assess first?

Patient with repaired right femoral shaft fracture who is complaining of tightness in the calf

Which information will the nurse include when teaching the patient with a urinary tract infection (UTI) about the use of phenazopyridine?

Phenazopyridine may change the urine color

Which information will the nurse monitor in order to determine the effectiveness of prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD)?

Phosphate level

A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of severe pleuritic chest pain. Which prescribed medication should the nurse give first?

Piperacillin/tazobactam (Zosyn)

A patient admitted to the hospital with pneumonia has a history of functional urinary incontinence. Which nursing action will be included in the plan of care?

Place a bedside commode close to the patient's bed.

Which action should the nurse plan to prevent aspiration in a high-risk patient?

Place a patient with altered consciousness in a side-lying position.

The home health registered nurse (RN) is planning care for a patient with a seizure disorder related to a recent head injury. Which nursing action can be delegated to a licensed practical/vocational nurse (LPN/LVN)?

Place medications in the home medication organizer.

Which action will the nurse include in the plan of care for a patient who is being admitted with Clostridium difficile?

Place the patient in a private room on contact isolation.

A 42-yr-old patient admitted with acute kidney injury due to dehydration has oliguria, anemia, and hyperkalemia. Which prescribed action should the nurse take first?

Place the patient on a cardiac monitor.

After several days of antibiotic therapy, an older hospitalized patient develops watery diarrhea. Which action should the nurse take first?

Place the patient on contact precautions.

An experienced nurse instructs a new nurse about how to care for a patient with dyspnea caused by a pulmonary fungal infection. Which action by the new nurse indicates a need for further teaching?

Placing the patient on droplet precautions in a private hospital room

Which information shown in the table below about a patient who has just arrived in the emergency department is most urgent for the nurse to communicate to the health care provider? Assessment • BP 110/68 • Pulse 98 beats/min • Brisk capillary refill • Multiple ecchymoses on arms Complete Blood Count • Hgb 10.6 g/dL • Hct 30% • WBC 5100/µL • Platelets 19,500/µL Patient History • Occasional aspirin use • Abdominal pain x 1 week • Large, dark stool this morning

Platelet count

A patient with immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion. Which information indicates that the nurse should consult with the health care provider before obtaining and administering platelets?

Platelet count is 42,000/μL.

Which menu choice by the patient who is receiving hemodialysis indicates that the nurse's teaching has been successful?

Poached eggs, whole-wheat toast, and apple juice

A patient is awaiting surgery for acute peritonitis. Which action will the nurse include in the plan of care?

Position patient with the knees flexed.

A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure?

Position the patient sitting up on the side of the bed.

Which collaborative problem will the nurse include in a care plan for a patient admitted to the hospital with idiopathic aplastic anemia?

Potential complication: infection

A 58-yr-old patient with blunt abdominal trauma from a motor vehicle crash undergoes peritoneal lavage. If the lavage returns brown fecal drainage, which action will the nurse plan to take next?

Prepare the patient for surgery.

A patient with Parkinson's disease is admitted to the hospital for treatment of pneumonia. Which nursing interventions will be included in the plan of care (select all that apply)?

Provide an elevated toilet seat, Cut patient's food into small pieces, Place an armchair at the patient's bedside.

Which action will the nurse anticipate taking for an otherwise healthy 50-yr-old who has just been diagnosed with stage 1 renal cell carcinoma?

Provide preoperative teaching about nephrectomy.

The nurse has just auscultated coarse crackles bilaterally on a patient with a tracheostomy tube in place. If the patient is unsuccessful in coughing up secretions, what action should the nurse take?

Put on sterile gloves and use a sterile catheter to suction.

A 74-yr-old male patient tells the nurse that growing old causes constipation so he has been using a suppository for constipation every morning. Which action should the nurse take first?

Question the patient about risk factors for constipation.

A 56-yr-old female patient is admitted to the hospital with new-onset nephrotic syndrome. Which assessment data will the nurse expect?

Recent weight gain

Which finding in the mouth of a patient who uses smokeless tobacco is suggestive of oral cancer?

Red, velvety patches on the buccal mucosa

The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best indicator that the treatment has been effective?

Reduced dyspnea with the head of bed at 30 degrees

After the insertion of an arteriovenous graft (AVG) in the right forearm, a patient complains of pain and coldness of the right fingers. Which action should the nurse take?

Report the patient's symptoms to the health care provider.

Which nursing action for a patient who has had right hip arthroplasty can the nurse delegate to experienced unlicensed assistive personnel (UAP)?

Reposition the patient every 1 to 2 hours.

An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action recommended by the nurse is intended to prevent lung disease?

Require the use of protective equipment.

Which information about prevention of lung disease should the nurse include for a patient with a 42 pack-year history of cigarette smoking?

Resources for support in smoking cessation

Which assessment is most important for the nurse to make regarding a patient with myasthenia gravis?

Respiratory effort

Which intervention will be included in the plan of care for a patient with acute kidney injury (AKI) who has a temporary vascular access catheter in the left femoral vein?

Restrict physical activity to bed rest.

Which action should the nurse take before administering gentamicin (Garamycin) to a patient with acute osteomyelitis?

Review the patient's serum creatinine.

When a patient with splenomegaly is scheduled for splenectomy, which action will the nurse include in the preoperative plan of care?

Schedule immunization with the pneumococcal vaccine (e.g., Pneumovax).

A new 19-yr-old male patient has familial adenomatous polyposis (FAP). Which action will the nurse in the gastrointestinal clinic include in the plan of care?

Schedule the patient for yearly colonoscopy.

Which prescribed intervention for a patient with chronic short bowel syndrome will the nurse question?

Senna 1 tablet every day

Which information obtained by the nurse assessing a patient admitted with multiple myeloma is most important to report to the health care provider?

Serum calcium level is 15 mg/dL.

Which patient information is most important for the nurse to monitor when evaluating the effectiveness of deferoxamine (Desferal) for a patient with hemochromatosis?

Serum iron level

A patient has recently started on digoxin (Lanoxin) in addition to furosemide (Lasix) and captopril for the management of heart failure. Which assessment finding by the home health nurse is a priority to communicate to the health care provider?

Serum potassium level 3.0 mEq/L after 1 week of therapy

A 25-yr-old male patient has been admitted with a severe crushing injury after an industrial accident. Which laboratory result will be most important to report to the health care provider?

Serum potassium level of 6.5 mEq/L

A patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient's assigned room (select all that apply)?

Side-rail pads, oxygen mask, suction tubing

A patient is admitted to the emergency department with a left femur fracture. Which information obtained by the nurse is most important to report to the health care provider?

Slow capillary refill of the left foot

A patient is admitted with active tuberculosis (TB). The nurse should question a health care provider's order to discontinue airborne precautions unless which assessment finding is documented?

Sputum smears for acid-fast bacilli are negative.

Which action will the nurse include in the plan of care for a patient who had a cemented right total knee arthroplasty?

Start progressive knee exercises to obtain 90-degree flexion.

A hospitalized patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first?

Start the prescribed PRN O2 at 6 L/min.

Which nursing action could the registered nurse (RN) working in a skilled care hospital unit delegate to an experienced licensed practical/vocational nurse (LPN/LVN) caring for a patient with a permanent tracheostomy?

Suction the tracheostomy when directed.

Which intervention will the nurse include in the plan of care for a patient with primary restless legs syndrome (RLS) who is having difficulty sleeping?

Suggest that the patient exercise regularly during the day.

A patient with Parkinson's disease has bradykinesia. Which action will the nurse include in the plan of care?

Suggest that the patient rock from side to side to initiate leg movement.

A young adult patient is admitted to the hospital for evaluation of right lower quadrant abdominal pain with nausea and vomiting. Which action should the nurse take?

Suggest the patient lie on the side, flexing the right leg.

After sleeve gastrectomy, a 42-yr-old male patient returns to the surgical nursing unit with a nasogastric tube to low, intermittent suction and a patient-controlled analgesia (PCA) machine for pain control. Which nursing action should be included in the postoperative plan of care?

Support the surgical incision during patient coughing and turning in bed.

After a patient has had a hemorrhoidectomy at an outpatient surgical center, which instructions will the nurse include in discharge teaching?

Take prescribed pain medications before you expect a bowel movement.

Which assessment should the nurse perform first for a patient who just vomited bright red blood?

Taking the blood pressure (BP) and pulse

A patient is admitted to the emergency department with an open stab wound to the left chest. What action should the nurse take?

Tape a nonporous dressing on three sides over the wound.

Which problem reported by a patient with hemophilia is most important for the nurse to communicate to the health care provider?

Tarry stools

Which intervention will the nurse include in the plan of care for a patient who is diagnosed with a lung abscess?

Teach about the need for prolonged antibiotic therapy after discharge from the hospital.

Which action will the nurse take when caring for a patient with osteomalacia?

Teach about the use of vitamin D supplements.

The nurse is caring for a patient who has acute pharyngitis caused by Candida albicans. Which action is appropriate for the nurse to include in the plan of care?

Teach patient to "swish and swallow" prescribed oral nystatin

The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take?

Teach the patient about providing specimens for 3 consecutive days.

A patient in the urology clinic is diagnosed with monilial urethritis. Which action will the nurse include in the plan of care?

Teach the patient about the use of antifungal medications.

A 55-yr-old woman admitted for shoulder surgery asks the nurse for a perineal pad, stating that laughing or coughing causes leakage of urine. Which intervention is most appropriate to include in the care plan?

Teach the patient how to perform Kegel exercises.

Which action will the nurse plan to take for a patient with multiple sclerosis who has urinary retention caused by a flaccid bladder?

Teach the patient how to use the Credé method.

A patient who has acute myelogenous leukemia develops an absolute neutrophil count of 850/µL while receiving outpatient chemotherapy. Which action by the outpatient clinic nurse is most appropriate?

Teach the patient to administer filgrastim (Neupogen) injections.

Which action by the nurse will be most effective in decreasing the spread of pertussis in a community setting?

Teaching patients about the need for adult pertussis immunizations

Which assessment finding for a patient who has had surgical reduction of an open fracture of the right radius requires notification of the health care provider?

Temperature 101.4° F (38.6° C)

The nurse is assessing a patient who had a total gastrectomy 8 hours ago. What information is most important to report to the health care provider?

Temperature 102.1°F (38.9°C)

A licensed practical/vocational nurse (LPN/LVN) is caring for a patient with stage 2 chronic kidney disease. Which observation by the RN requires an intervention?

The LPN/LVN administers the iron supplement and phosphate binder with lunch.

The nurse and a licensed practical/vocational nurse (LPN/LVN) are working together to care for a patient who had an esophagectomy 2 days ago. Which action by the LPN/LVN requires that the nurse intervene?

The LPN/LVN positions the head of the bed in the flat position.

The nurse is caring for a patient with idiopathic pulmonary arterial hypertension (IPAH). Which assessment information requires the most immediate action by the nurse?

The epoprostenol (Flolan) infusion is disconnected.

The nurse is caring for a hospitalized older patient who has nasal packing in place after a nosebleed. Which assessment finding will require the most immediate action by the nurse?

The oxygen saturation is 89%.

A patient who is to have no weight bearing on the left leg is learning to walk using crutches. Which observation by the nurse indicates the patient can safely ambulate independently?

The patient advances the left leg and both crutches together and then advances the right leg.

A patient who had a total laryngectomy has a nursing diagnosis of hopelessness related to loss of control of personal care. Which information obtained by the nurse indicates that this identified problem is resolving?

The patient asks how to clean the tracheostomy stoma and tube.

Which action by a patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD?

The patient cleans the catheter while taking a bath each day.

The health care provider is considering the use of sumatriptan (Imitrex) for a 54-yr-old male patient with migraine headaches. Which information obtained by the nurse is most important to report to the health care provider?

The patient had a recent acute myocardial infarction.

Which information about a 60-yr-old patient with multiple sclerosis indicates that the nurse should consult with the health care provider before giving the prescribed dose of dalfampridine (Ampyra)?

The patient has an increased serum creatinine level.

Which information in a patient's history indicates to the nurse that the patient is not an appropriate candidate for kidney transplantation?

The patient has metastatic lung cancer.

A patient returned from a laparoscopic Nissen fundoplication for hiatal hernia 4 hours ago. Which assessment finding is most important for the nurse to address immediately?

The patient has no breath sounds in the left anterior chest.

Which information obtained by the nurse interviewing a 30-yr-old male patient is most important to communicate to the health care provider?

The patient has noticed blood in the stools.

Which information from a patient who had a transurethral resection with fulguration for bladder cancer 3 days ago is most important to report to the health care provider?

The patient has seen clots in the urine.

A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the health care provider?

The patient is being treated with antiretrovirals for HIV infection.

Which assessment finding should the nurse caring for a patient with thrombocytopenia communicate immediately to the health care provider?

The patient is difficult to arouse.

A 58-yr-old patient has just been admitted to the emergency department with nausea and vomiting. Which information requires the most rapid intervention by the nurse?

The patient is lethargic and difficult to arouse.

Which finding for a patient who has been taking orlistat (Xenical) is most important to report to the health care provider?

The patient is pale and has many bruises.

A patient is being discharged 4 days after hip arthroplasty using the posterior approach. Which patient action requires intervention by the nurse?

The patient leans over to pull on shoes and socks.

A 22-yr-old female patient with an exacerbation of ulcerative colitis is having 15 to 20 stools daily and has excoriated perianal skin. Which patient behavior indicates that teaching regarding maintenance of skin integrity has been effective?

The patient uses witch hazel compresses to soothe irritation.

Which patient requires the most rapid assessment and care by the emergency department nurse?

The patient with neutropenia who has a temperature of 101.8° F

A 62-yr-old patient who has Parkinson's disease is taking bromocriptine (Parlodel). Which information obtained by the nurse may indicate a need for a decrease in the dosage?

The patient's blood pressure is 92/52 mm Hg.

The nurse is assessing a patient 4 hours after a kidney transplant. Which information is most important to communicate to the health care provider?

The patient's central venous pressure (CVP) is decreased.

The nurse is administering IV fluid boluses and nasogastric irrigation to a patient with acute gastrointestinal (GI) bleeding. Which assessment finding is most important for the nurse to communicate to the health care provider?

The patient's lungs have crackles audible to the midchest.

A female patient with chronic kidney disease (CKD) is receiving peritoneal dialysis with 2-L inflows. Which information should the nurse report promptly to the health care provider?

The patient's peritoneal effluent appears cloudy.

A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment is effective?

The patient's white blood cell (WBC) count is 9000/µL

Which finding for a patient admitted with glomerulonephritis indicates to the nurse that treatment has been effective?

The periorbital and peripheral edema are resolved.

A patient arrived at the emergency department after tripping over a rug and falling at home. Which finding is most important for the nurse to communicate to the health care provider?

The right arm appears shorter than the left.

The nurse is providing preoperative teaching for a patient scheduled for an abdominal-perineal resection. Which information will the nurse include?

The site where the stoma will be located will be marked on the abdomen preoperatively.

A 33-yr-old male patient with a gunshot wound to the abdomen undergoes surgery, and a colostomy is formed as shown in the accompanying figure. Which information will be included in patient teaching?

This type of colostomy is usually temporary.

While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take?

Time and observe and record the details of the seizure and postictal state.

A patient who has a history of a transfusion-related acute lung injury (TRALI) is to receive a transfusion of packed red blood cells (PRBCs). Which action by the nurse will decrease the risk for TRALI for this patient?

Transfuse only leukocyte-reduced PRBCs.

The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed?

UAP lower the head of the patient's bed to 15 degrees.

A patient is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease. Which information indicates a need for change in the medication or dosage?

Uncontrolled head movement

The nurse is titrating the IV fluid infusion rate immediately after a patient has had kidney transplantation. Which parameter will be most important for the nurse to consider?

Urine output

A 48-yr-old male patient who weighs 242 lb (110 kg) undergoes a nephrectomy for massive kidney trauma from a motor vehicle crash. Which postoperative assessment finding is most important to communicate to the surgeon?

Urine output is 20 mL/hr for 2 hours.

A 62-yr-old female patient has been hospitalized for 4 days with acute kidney injury (AKI) caused by dehydration. Which information will be most important for the nurse to report to the health care provider?

Urine output over an 8-hour period is 2500 mL.

When a patient arrives in the emergency department with a facial fracture, which action will the nurse take first?

Use a cervical collar to stabilize the spine.

A critically ill patient with sepsis is frequently incontinent of watery stools. What action by the nurse will prevent complications associated with ongoing incontinence?

Use a fecal management system

The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy tube. Which action by the nurse would determine if the cuff has been properly inflated?

Use a hand-held manometer to measure cuff pressure.

When assessing a patient with a sore throat, the nurse notes anterior cervical lymph node swelling, a temperature of 101.6° F (38.7° C), and yellow patches on the tonsils. Which action will the nurse anticipate taking?

Use a swab to obtain a sample for a rapid strep antigen test.

Following rectal surgery, a patient voids about 50 mL of urine every 30 to 60 minutes for the first 4 hours. Which nursing action is most appropriate?

Use an ultrasound scanner to check the postvoiding residual volume.

Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has no symptoms of TB. Which information should the occupational health nurse plan to teach the staff nurse?

Use and side effects of isoniazid

Which information will the nurse include in teaching a patient who had a proctocolectomy and ileostomy for ulcerative colitis?

Use care when eating high-fiber foods to avoid obstruction of the ileum.

Which discharge instruction will the emergency department nurse include for a patient with a sprained ankle?

Use pillows to elevate the ankle above the heart.

The nurse is coaching a community group for individuals who are overweight. Which participant behavior is an example of the best exercise plan for weight loss?

Walking for 40 minutes 6 or 7 days/week

The nurse is caring for a patient who is being discharged after an emergency splenectomy following a motor vehicle crash. Which instructions should the nurse include in the discharge teaching?

Wash hands and avoid persons who are ill.

After assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis?

Weak cough effort

The nurse reviews the laboratory test results of a patient admitted with abdominal pain. Which information will be most important for the nurse to communicate to the health care provider?

White blood cell (WBC) count 15,500/µL

A nurse reviews the laboratory data for an older patient. The nurse would be most concerned about which finding?

White blood cell (WBC) count of 2800/µL

A young adult arrives in the emergency department with ankle swelling and severe pain after twisting an ankle playing basketball. Which of these prescribed interprofessional interventions will the nurse implement first?

Wrap the ankle and apply an ice pack.

An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse should notify the health care provider if the patient exhibits which finding?

Yellow-tinged sclera

A 62-year old man with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patient's laboratory test findings to include

a hemoglobin (Hgb) of 8.6 g/dL (86 g/L).

An assessment finding for a 55-yr-old patient that alerts the nurse to the presence of osteoporosis is

a loss of height

IV sodium nitroprusside is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to titrate the nitroprusside rate down if the patient develops

a systolic BP below 90 mm Hg.

A patient with diverticulosis has a large bowel obstruction. The nurse will monitor for

abdominal distention.

During a visit to a 78-yr-old patient with chronic heart failure, the home care nurse finds that the patient has ankle edema, a 2-kg weight gain over the past 2 days, and complains of "feeling too tired to get out of bed." Based on these data, a correct nursing diagnosis for the patient is

activity intolerance related to fatigue.

The nurse admitting a patient with acute diverticulitis explains that the initial plan of care is to

administer IV fluids.

A 38-year old woman receiving chemotherapy for breast cancer develops a Candida albicans oral infection. The nurse will anticipate the need for

administration of nystatin tablets.

An appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia is to

alternate periods of rest and activity.

Following an acute myocardial infarction, a previously healthy 63-yr-old develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about

angiotensin-converting enzyme (ACE) inhibitors.

The health care provider prescribes antacids and sucralfate (Carafate) for treatment of a patient's peptic ulcer. The nurse will teach the patient to take

antacids after meals and sucralfate 30 minutes before meals.

The nurse will anticipate teaching a patient with nephrotic syndrome who develops flank pain about treatment with

anticoagulants.

When a 74-yr-old patient is seen in the health clinic with new development of a stooped posture, shuffling gait, and pill rolling-type tremor, the nurse will anticipate teaching the patient about

antiparkinsonian drugs.

After successfully losing 1 lb weekly for several months, a patient at the clinic has not lost any weight for the past month. The nurse should first

ask the patient whether there have been any changes in exercise or diet patterns.

A patient who has acute myelogenous leukemia (AML) is considering treatment with a hematopoietic stem cell transplant (HSCT). The best approach for the nurse to assist the patient with a treatment decision is to

ask whether there are questions or concerns about HSCT.

The nurse observes a patient ambulating in the hospital hall when the patient's arms and legs suddenly jerk and the patient falls to the floor. The nurse will first

assess the patient for a possible injury.

A patient with chronic heart failure who is taking a diuretic and an angiotensin-converting enzyme (ACE) inhibitor and who is on a low-sodium diet tells the home health nurse about a 5-lb weight gain in the past 3 days. The nurse's priority action will be to

assess the patient for clinical manifestations of acute heart failure.

A pedestrian who was hit by a car is admitted to the emergency department with possible right lower leg fractures. The initial action by the nurse should be to

assess the pedal pulses.

A patient undergoes left above-the-knee amputation with an immediate prosthetic fitting. When the patient arrives on the orthopedic unit after surgery, the nurse should

assess the surgical site for hemorrhage.

When administering alendronate (Fosamax) to a patient with osteoporosis, the nurse will

assist the patient to sit up at the bedside.

A patient has a long-arm plaster cast applied for fracture immobilization. Until the cast has completely dried, the nurse should

avoid handling the cast using fingertips.

The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia. The nurse will plan to check the laboratory results for the

bilirubin level.

The nurse will plan to teach a 27-yr-old woman who smokes two packs of cigarettes daily about the increased risk for

bladder cancer.

A young adult who has von Willebrand disease is admitted to the hospital for minor knee surgery. The nurse will review the coagulation survey to check the

bleeding time.

A routine complete blood count for an active older man indicates possible myelodysplastic syndrome. The nurse will plan to teach the patient about

bone marrow biopsy.

Sodium polystyrene sulfonate (Kayexalate) is ordered for a patient with hyperkalemia. Before administering the medication, the nurse should assess the

bowel sounds.

A 68-yr-old male patient with a stroke is unconscious and unresponsive to stimuli. After learning that the patient has a history of gastroesophageal reflux disease (GERD), the nurse will plan to do frequent assessments of the patient's

breath sounds

A 54-yr-old woman who recently reached menopause and has a family history of osteoporosis is diagnosed with osteopenia following densitometry testing. In teaching the woman, the nurse explains that

calcium loss from bones can be slowed by increasing calcium intake and weight-bearing exercise.

A patient who has just been admitted with pulmonary edema is scheduled to receive the following medications. Which medication should the nurse question before giving?

carvedilol (Coreg) 3.125 mg

An appropriate nursing intervention for a patient with non-Hodgkin's lymphoma whose platelet count drops to 18,000/µL during chemotherapy is to

check all stools for occult blood.

A 19-yr-old woman is brought to the emergency department with a knife handle protruding from her abdomen. During the initial assessment of the patient, the nurse should

check for circulation and tissue perfusion.

Four hours after a bowel resection, a 74-yr-old male patient with a nasogastric tube to suction complains of nausea and abdominal distention. The first action by the nurse should be to

check for tube placement and reposition it.

After laminectomy with a spinal fusion to treat a herniated disc, a patient reports numbness and tingling of the right lower leg. The first action the nurse should take is to

check the chart for preoperative assessment data.

A patient calls the clinic to report a new onset of severe diarrhea. The nurse anticipates that the patient will need to

collect a stool specimen.

The nurse preparing for the annual physical exam of a 50-yr-old man will plan to teach the patient about

colonoscopy.

A patient who underwent a gastroduodenostomy (Billroth I) 12 hours ago complains of increasing abdominal pain. The patient has no bowel sounds and 200 mL of bright red nasogastric (NG) drainage in the past hour. The highest priority action by the nurse is to

contact the surgeon.

A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurse's first action should be to

disconnect the transfusion and infuse normal saline.

A patient being admitted with an acute exacerbation of ulcerative colitis reports crampy abdominal pain and passing 15 or more bloody stools a day. The nurse will plan to

discontinue the patient's oral food intake.

A patient who had surgery for creation of an ileal conduit 3 days ago will not look at the stoma and requests that only the ostomy nurse specialist does the stoma care. The nurse identifies a nursing diagnosis of

disturbed body image related to change in function.

A patient is transferred from the recovery room to a surgical unit after a transverse colostomy. The nurse observes the stoma to be deep pink with edema and a small amount of sanguineous drainage. The nurse should

document stoma assessment findings.

The nurse teaches an adult patient to prevent the recurrence of renal calculi by

drinking 2000 to 3000 mL of fluid each day.

When preparing a female patient with bladder cancer for intravesical chemotherapy, the nurse will teach about

emptying the bladder before the medication.

The nurse will anticipate preparing an older patient who is vomiting "coffee-ground" emesis for

endoscopy

It is important for the nurse providing care for a patient with sickle cell crisis to

evaluate the effectiveness of opioid analgesics.

The nurse will instruct the patient with a fractured left radius that the cast will need to remain in place

for at least 3 weeks.

A patient in the intensive care unit with acute decompensated heart failure (ADHF) complains of severe dyspnea and is anxious, tachypneic, and tachycardic. Several drugs have been ordered for the patient. The nurse's priority action will be to

give PRN IV morphine sulfate 4 mg.

A young adult male patient seen at the primary care clinic complains of feeling continued fullness after voiding and a split, spraying urine stream. The nurse will ask about a history of

gonococcal urethritis.

A patient with a fracture of the left femoral neck has Buck's traction in place while waiting for surgery. To assess for pressure areas on the patient's back and sacral area and to provide skin care, the nurse should

have the patient lift the buttocks slightly by using a trapeze over the bed.

The nurse's discharge teaching for a patient who has had a repair of a fractured mandible will include information about

how and when to cut the immobilizing wires.

The nurse is caring for a patient with type A hemophilia being admitted to the hospital with severe pain and swelling in the right knee. The nurse should

immobilize the knee joint.

A patient complains of leg cramps during hemodialysis. The nurse should

infuse a bolus of normal saline.

A young adult patient is hospitalized with massive abdominal trauma from a motor vehicle crash. The patient asks the nurse about the purpose of receiving famotidine (Pepcid). The nurse will explain that the medication will

inhibit development of stress ulcers.

When obtaining a health history and physical assessment for a 36-yr-old female patient with possible multiple sclerosis (MS), the nurse should

inquire about urinary tract problems.

A patient is receiving IV antibiotics at home to treat chronic osteomyelitis of the left femur. The nurse identifies a need for additional teaching related to health maintenance when the nurse finds that the patient

is unable to plantar flex the foot on the affected side.

An appropriate nursing intervention for a patient who has acute low back pain and muscle spasms is to teach the patient to

keep the head elevated slightly and flex the knees when resting in bed.

At his first postoperative checkup appointment after a gastrojejunostomy (Billroth II), a patient reports that dizziness, weakness, and palpitations occur about 20 minutes after each meal. The nurse will teach the patient to

lie down for about 30 minutes after eating.

A patient has been diagnosed with urinary tract calculi that are high in uric acid. Which foods will the nurse teach the patient to avoid (select all that apply)?

liver, chicken

The nurse is planning care for a patient with severe heart failure who has developed elevated blood urea nitrogen (BUN) and creatinine levels. The primary treatment goal in the plan will be

maintaining cardiac output.

A patient has a new diagnosis of Crohn's disease after having frequent diarrhea and a weight loss of 10 lb (4.5 kg) over 2 months. The nurse will plan to teach about

medication use.

A patient who requires daily use of a nonsteroidal antiinflammatory drug (NSAID) for the management of severe rheumatoid arthritis has recently developed melena. The nurse will anticipate teaching the patient about

misoprostol (Cytotec) to protect the gastrointestinal (GI) mucosa.

A factory line worker has repetitive strain syndrome in the left elbow. The nurse will plan to teach the patient about

modifying arm movements.

An expected action by the nurse caring for a patient who has an acute exacerbation of polycythemia vera is to

monitor fluid intake and output.

A patient preparing to undergo a colon resection for cancer of the colon asks about the elevated carcinoembryonic antigen (CEA) test result. The nurse explains that the test is used to

monitor the tumor status after surgery.

A patient who arrives at the emergency department experiencing severe left knee pain is diagnosed with a patellar dislocation. The initial patient teaching by the nurse will focus on the need for

monitored anesthesia care.

When planning teaching for a patient with benign nephrosclerosis, the nurse should include instructions regarding

monitoring and recording blood pressure.

The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide. Appropriate instructions for the patient include

notify the health care provider if nausea develops.

The occupational health nurse will teach the patient whose job involves many hours of typing to

obtain a keyboard pad to support the wrist.

The nurse will determine more teaching is needed if a patient with discomfort from a bunion says, "I will

only wear sandals, no closed-toe shoes."

A 40-yr-old patient is diagnosed with early Huntington's disease (HD). When teaching the patient, spouse, and adult children about this disorder, the nurse will provide information about the

option of genetic testing for the patient's children to determine their own HD risks.

The nurse evaluating effectiveness of prescribed calcitonin and ibandronate (Boniva) for a patient with Paget's disease will consider the patient's

pain intensity.

A patient who has chronic heart failure tells the nurse, "I was fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!" The nurse will document this assessment finding as

paroxysmal nocturnal dyspnea.

The nurse advises a patient with myasthenia gravis (MG) to

perform physically demanding activities early in the day.

An older patient with a bleeding duodenal ulcer has a nasogastric (NG) tube in place. The health care provider prescribes 30 mL of aluminum hydroxide/magnesium hydroxide (Maalox) to be instilled through the tube every hour. To evaluate the effectiveness of this treatment, the nurse

periodically aspirates and tests gastric pH.

The nurse should reposition the patient who has just had a laminectomy and diskectomy by

placing a pillow between the patient's legs and turning the entire body as a unit.

Before administration of captopril to a patient with stage 2 chronic kidney disease (CKD), the nurse will check the patient's

potassium.

The nurse will anticipate teaching a patient experiencing frequent heartburn about

proton pump inhibitors.

When a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30, the nurse will expect an assessment finding of

rapid, deep respirations.

To determine possible causes, the nurse will ask a patient admitted with acute glomerulonephritis about

recent sore throat and fever.

While admitting an 82-yr-old patient with acute decompensated heart failure to the hospital, the nurse learns that the patient lives alone and sometimes confuses the "water pill" with the "heart pill." When planning for the patient's discharge the nurse will facilitate a

referral to a home health care agency.

The day after a 60-yr-old patient has open reduction and internal fixation (ORIF) for an open, displaced tibial fracture, the nurse identifies the priority nursing diagnosis as

risk for infection related to disruption of skin integrity.

To prevent recurrence of uric acid renal calculi, the nurse teaches the patient to avoid eating

sardines and liver.

A patient with diabetes who has bacterial pneumonia is being treated with IV gentamicin 60 mg IV BID. The nurse will monitor for adverse effects of the medication by evaluating the patient's

serum creatinine.

Before administration of calcium carbonate to a patient with chronic kidney disease (CKD), the nurse should check laboratory results for

serum phosphate.

The nurse working on the heart failure unit knows that teaching an older female patient with newly diagnosed heart failure is effective when the patient states that

she will call the clinic if her weight goes up 3 pounds in 1 week.

A 26-yr-old patient with a family history of stomach cancer asks the nurse about ways to decrease the risk for developing stomach cancer. The nurse will teach the patient to avoid

smoked foods such as ham and bacon.

When assessing for Tinel's sign in a patient with possible right carpal tunnel syndrome, the nurse will ask the patient about

tingling in the right thumb and index finger.

When a patient is diagnosed with achalasia, the nurse will teach the patient that

treatment may include endoscopic procedures.

The nurse explaining esomeprazole (Nexium) to a patient with recurring heartburn describes that the medication

treats gastroesophageal reflux disease by decreasing stomach acid production.

The nurse expects the assessment of a patient who is experiencing a cluster headache to include

unilateral ptosis.

A patient vomiting blood-streaked fluid is admitted to the hospital with acute gastritis. To determine possible risk factors for gastritis, the nurse will ask the patient about

use of nonsteroidal antiinflammatory drugs (NSAIDs).

When teaching the patient with newly diagnosed heart failure about a 2000-mg sodium diet, the nurse explains that foods to be restricted include

yogurt and milk products.