Med-surge old exam study guide

The nurse provides education to patient who is diagnosed with an ankle sprain. Which patient statement indicates the need for further l teaching?

"I will not need to rest my ankle."

The nurse provides care to a patient who is scheduled for a corticotropic stimulation test. Which times require the nurse to draw blood for serum cortisol levels?

30 and 60 minutes before medication administration

The nurse determines which patient is at highest risk for the development of osteoporosis?

55-year old Caucasian patient with a BMI of 17 and history of hyperthyroidism

The nurse is caring for a patient with congestive heart failure who is admitted to the medical-surgical unit with acute hypokalemia. Which prescribed medication may have contributed to the patient's current hypokalemic state?

Furosemide (Lasix) (Loop Diuretic)

Which prescribed medication for the patient recovering from a traumatic amputation does the nurse correlate to the treatment of phantom limb pain?

Gabapentin

A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor while the patient is receiving this infusion?

Lung sounds

A patient with type 1 diabetes mellitus is experiencing elevated blood glucose levels in the morning. Which action is indicated to address this complication?

Measure blood glucose at 0200 hours.

What does the nurse teach the patient with type 1 diabetes mellitus to do in advance of playing tennis?

Measure blood glucose level.

During a wound assessment it is important for the nurse to

Measure the length, width, and depth of the wound every time the wound dressing is changed

Which exposure by the nurse is most likely to require post exposure prophylaxis when the patient's human immunodeficiency virus (HIV) status is unknown?

Needle stick with a needle and syringe used for a venipuncture

This is a chronic bone disorder. Normally, there is a process in which your bones break down and then regrow

Paget's disease

The nurse recognizes which finding as the earliest clinical manifestation of bladder cancer?

Painless hematuria

A patient receiving epidural morphine after abdominal surgery and has not voided for over 10 hours. What action should the nurse take first?

Palpate the patients bladder and perform a bladder scan

The nurse correlated a vitamin D deficiency in the patient with a disorder of which endocrine gland?

Parathyroid

The nurse is preparing a teaching tool on the major hormones of the body for a community program. Which gland does the nurse identify as controlling calcium levels in the body?

Parathyroid

A patient experiencing diabetic ketoacidosis (DKA) is receiving a normal saline infusion and intravenous insulin. What additional medication does the nurse expect to be prescribed for this patient?

Potassium

Which of the following statements most accurately describes Compartment Syndrome

Swelling that occurs post injury and causes increased pressure within a limited space that requires immediate attention

When assessing and treating the older adults pain, it is important to understand that the older adult usually requires less pain medication because

The older adult usually has decreased renal and liver function

The nurse is caring for a patient with celiac disease who lacks vitamin D absorption. What conclusion can the nurse make with this assessment finding?

The patient has a low calcium level

The nurse notes that an older patient is wearing a sweater and scarf on a warm summer day. What should this observation indicate to the nurse?

The patient's metabolism is slowing down.

Which of the following diet promotes best proper wound healing

High protein, high carbohydrates, high vitamin C

Which parameter does the nurse use to guide the effectiveness of intravenous fluid replacement in the patient with diabetes insipidus?

Serum sodium level

The nurse correlates which clinical manifestations to the diagnosis of rheumatoid arthritis?

Swan-neck deformity

What is acute pain?

When the course of pain decreases over time and goes away as recovery occurs

The nurse is preparing a teaching tool for a community health program. What does the nurse include as a risk factor for the development of carpal tunnel syndrome (CTS)?

Work that is repetative

The nurse is assessing a patient's postoperative wound and finds it has separated from the suture line. How does the nurse document this finding?

Wound dehiscence

A patient who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, "I feel obsessed with morbid thoughts about dying." Which response by the nurse is appropriate?

"Can you tell me more about the thoughts that you are having?"

A patient who uses injectable illegal drugs asks the nurse how to prevent acquired immunodeficiency syndrome (AIDS). Which response by the nurse is most accurate?

"Consider participating in a needle-exchange program."

The nurse is conducting an in-service on the spread of infection in the hospital environment. Which statement does the nurse include regarding the most common mode of pathogen transmission?

"Contact transmission is the most common mode."

Which statement by a patient would alert the nurse to a risk for decreased immune function?

"I had my spleen removed after a car accident."

In reviewing teaching with a patient being treated with antibiotics and Pyridium for a urinary tract infection (UTI), which patient statement indicates the need for further teaching?

"I will report if my urine is orange or red in color."

The nurse is teaching a class about the risks of bladder cancer. Which statement by one of the participants indicates that the teaching was effective?

"I will stop smoking."

Which statement by the patient diagnosed with pyelonephritis indicates the need for further teaching?

"I will take my entire course of phenazopyridine to treat future UTIs."

The nurse is providing care to a patient who states, "My doctor says I am experiencing urinary retention. What does that mean?" Which response by the nurse is best?

"It means you are unable to completely empty your bladder."

The nurse is teaching a patient about the different routes of transmission. Which patient statement indicates correct understanding of contact transmission?

"It occurs when I come in direct contact with a pathogen."

The nurse is teaching a patient about the different routes of transmission. Which patient statement indicates correct understanding of airborne transmission?

"It occurs when I come into contact with pathogens by breathing."

The nurse is teaching a patient about the different routes of transmission. Which patient statement indicates correct understanding of vehicle transmission?

"It occurs when I ingest food containing a disease-carrying organism."

Which statement by the patient with rheumatoid arthritis indicates the need for further teaching?

"My immunosuppressive medications need to be increased if I get an infection."

Which statement by the patient diagnosed with chronic kidney disease who is prescribed furosemide (Lasix) indicates that teaching about this medication was effective?

"This pill will reduce the swelling in my body and get rid of the extra potassium."

A patient with adrenal insufficiency asks why their skin looks so tan. What is the best response by the nurse?

"The hormone causing the darker skin shares the same hormone as the one helping to overcome the insufficiency."

A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4+ count of less than 200 cells/mL. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct?

"The patient has developed acquired immunodeficiency syndrome (AIDS)."

The nurse provides care to a patient diagnosed with type 1 diabetes mellitus (DM) whose hemoglobin A1c level remains elevated despite the use of the prescribed sliding scale insulin. The healthcare provider prescribes an insulin pump. The patient asks, "Why did my doctor prescribe a pump?" Which response by the nurse is best?

"The pump provides better control of your blood sugar."

The sister of a patient diagnosed with BRCA gene-related breast cancer asks the nurse, "Do you think I should be tested for the gene?" Which response by the nurse is most appropriate?

"There are many things to consider before deciding to have genetic testing. I recommend you speak to a genetic counselor before you make a decision on genetic testing."

The nurse is caring for a patient who is pale and experiencing fatigue secondary to anemia related to chronic kidney disease. When the patient's spouse asks why the patient is anemic, what response by the nurse is the best?

"There is a decreased production by the kidneys of the hormone erythropoietin, which is the cause of anemia."

A middle-aged female patient has been offered testing for HIV/AIDS upon admission to the hospital for an unrelated health problem. The nurse observes that the patient is visibly surprised and embarrassed by this offer. How should the nurse best respond?

"This testing is offered to every adolescent and adult regardless of their lifestyle, appearance or history."

A 40-year old patient is surprised to learn of the diagnosis of type 1 diabetes mellitus. What is the nurse's best response?

"Type 1 diabetes mellitus can occur at any stage of life."

A patient with type 1 diabetes mellitus is scheduled for a hemoglobin A1c level. What information does the nurse include in the patient teaching about this diagnostic test?

"You can have this test drawn at any time during the day."

The nurse provides care for the patient diagnosed with a kidney stone that has not passed. What statement is most important to include in the teaching for this patient?

"You must strain all urine to confirm whether or not the stone has passed."

The nurse is advising a patient who was exposed 4 days ago to human immunodeficiency virus (HIV) through unprotected sexual intercourse. The patient's antigen-antibody test has just been reported as negative for HIV. What information should the nurse give to this patient?

"You will need to be retested in 2 weeks."

A patient is prescribed to have a cortisol blood level drawn. At which time should this sample be drawn?

0700

The nurse is assisting with the secondary survey of a patient with 50% total body surface area electrical burns. Which test would be a priority for this patient?

12-lead electrocardiogram

The nurse is providing care to a trauma patient who will require the rapid administration of large volumes of fluid in addition to a blood transfusion. Which gauge should the nurse use when initiating intravenous (IV) access for this patient?

18

Which area of the abdomen shown in the accompanying figure will the nurse palpate to assess for splenomegaly?

2

In the rule of nines for burn injuries the head makes up what percentage of the total body surface area?

9%

Which patient would benefit from education about HIV pre exposure prophylaxis (PrEP)?

A 52-yr-old recently single woman just diagnosed with chlamydia

Which of the following patients is MOST at risk for osteoporosis

A 65 year old post menopausal Asian woman of thin stature who smokes a pack of cigarettes a day, drinks a glass of wine a night, has a diagnosis of hypothyroidism and whose mother had osteoporosis

The nurse is reviewing the medical records for patients who are scheduled for surgery the next day. Which patient may not provide consent to receive blood products?

A Caucasian Jehovah's Witness patient

A classic symptom of Systemic Lupus Erythematosus (SLE) is

A butterfly rash on the cheeks or nose

A patient being treated for adrenal insufficiency has a serum potassium level of 5.9 mEq/L. The nurse correlates that the action of which medication is indicated in this situation?

Kayexalate

A patient with an exacerbation of Gout on their right great toe comes to the emergency room. Which medication is the most common mediation used to treat Gout that might he be prescribed?

Allopurinol

In assessing a patient's muscle function, the nurse asks the patient to raise the arm horizontally away from the body. What voluntary movement is the nurse assessing?

Abduction

Which finding by the nurse during abdominal auscultation indicates a need for a focused abdominal assessment?

Absent bowel sounds

A patient in the health care provider's office for allergen testing using the cutaneous scratch method develops itching and swelling at the skin site and is havu=ing difficulty breathing. Which action should the nurse plan to take first?

Administer a dose of epinephrine.

The nurse is caring for a patient with a history of latex allergies. The patient develops audible wheezing, pruritus, urticaria, and signs of angioedema. Which is the priority intervention for this patient?

Administer prescribed epinephrine 1:1,000 by subcutaneous injection per the healthcare provider's orders.

In providing care to a patient admitted with a suspected inhalation injury, what nursing action in the priority?

Administering 100% humidified oxygen

A patient is scheduled for a bilateral adrenalectomy. The nurse includes teaching about which disorder in preparing the patient for this procedure?

Adrenal insufficiency

If the air is not removed from the IV line tubing prior to administering 0.9% NS at 125 ml/hr the patient is at risk for which complication?

Air Embolism

What are the priority interventions the nurse performs when admitting the patient to the PACU?

Assess for airway patency and quality of respirations and obtain vital signs

The nurse correlates which laboratory result to an increased risk for fracture in the adult patient?

Low Serum calcium

An adolescent is experiencing delayed puberty. Which gland function should be evaluated?

Anterior pituitary

A 49 year old male patient is 3 days post op from an abdominal surgery. He had a gastric bypass and he has been refusing to get out of bed. What would be the best intervention the nurse can use to prevent a DVT in a bedridden patient?

Apply compression stockings or a pneumatic compression device to the patients lower legs

The nurse is caring for a patient in the postanesthesia care unit (PACU) who is restless and confused and has a pulse oximeter reading of 89% on room air. What action should the nurse take next?

Apply oxygen

Your patient has just arrived in the PACU and is lethargic with a pulse ox of 86%. What is the nurses priority intervention for this patient?

Apply oxygen at 2 liters nasal cannula

Trousseau's sign is elicited by

Applying a blood pressure cuff to the upper arm and inflating it

The nurse prepares the patient diagnosed with chronic obstructive pulmonary disease (COPD) for which diagnostic test to monitor acid-base balance?

Arterial blood gases

The patient tells the nurse in the preoperative setting that she has noticed she has a reaction when wearing rubber gloves. What is the most appropriate action?

Ask additional questions to assess for a possible latex allergy

A patient is anxious and reports difficulty breathing after being stung by a wasp. What is the nurse's priority action?

Assess the patient's airway.

A patient who is 24 hours post op from an abdominal surgery develops a fever of 101.2. What does the nurse suspect is the cause of the patients fever?

Atelectasis

A patient arrives in the emergency room and is alert and oriented with burns to the upper chest and bilateral upper extremities. She reports severe pain. Which nursing action is the priority?

Auscultate the patients chest

The nurse is reviewing type 1 diabetes mellitus with a group of patients newly diagnosed with the disorder. What should the nurse explain as the major cause for the disorder?

Autoimmune process

The nurse notes that a patient has a tumor on the thyroid gland. Where should the nurse expect to palpate this tumor?

Below the cricoid cartilage

The nurse monitors for which clinical manifestation in the patient diagnosed with Paget's disease?

Bone deformity

The nurse monitors for which of the following clinical manifestations in the patient diagnosed with osteoarthritis?

Bouchard's nodes

When a newly diagnosed patient with SLE (Systemic Lupus Erythematosus) asks what she can do to avoid flare ups you would tell her to avoid which of the following Select all that apply

Drying soaps, emotional stress, prolonged sun exposure

Which of the following statements are true about a fat embolism

Dyspnea, respiratory failure, tachycardia and low grade fever

Vitamin D and these supplements must be taken together in order to be absorbed and metabolized properly

Calcium and Phosphorus

The nurse is caring for a patient who is to have a peripherally inserted central catheter (PICC) line inserted tomorrow. Which site would be the MOST appropriate for a PICC line?

Cephalic Vein

What is the priority nursing action to decrease the risk of a blood transfusion reaction from a patient receiving incompatible blood?

Checking the bag to ensure it is the correct blood type

A patient who had abdominal surgery yesterday is receiving morphine through patient-controlled analgesia (PCA). What action by the nurse is a priority?

Checking the respiratory rate

Which step followed by a nurse while caring for a patient in the preoperative phase can prevent aspiration during intubation and extubation?

Confirming the last oral intake of the patient

Some factors that can delay wound healing are

Corticosteroids, diabetes, poor circulation, smoking, Anemia, obesity, mechanical friction, advanced age

The nurse monitors for which assessment data in the patient diagnosed with a kidney infection?

Costovertebral angle tenderness is present.

The nurse prepares the patient with suspected bladder cancer for which diagnostic test that is needed for the definitive diagnosis?

Cystoscopy with biopsy

A patient has a magnesium level of 1.3 mg/dL (hypomagnesemia). Which assessment would help the nurse identify a likely cause of this value?

Daily alcohol intake

A patient has a magnesium level of 1.3 mg/dL. Which assessment would help the nurse identify a likely cause of this value?

Daily alcohol intake

The nurse recognizes which intervention as the priority in the care of the patient with a serum phosphorus level of 5.0 mg/dL?

Daily calcium supplements

Tolerance is defined as

Need for increased dose to maintain same degree of pain control

A patient with multiple draining wounds is admitted for hypovolemia. What would be the most accurate way for the nurse to evaluate fluid balance?

Daily weight

Which assessment data from a patient who has been on long-term steroid therapy requires an immediate intervention?

Decreased blood glucose

Which of the following symptoms is a reason for the nurse to hold the patients scheduled morphine?

Decreased level of consciousness and decreased respirations

A patient asks for a definition of adrenal insufficiency. Which response by the nurse is best?

Decreased secretion of hormones from the anterior pituitary gland

The nurse monitors for which therapeutic effect in the patient receiving sodium polystyrene sulfonate (Kayexalate) for the treatment of chronic kidney disease?

Decreased serum potassium

The nurse correlates which assessment findings to a patient experiencing diabetic ketoacidosis?

Deep rapid respirations

The nurse notes that a patient's surgical abdominal wound that just had staples removed appears to be opening at the distal end. What would this be called?

Dehiscence

Some complications of healing are

Dehiscence, contractures, adhesions

The nurse recognizes that the patient with dysfunction of the posterior pituitary gland is at risk for which disorder?

Diabetes insipidus

The nurse assesses a patient's surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is appropriate?

Document the assessment.

What is chronic pain?

Does not go away; characterized by periods of increasing and decreasing

What term does the nurse use to document a patient's complaints of painful urination?

Dysuria

What is the nurses first PRIORITY when a patient is receiving narcotic analgesics for pain after having a bilateral mastectomy?

Effective airway and respirations

The nurse is reviewing medications prescribed for a patient with hypopituitarism. Which medications are indicated for the treatment of this disorder?

Electrolyte supplements

A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which action by the nurse is appropriate?

Elevate the ankle above heart level.

The nurse correlates which clinical manifestations in the patient diagnosed with hyperaldosteronism?

Elevated blood pressure

A patient is admitted for treatment of Cushing's syndrome. The nurse correlates this disease process to which alteration in endocrine function?

Elevated glucocorticoid level

The nurse administers a large dose of the prescribed opioid analgesic in preparation for a dressing change for a patient with significant burn injury. What is the nurse's priority in this situation?

Ensuring a bag and mask is at the bedside

The nurse provides care to a patient, diagnosed with adrenal insufficiency, who is scheduled for an insulin tolerance test to evaluate the hypothalamic-pituitary axis. Which information noted in the patient's history requires an intervention by the nurse?

Epilepsy

In assessing pain in the patient with a urinary tract infection, which clinical manifestation does the nurse correlate to progression of the infection to pyelonephritis?

Flank pain

The nurse prioritizes which nursing diagnosis to guide care for the patient diagnosed with diabetes insipidus?

Fluid Volume Deficit

What term does the nurse use to document a patient's complaints of blood in the urine?

Hematuria

A patient who normally takes 40 units of long acting insulin at bedtime asks the nurse what she should do about her dose the night before her surgery. The best response would be to have her

Get instructions from her surgeon ir HCP on any insulin adjustments for the night before surgery

A patient has not eaten for 18 hours because of diagnostic testing. Which pancreatic hormone is maintaining this patient's blood glucose level?

Glucagon

A patient comes to the emergency room in the morning with Intense joint pain in his big toe. He says he woke up that way and denied injury. Upon assessment the area is noted to be red, swollen and warm with limited range of motion. The patients laboratory results show an elevated uric acid level. You suspect the patient has a diagnosis of

Gout

Which of the following symptoms are objective signs of pain (select all that apply)

Grimacing, agitation, irratibility

The nurse is preparing a teaching tool that focuses on the endocrine system. How should the nurse explain the negative feedback system?

Hormone secretion increases when circulating levels drop.

In providing care to the patient who may have (PKD) polycystic kidney disease, the nurse recognizes which finding as the first clinical manifestation of this disease process?

Hypertension

The patient who has been receiving Total Parenteral Nutrition (TPN) is being tapered from this therapy. It is important for the nurse to monitor for which complication if the solution is discontinued too rapidly?

Hypoglycemia

A patient who is taking a potassium-wasting diuretic for treatment of hypertension reports generalized weakness. As the nurse you suspect the patient has a diagnosis of?

Hypokalemia

A patient has received doses of prednisone for treatment of rheumatoid arthritis for the past 3 months. If this medication is suddenly discontinued, the nurse assesses for which complication?

Hypovolemia

The nurse monitors for which clinical manifestation in the patient with a decrease in antidiuretic hormone (ADH) secretion?

Increased urine output

IV potassium chloride (KCl) 60 mEq is prescribed for a patient with severe hypokalemia. Which action should the nurse take?

Infuse the KCl at a maximum rate of 10 mEq/hr.

A patient has full-thickness burns over 30% of total body surface area. Which intervention to address the patient's comfort does the nurse question?

Medicate for pain around the clock.

A patient who is lethargic and with deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 35 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results?

Metabolic acidosis

PH: 7.30 PaCO2: 37 HCO3: 20 PaO2: 87 O2 Sat 95%

Metabolic acidosis

PH 7.50 PaCO2 40 HCO3 30 PaO2 99 O2 Sat 99%

Metabolic alkalosis

A 67 year old patient is admitted to the hospital with a diagnosis of hypermagnesemia. The patient lists daily medications that they have been taking at home as Lasix 20mg PO QD Motrin 400mg PO QD Milk of Magnesia PO QD (unknown dosage) Potassium supplements 1 tablet PO QD (unknown dosage) Which of these medications would be potentially elevating the patients magnesium levels?

Milk of Magnesia PO QD (unknown dosage)

The nurse is caring for a patient with severe pain. An opioid is delivered. What assessment should the nurse make after the administration?

Monitor respiratory rate

A pregnant woman with asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, "I am very nervous about making my baby sick." Which information will the nurse include when teaching the patient?

Most infants born to HIV-positive mothers are not infected with the virus.

What is the rationale for frequent mouth care in a patient after undergoing a transsphenoidal hypophysectomy for removal of a pituitary tumor?

Mouth breathing because of nasal packing

Mr. Jones is day three post op from having a hernia repair. The nurse suspects Mr. Jones may have a post operative ileus. Which signs and symptoms support this?

Nausea, absence of bowel sounds in one or more abdominal quadrants and no BM in four days

Addiction is defined as

Neurobiologic condition with drive to obtain and take substances for other than prescribed therapeutic value

A patient who was diagnosed with type 2 diabetes 2 years ago begins to have complaints of pain, numbness and tingling in his fingers. This would be an example of which type of pain?

Neuropathic

PH: 7.39 PaCO2 45 HCO3: 25 PaO2 80 O2 Sat 96%

Normal ABG

A patient is scheduled for surgery requiring general anesthesia at an ambulatory surgery center. The nurses asks him when he last ate. The patient replies that he had a light breakfast a couple of hours before coming to the surgery center. What should the nurse do first?

Notify the anesthesia care provider of when and what the patient last ate

The nurse monitors for which skin changes in the patient diagnosed with type 2 diabetes mellitus (DM)?

Numbness in the extremities

The nurse monitors for which assessment findings in the patient admitted with superficial partial-thickness burns over both anterior lower arms?

Open or closed blisters, mild edema, easily blanches

A slow progressive noninflammatory disorder of the synovial joints that can manifest with Bouchard's Nodes

Osteoarthritis

Alendronate or Fosamax is take either once daily or once weekly to prevent

Osteoporosis

The nurse is caring for a patient in the postanesthesia care unit (PACU) who has not voided since surgery despite having over 2 liters of fluid infused. What action should the nurse take next?

Perform a bladder scan.

The nurse is planning care for the patient with acute kidney injury. Which assessment data best supports the nursing diagnosis Excess Fluid Volume?

Pitting edema in the lower extremities

Immediately after the nurse administers an intradermal injection of an allergen on the forearm, the patient reports itching at the site, weakness, and dizziness. What action should the nurse take first?

Place a tourniquet above the site.

During a home visit, the nurse is concerned that an older adult patient is developing chronic kidney disease. Because the patient has no history of cardiovascular disease, what data requires further consideration by the nurse?

Progressive edema

The nurse is caring for a patient with a major burn on the right arm. Which function of the skin is most affected by this injury?

Protection

What is the best way to determine the patients oxygen saturation at the bedside?

Pulse Oximeter

In the patient with metabolic acidosis, what is the role of the kidneys in acid-base balance?

Reabsorbs bicarbonate ions

What are the local manifestations of the inflammatory response?

Redness, heat, pain, swelling, loss of function

A patient comes in to the emergency room with a cut that he got while chopping wood five days ago. What symptoms would indicate that the wound is infected?

Redness, swelling, purulent drainage

Which of the following assessment findings indicates infection?

Redness, swelling, purulent drainage at the incision site 72 hours post op

A patient has a PICC line in the left arm brachial vein. What symptoms would indicate the PICC line site may have an infection?

Redness, warmth, swelling and yellow drainage and tenderness at the insertion site

The nurse notes that a patient with adrenal insufficiency has muscular weakness and correlates this to which laboratory data?

Serum potassium 5.8 mEq/L

A patient informed of a positive rapid screening test result for human immunodeficiency virus (HIV) is anxious and does not appear to hear what the nurse is saying. What action by the nurse is most important at this time?

Remind the patient to return for retesting to verify the results.

Which clinical manifestations does the nurse assess for in the patient diagnosed with gout?

Reports of severe pain, redness and swelling in the great toe

PH: 7.26 PaCO2: 52 HCO3: 23 PaO2: 82 O2 Sat 93%

Respiratory acidosis

The nurse is providing care to patient with the following laboratory values: pH 7.31; PaCO2 48 mm Hg; and HCO3 24 mEq/L. The nurse correlates these values to which acid-base disorder?

Respiratory acidosis

PH: 7.53 PaCO2: 30 HCO3: 23 PaO2 90 02 Sat 98%

Respiratory alkalosis

What are some common side effects of opioids? (select all that apply)

Respiratory depression, sedation, constipation, nausea, and vomiting

This disorder is a chronic systemic autoimmune disease that causes inflammation of connective tissues in the synovial joints

Rheumatoid Arthritis

This arthritis is caused by microorganisms that have invaded the joint cavity and the most common causative agent is staphylococcus aureus

Septic Arthritis

When a spleen is removed long term effects are that the patient will be at higher risk of

Serious infections

The nurse is monitoring laboratory results on assigned patients. The patient with which laboratory has the highest risk of laryngospasm?

Serum calcium 7.5 mg/dL

The nurse correlates which laboratory result as the most reliable indicator of impaired renal function?

Serum creatinine 2.4 mg/dL

A nurse assesses a postoperative patient 2 days after chest surgery. What findings indicate that the patient requires better pain management? (Select all that apply)

Shallow breathing, elvated temperature, poor cough effort, confusion

A victim of a house fire is brought to the emergency department for burn treatment. The nurse correlates which assessment to an inhalation injury?

Singed nasal hair

The nurse is reviewing statistics about the frequency of anterior cruciate ligament (ACL) tears. Which sports activity has the greatest risk of this type of injury?

Soccer

A patient with syndrome of inappropriate antidiuretic hormone (SIADH) is experiencing a headache and confusion. The nurse correlates which laboratory result to this clinical presentation of SIADH?

Sodium 125 mEq/L

The nurse is preparing to palpate a patient's thyroid gland. Which technique should be used for this assessment?

Stand behind the patient and place fingers on both sides of the neck.

The patient enters the outpatient clinic and states to the triage nurse, "I think I have the flu. I'm so tired, I have no appetite, and everything hurts." The triage nurse assesses the patient and finds a butterfly rash over the bridge of nose and on the cheeks. Then nurse correlates this data with the clinical manifestations of which disorder?

Systemic lupus erythematosus

Chvostek's sign is elicited by

Tapping the muscles by the facial nerve about 2 cm in front of the earlobe

A 49 year old male patient is 12 hours post op from an abdominal surgery. He had a gastric bypass and he has orders to remain on bedrest. What would be the best intervention the nurse can use to prevent atelectasis?

Teach the patient how to use the incentive spirometer q1h

The nurse identifies the nursing diagnosis of Chronic Pain for a patient with fibromyalgia. Which manifestation supports this nursing diagnosis?

Tender points in the knees

Referred or referral pain is

The location of a stimulus may be distant from the pain location reported by the patient

A patient has a serum calcium level of 7.0 mEq/L (hypocalcemia). Which assessment finding is most important for the nurse to report to the health care provider?

The patient is experiencing stridor.

In which situation does the nurse consider withholding morphine until further assessments can be completed?

The patients level of consciousness fluctuates from alert to lethargic

A 68-year-old female patient has a history of chronic renal insufficiency. The patient undergoes coronary bypass surgery and is on pain medications. Which factor has the biggest impact on the patient's response to pain medication?

The patients renal function

A patient was involved in a motor vehicle crash and is admitted to the hospital with internal bleeding. An exploratory laparotomy is performed and it is discovered that the patients spleen has ruptured. and must be removed. The patient asks the nurse what the function of the spleen was. What is the nurse going tp tell the patient about the functions of the spleen?

The spleen has many functions such as filtering the blood, and helping to fight certain infections

During the primary intention phase of healing

The wound is pink and vascular but friable with increased risk of dehiscence

A patient presents to the emergency room seeking treatment for radiation burns. What needs to be considered before providing care to this patient?

Type, dose, and length of exposure

A patient is prescribed regular insulin 5 units subcutaneous injection now. Which syringe should the nurse use for this dose if all are readily available?

U-30

In providing care to a patient with suspected urinary retention, the nurse prepares the patient for which diagnostic study?

Ultrasonic bladder scan

The nurse correlates which physiological factor to the decreased risk of urinary tract infection in men compared with women?

Urethral length

The nurse prepares the patient with complaints of burning on urination for which diagnostic study?

Urinalysis

The nurse monitors for which clinical manifestation in the patient diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH)?

Urine specific gravity 1.035

A patient presents in the emergency department (ED) with fever, nausea, and vomiting over the past 2 days. The nurse monitors for which laboratory result in this patient?

Urine specific gravity of 1.040

To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review?

Viral load testing

If a patient reports having abdominal pain that is dull, aching and burning this would be an example of what type of pain?

Visceral

The nurse is providing care to a patient at a local clinic. The nurse suspects that the patient is experiencing a urinary tract infection. Which urinalysis result supports the nurse's suspicions?

WBC 10-15

What is the most effective way to prevent the spread of infection

Wash your hands

The nurse is planning care for the patient with acute renal failure and incorporates the nursing diagnosis of Excess Fluid Volume. Which assessment data support this nursing diagnosis?

Wheezing and crackles in the lungs, 2+ pitting edema in the lower extremities and a weight gain of 4 pounds in 2 days

Appropriate nonopioid analgesics for mild pain include (select all that apply)

acetaminophen (Tylenol) ibuprofen (Advil)

The nurse expects the long-term treatment of a patient with hyperphosphatemia from renal failure will include

calcium supplements

An older woman is admitted to the medical unit with GI bleeding. Assessment findings that indicate fluid volume deficit include (select all that apply)

dry oral mucosa, decreased central venous pressure, weight lose over 2 pounds in one day

The nurse is unable to flush a central venous access device and suspects occlusion. The best nursing intervention would be to

have the patient change positions, raise arm, and cough

When positioning the patient in preparation for surgery, the nurse understands that injury to the patient can occur because of

inability to sense pressure over bony prominences

Barbiturate's are a risk factor associated with which disorder

osteoporosis

The nurse is providing care to a patient who is admitted to the hospital with sudden, severe abdominal pain. Which arterial blood gas supports the patient's current diagnosis of respiratory alkalosis?

pH is 7.47 and PaCO2 is 25.

A patient is admitted to the PACU after major abdominal surgery. During the initial assessment the patient tells the nurse he thinks he is going to throw up. A priority nursing intervention is to

position the patient in a lateral recovery position

A basic principle of wound management for all open wounds is to

protect new granulation and epithelial tissue.

During the post operative care of a 76 year old patient, the nurse monitors the patients intake and output carefully, knowing that the patient is at risk for fluid and electrolyte imbalances primarily because

small losses of fluid are significant because body fluids account for 45%-50% of body weight in older adults