Medsurg Final Practice Questions

louder discontinuous low pitch sounds (like blowing a straw underwater) Excess fluid in the lungs, heart failure, pulmonary edema, pneumonia w/ severe congestion, COPD

Coarse Crackles

** A patient who is diagnosed with cervical cancer classified as Tis, N0, M0 asks the nurse what the letters and numbers mean. Which response by the nurse is accurate? a. "The cancer involves only the cervix." b. "The cancer cells look like normal cells." c. "Further testing is needed to determine the spread of the cancer." d. "It is difficult to determine the original site of the cervical cancer."

** ANS: A a. "The cancer involves only the cervix."

** To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review? a. Viral load testing b. Enzyme immunoassay c. Rapid HIV antibody testing d. Immunofluorescence assay

** ANS: A a. Viral load testing

** A patient with Parkinson's disease is admitted to the hospital for treatment of pneumonia. Which interventions should the nurse include in the plan of care? (Select all that apply.) a. Provide an elevated toilet seat. b. Cut patient's food into small pieces. c. Serve high-protein foods at each meal. d. Place an armchair at the patient's bedside. e. Observe for sudden exacerbation of symptoms.

** ANS: A, B, D a. Provide an elevated toilet seat. b. Cut patient's food into small pieces. d. Place an armchair at the patient's bedside.

** The spouse of a 67-yr-old male patient with early stage Alzheimer's disease (AD) tells the nurse, "I am exhausted from worrying all the time. I don't know what to do." Which actions are best for the nurse to take at this time? (Select all that apply.) a. Suggest that a long-term care facility be considered. b. Offer ideas for ways to distract or redirect the patient. c. Teach the spouse about adult day care as a possible respite. d. Suggest that the spouse consult with the physician for antianxiety drugs. e. Ask the spouse what she knows and has considered about dementia care options.

** ANS: B, C, E b. Offer ideas for ways to distract or redirect the patient. c. Teach the spouse about adult day care as a possible respite. e. Ask the spouse what she knows and has considered about dementia care options.

A female patient who had a stroke 24 hours ago has expressive aphasia. What is an appropriate nursing intervention to help the patient communicate? a. Ask questions that the patient can answer with "yes" or "no." b. Develop a list of words that the patient can read and practice reciting. c. Have the patient practice her facial and tongue exercises with a mirror. d. Prevent embarrassing the patient by answering for her if she does not respond.

ANS: A a. Ask questions that the patient can answer with "yes" or "no."

Which statements will the nurse include when teaching a patient who is scheduled for oral glucose tolerance testing in the outpatient clinic? (Select all that apply.) a. "You will need to avoid smoking before the test." b. "Exercise should be avoided until the testing is complete." c. "Several blood samples will be obtained during the testing." d. "You should follow a low-calorie diet the day before the test." e. "The test requires that you fast for at least 8 hours before testing."

ANS: A, C, E a. "You will need to avoid smoking before the test." c. "Several blood samples will be obtained during the testing." e. "The test requires that you fast for at least 8 hours before testing."

A patient develops neutropenia after receiving chemotherapy. Which information about ways to prevent infection will the nurse include in the teaching plan? (Select all that apply.) a. Cook food thoroughly before eating. b. Choose low fiber, low residue foods. c. Avoid public transportation such as buses. d. Use rectal suppositories if needed for constipation. e. Talk to the oncologist before having any dental work.

ANS: A, C, E a. Cook food thoroughly before eating. c. Avoid public transportation such as buses. e. Talk to the oncologist before having any dental work.

A patient who is being treated for stage IV lung cancer tells the nurse about new-onset back pain. Which action should the nurse take first? a. Give the patient the prescribed PRN opioid. b. Assess for sensation and strength in the legs. c. Notify the health care provider about the symptoms. d. Teach the patient how to use relaxation to reduce pain.

ANS: B b. Assess for sensation and strength in the legs.

Which information about a 76-yr-old patient should the nurse identify as uncharacteristic of normal aging? a. Triceps reflex response graded at 1/5 b. Unintended weight loss of 15 pounds c. Patient report of chronic difficulty in falling asleep d. 10 mm Hg orthostatic drop in systolic blood pressure

ANS: B b. Unintended weight loss of 15 pounds

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? a. Heart rate b. Urine output c. Creatinine clearance d. Blood urea nitrogen (BUN) level

ANS: B b. Urine output

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? a. The creatinine level is 3.0 mg/dL. b. Urine output over an 8-hour period is 2500 mL. c. The blood urea nitrogen (BUN) level is 67 mg/dL. d. The glomerular filtration rate is less than 30 mL/min/1.73 m2.

ANS: B b. Urine output over an 8-hour period is 2500 mL.

An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy twice a day. Which potential complication should the nurse identify as a priority for this patient? a. Hypovolemic shock b. Venous thromboembolism c. Fluid and electrolyte imbalance d. Impaired surgical wound healing

ANS: B b. Venous thromboembolism

Which action should the nurse include in the plan of care for a patient with impaired functioning of the left glossopharyngeal nerve (CN IX) and vagus nerve (CN X)? a. Assist to stand and ambulate. b. Withhold oral fluids and food. c. Insert an oropharyngeal airway. d. Apply artificial tears every hour.

ANS: B b. Withhold oral fluids and food.

A hospitalized patient reports a bilateral headache (4/10 on the pain scale) that radiates from the base of the skull. Which prescribed PRN medication should the nurse administer initially? a. lorazepam (Ativan) b. acetaminophen (Tylenol) c. morphine sulfate (MS Contin) d. butalbital and aspirin (Fiorinal)

ANS: B b. acetaminophen (Tylenol)

To prevent recurrence of uric acid kidney stones, the nurse teaches the patient to avoid eating: a. milk and cheese. b. sardines and liver. c. spinach and chocolate. d. legumes and dried fruit.

ANS: B b. sardines and liver.

Which actions could the nurse delegate to a licensed practical/vocational nurse (LPN/VN) who is part of the team caring for a patient with Alzheimer's disease? (Select all that apply.) a. Develop a plan to minimize difficult behavior. b. Administer the prescribed memantine (Namenda). c. Remove potential safety hazards from the patient's environment. d. Refer the patient and caregivers to appropriate community resources. e. Help the patient and caregivers choose memory enhancement methods. f. Evaluate the effectiveness of enteral nutrition on the patient's nutrition status.

ANS: B, C b. Administer the prescribed memantine (Namenda). c. Remove potential safety hazards from the patient's environment.

The nurse develops a teaching plan to help increase activity tolerance at home for an older adult with severe chronic obstructive pulmonary disease (COPD). Which instructions would be appropriate for the nurse to include in the plan of care? a. Walk until pulse rate exceeds 130 beats/min. b. Stop exercising when you feel short of breath. c. Walk 15 to 20 minutes a day at least 3 times/wk. d. Limit exercise to activities of daily living (ADLs).

ANS: C c. Walk 15 to 20 minutes a day at least 3 times/wk.

Which action should the nurse take to prepare a patient for spirometry? a. Give the rescue medication immediately before testing. b. Administer oral corticosteroids 2 hours before the procedure. c. Withhold bronchodilators for 6 to 12 hours before the examination. d. Ensure that the patient has been NPO for several hours before the test.

ANS: C c. Withhold bronchodilators for 6 to 12 hours before the examination.

When teaching a patient with heart failure on a 2000-mg sodium diet, which foods should the nurse recommend limiting? a. Chicken and eggs b. Canned and frozen fruits c. Yogurt and milk products d. Fresh or frozen vegetables

ANS: C c. Yogurt and milk products

The nurse will anticipate teaching a patient with nephrotic syndrome who develops flank pain about treatment with: a. antibiotics. b. antifungals. c. anticoagulants. d. antihypertensives.

ANS: C c. anticoagulants.

In which order should the nurse complete actions when caring for a patient in the emergency department who has a right leg fracture? (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.

ANS: C, D, B, E, A, F c. Assess lung sounds. d. Take blood pressure. b. Check pedal pulses. e. Apply splint to the leg. a. Obtain x-rays. f. Administer tetanus prophylaxis.

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a. The patient's speech is difficult to understand. b. The patient's blood pressure (BP) is 144/90 mm Hg. c. The patient takes a diuretic because of a history of hypertension. d. The patient has atrial fibrillation and takes warfarin (Coumadin).

ANS: D d. The patient has atrial fibrillation and takes warfarin (Coumadin).

Which assessment finding should the nurse expect when a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30? a. Persistent skin tenting b. Rapid, deep respirations c. Hot, flushed face and neck d. Bounding peripheral pulses

ANS:B b. Rapid, deep respirations

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? a. Weight loss of 2 lb in 24 hours b. Hourly urine output greater than 60 mL c. Reduced dyspnea with the head of bed at 30 degrees d. Patient denies experiencing chest pain or chest pressure

ANS:C c. Reduced dyspnea with the head of bed at 30 degrees

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? a. Start continuous pulse oximetry. b. Restrict the patient's protein intake. c. Restrict physical activity to bed rest. d. Discontinue the urethral retention catheter.

ANS:C c. Restrict physical activity to bed rest.

short discontinuous high pitched sounds, heard before end of inspiration (hair rolling between fingers)

Fine Crackles/Rales

has a cracking sound, like walking on fresh snow

Pleural Effusion

creaking or grating sound, no change w cough

Pleural Friction Rub

** 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? a. "Clean drug injection equipment before each use." b. "Ask those who share equipment to be tested for HIV." c. "Consider participating in a needle-exchange program." d. "Avoid sexual intercourse when using injectable drugs."

** ANS: C c. "Consider participating in a needle-exchange program."

** Which assessment should the nurse identify as most important regarding a patient with myasthenia gravis? a. Pupil size b. Grip strength c. Respiratory effort d. Level of consciousness

** ANS: C c. Respiratory effort

** 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? a. Insert an oral airway during the seizure to maintain a patent airway. b. Restrain the patient's arms and legs to prevent injury during the seizure. c. Time and observe and record the details of the seizure and postictal state. d. Avoid touching the patient to prevent further nervous system stimulation.

** ANS: C c. Time and observe and record the details of the seizure and postictal state.

** A 63-yr-old patient who began experiencing right arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol? (Put a comma and a space between each answer choice [A, B, C, D].) a. Obtain CT scan without contrast. b. Infuse tissue plasminogen activator (tPA). c. Administer oxygen to keep O2 saturation >95%. d. Use National Institute of Health Stroke Scale to assess patient.

** ANS: C, D, A, B c. Administer oxygen to keep O2 saturation >95%. d. Use National Institute of Health Stroke Scale to assess patient. a. Obtain CT scan without contrast. b. Infuse tissue plasminogen activator (tPA).

** A patient undergoing external radiation has developed a dry desquamation of the skin in the treatment area. The nurse teaches the patient about the management of the skin reaction. Which statement, if made by the patient, indicates the teaching was effective? a. "I can use ice packs to relieve itching." b. "I will scrub the area with warm water." c. "I will expose my skin to a sun lamp each day." d. "I can buy some aloe vera gel to use on my skin."

** ANS: D d. "I can buy some aloe vera gel to use on my skin."

** 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? a. The Mantoux test had an induration of 7 mm. b. The chest x-ray showed infiltrates in the lower lobes. c. The patient has a cough that is productive of blood-tinged mucus. d. The patient is being treated with antiretrovirals for HIV infection.

** ANS: D d. The patient is being treated with antiretrovirals for HIV infection.

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 should the nurse administer?

ANS: 2.4

A patient with asthma has a personal best peak expiratory flow rate (PEFR) of 400 L/min. When explaining the asthma action plan, the nurse will teach the patient that a change in therapy is needed when the PEFR is less than ___ L/minute.

ANS: 320 (80%)

When admitting an acutely confused patient with a head injury, which action should the nurse take? a. Ask family members about the patient's health history. b. Ask leading questions to assist in obtaining health data. c. Wait until the patient is better oriented to ask questions. d. Obtain only the physiologic neurologic assessment data.

ANS: A A. Ask family members about the patient's health history.

A postoperative patient has not voided for 8 hours after return to the clinical unit. Which action should the nurse take first? a. Perform a bladder scan. b. Insert a straight catheter. c. Encourage increased oral fluid intake. d. Assist the patient to ambulate to the bathroom.

ANS: A a. Perform a bladder scan.

The nurse plans a presentation for community members about how to decrease the risk for antibiotic-resistant infections. Which information will the nurse include in the teaching plan? (Select all that apply.) a. Antibiotics may sometimes be prescribed to prevent infection. b. Continue taking antibiotics until all of the prescription is gone. c. Unused antibiotics that are more than a year old should be discarded. d. Antibiotics are effective in treating influenza associated with high fevers. e. Hand washing is effective in preventing many viral and bacterial infections.

ANS: A, B, E a. Antibiotics may sometimes be prescribed to prevent infection. b. Continue taking antibiotics until all of the prescription is gone. e. Hand washing is effective in preventing many viral and bacterial infections.

Which health promotion information should the nurse include when teaching a patient with a 42 pack-year history of cigarette smoking? (Select all that apply.) a. Resources for support in smoking cessation b. Reasons for annual sputum cytology testing c. Erlotinib (Tarceva) therapy to prevent tumor risk d. Computed tomography (CT) screening for cancer e. Importance of obtaining a yearly influenza vaccination

ANS: A, D, E a. Resources for support in smoking cessation d. Computed tomography (CT) screening for cancer e. Importance of obtaining a yearly influenza vaccination

The home health nurse is caring for a patient who has been receiving interferon therapy for treatment of cancer. Which statement by the patient indicates a need for further assessment? a. "I have frequent muscle aches and pains." b. "I rarely have the energy to get out of bed." c. "I experience chills after I inject the interferon." d. "I take acetaminophen (Tylenol) every 4 hours."

ANS: B b. "I rarely have the energy to get out of bed."

The nurse is assessing an alert and independent older adult patient for malnutrition risk. Which is the most appropriate initial question? a. "How do you get to the store to buy your food?" b. "Can you tell me the food that you ate yesterday?" c. "Do you have any difficulty in preparing or eating food?" d. "Are you taking any medications that alter your taste for food?"

ANS: B b. "Can you tell me the food that you ate yesterday?"

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." How should the nurse respond to specifically address the patient's concern? a. "You might benefit from some psychologic counseling." b. "Epilepsy usually can be well controlled with medications." c. "You will want to contact the Epilepsy Foundation for assistance." d. "The Department of Vocational Rehabilitation can help with work retraining."

ANS: B b. "Epilepsy usually can be well controlled with medications."

The nurse is administering a mental status examination to a patient who has hypertension. The nurse suspects depression when the patient responds to the nurse's questions with a. "Is that right?" b. "I don't know." c. "Wait, let me think about that." d. "Who are those people over there?"

ANS: B b. "I don't know."

During routine hemodialysis, a patient reports nausea and dizziness. Which action should the nurse take first? a. Slow down the rate of dialysis. b. Check the blood pressure (BP). c. Review the hematocrit (Hct) level. d. Give prescribed PRN antiemetic drugs.

ANS: B b. Check the blood pressure (BP).

According to the Center for Disease Control and Prevention (CDC) guidelines, which personal protective equipment will the nurse put on before assessing a patient who is on contact precautions for Clostridium difficile diarrhea? (Select all that apply.) a. Mask b. Gown c. Gloves d. Shoe covers e. Eye protection

ANS: B, C b. Gown c. Gloves

Which assessments should the nurse make to monitor a patient's cerebellar function? (Select all that apply.) a. Test for graphesthesia. b. Observe arm swing with gait. c. Perform the finger-to-nose test. d. Assess heat and cold sensation. e. Measure strength against resistance.

ANS: B, C b. Observe arm swing with gait. c. Perform the finger-to-nose test.

A patient has been diagnosed with urinary tract stones that are high in uric acid. Which foods will the nurse teach the patient to avoid? (Select all that apply.) a. Milk b. Liver c. Spinach d. Chicken e. Cabbage f. Chocolate

ANS: B, D b. Liver d. Chicken

Which nursing actions should be included in the plan of care for a patient after cerebral angiography? (Select all that apply.) a. Monitor for photophobia. b. Observe for bleeding at the puncture site. c. Keep patient NPO until gag reflex returns. d. Check pulse and blood pressure frequently. e. Assess orientation to person, place, and time.

ANS: B, D, E b. Observe for bleeding at the puncture site. d. Check pulse and blood pressure frequently. e. Assess orientation to person, place, and time.

The second day after admission with a fractured pelvis, a patient suddenly develops confusion. Which action should the nurse take first? a. Take the blood pressure. b. Check the O2 saturation. c. Assess patient orientation. d. Observe for facial asymmetry.

ANS: C

The nurse is caring for a patient receiving intravesical bladder chemotherapy. The nurse should monitor for which adverse effect? a. Nausea b. Alopecia c. Hematuria d. Xerostomia

ANS: C c. Hematuria

The nurse teaches a patient who has asthma about peak flowmeter use. Which action by the patient indicates that teaching was successful? a. The patient inhales rapidly through the peak flowmeter mouthpiece. b. The patient takes montelukast (Singulair) for peak flows in the red zone. c. The patient uses albuterol (Ventolin HFA) for peak flows in the yellow zone. d. The patient calls the health care provider when the peak flow is in the green zone.

ANS: C c. The patient uses albuterol (Ventolin HFA) for peak flows in the yellow zone.

Which stroke risk factor for a 48-yr-old male patient in the clinic is most important for the nurse to address? a. The patient is 25 pounds above the ideal weight. b. The patient drinks a glass of red wine with dinner daily. c. The patient's usual blood pressure (BP) is 170/94 mm Hg. d. The patient works at a desk and relaxes by watching television.

ANS: C c. The patient's usual blood pressure (BP) is 170/94 mm Hg.

A patient arrived at the emergency department after tripping over a rug and falling at home. Which finding should the nurse identify as most important to communicate to the health care provider? a. There is bruising at the shoulder area. b. The patient reports arm and shoulder pain. c. The right arm appears shorter than the left. d. There is decreased shoulder range of motion.

ANS: C c. The right arm appears shorter than the left.

Which laboratory value should the nurse review to determine whether a patient's hypothyroidism is caused by a problem with the anterior pituitary gland? a. Thyroxine (T4) level b. Triiodothyronine (T3) level c. Thyroid-stimulating hormone (TSH) level d. Thyrotropin-releasing hormone (TRH) level

ANS: C c. Thyroid-stimulating hormone (TSH) level

How should the nurse assess the patient's trigeminal and facial nerve function (CNs V and VII)? a. Check for unilateral eyelid droop. b. Shine a light into the patient's pupil. c. Touch a cotton wisp strand to the cornea. d. Have the patient read a magazine or book.

ANS: C c. Touch a cotton wisp strand to the cornea.

The nurse prepares to administer the following medications to a hospitalized patient with human immunodeficiency (HIV). Which medication is most important to administer at the scheduled time? a. Nystatin tablet b. Oral acyclovir (Zovirax) c. Aerosolized pentamidine (NebuPent) d. Oral tenofovir AF/emtricitabine/bictegravir (Biktarvy)

ANS: D d. Oral tenofovir AF/emtricitabine/bictegravir (Biktarvy)

The nurse completes an admission assessment on a patient with asthma. Which information indicates a need for a change in therapy? a. The patient uses albuterol (Ventolin HFA) before aerobic exercise. b. The patient says that the asthma symptoms are worse every spring. c. The patient's heart rate increases slightly after using the albuterol inhaler. d. The patient's only medications are albuterol (Ventolin HFA) and salmeterol (Serevent).

ANS: D d. The patient's only medications are albuterol (Ventolin HFA) and salmeterol (Serevent).

Which finding for a patient admitted with glomerulonephritis indicates to the nurse that treatment has been effective? a. The urine dipstick is negative for nitrites. b. The patient denies pain or burning with voiding. c. The antistreptolysin-O (ASO) titer has decreased. d. The periorbital and peripheral edema are resolved.

ANS: D d. The periorbital and peripheral edema are resolved.

The nurse is caring for a patient with an obstructed common bile duct. What condition should the nurse expect? a. Melena b. Steatorrhea c. Decreased serum cholesterol level d. Increased serum indirect bilirubin level

ANS:B b. Steatorrhea

The nurse teaches a patient how to administer formoterol (Perforomist) through a nebulizer. Which action by the patient indicates good understanding of the teaching? a. The patient attaches a spacer before using the inhaler. b. The patient coughs vigorously after using the inhaler. c. The patient removes the facial mask when misting stops. d. The patient activates the inhaler at the onset of expiration.

ANS:C c. The patient removes the facial mask when misting stops.

Which assessment finding for an older patient indicates that the nurse should take immediate action? a. Weak cough effort b. Barrel-shaped chest c. Dry mucous membranes d. Bilateral basilar crackles

ANS:D d. Bilateral basilar crackles

Continuous high pitched squeaking or musical sound first evident on expiration Heard in bronchospasms, (caused by asthma) airway obstruction (foreign body or substance, Tumor), COPD

Wheezes

** 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.) a. Side rail pads b. Tongue blade c. Oxygen mask d. Suction tubing e. Urinary catheter f. Nasogastric tube

** ANS: A, C, D a. Side rail pads c. Oxygen mask d. Suction tubing

** Several weeks after a stroke, a 50-yr-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention should be planned to begin an effective bladder training program? a. Limit fluid intake to 1200 mL daily to reduce urine volume. b. Assist the patient onto the bedside commode every 2 hours. c. Perform intermittent catheterization after each voiding to check for residual urine. d. Use an external "condom" catheter to protect the skin and prevent embarrassment.

** ANS: B b. Assist the patient onto the bedside commode every 2 hours.

** A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse indicates a need for further teaching? a. The patient ambulates around the room. b. The patient's visitors bring in fresh peaches. c. The patient cleans with a warm washcloth after having a stool. d. The patient uses soap and shampoo to shower every other day.

** ANS: B b. The patient's visitors bring in fresh peaches.

** A patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will the nurse include in the plan of care? a. Apply intermittent pneumatic compression stockings. b. Assist to dangle on edge of bed and assess for dizziness. c. Encourage patient to cough and deep breathe every 4 hours. d. Insert an oropharyngeal airway to prevent airway obstruction.

** ANS:A a. Apply intermittent pneumatic compression stockings.

** A 70-yr-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? a. Take the patient's blood pressure. b. Check the respiratory rate and effort. c. Assess the Glasgow Coma Scale score. d. Send the patient for a computed tomography (CT) scan.

** ANS:B b. Check the respiratory rate and effort.

** The nurse teaches a patient who is scheduled for a prostate needle biopsy about the procedure. Which statement by the patient indicates that teaching was effective? a. "The biopsy will remove the cancer in my prostate gland." b. "The biopsy will determine how much longer I have to live." c. "The biopsy will help decide the treatment for my enlarged prostate." d. "The biopsy will indicate whether the cancer has spread to other organs."

** ANS:C c. "The biopsy will help decide the treatment for my enlarged prostate."

** What should be the nurse's initial action for a patient with moderate dementia who develops increased restlessness and agitation? a. Reorient the patient to time, place, and person. b. Administer a PRN dose of lorazepam (Ativan). c. Assess for factors that might be causing discomfort. d. Assign unlicensed assistive personnel (UAP) to stay in the patient's room.

** ANS:C c. Assess for factors that might be causing discomfort.

** A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first? a. Complete blood count (CBC) b. Chest radiograph (chest x-ray) c. Computed tomography (CT) scan d. 12-Lead electrocardiogram (ECG)

** ANS:C c. Computed tomography (CT) scan

When admitting a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI) to the intensive care unit, which action should the nurse perform first? a. Attach the heart monitor. b. Obtain the blood pressure. c. Assess the peripheral pulses. d. Auscultate the breath sounds.

ANS: A a. Attach the heart monitor.

Which action will the nurse include in the plan of care to maintain the patency of a patient's left arm arteriovenous fistula? a. Auscultate for a bruit at the fistula site. b. Assess the quality of the left radial pulse. c. Compare blood pressures in the left and right arms. d. Irrigate the fistula site with saline every 8 to 12 hours.

ANS: A a. Auscultate for a bruit at the fistula site.

A patient with a right lower leg fracture will be discharged home with an external fixation device in place. Which statement should the nurse including in discharge teaching? a. "Check and clean the pin insertion sites daily." b. "Remove the external fixator for your shower." c. "Remain on bed rest until bone healing is complete." d. "Take prophylactic antibiotics until the fixator is removed."

ANS: A a. "Check and clean the pin insertion sites daily."

In preparation for discharge, the nurse teaches a patient with chronic stable angina how to use the prescribed short-acting and long-acting nitrates. Which patient statement indicates that the teaching has been effective? a. "I will sit down before I put the nitroglycerin under my tongue." b. "I will check my pulse rate before I take any nitroglycerin tablets." c. "I will put the nitroglycerin patch on as soon as I get any chest pain." d. "I will remove the nitroglycerin patch before taking sublingual nitroglycerin."

ANS: A a. "I will sit down before I put the nitroglycerin under my tongue."

After having a myocardial infarction (MI) and successful percutaneous coronary intervention, the patient states, "It was just a little chest pain. As soon as I get out of here, I'm going for my vacation as planned." Which reply would be most appropriate for the nurse to make? a. "What do you think caused your chest pain?" b. "Where are you planning to go for your vacation?" c. "Sometimes plans need to change after a heart attack." d. "Recovery from a heart attack takes at least a few weeks."

ANS: A a. "What do you think caused your chest pain?"

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? a. "You will need to be retested in 2 weeks." b. "You do not need to fear infecting others." c. "We won't know for about 10 years if you have HIV infection." d. "With no symptoms and this negative test, you do not have HIV."

ANS: A a. "You will need to be retested in 2 weeks."

After receiving change-of-shift report on the following four patients, which patient should the nurse see first? a. A 60-yr-old patient with right-sided weakness who has an infusion of tPA prescribed b. A 50-yr-old patient who has atrial fibrillation and a new order for warfarin (Coumadin) c. A 30-yr-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine scheduled d. A 40-yr-old patient who had a transient ischemic attack yesterday and has a dose of aspirin due

ANS: A a. A 60-yr-old patient with right-sided weakness who has an infusion of tPA prescribed

A patient will need vascular access for hemodialysis. Which statement by the nurse accurately describes an advantage of a fistula over a graft? a. A fistula is much less likely to clot. b. A fistula increases patient mobility. c. A fistula can be used sooner after surgery. d. A fistula can accommodate larger needles.

ANS: A a. A fistula is much less likely to clot.

A patient who had knee surgery received IV ketorolac 30 minutes ago and continues to report pain at a level of 7 (0 to 10 scale). Which action is most effective for the nurse to take at this time? a. Administer the prescribed PRN IV morphine sulfate. b. Notify the health care provider about the ongoing pain. c. Teach the patient that effects of ketorolac last 6 to 8 hours. d. Reassure the patient that pain is expected after knee surgery.

ANS: A a. Administer the prescribed PRN IV morphine sulfate.

Which information about a patient population would be most useful to help the nurse plan for human immunodeficiency virus (HIV) testing needs? a. Age b. Lifestyle c. Symptoms d. Sexual orientation

ANS: A a. Age

The nurse observes a patient ambulating in the hospital hall. The patient's arms and legs suddenly jerk and the patient falls to the floor. What action should the nurse take first? a. Assess the patient for a possible injury. b. Give the scheduled divalproex (Depakote). c. Document the timing and description of the seizure. d. Notify the patient's health care provider about the seizure.

ANS: A a. Assess the patient for a possible injury.

A patient who was admitted the previous day with pneumonia reports a sharp pain of 7 (on 0 to 10 scale) "whenever I take a deep breath." Which action will the nurse take next? a. Auscultate for breath sounds. b. Administer as-needed morphine. c. Have the patient cough forcefully. d. Notify the patient's health care provider.

ANS: A a. Auscultate for breath sounds.

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? a. Check the patient's prescribed weight-bearing status. b. Use a mechanical lift to transfer the patient to the chair. c. Decrease the pain medication before getting the patient up. d. Have the unlicensed assistive personnel (UAP) transfer the patient.

ANS: A a. Check the patient's prescribed weight-bearing status.

A patient tells the nurse about using acetaminophen (Tylenol) several times every day for recurrent bilateral headaches that are present on wakening. Which action should the nurse plan to take first? a. Discuss the need to stop taking acetaminophen. b. Suggest the use of biofeedback for headache control. c. Describe the use of botulism toxin (Botox) for headaches. d. Teach the patient about magnetic resonance imaging (MRI).

ANS: A a. Discuss the need to stop taking acetaminophen.

Eight years after seroconversion, a patient with human immunodeficiency virus infection has a CD4+ cell count of 800/μL and an undetectable viral load. What should be included in the plan of care at this time? a. Encourage adequate nutrition, exercise, and sleep. b. Teach about the side effects of antiretroviral agents. c. Explain opportunistic infections and antibiotic prophylaxis. d. Monitor symptoms of acquired immunodeficiency syndrome (AIDS).

ANS: A a. Encourage adequate nutrition, exercise, and sleep.

A patient with chronic obstructive pulmonary disease (COPD) has poor gas exchange. Which action by the nurse would support the patient's ventilation? a. Encourage the patient to sit in a chair and lean forward. b. Have the patient rest with the head elevated 15 degrees. c. Place the patient in the Trendelenburg position with pillows behind the head. d. Ask the patient to rest in bed in a high-Fowler's position with the knees flexed.

ANS: A a. Encourage the patient to sit in a chair and lean forward.

A patient reports feeling numbness and tingling of the left arm before experiencing a seizure. The nurse should know that this history is consistent with what type of seizure? a. Focal-onset b. Atonic c. Absence d. Myoclonic

ANS: A a. Focal-onset

A patient in the intensive care unit who has acute decompensated heart failure (ADHF) reports severe dyspnea and is anxious,tachypneic, and tachycardic. Several drugs have been prescribed for the patient. Which action should the nurse take first? a. Give PRN IV morphine sulfate 4 mg. b. Give PRN IV diazepam (Valium) 2.5 mg. c. Increase nitroglycerin infusion by 5 mcg/min. d. Increase dopamine infusion by 2 mcg/kg/min.

ANS: A a. Give PRN IV morphine sulfate 4 mg.

Which action could the postanesthesia care unit (PACU) nurse delegate to unlicensed assistive personnel (UAP) who help to transport a patient to the clinical unit? a. Help to transfer the patient onto a stretcher. b. Clarify postoperative orders with the surgeon. c. Document the appearance of the patient's incision in the chart. d. Provide hand-off communication to the surgical unit charge nurse.

ANS: A a. Help to transfer the patient onto a stretcher.

Interleukin-2 (IL-2) is used as adjuvant therapy for a patient with metastatic renal cell carcinoma. Which information should the nurse include when explaining the purpose of this therapy to the patient? a. IL-2 enhances the body's immunologic response to tumor cells. b. IL-2 prevents bone marrow depression caused by chemotherapy. c. IL-2 protects normal cells from harmful effects of chemotherapy. d. IL-2 stimulates cancer cells in their resting phase to enter mitosis.

ANS: A a. IL-2 enhances the body's immunologic response to tumor cells.

The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect? a. Increased tactile fremitus b. Dry, nonproductive cough c. Hyperresonance to percussion d. A grating sound on auscultation

ANS: A a. Increased tactile fremitus

A young adult patient who is being seen in the clinic has excessive secretion of the anterior pituitary hormones. Which laboratory test result should the nurse expect? a. Increased urinary cortisol b. Decreased serum thyroxine c. Elevated serum aldosterone d. Low urinary catecholamines

ANS: A a. Increased urinary cortisol

A patient with diabetic ketoacidosis is brought to the emergency department. Which prescribed action should the nurse implement first? a. Infuse 1 L of normal saline per hour. b. Give sodium bicarbonate 50 mEq IV push. c. Administer regular insulin 10 U by IV push. d. Start a regular insulin infusion at 0.1 units/kg/hr.

ANS: A a. Infuse 1 L of normal saline per hour.

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? a. Insert urethral catheter. b. Obtain renal ultrasound. c. Draw a complete blood count. d. Infuse normal saline at 50 mL/hr.

ANS: A a. Insert urethral catheter.

A patient has been taking phenytoin (Dilantin) for 2 years. Which action should the nurse take when evaluating possible adverse effects of the medication? a. Inspect the oral mucosa. b. Listen to the lung sounds. c. Auscultate the bowel sounds. d. Check pupil reaction to light.

ANS: A a. Inspect the oral mucosa

On auscultation of a patient's lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third bilaterally. How should the nurse document this finding? a. Inspiratory crackles at the bases b. Expiratory wheezes in both lungs c. Abnormal lung sounds in the apices of both lungs d. Pleural friction rub in the right and left lower lobes

ANS: A a. Inspiratory crackles at the bases

The day shift nurse at the long-term care facility learns that a patient with dementia experienced sundowning late in the afternoon on the previous two days. Which action should the nurse take? a. Keep window blinds open during the day. b. Have the patient take a mid-morning nap. c. Provide hourly orientation to time and place. d. Move the patient to a quiet room in the afternoon.

ANS: A a. Keep window blinds open during the day.

A patient who is experiencing an acute asthma attack is admitted to the emergency department. Which assessment should the nurse complete first? a. Listen to the patient's breath sounds. b. Ask about inhaled corticosteroid use. c. Determine when the dyspnea started. d. Measure forced expiratory volume (FEV) flow rate.

ANS: A a. Listen to the patient's breath sounds.

An older adult who takes medications for coronary artery disease and hypertension is newly diagnosed with HIV infection and is starting antiretroviral therapy. Which information will the nurse include in patient teaching? a. Many drugs interact with antiretroviral medications. b. HIV infections progress more rapidly in older adults. c. Less frequent CD4+ level monitoring is needed in older adults. d. Hospice care is available for patients with terminal HIV infection.

ANS: A a. Many drugs interact with antiretroviral medications.

Which action should the nurse include in the plan of care for a patient admitted with acute decompensated heart failure (ADHF) who is receiving nesiritide (Natrecor)? a. Monitor blood pressure frequently. b. Encourage patient to ambulate in room. c. Teach patient to drink at least 3 liters of fluid daily. d. Titrate nesiritide dose down slowly before stopping.

ANS: A a. Monitor blood pressure frequently.

A patient who had open reduction and internal fixation (ORIF) of left lower leg fractures continues to report severe pain in the leg 15 minutes after receiving the prescribed IV morphine. The nurse determines pulses are faintly palpable and the foot is cool to thetouch. Which action should the nurse take next? a. Notify the health care provider. b. Assess the incision for redness. c. Reposition the left leg on pillows. d. Check the patient's blood pressure.

ANS: A a. Notify the health care provider.

A patient who is experiencing an asthma attack develops bradycardia and a decrease in wheezing. Which action should the nurse take first? a. Notify the health care provider. b. Document changes in respiratory status. c. Encourage the patient to cough and deep breathe. d. Administer IV methylprednisolone (Solu-Medrol).

ANS: A a. Notify the health care provider.

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? a. O2 saturation is 88%. b. Blood pressure is 155/90 mm Hg. c. Respiratory rate is 24 breaths/min when lying flat. d. Pain level is 5 (on 0 to 10 scale) with a deep breath.

ANS: A a. O2 saturation is 88%.

The emergency department nurse is evaluating the outcomes for a patient who has received treatment during an asthma attack. Which assessment finding is the best indicator that the therapy has been effective? a. O2 saturation is >90%. b. No wheezes are audible. c. Respiratory rate is 16 breaths/min. d. Accessory muscle use has decreased.

ANS: A a. O2 saturation is >90%.

A patient hospitalized with chronic obstructive pulmonary disease (COPD) is being discharged home on O2 therapy. Which instruction should the nurse include in the discharge teaching? a. O2 use can improve the patient's quality of life. b. Travel is not possible with the use of O2 devices. c. O2 flow should be increased if the patient has more dyspnea. d. Storage of O2 requires large metal tanks that last 4 to 6 hours.

ANS: A a. O2 use can improve the patient's quality of life.

After receiving change-of-shift report about these postoperative patients, which patient should the nurse assess first? a. Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating. b. Patient who has 30 mL of sanguineous drainage in the wound drain 10 hours after hip replacement surgery. c. Patient who has bibasilar crackles and a temperature of 100° F (37.8 °C) on the first postoperative day after chest surgery. d. Patient who continues to have incisional pain 15 minutes after hydrocodone and acetaminophen (Vicodin) was given.

ANS: A a. Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating.

A 58-yr-old patient has just returned to the nursing unit after an esophagogastroduodenoscopy (EGD). Which action by unlicensed assistive personnel (UAP) requires that the registered nurse (RN) intervene? a. Offering the patient a pitcher of water b. Positioning the patient on the right side c. Checking the vital signs every 30 minutes d. Swabbing the patient's mouth with a wet cloth

ANS: A a. Offering the patient a pitcher of water

After change-of-shift report, which patient should the nurse assess first? a. Patient with myasthenia gravis who is reporting increased muscle weakness. b. Patient with a bilateral headache described as "like a band around my head." c. Patient with seizures who is scheduled to receive a dose of phenytoin (Dilantin). d. Patient with Parkinson's disease who has developed cogwheel rigidity of the arms.

ANS: A a. Patient with myasthenia gravis who is reporting increased muscle weakness.

A patient is being scheduled for endoscopic retrograde cholangiopancreatography (ERCP) as soon as possible. Which prescribed action should the nurse take first? a. Place the patient on NPO status. b. Administer sedative medications. c. Ensure the consent form is signed. d. Teach the patient about the procedure.

ANS: A a. Place the patient on NPO status.

A 27-yr-old patient admitted with diabetic ketoacidosis (DKA) has a serum glucose level of 732 mg/dL and serum potassium level of 3.1 mEq/L. Which action prescribed by the health care provider should the nurse take first? a. Place the patient on a cardiac monitor. b. Administer IV potassium supplements. c. Ask the patient about home insulin doses. d. Start an insulin infusion at 0.1 units/kg/hr.

ANS: A a. Place the patient on a cardiac monitor.

A patient has a tumor in the cerebellum. What goal should the nurse use to focus the plan of care? a. Prevent falls. b. Stabilize mood. c. Avoid aspiration. d. Improve memory.

ANS: A a. Prevent falls.

A patient had a non-ST-segment-elevation myocardial infarction (NSTEMI) 3 days ago. Which nursing intervention is appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/VN)? a. Reinforcement of teaching about the prescribed medications b. Evaluation of the patient's response to walking in the hallway c. Completion of the referral form for a home health nurse follow-up d. Education of the patient about the pathophysiology of heart disease

ANS: A a. Reinforcement of teaching about the prescribed medications

The nurse should suggest which food choice for a patient scheduled to receive external-beam radiation for abdominal cancer? a. Fruit salad b. Baked chicken c. Creamed broccoli d. Toasted wheat bread

ANS: B b. Baked chicken

The nurse assesses a patient with chronic obstructive pulmonary disease (COPD) who has been admitted after increasing dyspnea over the past 3 days. Which finding is important for the nurse to report to the health care provider? a. Respirations are 36 breaths/min. b. Anterior-posterior chest ratio is 1:1. c. Lung expansion is decreased bilaterally. d. Hyperresonance to percussion is present.

ANS: A a. Respirations are 36 breaths/min.

Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness. Which patient problem do they determine has the highest priority for the patient? a. Risk for aspiration b. Impaired skin integrity c. Impaired physical mobility d. Disturbed sensory perception

ANS: A a. Risk for aspiration

The nurse assesses a patient with non-Hodgkin's lymphoma who is receiving an infusion of rituximab (Rituxan). Which assessment finding would require the most rapid action by the nurse? a. Shortness of breath b. Shivering and chills c. Muscle aches and pains d. Temperature of 100.2° F (37.9° C)

ANS: A a. Shortness of breath

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? a. Start the prescribed PRN O2 at 6 L/min. b. Put a moist hot pack on the patient's neck. c. Give the ordered PRN acetaminophen (Tylenol). d. Notify the patient's health care provider immediately.

ANS: A a. Start the prescribed PRN O2 at 6 L/min.

Which action should the nurse take when caring for a patient who is receiving chemotherapy and reports problems with concentration? a. Suggest use of a daily planner and encourage adequate sleep. b. Teach the patient to rest the brain by avoiding new activities. c. Teach that "chemo-brain" is a short-term effect of chemotherapy. d. Report patient symptoms immediately to the health care provider.

ANS: A a. Suggest use of a daily planner and encourage adequate sleep.

When caring for a patient who has pancytopenia, which action by unlicensed assistive personnel (UAP) indicates a need for the nurse to intervene? a. The UAP assists the patient to use dental floss after eating. b. The UAP adds baking soda to the patient's saline oral rinses. c. The UAP puts fluoride toothpaste on the patient's toothbrush. d. The UAP has the patient rinse after meals with a saline solution.

ANS: A a. The UAP assists the patient to use dental floss after eating.

A patient hospitalized with pneumonia is disoriented and confused 3 days after admission. Which information indicates that the patient is experiencing delirium rather than dementia? a. The patient was oriented and alert when admitted. b. The patient's speech is fragmented and incoherent. c. The patient is oriented to person but disoriented to place and time. d. The patient has a history of increasing confusion over several years.

ANS: A a. The patient was oriented and alert when admitted.

After reviewing the health record shown in the accompanying figure for a patient who has multiple risk factors for Alzheimer's disease (AD), which topic will be most important for the nurse to discuss with the patient? a. Tobacco use b. Family history c. Cholesterol level d. Head injury history

ANS: A a. Tobacco use

Which finding by the nurse most specifically indicates that a patient is not able to effectively clear the airway? a. Weak cough effort b. Profuse green sputum c. Respiratory rate of 28 breaths/min d. Resting pulse oximetry (SpO2) of 85%

ANS: A a. Weak cough effort

The nurse in the emergency department receives arterial blood gas results for 4 recently admitted patients with obstructive pulmonary disease. The results for which patient will require the most rapid action by the nurse? a. pH 7.28, PaCO2 50 mm Hg, and PaO2 58 mm Hg b. pH 7.48, PaCO2 30 mm Hg, and PaO2 65 mm Hg c. pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg d. pH 7.31, PaCO2 58 mm Hg, and PaO2 64 mm Hg

ANS: A a. pH 7.28, PaCO2 50 mm Hg, and PaO2 58 mm Hg

A young adult patient who denies any history of smoking is seen in the clinic with a new diagnosis of chronic obstructive pulmonary disease (COPD). What topic should the nurse plan to teach the patient? a. α1-antitrypsin testing b. Leukotriene modifiers c. Use of the nicotine patch d. Continuous pulse oximetry

ANS: A a. α1-antitrypsin testing

The nurse is caring for a patient living with asymptomatic chronic HIV infection (HIV). Which prophylactic measures will the nurse include in the plan of care? (Select all that apply.) a. Hepatitis B vaccine b. Pneumococcal vaccine c. Influenza virus vaccine d. Trimethoprim-sulfamethoxazole e. Varicella zoster immune globulin

ANS: A, B a. Hepatitis B vaccine b. Pneumococcal vaccine

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.

ANS: A, B, D, C a. Obtain the O2 saturation. b. Check the patient's pulse rate. d. Notify the health care provider. c. Document the change in status.

A patient is scheduled for a computed tomography (CT) scan of the chest with contrast media. Which assessment findings should the nurse report to the health care provider before the patient goes for the CT (Select all that apply.)? a. Allergy to shellfish b. Patient reports claustrophobia c. Elevated serum creatinine level d. Recent bronchodilator inhaler use e. Inability to remove a wedding band

ANS: A, C a. Allergy to shellfish c. Elevated serum creatinine level

While ambulating in the room, a patient reports feeling dizzy. In what order will the nurse accomplish the following activities? a. Have the patient sit down in a chair. b. Give the patient something to drink. c. Take the patient's blood pressure (BP). d. Inform the patient's health care provider.

ANS: A, C, B, D a. Have the patient sit down in a chair. c. Take the patient's blood pressure (BP). b. Give the patient something to drink. d. Inform the patient's health care provider.

Which information will be included when the nurse is teaching self-management to a patient who is receiving peritoneal dialysis? (Select all that apply.) a. Avoid commercial salt substitutes. b. Restrict fluid intake to 1000 mL daily. c. Take phosphate binders with each meal. d. Choose high-protein foods for most meals. e. Have several servings of dairy products daily.

ANS: A, C, D a. Avoid commercial salt substitutes. c. Take phosphate binders with each meal. d. Choose high-protein foods for most meals

The nurse at the clinic is interviewing a 64-yr-old woman who is 5 feet, 3 inches tall and weighs 125 lb (57 kg). The patient has not seen a health care provider for 20 years. She walks 5 miles most days and has a glass of wine 2 or 3 times a week. Which topics will the nurse plan to include in patient teaching about cancer screening and decreasing cancer risk? (Select all that apply.) a. Pap testing b. Tobacco use c. Sunscreen use d. Mammography e. Colorectal screening

ANS: A, C, D, E a. Pap testing c. Sunscreen use d. Mammography e. Colorectal screening

In which order will the nurse take these steps to prepare NPH 20 units and regular insulin 2 units using the same syringe? (Put a comma and a space between each answer choice [A, B, C, D, E]). a. Rotate NPH vial. b. Withdraw regular insulin. c. Withdraw 20 units of NPH. d. Inject 20 units of air into NPH vial. e. Inject 2 units of air into regular insulin vial.

ANS: A, D, E, B, C a. Rotate NPH vial. d. Inject 20 units of air into NPH vial. e. Inject 2 units of air into regular insulin vial. b. Withdraw regular insulin. c. Withdraw 20 units of NPH.

A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first? a. Chest x-ray via stretcher b. Blood cultures from two sites c. Ciprofloxacin (Cipro) 400 mg IV d. Acetaminophen (Tylenol) suppository

ANS: B b. Blood cultures from two sites

The nurse provides dietary teaching for a patient with chronic obstructive pulmonary disease (COPD) who has a low body mass index (BMI). Which patient statement indicates that the teaching has been effective? a. "I will drink lots of fluids with my meals." b. "I can have ice cream as a snack every day." c. "I will exercise for 15 minutes before meals." d. "I will decrease my intake of beef and poultry."

ANS: B b. "I can have ice cream as a snack every day."

A patient who is recovering from an acute myocardial infarction (AMI) asks the nurse about safely resuming sexual intercourse. Which response by the nurse is best? a. "Most patients are able to enjoy intercourse without any complications." b. "Sexual activity uses about as much energy as climbing two flights of stairs." c. "The doctor will provide sexual guidelines when your heart is strong enough." d. "Holding and cuddling are good ways to maintain intimacy after a heart attack."

ANS: B b. "Sexual activity uses about as much energy as climbing two flights of stairs."

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? a. "It depends on which type of dialysis you are considering." b. "Tell me more about what you are thinking regarding dialysis." c. "You are the only one who can make the decision about dialysis." d. "Many people your age use dialysis and have a good quality of life."

ANS: B b. "Tell me more about what you are thinking regarding dialysis."

A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate? a. "The diseased portion of the artery is replaced with a synthetic graft." b. "The obstructing plaque is surgically removed from inside an artery in the neck." c. "A wire is threaded through an artery in the leg to the clots in the carotid artery, and clots are removed." d. "A catheter with a deflated balloon is positioned at the narrow area, and the balloon flattens the plaque."

ANS: B b. "The obstructing plaque is surgically removed from inside an artery in the neck."

A widowed mother of 4 school-age children is hospitalized with metastatic ovarian cancer. The patient is crying and tells the nurse that she does not know what will happen to her children when she dies. Which response by the nurse is most appropriate? a. "Don't you have any friends that will raise the children for you?" b. "Would you like to talk about options for the care of your children?" c. "For now you need to concentrate on getting well and not worrying about your children." d. "Many patients with cancer live for a long time, so there is time to plan for your children."

ANS: B b. "Would you like to talk about options for the care of your children?"

Which area of the abdomen shown in the accompanying figure will the nurse palpate to assess for splenomegaly? a. 1 b. 2 c. 3 d. 4

ANS: B b. 2

After change-of-shift report, which patient should the nurse assess first? a. A 19-yr-old patient with type 1 diabetes who has a hemoglobin A1C of 12% b. A 23-yr-old patient with type 1 diabetes who has a blood glucose of 40 mg/dL c. A 50-yr-old patient who uses exenatide (Byetta) and is reporting acute abdominal pain d. A 40-yr-old patient who is pregnant and whose oral glucose tolerance test is 202 mg/dL

ANS: B b. A 23-yr-old patient with type 1 diabetes who has a blood glucose of 40 mg/dL

Which patient would benefit from education about HIV preexposure prophylaxis (PrEP)? a. A 23-yr-old woman living with HIV infection. b. A 52-yr-old recently single woman just diagnosed with chlamydia. c. A 33-yr-old hospice worker who received a needle stick injury 3 hours ago. d. A 60-yr-old male in a monogamous relationship with an HIV-uninfected partner.

ANS: B b. A 52-yr-old recently single woman just diagnosed with chlamydia.

Several patients have been hospitalized for diagnosis of neurologic problems. Which patient should the nurse assess first? a. A patient with a transient ischemic attack (TIA) returning from carotid duplex studies b. A patient with a brain tumor who has just arrived on the unit after a cerebral angiogram c. A patient with a seizure disorder who has just completed an electroencephalogram (EEG) d. A patient prepared for a lumbar puncture whose health care provider is waiting for assistance

ANS: B b. A patient with a brain tumor who has just arrived on the unit after a cerebral angiogram

The nurse receives a change-of-shift report on the following patients with chronic obstructive pulmonary disease (COPD). Which patient should the nurse assess first? a. A patient with loud expiratory wheezes b. A patient with a respiratory rate of 38 breaths/min c. A patient who has a cough productive of thick, green mucus d. A patient with jugular venous distention and peripheral edema

ANS: B b. A patient with a respiratory rate of 38 breaths/min

The nurse is caring for a patient who is recovering from a sudden cardiac death (SCD) event and has no evidence of an acute myocardial infarction (AMI). What should the nurse anticipate teaching the patient? a. Sudden cardiac death events rarely reoccur. b. Additional diagnostic testing will be required. c. Long-term anticoagulation therapy will be needed. d. Limiting physical activity will prevent future SCD events.

ANS: B b. Additional diagnostic testing will be required.

The nurse observes that a patient with respiratory disease experiences a decrease in SpO2 from 93% to 88% while ambulating. What is the priority action of the nurse? a. Notify the health care provider. b. Administer PRN supplemental O2. c. Document the response to exercise. d. Encourage the patient to pace activity.

ANS: B b. Administer PRN supplemental O2.

A patient seen in the asthma clinic has recorded daily peak flowrates that are 75% of the baseline. Which action will the nurse plan to take next? a. Teach the patient about the use of oral corticosteroids. b. Administer a bronchodilator and recheck the spirometry. c. Recommend increasing the dose of the leukotriene inhibitor. d. Instruct the patient to keep the scheduled follow-up appointment.

ANS: B b. Administer a bronchodilator and recheck the spirometry.

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? a. Stay with the patient and offer reassurance. b. Administer prescribed PRN O2 at 4 L/min. c. Check the patient's legs for swelling or tenderness. d. Notify the health care provider about the symptoms.

ANS: B b. Administer prescribed PRN O2 at 4 L/min.

Which action by the nurse will be most helpful to a patient who is expected to ambulate, deep breathe, and cough on the first postoperative day? a. Schedule the activity to begin after the patient has taken a nap. b. Administer prescribed analgesic medications before the activities. c. Ask the patient to state two possible complications of immobility. d. Encourage the patient to discuss the purpose of splinting the incision.

ANS: B b. Administer prescribed analgesic medications before the activities.

An hour after a left thoracotomy, a patient reports 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? a. Clamp the chest tube in two places. b. Administer the prescribed morphine. c. Milk the chest tube to remove any clots. d. Assist the patient with incentive spirometry.

ANS: B b. Administer the prescribed morphine.

An older patient reports chronic constipation. To promote bowel evacuation, when should the nurse suggest that the patient attempt defecation? a. In the mid-afternoon b. After eating breakfast c. Right after awakening in the morning d. Immediately before the first daily meal

ANS: B b. After eating breakfast

Which finding would indicate to the nurse that a postoperative patient is at increased risk for poor wound healing? a. Potassium 3.5 mEq/L b. Albumin level 2.2 g/dL c. Hemoglobin 10.2 g/dL d. White blood cells 11,900/μL

ANS: B b. Albumin level 2.2 g/dL

The nurse reviews the medication administration record (MAR) for a patient having an acute asthma attack. Which medication should the nurse administer first? a. Methylprednisolone (Solu-Medrol) 60 mg IV b. Albuterol (Ventolin HFA) 2.5 mg per nebulizer c. Salmeterol (Serevent) 50 mcg per dry-powder inhaler (DPI) d. Ipratropium (Atrovent) 2 puffs per metered-dose inhaler (MDI)

ANS: B b. Albuterol (Ventolin HFA) 2.5 mg per nebulizer

A patient with a possible pituitary adenoma is scheduled for a computed tomography (CT) scan with contrast media. Which patient information is important for the nurse to communicate to the health care provider before the test? a. Bilateral poor peripheral vision b. Allergies to iodine and shellfish c. Recent weight loss of 20 pounds d. Patient reports ongoing headaches

ANS: B b. Allergies to iodine and shellfish

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. What should the nurse anticipate explaining to the patient? a. Oral corticosteroids b. Antiparkinsonian drugs c. Magnetic resonance imaging (MRI) d. Electroencephalogram (EEG) testing

ANS: B b. Antiparkinsonian drugs

During the teaching session for a patient who has a new diagnosis of acute leukemia, the patient is restless and looks away without making eye contact. The patient asks the nurse to repeat the information about the complications associated with chemotherapy. Based on this assessment, which patient problem should the nurse identify? a. Denial b. Anxiety c. Acute confusion d. Ineffective adherence to treatment

ANS: B b. Anxiety

Which action will the nurse take to evaluate the effectiveness of IV nitroglycerin for a patient with a myocardial infarction (MI)? a. Monitor heart rate. b. Ask about chest pain. c. Check blood pressure. d. Observe for dysrhythmias.

ANS: B b. Ask about chest pain.

A patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU) is restless and shouting at the nurse. The patient's oxygen saturation is 96%, and recent laboratory results are all normal. Which action by the nurse is most appropriate? a. Increase the IV fluid rate. b. Assess for bladder distention. c. Notify the anesthesia care provider (ACP). d. Demonstrate the use of the nurse call bell button.

ANS: B b. Assess for bladder distention.

On the second postoperative day, the patient's nasogastric (NG) tube is removed and the patient begins drinking clear liquids. Four hours later, the patient reports frequent, cramping gas pains. What action by the nurse is the most appropriate? a. Reinsert the NG tube. b. Assist the patient to ambulate. c. Place the patient on NPO status. d. Give the prescribed PRN IV opioid.

ANS: B b. Assist the patient to ambulate.

A patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which action should the nurse include in the plan of care? a. Observe for agitation and paranoia. b. Assist with active range of motion (ROM). c. Give muscle relaxants as needed to reduce spasms. d. Use simple words and phrases to explain procedures.

ANS: B b. Assist with active range of motion (ROM).

A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. What topic should the nurse anticipate teaching the patient? a. tPA b. Asspirin c. Warfarin d. Nimodipine

ANS: B b. Asspirin

The nurse should instruct a patient with a nondisplaced fractured left radius that the cast will need to remain in place for what amount of time? a. Two weeks b. At least six weeks c. Until swelling of the wrist has resolved d. Until x-rays show complete bony union

ANS: B b. At least six weeks

The nurse teaches a patient with liver cancer about high-protein, high-calorie diet choices. Which snack choice by the patient indicates that the teaching has been effective? a. Lime sherbet b. Blueberry yogurt c. Fresh strawberries d. Cream cheese bagel

ANS: B b. Blueberry yogurt

What will the nurse tell the patient who has cerebral atherosclerosis about taking clopidogrel (Plavix)? a. Monitor and record the blood pressure daily. b. Call the health care provider if stools are tarry. c. Clopidogrel will dissolve clots in the cerebral arteries. d. Clopidogrel will reduce cerebral artery plaque formation.

ANS: B b. Call the health care provider if stools are tarry.

A patient has arrived for a scheduled hemodialysis session. Which nursing action is appropriate for the registered nurse (RN) to delegate to a dialysis technician? a. Teach the patient about fluid restrictions. b. Check blood pressure before starting dialysis. c. Assess for causes of an increase in predialysis weight. d. Determine the ultrafiltration rate for the hemodialysis.

ANS: B b. Check blood pressure before starting dialysis.

A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action should the nurse take first? a. Administer the prescribed opioid. b. Check the oxygen (O2) saturation. c. Take the blood pressure and pulse. d. Apply wrist restraints to secure IV lines.

ANS: B b. Check the oxygen (O2) saturation.

What should the nurse advise a patient with myasthenia gravis (MG) to do? a. Anticipate the need for weekly plasmapheresis treatments. b. Complete physically demanding activities early in the day. c. Protect the extremities from injury due to poor sensory perception. d. Perform frequent weight-bearing exercise to prevent muscle atrophy.

ANS: B b. Complete physically demanding activities early in the day.

A patient who has just been transported from the operating room to the postanesthesia care unit (PACU) is shivering and has a temperature of 96.5° F (35.8° C). Which action should the nurse take next? a. Notify the anesthesia care provider. b. Cover the patient with a warm blanket. c. Hold opioid analgesics until the patient is warmer. d. Give acetaminophen 650 mg suppository rectally.

ANS: B b. Cover the patient with a warm blanket.

The nurse assesses a patient who is receiving interleukin-2. Which finding should the nurse report immediately to the health care provider? a. Generalized muscle aches b. Crackles at the lung bases c. Reports of nausea and anorexia d. Oral temperature of 100.6° F (38.1° C)

ANS: B b. Crackles at the lung bases

A patient with a large stomach tumor attached to the liver is scheduled for a debulking procedure. What should the nurse teach the patient about the outcome of this procedure? a. Pain will be relieved by cutting sensory nerves in the stomach. b. Decreasing the tumor size will improve the effects of other therapy. c. Relieving the pressure in the stomach will promote optimal nutrition. d. Tumor growth will be controlled by removing all the cancerous tissue.

ANS: B b. Decreasing the tumor size will improve the effects of other therapy.

An older adult patient is being discharged from the ambulatory surgical unit after left eye surgery. The patient tells the nurse, "I don't know if I can take care of myself once I'm home." Which action by the nurse is most appropriate to implement first? a. Assess the patient's home support system. b. Discuss patient concerns regarding self-care. c. Refer the patient for home health care services. d. Provide written instructions for the patient's care.

ANS: B b. Discuss patient concerns regarding self-care.

What should the nurse include when teaching an adult patient to prevent the recurrence of kidney stones? a. Using a filter to strain all urine b. Drinking 3000 mL of fluid each day c. Avoiding dietary sources of calcium d. Choosing diuretic fluids such as coffee

ANS: B b. Drinking 3000 mL of fluid each day

The nurse is developing a teaching plan for a 64-year-old patient with coronary artery disease (CAD). Which factor should the nurse focus on during the teaching session? a. Family history of coronary artery disease b. Elevated low-density lipoprotein (LDL) level c. Greater risk associated with the patient's gender d. Increased risk of cardiovascular disease with aging

ANS: B b. Elevated low-density lipoprotein (LDL) level

A chemotherapy drug that causes alopecia is prescribed for a patient. Which action should the nurse take to support the patient's self-esteem? a. Suggest that the patient limit social contacts until hair regrowth occurs. b. Encourage the patient to purchase a wig or hat to wear when hair loss begins. c. Teach the patient to wash hair gently with mild shampoo to minimize hair loss. d. Inform the patient that hair usually grows back once chemotherapy is complete.

ANS: B b. Encourage the patient to purchase a wig or hat to wear when hair loss begins.

In the postanesthesia care unit (PACU), a patient's vital signs are blood pressure 116/72 mm Hg, pulse 74 beats/min, respirations 12 breaths/min, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take first? a. Place the patient in a side-lying position. b. Encourage the patient to take deep breaths. c. Prepare to transfer the patient to a clinical unit. d. Increase the rate of the postoperative IV fluids.

ANS: B b. Encourage the patient to take deep breaths.

A patient with Hodgkin's lymphoma who is undergoing external radiation therapy tells the nurse, "I am so tired I can hardly get out of bed in the morning." Which intervention should the nurse add to the plan of care? a. Minimize activity until the treatment is completed. b. Establish time to take a short walk almost every day. c. Consult with a psychiatrist for treatment of depression. d. Arrange for delivery of a hospital bed to the patient's home.

ANS: B b. Establish time to take a short walk almost every day.

Which problem should the nurse expect for a patient who has a positive Romberg test result? a. Pain b. Falls c. Aphasia d. Confusion

ANS: B b. Falls

Which finding should the nurse expect when assessing the legs of a patient who has a lower motor neuron lesion? a. Spasticity b. Flaccidity c. Impaired sensation d. Hyperactive reflexes

ANS: B b. Flaccidity

The nurse is caring for a patient during a water deprivation test. Which finding is most important for the nurse to communicate to the health care provider? a. The patient reports intense thirst. b. The patient has a 5-lb (2.3-kg) weight loss. c. The patient feels dizzy when sitting on the bed. d. The patient's urine osmolality does not increase.

ANS: B b. The patient has a 5-lb (2.3-kg) weight loss.

On the second postoperative day after abdominal surgery for removal of a large pancreatic cyst, a patient has an oral temperature of 100.8° F (38.2° C). Which action should the nurse take next? a. Place ice packs in the patient's axillae. b. Have the patient use the incentive spirometer. c. Request a prescription for acetaminophen suppositories. d. Ask the health care provider to change the antibiotic prescription.

ANS: B b. Have the patient use the incentive spirometer.

Which nursing action will be most effective in ensuring daily medication compliance for a patient with mild dementia? a. Setting the medications up monthly in a medication box b. Having the patient's family member administer the medication c. Posting reminders to take the medications in the patient's house d. Calling the patient weekly with a reminder to take the medication

ANS: B b. Having the patient's family member administer the medication

A patient who has recently had an acute myocardial infarction (AMI) ambulates in the hospital hallway. Which data would indicate to the nurse that the patient should stop and rest? a. O2 saturation drops from 99% to 95%. b. Heart rate increases from 66 to 98 beats/min. c. Respiratory rate goes from 14 to 20 breaths/min. d. Blood pressure (BP) changes from 118/60 to 126/68 mm Hg.

ANS: B b. Heart rate increases from 66 to 98 beats/min.

The nurse is caring for a patient with a possible pituitary tumor who is scheduled for a computed tomography scan with contrast. Which information about the patient is important to discuss with the health care provider before the test? a. Report of chronic headache b. History of renal insufficiency c. Recent bilateral visual field loss d. Blood glucose level of 134 mg/dL

ANS: B b. History of renal insufficiency

A patient with leukemia is considering whether to have hematopoietic stem cell transplantation (HSCT). Which information should the nurse include in the patient's teaching plan? a. Donor bone marrow is transplanted through a sternal or hip incision. b. Hospitalization is required for several weeks after the stem cell transplant. c. The transplant procedure takes place in a sterile operating room to decrease the risk for infection. d. Transplant of the donated cells can be very painful because of the nerves in the tissue lining the bone.

ANS: B b. Hospitalization is required for several weeks after the stem cell transplant.

Which information should the nurse include in discharge teaching for a patient who has had a repair of a fractured mandible? a. Administration of nasogastric tube feedings b. How and when to cut the immobilizing wires c. The importance of high-fiber foods in the diet d. The use of sterile technique for dressing changes

ANS: B b. How and when to cut the immobilizing wires

Which patient problem should the nurse identify as of highest priority for a patient who has Parkinson's disease and is unable to move the facial muscles? a. Activity intolerance b. Inadequate nutrition c. Disturbed body image d. Impaired physical mobility

ANS: B b. Inadequate nutrition

Several hours after a patient had an open surgical repair of an abdominal aortic aneurysm, the UAP reports to the nurse that urinary output for the past 2 hours has been 45 mL. What should the nurse anticipate will be prescribed? a. Hemoglobin count b. Increased IV fluids c. Additional antibiotics d. Serum creatinine level

ANS: B b. Increased IV fluids

What action should the nurse include in completing a health history and physical assessment for a 36-yr-old female patient with possible multiple sclerosis (MS)? a. Assess for the presence of chest pain. b. Inquire about urinary tract problems. c. Inspect the skin for rashes or discoloration. d. Ask the patient about any increase in libido.

ANS: B b. Inquire about urinary tract problems.

A patient with diabetes has arterial blood gas (ABG) results pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg; HCO3 18 mEq/L. The nurse would expect which finding? a. Intercostal retractions b. Kussmaul respirations c. Low oxygen saturation (SpO2) d. Decreased venous O2 pressure

ANS: B b. Kussmaul respirations

Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a. Listen to a patient's lung sounds for wheezes or crackles. b. Label specimens obtained during percutaneous lung biopsy. c. Instruct a patient about how to use home spirometry testing. d. Measure induration at the site of a patient's intradermal skin test.

ANS: B b. Label specimens obtained during percutaneous lung biopsy.

An adult with a body mass index (BMI) of 22 kg/m2 is being admitted to the hospital for elective knee surgery. Which assessment finding should the nurse report to the health care provider? a. Tympany on percussion of the abdomen b. Liver edge 3 cm below the costal margin c. Bowel sounds of 20/min in each quadrant d. Aortic pulsations visible in the epigastric area

ANS: B b. Liver edge 3 cm below the costal margin

A patient who has severe Alzheimer's disease (AD) is being admitted to the hospital for surgery. Which intervention will the nurse include in the plan of care? a. Encourage the patient to discuss events from the past. b. Maintain a consistent daily routine for the patient's care. c. Reorient the patient to the date and time every 2 to 3 hours. d. Provide the patient with current newspapers and magazines.

ANS: B b. Maintain a consistent daily routine for the patient's care.

The nurse is admitting a patient diagnosed with an acute exacerbation of chronic obstructive pulmonary disease (COPD). How should the nurse determine the appropriate O2 flowrate? a. Minimize O2 use to avoid O2 dependency. b. Maintain the pulse oximetry level at 90% or greater. c. Administer O2 according to the patient's level of dyspnea. d. Avoid administration of O2 at a rate of more than 2 L/min.

ANS: B b. Maintain the pulse oximetry level at 90% or greater.

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? a. The antiretroviral medications used to treat HIV infection are teratogenic. b. Most infants born to HIV-positive mothers are not infected with the virus. c. Because it is an early stage of HIV infection, the infant will not contract HIV. d. Her newborn will be born with HIV unless she uses antiretroviral therapy (ART).

ANS: B b. Most infants born to HIV-positive mothers are not infected with the virus.

After a thymectomy, a patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient reports nausea and severe abdominal cramps. Which action should the nurse take first? a. Auscultate the patient's bowel sounds. b. Notify the patient's health care provider. c. Administer the prescribed PRN antiemetic drug. d. Give the scheduled dose of prednisone (Deltasone).

ANS: B b. Notify the patient's health care provider.

The nurse is caring for a patient immediately after repair of an abdominal aortic aneurysm. On assessment, the patient has absent popliteal, posterior tibial, and dorsalis pedis pulses. The legs are cool and mottled. Which action should the nurse take first? a. Wrap both legs in a warming blanket. b. Notify the surgeon and anesthesiologist. c. Document the findings and recheck in 15 minutes. d. Compare findings to the preoperative assessment of the pulses.

ANS: B b. Notify the surgeon and anesthesiologist.

During a routine health examination, a 40-yr-old patient tells the nurse about a family history of colon cancer. Which action should the nurse take next? a. Schedule a sigmoidoscopy to provide baseline data. b. Obtain more information about the patient's relatives. c. Teach the patient about the need for a colonoscopy at age 50. d. Teach the patient how to do home testing for fecal occult blood.

ANS: B b. Obtain more information about the patient's relatives.

Which information about a patient with a lumbar vertebral compression fracture should the nurse immediately report to the health care provider? a. Patient declines to be turned due to back pain. b. Patient has been incontinent of urine and stool. c. Patient reports lumbar area tenderness to palpation. d. Patient frequently uses oral corticosteroids to treat asthma.

ANS: B b. Patient has been incontinent of urine and stool.

After change-of-shift report, which patient should the nurse assess first? a. Patient with a repaired mandibular fracture who is reporting facial pain. b. Patient with repaired right femoral shaft fracture who reports tightness in the calf. c. Patient with an unrepaired Colles' fracture who has right wrist swelling and deformity. d. Patient with an unrepaired intracapsular left hip fracture whose leg is externally rotated.

ANS: B b. Patient with repaired right femoral shaft fracture who reports tightness in the calf.

Which patient at the cardiovascular clinic requires the most immediate action by the nurse? a. Patient with type 2 diabetes whose current blood glucose level is 145 mg/dL. b. Patient with stable angina whose chest pain has recently increased in frequency. c. Patient with familial hypercholesterolemia and a total cholesterol of 465 mg/dL. d. Patient with chronic hypertension whose blood pressure today is 172/98 mm Hg.

ANS: B b. Patient with stable angina whose chest pain has recently increased in frequency.

The home health registered nurse (RN) is planning care for a patient with seizure disorder related to a recent head injury. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/VN)? a. Make referrals to appropriate community agencies. b. Place medications in the home medication organizer. c. Teach the patient and family how to manage seizures. d. Assess for use of medications that may precipitate seizures.

ANS: B b. Place medications in the home medication organizer.

What action should the nurse take after assisting with a needle biopsy of the liver at a patient's bedside? a. Elevate the head of the bed to facilitate breathing. b. Place the patient on the right side with the bed flat. c. Check the patient's post biopsy coagulation studies. d. Position a sandbag over the liver to provide pressure.

ANS: B b. Place the patient on the right side with the bed flat.

Which menu choice by the patient who is receiving hemodialysis indicates that the nurse's teaching has been successful? a. Split-pea soup, English muffin, and nonfat milk b. Poached eggs, whole-wheat toast, and apple juice c. Oatmeal with cream, half a banana, and herbal tea d. Cheese sandwich, tomato soup, and cranberry juice

ANS: B b. Poached eggs, whole-wheat toast, and apple juice

What laboratory value should the nurse check before administering captopril to a patient with stage 2 chronic kidney disease? a. Glucose b. Potassium c. Creatinine d. Phosphate

ANS: B b. Potassium

An unconscious male patient has just arrived in the emergency department with a head injury caused by a motorcycle crash. Which planned intervention by the health care provider should the nurse question? a. Obtain x-rays of the skull and spine. b. Prepare the patient for lumbar puncture. c. Send for computed tomography (CT) scan. d. Perform neurologic checks every 15 minutes

ANS: B b. Prepare the patient for lumbar puncture.

Which cerebrospinal fluid analysis result should the nurse recognize as abnormal and communicate to the health care provider? a. Specific gravity of 1.007 b. Protein of 65 mg/dL (0.65 g/L) c. Glucose of 45 mg/dL (1.7 mmol/L) d. White blood cell (WBC) count of 4 cells/μL

ANS: B b. Protein of 65 mg/dL (0.65 g/L)

Which assessment finding in a patient with impaired gas exchange is most useful in evaluating the effectiveness of treatment? a. Even, unlabored respirations b. Pulse oximetry reading of 92% c. Absence of wheezes or crackles d. Respiratory rate of 18 breaths/min

ANS: B b. Pulse oximetry reading of 92%

An adult patient is admitted to the hospital with new-onset nephrotic syndrome. Which assessment data will the nurse expect? a. Poor skin turgor b. Recent weight gain c. Elevated urine ketones d. Decreased blood pressure

ANS: B b. Recent weight gain

Which intervention will the nurse include in the plan of care for a patient with moderate dementia who is admitted for other health problems? a. Provide complete personal hygiene care for the patient. b. Remind the patient frequently about being in the hospital. c. Reposition the patient frequently to avoid skin breakdown. d. Place suction at the bedside to decrease the risk for aspiration.

ANS: B b. Remind the patient frequently about being in the hospital.

Which of the following should the nurse consider the priority nursing assessment for a patient being admitted with a brainstem infarction? a. Pupil reaction b. Respiratory rate c. Reflex reaction time d. Level of consciousness

ANS: B b. Respiratory rate

A 60-yr-old patient had open reduction and internal fixation (ORIF) for an open, displaced tibial fracture, What should the nurse identify as the priority patient problem? a. Acute pain b. Risk for infection c. Activity intolerance d. Risk for constipation

ANS: B b. Risk for infection

A patient seen in the outpatient clinic is newly diagnosed with mild cognitive impairment (MCI). Which action will the nurse include in the plan of care? a. Suggest a move into an assisted living facility. b. Schedule the patient for more frequent appointments. c. Ask family members to supervise the patient's daily activities. d. Discuss the preventive use of acetylcholinesterase medications.

ANS: B b. Schedule the patient for more frequent appointments.

Which laboratory result should the nurse check before administering calcium carbonate to a patient with chronic kidney disease? a. Serum potassium b. Serum phosphate c. Serum creatinine d. Serum cholesterol

ANS: B b. Serum phosphate

A patient admitted to the emergency department with a sudden onset of shortness of breath is diagnosed with a possible pulmonary embolus. How should the nurse prepare the patient for diagnostic testing to confirm the diagnosis? a. Ensure that the patient has been NPO. b. Start an IV so contrast media may be given. c. Inform radiology that radioactive glucose preparation is needed. d. Instruct the patient to expect to inspire deeply and exhale forcefully.

ANS: B b. Start an IV so contrast media may be given.

The registered nurse (RN) is caring for a patient who is living with HIV and admitted with tuberculosis. Which task can the RN delegate to unlicensed assistive personnel (UAP)? a. Teach the patient how to dispose of tissues with respiratory secretions. b. Stock the patient's room with the necessary personal protective equipment. c. Interview the patient to obtain the names of family members and close contacts. d. Tell the patient's family members the reason for the use of airborne precautions.

ANS: B b. Stock the patient's room with the necessary personal protective equipment.

The nurse administers an IV vesicant chemotherapeutic agent to a patient. Which action is most important for the nurse to take? a. Infuse the medication over a short period of time. b. Stop the infusion if swelling is observed at the site. c. Administer the chemotherapy through a small-bore catheter. d. Hold the medication unless a central venous line is available.

ANS: B b. Stop the infusion if swelling is observed at the site.

Which intervention should the nurse include in the plan of care for a patient who has primary restless legs syndrome (RLS) and is having difficulty sleeping? a. Teach about the use of antihistamines to improve sleep. b. Suggest that the patient exercise regularly during the day. c. Make a referral to a massage therapist for deep massage of the legs. d. Assure the patient that the problem is transient and likely to resolve.

ANS: B b. Suggest that the patient exercise regularly during the day.

A patient with Parkinson's disease has bradykinesia. Which action should the nurse include in the plan of care? a. Instruct the patient in activities that can be done while lying or sitting. b. Suggest that the patient rock from side to side to initiate leg movement. c. Have the patient take small steps in a straight line directly in front of the feet. d. Teach the patient to keep the feet in contact with the floor and slide them forward.

ANS: B b. Suggest that the patient rock from side to side to initiate leg movement.

Which action should the nurse plan to take for a patient with multiple sclerosis who has urinary retention caused by a flaccid bladder? a. Encourage decreased evening intake of fluid. b. Teach the patient how to use the Credé method. c. Suggest the use of adult incontinence briefs for nighttime only. d. Assist the patient to the commode every 2 hours during the day.

ANS: B b. Teach the patient how to use the Credé method.

The home health nurse is visiting a patient with chronic obstructive pulmonary disease (COPD). Which nursing action is appropriate to implement for a patient who has an impaired breathing pattern due to anxiety? a. Titrate O2 to keep saturation at least 90%. b. Teach the patient how to use the pursed-lip technique. c. Discuss a high-protein, high-calorie diet with the patient. d. Suggest the use of over-the-counter sedative medications.

ANS: B b. Teach the patient how to use the pursed-lip technique.

A patient with chronic obstructive pulmonary disease (COPD) has coarse crackles throughout the lung fields and a chronic, nonproductive cough. Which nursing intervention will be most effective? a. Increase the O2 flow rate to the highest prescribed rate. b. Teach the patient to use a Flutter airway clearance device. c. Reinforce the ongoing use of pursed-lip breathing techniques. d. Teach the patient about consistent use of inhaled corticosteroids.

ANS: B b. Teach the patient to use a Flutter airway clearance device.

The clinic nurse makes a follow-up telephone call to a patient with asthma. The patient reports having a baseline peak flow reading of 600 L/min, and the current peak flow is 420 L/min. Which action should the nurse take first? a. Tell the patient to go to the hospital emergency department. b. Teach the patient to use the prescribed albuterol (Ventolin HFA). c. Ask about recent exposure to any new allergens or asthma triggers. d. Question the patient about use of the prescribed inhaled corticosteroids.

ANS: B b. Teach the patient to use the prescribed albuterol (Ventolin HFA).

The nurse supervises the care of a patient with a temporary radioactive cervical implant. Which action by unlicensed assistive personnel (UAP), if observed by the nurse, would require an intervention? a. The UAP flushes the toilet once after emptying the patient's bedpan. b. The UAP stands by the patient's bed for 30 minutes talking with the patient. c. The UAP places the patient's bedding in the laundry container in the hallway. d. The UAP gives the patient an alcohol-containing mouthwash to use for oral care.

ANS: B b. The UAP stands by the patient's bed for 30 minutes talking with the patient.

The nurse is admitting a patient who has chest pain. Which assessment data suggest that the pain is from an acute myocardial infarction? a. The pain increases with deep breathing. b. The pain has lasted longer than 30 minutes. c. The pain is relieved after the patient takes nitroglycerin. d. The pain is reproducible when the patient raises the arms.

ANS: B b. The pain has lasted longer than 30 minutes.

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? a. The patient drinks 1 to 2 cups of coffee daily. b. The patient had a recent acute myocardial infarction. c. The patient has had migraine headaches for 30 years. d. The patient has taken topiramate (Topamax) for 2 months.

ANS: B b. The patient had a recent acute myocardial infarction.

The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? a. The pulse rate is 102 beats/min. b. The patient has difficulty speaking. c. The blood pressure is 144/86 mm Hg. d. There are fine crackles at the lung bases.

ANS: B b. The patient has difficulty speaking.

Which information about a patient with multiple sclerosis indicates that the nurse should consult with the health care provider before giving the prescribed dose of dalfampridine (Ampyra)? a. The patient reports pain with neck flexion. b. The patient has increased serum creatinine. c. The patient walks a mile each day for exercise. d. The patient has the relapsing-remitting form of MS.

ANS: B b. The patient has increased serum creatinine.

The nurse teaches a patient who has chronic bronchitis about a new prescription for combined fluticasone and salmeterol (Advair Diskus). Which patient action indicates to the nurse that teaching about medication administration has been successful? a. The patient shakes the device before use. b. The patient rapidly inhales the medication. c. The patient attaches a spacer to the device. d. The patient performs huff coughing after inhalation.

ANS: B b. The patient rapidly inhales the medication.

A 39-yr-old patient with a suspected herniated intervertebral disc is scheduled for a myelogram. Which information communicated by the nurse to the health care provider before the procedure would change the procedural plans? a. The patient is anxious about the test results. b. The patient reports a previous allergy to shellfish. c. The patient has back pain when lying flat for more than 4 hours. d. The patient drank apple juice 4 hours before the scheduled procedure.

ANS: B b. The patient reports a previous allergy to shellfish.

The nurse is caring for a patient with colon cancer who is scheduled for external radiation therapy to the abdomen. Which information obtained by the nurse would indicate a need for patient teaching? a. The patient has a history of dental caries. b. The patient swims several days each week. c. The patient snacks frequently during the day. d. The patient showers each day with mild soap.

ANS: B b. The patient swims several days each week.

Which information about a patient who is scheduled for an oral glucose tolerance test should the nurse consider in interpreting the test results? a. The patient reports having occasional orthostatic dizziness. b. The patient takes oral corticosteroids for rheumatoid arthritis. c. The patient has had a 10 pound weight gain in the last month. d. The patient drank several glasses of water an hour previously.

ANS: B b. The patient takes oral corticosteroids for rheumatoid arthritis

Which information about the patient who had a subarachnoid hemorrhage is most important to communicate to the health care provider? a. The patient reports having a stiff neck. b. The patient's blood pressure (BP) is 90/50 mm Hg. c. The patient reports a severe and unrelenting headache. d. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).

ANS: B b. The patient's blood pressure (BP) is 90/50 mm Hg.

The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider? a. The patient's temperature is 100.3° F (37.9° C). b. The patient's calf is swollen and warm to touch. c. The patient reports abdominal pain when ambulating. d. The patient has fluid intake 600 mL greater than the output.

ANS: B b. The patient's calf is swollen and warm to touch.

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? a. The patient has an outflow volume of 1800 mL. b. The patient's peritoneal effluent appears cloudy. c. The patient's abdomen appears bloated after the inflow. d. The patient has abdominal pain during the inflow phase.

ANS: B b. The patient's peritoneal effluent appears cloudy.

Which additional information should the nurse consider when reviewing the laboratory results for a patient's total calcium level? a. The blood glucose b. The serum albumin c. The phosphate level d. The magnesium level

ANS: B b. The serum albumin

The nurse observes a student who is listening to a patient's lungs. Which action by the student indicates a need to review respiratory assessment skills? a. The student compares breath sounds from side to side at each level. b. The student listens during the inspiratory phase, then moves the stethoscope. c. The student starts at the apices of the lungs, moving down toward the lung bases. d. The student instructs the patient to breathe slowly and deeply through the mouth.

ANS: B b. The student listens during the inspiratory phase, then moves the stethoscope.

After administering medication, the nurse asks the patient if pain was relieved. What is the purpose of the evaluation phase of the nursing process? a. To document the nursing care plan in the progress notes of the health record b. To determine if interventions have been effective in meeting patient outcomes c. To decide whether the patient's health problems have been completely resolved d. To establish if the patient agrees that the nursing care provided was satisfactory

ANS: B b. To determine if interventions have been effective in meeting patient outcomes

What should the nurse teach a patient who is scheduled to complete a 24-hour urine collection for 17-ketosteroids? a. To insert and maintain a retention catheter b. To keep the specimen refrigerated or on ice c. To drink at least 3 L of fluid during the 24 hours d. To void and save the specimen to start the collection

ANS: B b. To keep the specimen refrigerated or on ice

Which finding on a patient's nursing admission assessment is congruent with the initial medical diagnosis of a 6-cm thoracic aortic aneurysm? a. Low back pain b. Trouble swallowing c. Abdominal tenderness d. Changes in bowel habits

ANS: B b. Trouble swallowing

Which equipment should the nurse obtain to assess vibration sense in a patient with diabetes who has peripheral nerve dysfunction? a. Sharp pin b. Tuning fork c. Reflex hammer d. Calibrated compass

ANS: B b. Tuning fork

Which finding should the nurse expect when assessing a patient who is experiencing a cluster headache? a. Nuchal rigidity b. Unilateral ptosis c. Projectile vomiting d. Bilateral facial pain

ANS: B b. Unilateral ptosis

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? a. Acetaminophen b. Calcium phosphate c. Magnesium hydroxide d. Multivitamin with iron

ANS: C b. Calcium phosphate

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? a. "Thinking about dying will not improve the course of AIDS." b. "Do you think that taking an antidepressant might be helpful?" c. "Can you tell me more about the thoughts that you are having?" d. "It is important to focus on the good things about your life now."

ANS: C c. "Can you tell me more about the thoughts that you are having?"

The nurse is caring for a patient diagnosed with stage I colon cancer. When assessing the need for psychological support, which question by the nurse will provide the most information? a. "How long ago were you diagnosed with this cancer?" b. "Do you have any concerns about body image changes?" c. "Can you tell me what has been helpful when coping with past stressful events?" d. "Are you familiar with the stages of emotional adjustment to cancer of the colon?"

ANS: C c. "Can you tell me what has been helpful when coping with past stressful events?"

When preparing a clinic patient who has chronic obstructive pulmonary disease (COPD) for pulmonary spirometry, what question should the nurse ask? a. "Are you claustrophobic?" b. "Are you allergic to shellfish?" c. "Have you taken any bronchodilators today?" d. "Do you have any metal implants or prostheses?"

ANS: C c. "Have you taken any bronchodilators today?"

Heparin is ordered for a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI). How should the nurse explain the purpose of the heparin to the patient? a. "Heparin enhances platelet aggregation at the plaque site." b. "Heparin decreases the size of the coronary artery plaque." c. "Heparin prevents the development of new clots in the coronary arteries." d. "Heparin dissolves clots that are blocking blood flow in the coronary arteries."

ANS: C c. "Heparin prevents the development of new clots in the coronary arteries."

Which statement made by a 50-yr-old female patient indicates to the nurse that further assessment of thyroid function may be needed? a. "I am so thirsty that I drink all day long." b. "I get up several times at night to urinate." c. "I feel a lump in my throat when I swallow." d. "I notice my breasts are always tender lately."

ANS: C c. "I feel a lump in my throat when I swallow."

Which patient statement indicates understanding of the nurse's teaching about a new short-arm synthetic cast? a. "I can remove the cast in 4 weeks using industrial scissors." b. "I should avoid moving my fingers until the cast is removed." c. "I will apply an ice pack to the cast over the fracture site off and on for 24 hours." d. "I can use a cotton-tipped applicator to rub lotion on any dry areas under the cast."

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

A patient with chronic 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? a. "I plan to take the medication with food." b. "I should eat more potassium-rich foods." c. "I will call for help when I need to get up to use the bathroom." d. "I can expect to feel more short of breath for the next few days."

ANS: C c. "I will call for help when I need to get up to use the bathroom."

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? a. "I will buy seven new catheters weekly and use a new one every day." b. "I will use a sterile catheter and gloves for each time I self-catheterize." c. "I will clean the catheter carefully before and after each catheterization." d. "I will take prophylactic antibiotics to prevent any urinary tract infections."

ANS: C c. "I will clean the catheter carefully before and after each catheterization."

The nurse teaches a patient about pulmonary spirometry testing. Which statement by the patient indicates teaching was effective? a. "I should use my inhaler right before the test." b. "I won't eat or drink anything 8 hours before the test." c. "I will inhale deeply and blow out hard during the test." d. "My blood pressure and pulse will be checked every 15 minutes."

ANS: C c. "I will inhale deeply and blow out hard during the test."

The nurse should determine that teaching about migraine headaches has been effective when the patient says which of the following? a. "I can take the (Topamax) as soon as a headache starts." b. "A glass of wine might help me relax and prevent a headache." c. "I will lie down someplace dark and quiet when the headaches begin." d. "I should avoid taking aspirin and sumatriptan (Imitrex) at the same time."

ANS: C c. "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? a. "I need to get most of my protein from low-fat dairy products." b. "I will increase my intake of fruits and vegetables to 5 per day." c. "I will measure my output each day to help calculate the amount I can drink." d. "I need erythropoietin injections to boost my immunity and prevent infection."

ANS: C c. "I will measure my output each day to help calculate the amount I can drink."

The nurse teaches a postmenopausal patient with stage III breast cancer about the expected outcomes of cancer treatment. Which patient statement indicates that the teaching has been effective? a. "After cancer has not recurred for 5 years, it is considered cured." b. "The cancer will be cured if the entire tumor is surgically removed." c. "I will need follow-up examinations for many years after treatment before I can be considered cured." d. "Cancer is never cured, but the tumor can be controlled with surgery, chemotherapy, and radiation."

ANS: C c. "I will need follow-up examinations for many years after treatment before I can be considered cured."

A patient who is scheduled for a breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is accurate? a. "Benign tumors do not cause damage to other tissues." b. "Benign tumors are likely to recur in the same location." c. "Malignant tumors may spread to other tissues or organs." d. "Malignant cells reproduce more rapidly than normal cells."

ANS: C c. "Malignant tumors may spread to other tissues or organs."

A woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. How should the nurse respond? a. "MS symptoms will be worse after the pregnancy." b. "Women with MS frequently have premature labor." c. "Symptoms of MS are likely to improve during pregnancy." d. "MS is associated with an increased risk for congenital defects."

ANS: C c. "Symptoms of MS are likely to improve during pregnancy."

The nurse teaches a student nurse about how to apply the nursing process when providing patient care. Which statement by the student nurse indicates that teaching was successful? a. "The nursing process is a research method of diagnosing the patient's health care problems." b. "The nursing process is used primarily to explain nursing interventions to other health care professionals." c. "The nursing process is a problem-solving tool used to identify and treat the patients' health care needs." d. "The nursing process is based on nursing theory that incorporates the biopsychosocial nature of humans."

ANS: C c. "The nursing process is a problem-solving tool used to identify and treat the patients' health care needs."

A 53-yr-old patient with stage D heart failure and type 2 diabetes asks the nurse whether heart transplant is an option. Which response is accurate? a. "Your heart failure has not reached the end stage yet." b. "You could not manage the multiple complications of that surgery." c. "The suitability of a heart transplant for you depends on many factors." d. "Because you have diabetes, you would not be a heart transplant candidate."

ANS: C c. "The suitability of a heart transplant for you depends on many factors."

Which instruction should the nurse include in an exercise teaching plan for a patient with chronic obstructive pulmonary disease (COPD)? a. "Avoid upper body exercises to prevent dyspnea." b. "Stop exercising if you start to feel short of breath." c. "Use the bronchodilator before you start to exercise." d. "Breathe in and out through the mouth while exercising."

ANS: C c. "Use the bronchodilator before you start to exercise."

A 72-yr-old patient is brought to the clinic by the patient's spouse, who reports that the patient is unable to solve common problems around the house. To obtain information about the patient's current mental status, which question should the nurse ask the patient? a. "Are you sad right now?" b. "How is your self-image?" c. "What did you eat for lunch?" d. "Where were you were born?"

ANS: C c. "What did you eat for lunch?"

A patient with ST-segment elevation in three contiguous electrocardiographic leads is admitted to the emergency department and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which question should the nurse ask to determine whether the patient is a candidate for thrombolytic therapy? a. "Do you have any allergies?" b. "Do you take aspirin daily?" c. "What time did your pain begin?" d. "Can you rate the pain on a 0 to 10 scale?"

ANS: C c. "What time did your pain begin?"

In preparation for which test should the nurse teach the patient to minimize physical and emotional stress? a. A water deprivation test b. A test for serum T3 and T4 levels c. A 24-hour urine test for free cortisol d. A radioactive iodine (I-131) uptake test

ANS: C c. A 24-hour urine test for free cortisol

The nurse receives change-of-shift report on the oncology unit. Which patient should the nurse assess first? a. A 35-yr-old patient who has wet desquamation associated with abdominal radiation b. A 42-yr-old patient who is sobbing after receiving a new diagnosis of ovarian cancer c. A 24-yr-old patient who received neck radiation and has blood oozing from the neck d. A 56-yr-old patient who developed a new pericardial friction rub after chest radiation ANS: C

ANS: C c. A 24-yr-old patient who received neck radiation and has blood oozing from the neck

After change-of-shift report, which patient should the nurse assess first? a. A 40-yr-old with a pleural effusion who reports severe stabbing chest pain b. A 72-yr-old with cor pulmonale who has 4+ bilateral edema in his legs and feet c. A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter insertion d. A 28-yr-old with a history of a lung transplant 1 month ago and a fever of 101° F (38.3° C)

ANS: C c. A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter insertion

After the nurse has received change-of-shift report, which patient should the nurse assess first? a. A patient with pneumonia who has crackles in the right lung base. b. A patient with chronic bronchitis who has a low forced vital capacity. c. A patient with possible lung cancer who has just returned after bronchoscopy. d. A patient with hemoptysis and a 16-mm induration after tuberculin skin testing.

ANS: C c. A patient with possible lung cancer who has just returned after bronchoscopy.

A patient with a complex pelvic fracture from a motor vehicle crash is on bed rest. Which assessment finding should indicate to the nurse a potential complication of the fracture? a. The patient states the pelvis feels unstable. b. The patient reports pelvic pain with palpation. c. Abdomen is distended, and bowel sounds are absent. d. Ecchymoses are visible across the abdomen and hips.

ANS: C c. Abdomen is distended, and bowel sounds are absent.

What should the nurse include in a focused assessment of a patient's left posterior temporal lobe functions? a. Sensation on the left side of the body b. Reasoning and problem-solving ability c. Ability to understand written and oral language d. Voluntary movements on the right side of the body

ANS: C c. Ability to understand written and oral language

Which finding by the nurse during abdominal auscultation indicates a need for a focused abdominal assessment? a. Loud gurgles b. High-pitched gurgles c. Absent bowel sounds d. Frequent clicking sounds

ANS: C c. Absent bowel sounds

Which prescribed intervention should the emergency department nurse implement first for a patient who is experiencing continuous tonic-clonic seizures? a. Give phenytoin (Dilantin) 100 mg IV. b. Monitor level of consciousness (LOC). c. Administer lorazepam (Ativan) 4 mg IV. d. Obtain computed tomography (CT) scan.

ANS: C c. Administer lorazepam (Ativan) 4 mg IV.

A patient with metastatic colon cancer has severe vomiting after each administration of chemotherapy. Which action by the nurse is appropriate? a. Have the patient eat large meals when nausea is not present. b. Offer dry crackers and carbonated fluids during chemotherapy. c. Administer prescribed antiemetics 1 hour before the treatments. d. Give the patient a glass of a citrus fruit beverage during treatments.

ANS: C c. Administer prescribed antiemetics 1 hour before the treatments.

The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/VN)? a. Assess the patient's gag and cough reflexes. b. Determine when the stroke symptoms began. c. Administer the prescribed short-acting insulin. d. Infuse the prescribed IV metoprolol (Lopressor).

ANS: C c. Administer the prescribed short-acting insulin.

A patient has inadequate nutrition due to painful oral ulcers. Which nursing action will be most effective in improving oral intake? a. Offer the patient frequent small snacks between meals. b. Assist the patient to choose favorite foods from the menu. c. Apply prescribed anesthetic gel to oral lesions before meals. d. Teach the patient about the importance of nutritional intake.

ANS: C c. Apply prescribed anesthetic gel to oral lesions before meals.

A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan? a. Purpose of antibiotic therapy b. Ways to limit oral fluid intake c. Appropriate use of cough suppressants d. Safety concerns with home O2 therapy

ANS: C c. Appropriate use of cough suppressants

When administering the Mini-Cog exam to a patient with possible Alzheimer's disease, which action will the nurse take? a. Check the patient's orientation to time and date. b. Obtain a list of the patient's prescribed medications. c. Ask the patient to indicate a specific time on a clock drawing. d. Determine the patient's ability to recognize a common object.

ANS: C c. Ask the patient to indicate a specific time on a clock drawing.

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? a. Teach about the use of triptan drugs. b. Refer the patient for stress counseling. c. Ask the patient to keep a headache diary. d. Suggest the use of muscle-relaxation techniques.

ANS: C c. Ask the patient to keep a headache diary.

The charge nurse is observing a new nurse who is assessing a patient with a traumatic spinal cord injury for sensation. Which action by the new nurse indicates the need for further teaching about neurologic assessment? a. Tests for light touch before testing for pain. b. Has the patient close the eyes during testing. c. Asks the patient if the instrument feels sharp. d. Uses an irregular pattern to test for intact touch.

ANS: C c. Asks the patient if the instrument feels sharp.

After a motorcycle accident, a patient arrives in the emergency department with severe swelling of the left lower leg. Which action should the nurse take first? a. Elevate the leg on 2 pillows. b. Apply a compression bandage. c. Assess leg pulses and sensation. d. Place ice packs on the lower leg.

ANS: C c. Assess leg pulses and sensation.

A patient who slipped and fell in the shower at home has a proximal left humerus fracture immobilized with a sling. Which intervention should the nurse include in the plan of care? a. Use surgical net dressing to hang the arm from an IV pole. b. Immobilize the fingers of the left hand with gauze dressings. c. Assess the left axilla and change absorbent dressings as needed. d. Assist the patient in passive range of motion (ROM) for the right arm.

ANS: C c. Assess the left axilla and change absorbent dressings as needed.

A pedestrian who was hit by a car is admitted to the emergency department with possible right lower leg fractures. What initial action should the nurse take? a. Elevate the right leg. b. Splint the lower leg. c. Assess the pedal pulses. d. Verify tetanus immunization.

ANS: C c. Assess the pedal pulses.

A patient will attempt oral feedings for the first time after having a stroke. After assessing the gag reflex, what action should the nurse take? a. Order a varied pureed diet. b. Assess the patient's appetite. c. Assist the patient into a chair. d. Offer the patient a sip of juice.

ANS: C c. Assist the patient into a chair.

A left-handed patient with left-sided hemiplegia has difficulty feeding himself. Which intervention should the nurse include in the plan of care? a. Provide a wide variety of food choices. b. Provide oral care before and after meals. c. Assist the patient to eat with the right hand. d. Teach the patient the "chin-tuck" technique.

ANS: C c. Assist the patient to eat with the right hand.

A 68-yr-old patient admitted to the hospital with dehydration is confused and incontinent of urine. Which nursing action should be included in the plan of care? a. Restrict fluids between meals and after the evening meal. b. Insert an indwelling catheter until the symptoms have resolved. c. Assist the patient to the bathroom every 2 hours during the day. d. Apply absorbent adult incontinence diapers and pads over the bed linens.

ANS: C c. Assist the patient to the bathroom every 2 hours during the day.

Which information about a patient with Goodpasture syndrome requires the most rapid action by the nurse? a. Blood urea nitrogen level is 70 mg/dL. b. Urine output over the last 2 hours is 30 mL. c. Audible crackles bilaterally over the posterior chest to the midscapular level. d. Elevated level of antiglomerular basement membrane (anti-GBM) antibodies.

ANS: C c. Audible crackles bilaterally over the posterior chest to the midscapular level.

A patient recovering from a myocardial infarction (MI) develops chest pain on day 3 that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take as focused follow-up on this symptom? a. Assess both feet for pedal edema. b. Palpate the radial pulses bilaterally. c. Auscultate for a pericardial friction rub. d. Check the heart monitor for dysrhythmias.

ANS: C c. Auscultate for a pericardial friction rub.

A patient who has chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. Which action should the nurse take first? a. Auscultate the abdomen. b. Check the capillary refill. c. Auscultate the breath sounds. d. Ask about the patient's allergies.

ANS: C c. Auscultate the breath sounds.

A patient with cancer is eating very little due to altered taste sensation. Which nursing action would address the cause of the patient problem? a. Add protein powder to foods such as casseroles. b. Tell the patient to eat foods that are high in nutrition. c. Avoid giving the patient foods that are strongly disliked. d. Add spices to enhance the flavor of foods that are served.

ANS: C c. Avoid giving the patient foods that are strongly disliked.

Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute shortness of breath has heart failure? a. Serum troponin b. Arterial blood gases c. B-type natriuretic peptide d. 12-lead electrocardiogram

ANS: C c. B-type natriuretic peptide

The nurse obtains the following data when assessing a patient who experienced an ST-segment-elevation myocardial infarction (STEMI) 2 days previously. Which information is most important to report to the health care provider? a. The troponin level is elevated. b. The patient denies having a heart attack. c. Bilateral crackles in the mid-lower lobes. d. Occasional premature atrial contractions (PACs).

ANS: C c. Bilateral crackles in the mid-lower lobes.

A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient? a. Ask the patient to lie down to complete a full physical assessment. b. Complete the health history and check for allergies before treatment. c. Briefly ask specific questions about this episode of respiratory distress. d. Delay the physical assessment to first complete pulmonary function tests.

ANS: C c. Briefly ask specific questions about this episode of respiratory distress.

What should the nurse include when teaching older adults at a community recreation center about ways to prevent fractures? a. Tack down scatter rugs on the floor in the home. b. Expect most falls to happen outside the home in the yard. c. Buy shoes that provide good support and are comfortable to wear. d. Get instruction in range-of-motion exercises from a physical therapist.

ANS: C c. Buy shoes that provide good support and are comfortable to wear.

Which information should the nurse include in discharge instructions for a patient with comminuted left forearm fractures and along-arm cast? a. Keep the left shoulder elevated on a pillow or cushion. b. Avoid nonsteroidal antiinflammatory drugs (NSAIDs). c. Call the health care provider for numbness of the hand. d. Keep the hand immobile to prevent soft tissue swelling.

ANS: C c. Call the health care provider for numbness of the hand.

Which finding in a patient with a Colles' fracture of the left wrist should the nurse identify as most important to communicate immediately to the health care provider? a. The patient reports severe pain. b. Swelling is noted around the wrist. c. Capillary refill to the fingers is slow. d. The wrist has a deformed appearance.

ANS: C c. Capillary refill to the fingers is slow.

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? a. Urine volume b. Calcium level c. Cardiac rhythm d. Neurologic status

ANS: C c. Cardiac rhythm

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? a. Notify the patient's health care provider. b. Document the QRS interval measurement. c. Check the patient's most recent potassium level. d. Review the chart for the patient's current creatinine level.

ANS: C c. Check the patient's most recent potassium level.

The nurse is examining an adult patient. For what purpose would the nurse use palpation? a. Determining kidney function b. Identifying renal artery bruits c. Checking for bladder distention d. Assessing for ureteral peristalsis

ANS: C c. Checking for bladder distention

What action should the nurse incorporate when administering a mental status examination to a patient with delirium? a. Wait until the patient is well-rested. b. Administer an anxiolytic medication. c. Choose a place without distracting stimuli. d. Reorient the patient during the examination.

ANS: C c. Choose a place without distracting stimuli.

External-beam radiation is planned for a patient with cervical cancer. What instructions should the nurse give to the patient to prevent complications from the effects of the radiation? a. Test all stools for the presence of blood. b. Maintain a high-residue, high-fiber diet. c. Clean the perianal area carefully after every bowel movement. d. Inspect the mouth and throat daily for the appearance of thrush.

ANS: C c. Clean the perianal area carefully after every bowel movement.

A patient is admitted to the postanesthesia care unit (PACU) with a blood pressure (BP) 122/72 mm Hg. Thirty minutes after admission, the BP is 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate? a. Increase the postoperative IV fluid rate. b. Notify the anesthesia care provider (ACP). c. Continue to take vital signs every 15 minutes. d. Administer oxygen therapy at 100% per mask.

ANS: C c. Continue to take vital signs every 15 minutes.

The nurse is administering a thrombolytic agent to a patient with an acute myocardial infarction. What patient data indicates that the nurse should stop the drug infusion? a. Bleeding from the gums b. An increase in blood pressure c. Decreased level of consciousness d. A nonsustained episode of ventricular tachycardia

ANS: C c. Decreased level of consciousness

What concern should the nurse anticipate for a patient who had a right hemisphere stroke? a. Right-sided hemiplegia b. Speech-language deficits c. Denial of deficits and impulsiveness d. Depression and distress about disability

ANS: C c. Denial of deficits and impulsiveness

A patient who has ovarian cancer is crying and tells the nurse, "My husband rarely visits. He just doesn't care." The husband tells the nurse that he does not know what to say to his wife. Which problem is appropriate for the nurse to address in the plan of care? a. Anxiety b. Death anxiety c. Difficulty coping d. Lack of knowledge

ANS: C c. Difficulty coping

The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. Which sounds would the nurse most likely hear on auscultation? a. Continuous rumbling, snoring, or rattling sounds mainly on expiration b. Continuous high-pitched musical sounds on inspiration and expiration c. Discontinuous high-pitched sounds of short duration during inspiration d. A series of long-duration, discontinuous, low-pitched sounds during inspiration

ANS: C c. Discontinuous high-pitched sounds of short duration during inspiration

A patient treated for human immunodeficiency virus (HIV) infection for 6 years has developed fat redistribution to the trunk with wasting of the arms, legs, and face. What recommendation will the nurse give to the patient? a. Review foods that are higher in protein. b. Teach about the benefits of daily exercise. c. Discuss a change in antiretroviral therapy. d. Talk about treatment with antifungal agents.

ANS: C c. Discuss a change in antiretroviral therapy.

A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, "I don't need the aspirin today. I don't have a fever." Which action should the nurse take? a. Document that the patient refused the aspirin. b. Tell the patient that the aspirin is used to prevent a fever. c. Explain that the aspirin is ordered to decrease stroke risk. d. Call the health care provider to clarify the medication order.

ANS: C c. Explain that the aspirin is ordered to decrease stroke risk.

The nurse palpates enlarged cervical lymph nodes on a patient diagnosed with acute human immunodeficiency virus (HIV) infection. Which action would be appropriate for the nurse to take? a. Instruct the patient to apply ice to the neck. b. Tell the patient a secondary infection is present. c. Explain to the patient that this is an expected finding. d. Request that an antibiotic be prescribed for the patient.

ANS: C c. Explain to the patient that this is an expected finding.

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? a. Bed rest for the first 24 hours b. Positioning only on the right side c. Frequent use of an incentive spirometer d. Chest tube placement to continuous suction

ANS: C c. Frequent use of an incentive spirometer

During the neurologic assessment, the patient is unable to respond verbally to the nurse but cooperates with the nurse's directions to move his hands and feet. What should the nurse suspect as a likely cause of these findings? a. Cerebellar injury b. A brainstem lesion c. Frontal lobe damage d. A temporal lobe lesion

ANS: C c. Frontal lobe damage

Postural drainage with percussion and vibration is ordered twice daily for a patient with chronic obstructive pulmonary disease. Which intervention should the nurse include in the plan of care? a. Schedule the procedure 1 hour after the patient eats. b. Maintain the patient in the lateral position for 20 minutes. c. Give the prescribed albuterol (Ventolin HFA) before the therapy. d. Perform percussion before assisting the patient to the drainage position.

ANS: C c. Give the prescribed albuterol (Ventolin HFA) before the therapy.

A patient is hospitalized with acute kidney injury (AKI). Which information will be most useful to the nurse in evaluating improvement in kidney function? a. Urine volume b. Creatinine level c. Glomerular filtration rate (GFR) d. Blood urea nitrogen (BUN) level

ANS: C c. Glomerular filtration rate (GFR)

What information will a review of a patient's glycosylated hemoglobin (A1C) results provide to the nurse? a. Fasting preprandial glucose levels b. Glucose levels 2 hours after a meal c. Glucose control over the past 90 days d. Hypoglycemic episodes in the past 3 months

ANS: C c. Glucose control over the past 90 days

The nurse is caring for a patient who has a pelvic fracture and an external fixation device. How should the nurse perform assessment of pressure areas and provide skin care to the patient's back and sacrum? a. Ask the patient to turn to the side independently. b. Defer back assessment until the patient is ambulatory. c. Have the patient lift the back and buttocks using a trapeze. d. Roll the patient over to the side by pushing on the patient's hips.

ANS: C c. Have the patient lift the back and buttocks using a trapeze.

Which nursing action will be most useful in assisting a young adult to adhere to a newly prescribed antiretroviral therapy (ART) regimen? a. Give the patient detailed information about possible medication side effects. b. Remind the patient of the importance of taking the medications as scheduled. c. Help the patient develop a schedule to decide when the drugs should be taken. d. Encourage the patient to join a support group for adults who are HIV positive.

ANS: C c. Help the patient develop a schedule to decide when the drugs should be taken.

A patient with bacterial pneumonia has coarse crackles and thick sputum. Which action should the nurse plan to promote airway clearance? a. Restrict oral fluids during the day. b. Encourage pursed-lip breathing technique. c. Help the patient to splint the chest when coughing. d. Encourage the patient to wear the nasal O2 cannula.

ANS: C c. Help the patient to splint the chest when coughing.

A 33-yr-old patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information should the nurse include in patient teaching? a. Recommendation to drink at least 4 L of fluid daily b. Need to avoid driving or operating heavy machinery c. How to draw up and administer injections of the medication d. Use of contraceptive methods other than oral contraceptives

ANS: C c. How to draw up and administer injections of the medication

While assessing an older adult patient, the nurse notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. What does this finding indicate? a. Decreased fluid volume b. Jugular vein atherosclerosis c. Increased right atrial pressure d. Incompetent jugular vein valves

ANS: C c. Increased right atrial pressure

A patient with a chronic cough is scheduled to have a bronchoscopy with biopsy. Which intervention will the nurse implement directly after the procedure? a. Encourage the patient to drink clear liquids. b. Place the patient on bed rest for at least 4 hours. c. Keep the patient NPO until the gag reflex returns. d. Maintain the head of the bed elevated 90 degrees.

ANS: C c. Keep the patient NPO until the gag reflex returns.

A patient is diagnosed with moderate dementia after multiple strokes. What would the nurse expect to find during assessment of the patient? a. Excessive nighttime sleepiness. b. Difficulty eating and swallowing. c. Loss of recent and long-term memory. d. Fluctuating ability to perform simple tasks.

ANS: C c. Loss of recent and long-term memory.

When caring for a patient on the first postoperative day after an abdominal aortic aneurysm repair, which assessment finding is most important for the nurse to communicate to the health care provider? a. Presence of flatus b. Hypoactive bowel sounds c. Maroon-colored liquid stool d. Abdominal pain with palpation

ANS: C c. Maroon-colored liquid 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? a. Assist the patient to sit upright in a chair. b. Splint the patient's chest during coughing. c. Medicate the patient with prescribed morphine. d. Observe the patient use the incentive spirometer.

ANS: C c. Medicate the patient with prescribed morphine.

Which exposure by the nurse is most likely to require postexposure prophylaxis when the patient's human immunodeficiency virus (HIV) status is unknown? a. Bite to the arm that does not result in open skin b. Splash into the eyes while emptying a bedpan containing stool c. Needle stick with a needle and syringe used for a venipuncture d. Contamination of open skin lesions with patient vaginal secretions

ANS: C c. Needle stick with a needle and syringe used for a venipuncture

Which information about a patient receiving thrombolytic therapy for an acute myocardial infarction is most important for the nurse to communicate to the health care provider? a. An increase in troponin levels from baseline b. A large bruise at the patient's IV insertion site c. No change in the patient's reported level of chest pain d. A decrease in ST-segment elevation on the electrocardiogram

ANS: C c. No change in the patient's reported level of chest pain

The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide. Which instruction should the nurse include? a. Limit dietary sources of potassium. b. Take the hydrochlorothiazide at bedtime. c. Notify the health care provider if nausea develops. d. Take the digoxin if the pulse is below 60 beats/min.

ANS: C c. Notify the health care provider if nausea develops.

A patient who was admitted with diabetic ketoacidosis secondary to a urinary tract infection has been weaned off an insulin drip 30 minutes ago. The patient reports feeling lightheaded and sweaty. Which action should the nurse take first? a. Infuse dextrose 50% by slow IV push. b. Administer 1 mg glucagon subcutaneously. c. Obtain a glucose reading using a finger stick. d. Have the patient drink 4 ounces of orange juice.

ANS: C c. Obtain a glucose reading using a finger stick.

What topic should the nurse anticipate teaching a patient who had a brief episode of tinnitus, diplopia, and dysarthria with non residual effects? a. Cerebral aneurysm clipping b. Heparin intravenous infusion c. Oral low-dose aspirin therapy d. Tissue plasminogen activator (tPA)

ANS: C c. Oral low-dose aspirin therapy

A patient has a chest wall contusion as a result of being struck in the chest with a baseball bat. Which initial assessment finding is of most concern to the emergency department nurse? a. Report of chest wall pain b. Heart rate of 110 beats/min c. Paradoxical chest movement d. Large bruised area on the chest

ANS: C c. Paradoxical chest movement

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!" How should the nurse document this finding? a. Orthopnea b. Pulsus alternans c. Paroxysmal nocturnal dyspnea d. Acute bilateral pleural effusion

ANS: C c. Paroxysmal nocturnal dyspnea

Which patient who has arrived at the human immunodeficiency virus (HIV) clinic should the nurse assess first? a. Patient whose rapid HIV-antibody test is positive. b. Patient whose latest CD4+ count has dropped to 250/μL. c. Patient who has had 10 liquid stools in the last 24 hours. d. Patient who has nausea from prescribed antiretroviral drugs.

ANS: C c. Patient who has had 10 liquid stools in the last 24 hours.

After change-of-shift report on the oncology unit, which patient should the nurse assess first? a. Patient who has a platelet count of 82,000/μL after chemotherapy. b. Patient who has xerostomia after receiving head and neck radiation. c. Patient who is neutropenic and has a temperature of 100.5° F (38.1° C). d. Patient who is worried about getting the prescribed long-acting opioid on time.

ANS: C c. Patient who is neutropenic and has a temperature of 100.5° F (38.1° C).

Which hospitalized patient will the nurse assign to the room closest to the nurses' station? a. Patient with Alzheimer's disease who has long-term memory deficit b. Patient with vascular dementia who takes medications for depression c. Patient with new-onset confusion, restlessness, and irritability after surgery d. Patient with dementia who has an abnormal Mini-Mental State Examination

ANS: C c. Patient with new-onset confusion, restlessness, and irritability after surgery

A postoperative patient has ineffective airway clearance. Which data would indicate to the nurse that interventions for this patient problem have been successful? a. Patient drinks 2 to 3 L of fluid in 24 hours. b. Patient uses the spirometer 10 times every hour. c. Patient's breath sounds are clear to auscultation. d. Patient's temperature is less than 100.2° F orally.

ANS: C c. Patient's breath sounds are clear to auscultation.

An unconscious patient who was transferred from surgery to the postanesthesia care unit (PACU) 15 minutes ago has an oxygen saturation of 89%. Which action should the nurse take first? a. Suction the patient's mouth. b. Increase the oxygen flowrate. c. Perform the jaw-thrust maneuver. d. Elevate the patient's head on two pillows.

ANS: C c. Perform the jaw-thrust maneuver.

Which intervention should the nurse include in the plan of care for a patient with new right-sided homonymous hemianopsia after a stroke?? a. Apply an eye patch to the right eye. b. Approach the patient from the right side. c. Place needed objects on the patient's left side. d. Teach the patient that the left visual deficit will resolve.

ANS: C c. Place needed objects on the patient's left side.

A patient with Alzheimer's disease (AD) who is being admitted to a long-term care facility has had several episodes of wandering away from home. Which action will the nurse include in the plan of care? a. Reorient the patient several times daily. b. Have the family bring in familiar items. c. Place the patient in a room close to the nurses' station. d. Remind the patient not to wander from the nursing unit.

ANS: C c. Place the patient in a room close to the nurses' station.

A patient admitted with acute kidney injury due to dehydration has oliguria, anemia, and hyperkalemia. Which prescribed action should the nurse take first? a. Insert a urinary retention catheter. b. Administer epoetin alfa (Epogen). c. Place the patient on a cardiac monitor. d. Give sodium polystyrene sulfonate (Kayexalate).

ANS: C c. Place the patient on a cardiac monitor.

A patient in metabolic alkalosis is admitted to the emergency department and pulse oximetry (SpO2) indicates that the O2 saturation is 94%. Which action should the nurse expect to take next? a. Complete a head-to-toe assessment. b. Administer an inhaled bronchodilator. c. Place the patient on high-flow oxygen. d. Obtain repeat arterial blood gases (ABGs).

ANS: C c. Place the patient on high-flow oxygen.

The nurse designs a program to decrease the incidence of human immunodeficiency virus (HIV) infection in the adolescent and young adult populations. Which information should the nurse assign as the highest priority? a. Methods to prevent perinatal HIV transmission. b. Ways to sterilize needles used by injectable drug users. c. Prevention of HIV transmission between sexual partners. d. Means to prevent transmission through blood transfusions.

ANS: C c. Prevention of HIV transmission between sexual partners.

A patient with diabetes mellitus and chronic stable angina has a new order for captopril. What should the nurse teach this patient about the primary purpose of captopril? a. Decreases the heart rate. b. Controls blood glucose levels. c. Prevents changes in heart muscle. d. Reduces the frequency of chest pain.

ANS: C c. Prevents changes in heart muscle.

The home health nurse is caring for an 81-yr-old who had a stroke 2 months ago. Based on patient information shown in the accompanying figure, which action should the nurse take? a. Teach about preventing hypoglycemia. b. Begin processes to obtain a wheelchair. c. Provide support to the spouse caregiver. d. Remind the patient to take prescribed medications.

ANS: C c. Provide support to the spouse caregiver.

What should the nurse ask the patient about to determine possible causes of acute glomerulonephritis? a. Recent bladder infection b. History of kidney stones c. Recent sore throat and fever d. History of high blood pressure

ANS: C c. Recent sore throat and fever

Using the illustrated technique, the nurse is assessing for which finding in a patient with chronic obstructive pulmonary disease (COPD)? a. Hyperresonance b. Tripod positioning c. Reduced excursion d. Accessory muscle use

ANS: C c. Reduced excursion

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." What should the nurse include in the discharge plan? a. Consult with a psychologist. b. Transfer to a long-term care facility. c. Referral to a home health care agency. d. Arrangements for around-the-clock care.

ANS: C c. Referral to a home health care agency.

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? a. Inform the patient about the available treatments. b. Teach the patient how to manage a possible drug regimen. c. Remind the patient to return for retesting to verify the results. d. Ask the patient to identify those persons who had intimate contact.

ANS: C c. Remind the patient to return for retesting to verify the results.

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? a. Treat workers with pulmonary fibrosis. b. Teach about symptoms of lung disease. c. Require the use of protective equipment. d. Monitor workers for coughing and wheezing.

ANS: C c. Require the use of protective equipment.

The nurse is caring for a patient with left-sided lung cancer. Which finding would be most important for the nurse to report to the health care provider? a. Hematocrit of 32% b. Pain with deep inspiration c. Serum sodium of 126 mEq/L d. Decreased breath sounds on left side

ANS: C c. Serum sodium of 126 mEq/L

A patient is admitted to the emergency department with a left femur fracture. Which assessment finding by the nurse is most important to report to the health care provider? a. Bruising of the left thigh b. Reports of severe thigh pain c. Slow capillary refill of the left foot d. Outward pointing toes on the left foot

ANS: C c. Slow capillary refill of the left foot

A patient admitted with possible stroke has been aphasic for 3 hours and has a current blood pressure (BP) of 174/94 mm Hg. Which order by the health care provider should the nurse question? a. Keep head of bed elevated at least 30 degrees. b. Infuse normal saline intravenously at 75 mL/hr. c. Start a labetalol drip to keep BP less than 140/90 mm Hg. d. Begin tissue plasminogen activator (tPA) intravenously per protocol.

ANS: C c. Start a labetalol drip to keep BP less than 140/90 mm Hg.

IV sodium nitroprusside is ordered for a patient with acute pulmonary edema. Which reassessment finding during the first hours of administration indicates that the nurse should decrease the rate of nitroprusside infusion? a. Ventricular ectopy b. Dry, hacking cough c. Systolic BP below 90 mm Hg d. Heart rate below 50 beats/min

ANS: C c. Systolic BP below 90 mm Hg

A patient is transferred from the postanesthesia care unit (PACU) to the clinical unit. Which action by the nurse on the clinical unit should be performed first? a. Assess the patient's pain. b. Orient the patient to the unit. c. Take the patient's vital signs. d. Read the postoperative orders.

ANS: C c. Take the patient's vital signs.

The nurse is caring for a patient the first postoperative day following a laparotomy for a small bowel obstruction. The nurse notices new bright-red drainage about 5 cm in diameter on the dressing. Which action should the nurse take first? a. Reinforce the dressing. b. Apply an abdominal binder. c. Take the patient's vital signs. d. Plan to recheck the dressing in 1 hour.

ANS: C c. Take the patient's vital signs.

An experienced nurse orients a new nurse to the postanesthesia care unit (PACU). Which action by the new nurse, if observed by the experienced nurse, indicates that the orientation was successful? a. The new nurse assists a nauseated patient to a supine position. b. The new nurse places a sleeping patient supine with the head elevated. c. The new nurse positions an unconscious patient on the side upon arrival in the PACU. d. The new nurse places a patient in the Trendelenburg position for a low blood pressure.

ANS: C c. The new nurse positions an unconscious patient on the side upon arrival in the PACU.

A patient has just arrived in the recovery area after an upper endoscopy. Which information collected by the nurse is most important to communicate to the health care provider? a. The patient is very drowsy. b. The patient reports a sore throat. c. The oral temperature is 101.4° F. d. The apical pulse is 100 beats/min.

ANS: C c. The oral temperature is 101.4° F.

A patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving a prescribed dose of aspirin? a. The patient has dysphasia. b. The patient has atrial fibrillation. c. The patient reports that symptoms began with a severe headache. d. The patient has a history of brief episodes of right-sided hemiplegia.

ANS: C c. The patient reports that symptoms began with a severe headache.

The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). Which information would prompt the nurse to consult with the health care provider before administering the prescribed theophylline? a. The patient reports a recent 15 pound weight gain. b. The patient denies shortness of breath at present. c. The patient takes cimetidine (Tagamet HB) daily. d. The patient reports coughing up some green mucus.

ANS: C c. The patient takes cimetidine (Tagamet HB) daily.

A patient who has severe pain with terminal pancreatic cancer is being cared for at home by family members. Which finding by the nurse indicates that teaching about pain management has been effective? a. The patient uses the ordered opioid pain medication whenever the pain is greater than 5 (0 to 10 scale). b. The patient agrees to take the medications by the IV route to improve analgesic effectiveness. c. The patient takes opioids around the clock on a regular schedule and uses additional doses when breakthrough pain occurs. d. The patient states that nonopioid analgesics may be used if the maximal dose of the opioid is reached without adequate pain relief.

ANS: C c. The patient takes opioids around the clock on a regular schedule and uses

The nurse takes an admission history on a patient with possible asthma who has new-onset wheezing and shortness of breath. Which information may indicate a need for a change in therapy? a. The patient has chronic inflammatory bowel disease. b. The patient has a history of pneumonia 6 months ago. c. The patient takes propranolol (Inderal) for hypertension. d. The patient uses acetaminophen (Tylenol) for headaches.

ANS: C c. The patient takes propranolol (Inderal) for hypertension.

Which information about an 80-yr-old male patient at the senior center is of most concern to the nurse? a. Decreased appetite b. Occasional indigestion c. Unintended weight loss d. Difficulty chewing food

ANS: C c. Unintended weight loss

When a patient arrives in the emergency department with a facial fracture, which action should the nurse take first? a. Assess for nasal bleeding and pain. b. Apply ice to the face to reduce swelling. c. Use a cervical collar to stabilize the spine. d. Check the patient's alertness and orientation.

ANS: C c. Use a cervical collar to stabilize the spine.

Which assessment finding for a patient with a history of asthma indicates that the nurse should take immediate action? a. Pulse oximetry reading of 91% b. Respiratory rate of 26 breaths/min c. Use of accessory muscles in breathing d. Peak expiratory flow rate of 240 L/min

ANS: C c. Use of accessory muscles in breathing

Which discharge instruction should the emergency department nurse include for a patient with a sprained ankle? a. Keep the ankle loosely wrapped with gauze. b. Apply a heating pad to reduce muscle spasms. c. Use pillows to elevate the ankle above the heart. d. Gently move the ankle through the range of motion.

ANS: C c. Use pillows to elevate the ankle above the heart.

Which action will help the nurse determine whether a new patient's confusion is caused by dementia or delirium? a. Ask about a family history of dementia. b. Administer the Mini-Mental Status Exam. c. Use the Confusion Assessment Method tool. d. Obtain a list of the patient's usual medications.

ANS: C c. Use the Confusion Assessment Method tool.

During change of shift report, a nurse is told that a patient has an occluded left posterior cerebral artery. What finding should the nurse anticipate? a. Dysphasia b. Confusion c. Visual deficits d. Poor judgment

ANS: C c. Visual deficits

Which question should the nurse ask to assess a patient's dysuria? a. "Do you have to urinate at night?" b. "Do you have blood in your urine?" c. "Do you have to urinate frequently?" d. "Do you have pain when you urinate?"

ANS: D d. "Do you have pain when you urinate?"

Which statement to the nurse from a patient with jaundice indicates a need for teaching? a. "I used cough syrup several times a day last week." b. "I take a baby aspirin every day to prevent strokes." c. "I take an antacid for indigestion several times a week" d. "I use acetaminophen (Tylenol) every 4 hours for pain."

ANS: D d. "I use acetaminophen (Tylenol) every 4 hours for pain."

Which patient statement indicates that the nurse's teaching about sublingual nitroglycerin (Nitrostat) has been effective? a. "I can expect nausea as a side effect of nitroglycerin." b. "I should only take nitroglycerin when I have chest pain." c. "Nitroglycerin helps prevent a clot from forming and blocking blood flow to my heart." d. "I will call an ambulance if I have pain after taking 3 nitroglycerin 5 minutes apart."

ANS: D d. "I will call an ambulance if I have pain after taking 3 nitroglycerin 5 minutes apart."

Which statement by a patient with newly diagnosed heart failure indicates to the nurse that teaching was effective? a. "I will take furosemide (Lasix) every day just before bedtime." b. "I will use the nitroglycerin patch whenever I have chest pain." c. "I will use an additional pillow if I am short of breath at night." d. "I will call the clinic if my weight goes up 3 pounds in a week."

ANS: D d. "I will call the clinic if my weight goes up 3 pounds in a week."

Which statement by a 22-yr-old female patient with cystitis indicates to the nurse that instruction regarding prevention of future urinary tract infections (UTIs) has been effective? a. "I can use vaginal antiseptic sprays to reduce bacteria." b. "I will drink a quart of water or other fluids every day." c. "I will wash with soap and water before sexual intercourse." d. "I will empty my bladder every 3 to 4 hours during the day."

ANS: D d. "I will empty my bladder every 3 to 4 hours during the day."

The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which patient statement indicates that teaching has been effective? a. "I am going to buy a rib binder to wear during the day." b. "I can take shallow breaths to prevent my chest from hurting." c. "I should plan on taking the pain pills only at bedtime so I can sleep." d. "I will use the incentive spirometer every hour or two during the day."

ANS: D d. "I will use the incentive spirometer every hour or two during the day."

The nurse admits a patient who has a diagnosis of acute asthma. Which statement indicates that the patient may need teaching regarding medication use? a. "I have not had any acute asthma attacks during the past year." b. "I became short of breath an hour before coming to the hospital." c. "I've been taking acetaminophen every 6 hours for chest wall pain." d. "I've been using my albuterol inhaler frequently over the last 4 days."

ANS: D d. "I've been using my albuterol inhaler frequently over the last 4 days."

Which information from a patient helps the nurse confirm the previous diagnosis of chronic stable angina? a. "The pain wakes me up at night." b. "The pain is level 3 to 5 (0 to 10 scale)." c. "The pain has gotten worse over the last week." d. "The pain goes away after a nitroglycerin tablet."

ANS: D d. "The pain goes away after a nitroglycerin tablet."

A patient with a possible pulmonary embolism reports 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? a. Administer anticoagulant drug therapy. b. Notify the patient's health care provider. c. Prepare patient for a spiral computed tomography (CT). d. Elevate the head of the bed to a semi-Fowler's position.

ANS: D d. Elevate the head of the bed to a semi-Fowler's position.

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/μL. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct? a. "The patient meets the criteria for a diagnosis of acute HIV infection." b. "The patient will be diagnosed with asymptomatic chronic HIV infection." c. "The patient will likely develop symptomatic HIV infection within 1 year." d. "The patient has developed acquired immunodeficiency syndrome (AIDS)."

ANS: D d. "The patient has developed acquired immunodeficiency syndrome (AIDS)."

The nurse assesses a patient on the second postoperative day after abdominal surgery to repair a perforated duodenal ulcer. Which finding is most important for the nurse to report to the surgeon? a. Tympanic temperature 99.2° F (37.3° C) b. Fine crackles audible at both lung bases c. Redness and swelling along the suture line d. 200 mL sanguineous fluid in the wound drain

ANS: D d. 200 mL sanguineous fluid in the wound drain

An 18-yr-old male patient with small stature is scheduled for a growth hormone stimulation test. What should the nurse obtain in preparation for the test? a. Ice in a basin b. Glargine insulin c. A cardiac monitor d. 50% dextrose solution

ANS: D d. 50% dextrose solution

After change-of-shift report, which patient will the nurse assess first? a. A 19-yr-old patient with type 1 diabetes who was admitted with dawn phenomenon b. A 35-yr-old patient with type 1 diabetes whose most recent blood glucose reading was 230 mg/dL c. A 68-yr-old patient with type 2 diabetes who has severe peripheral neuropathy and reports burning foot pain d. A 60-yr-old patient with hyperosmolar hyperglycemic syndrome who has poor skin turgor and dry oral mucosa

ANS: D d. A 60-yr-old patient with hyperosmolar hyperglycemic syndrome who has poor skin turgor and dry oral mucosa

A patient is being evaluated for Alzheimer's disease (AD). What should the nurse explain to the patient's adult children? a. Brain atrophy detected by an MRI would confirm the diagnosis of AD. b. New drugs can reverse AD deterioration dramatically in some patients. c. The most important risk factor for AD is a family history of the disorder. d. A diagnosis of AD is made only after other causes of dementia are ruled out.

ANS: D d. A diagnosis of AD is made only after other causes of dementia are ruled out.

Following an acute myocardial infarction, a previously healthy 63-yr-old develops heart failure. What medication topic should the nurse anticipate including in discharge teaching? a. β-Adrenergic blockers b. Calcium channel blockers c. Digitalis and potassium therapy regimen d. Angiotensin-converting enzyme (ACE) inhibitors

ANS: D d. Angiotensin-converting enzyme (ACE) inhibitors

The nurse is concerned about a postoperative patient's risk for injury during an episode of delirium. What is the nurse's most appropriate action? a. Secure the patient in bed using a soft chest restraint. b. Ask the health care provider to prescribe an antipsychotic drug. c. Instruct family members to remain at the patient's bedside and prevent injury. d. Assign unlicensed assistive personnel (UAP) to stay with and reorient the patient.

ANS: D d. Assign unlicensed assistive personnel (UAP) to stay with and reorient the patient.

A young adult employed as a hair stylist who has a 15 pack-year history of cigarette smoking arrives for an annual physical examination. Which area of increased risk should the nurse plan to teach the patient? a. Renal failure b. Kidney stones c. Pyelonephritis d. Bladder cancer

ANS: D d. Bladder cancer

A patient who has had chest pain for several hours is admitted with a diagnosis of rule out acute myocardial infarction (AMI). Which laboratory test is most specific for the nurse to monitor in determining whether the patient has had an AMI? a. Myoglobin b. Homocysteine c. C-reactive protein d. Cardiac-specific troponin

ANS: D d. Cardiac-specific troponin

The emergency department nurse notes tachycardia and absent breath sounds over the right thorax of a patient who has just arrived after an automobile accident. For which intervention will the nurse prepare the patient? a. Emergency pericardiocentesis b. Stabilization of the chest wall c. Bronchodilator administration d. Chest tube connected to suction

ANS: D d. Chest tube connected to suction

What condition should the nurse anticipate when caring for a patient with a history of a total gastrectomy? a. Constipation b. Dehydration c. Elevated total serum cholesterol d. Cobalamin (vitamin B12) deficiency

ANS: D d. Cobalamin (vitamin B12) deficiency

A patient being admitted with a stroke has right-sided facial drooping and right-sided arm and leg paralysis. Which finding should the nurse expect? a. Impulsive behavior b. Right-sided neglect c. Hyperactive left-sided tendon reflexes d. Difficulty comprehending instructions

ANS: D d. Difficulty comprehending instructions

Which medication taken by a patient with restless legs syndrome should the nurse discuss with the patient? a. Ibuprofen b. Multivitamin c. Acetaminophen d. Diphenhydramine

ANS: D d. Diphenhydramine

The nurse is caring for a patient who smokes 2 packs/day. Which action by the nurse could help reduce the patient's risk of lung cancer? a. Teach the patient about the seven warning signs of cancer. b. Plan to monitor the patient's carcinoembryonic antigen (CEA) level. c. Teach the patient about annual chest x-rays for lung cancer screening. d. Discuss risks associated with cigarettes during each patient encounter.

ANS: D d. Discuss risks associated with cigarettes during each patient encounter.

A patient's T-tube is draining dark green fluid after gallbladder surgery. What action by the nurse is the most appropriate? a. Notify the patient's surgeon. b. Place the patient on bed rest. c. Irrigate the T-tube with sterile saline. d. Document the drainage characteristics.

ANS: D d. Document the drainage characteristics.

Which test should the nurse anticipate discussing with a patient who has a possible seizure disorder? a. Cerebral angiography b. Evoked potential studies c. Electromyography (EMG) d. Electroencephalography (EEG)

ANS: D d. Electroencephalography (EEG)

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? a. Poor perfusion b. Inadequate nutrition c. Activity intolerance d. Excess fluid volume

ANS: D d. Excess fluid volume

A 40-yr-old patient is diagnosed with early Huntington's disease (HD). What information should the nurse provide when teaching the patient, spouse, and adult children about this disorder? a. Improved nutrition and exercise can delay disease progression. b. Levodopa-carbidopa (Sinemet) will help reduce HD symptoms. c. Prophylactic antibiotics decrease the risk for aspiration pneumonia. d. Genetic testing is an option for the children to determine their HD risk.

ANS: D d. Genetic testing is an option for the children to determine their HD risk.

A patient with suspected meningitis is scheduled for a lumbar puncture. What action should the nurse take before the procedure? a. Enforce NPO status for 4 hours. b. Transfer the patient to radiology. c. Administer a sedative medication. d. Help the patient to a lateral position.

ANS: D d. Help the patient to a lateral position.

Which nursing intervention for a patient who had an open repair of an abdominal aortic aneurysm 2 days previously is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a. Monitor the quality and presence of the pedal pulses. b. Teach the patient the signs of possible wound infection. c. Check the lower extremities for strength and movement. d. Help the patient to use a pillow to splint while coughing.

ANS: D d. Help the patient to use a pillow to splint while coughing.

The nurse obtains information about a hospitalized patient who is receiving chemotherapy for colorectal cancer. Which information about the patient alerts the nurse to discuss a possible change in cancer therapy with the health care provider? a. Frequent loose stools b. Nausea and vomiting c. Elevated white blood count (WBC) d. Increased carcinoembryonic antigen (CEA)

ANS: D d. Increased carcinoembryonic antigen (CEA)

A patient reports leg cramps during hemodialysis. What action should the nurse take? a. Massage the patient's legs. b. Reposition the patient supine. c. Give acetaminophen (Tylenol). d. Infuse a bolus of normal saline.

ANS: D d. Infuse a bolus of normal saline.

A patient admitted with pneumonia has a total serum calcium level of 13.3 mg/dL. What should the nurse anticipate will be tested next? a. Calcitonin b. Catecholamine c. Thyroid hormone d. Parathyroid hormone

ANS: D d. Parathyroid hormone

Nadolol (Corgard) is prescribed for a patient with chronic stable angina and left ventricular dysfunction. What data would indicate to the nurse that the drug is effective? a. Decreased blood pressure and heart rate b. Improvement in the strength of the distal pulses c. Fewer complaints of having cold hands and feet d. Participation in daily activities without chest pain

ANS: D d. Participation in daily activities without chest pain

An older adult patient who has colorectal cancer is receiving IV fluids at 175 mL/hr in conjunction with the prescribed chemotherapy. Which finding by the nurse is most important to report to the health care provider? a. Patient reports having severe fatigue. b. Patient voids every hour during the day. c. Patient takes only 50% of meals and refuses snacks. d. Patient has crackles up to the midline posterior chest.

ANS: D d. Patient has crackles up to the midline posterior chest.

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? a. Patient has tonic-clonic seizures. b. Patient experiences an aura before seizures. c. Patient's most recent blood pressure is 156/92 mm Hg. d. Patient has slight elevations in liver function test results.

ANS: D d. Patient has slight elevations in liver function test results.

After change-of-shift report on the Alzheimer's disease/dementia unit, which patient will the nurse assess first? a. Patient who has not had a bowel movement for 5 days. b. Patient who has a stage II pressure ulcer on the coccyx. c. Patient who is refusing to take the prescribed medications. d. Patient who developed a new cough after eating breakfast.

ANS: D d. Patient who developed a new cough after eating breakfast.

After receiving change-of-shift report, which patient should the nurse assess first? a. Patient who is scheduled for the drain phase of a peritoneal dialysis exchange. b. Patient with stage 4 chronic kidney disease who has an elevated phosphate level. c. Patient with stage 5 chronic kidney disease who has a potassium level of 3.4 mEq/L. d. Patient who has just returned from having hemodialysis with a heart rate of 110/min.

ANS: D d. Patient who has just returned from having hemodialysis with a heart rate of 110/min.

A patient who is human immunodeficiency virus (HIV)-infected has a CD4+ cell count of 400/μL. Which factor is most important for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient? a. CD4+ cell count b. How the patient obtained HIV c. Patient's tolerance for potential medication side effects d. Patient's ability to follow a complex medication regimen

ANS: D d. Patient's ability to follow a complex medication regimen

A patient receiving head and neck radiation for larynx cancer has ulcerations over the oral mucosa and tongue and thick, ropey saliva. Which instructions should the nurse give to this patient? a. Remove food debris from the teeth and oral mucosa with a stiff toothbrush. b. Use cotton-tipped applicators dipped in hydrogen peroxide to clean the teeth. c. Gargle and rinse the mouth several times a day with an antiseptic mouthwash. d. Rinse the mouth before and after each meal and at bedtime with a saline solution.

ANS: D d. Rinse the mouth before and after each meal and at bedtime with a saline solution.

A patient newly diagnosed with asthma is being discharged. The nurse anticipates including which topic in the discharge teaching? a. Complications associated with O2 therapy b. Use of long-acting β-adrenergic medications c. Side effects of sustained-release theophylline d. Self-administration of inhaled corticosteroids

ANS: D d. Self-administration of inhaled corticosteroids

The nurse prepares a patient who has a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient? a. High-Fowler's position with the left arm extended b. Supine with the head of the bed elevated 30 degrees c. On the right side with the left arm extended above the head d. Sitting upright with the arms supported on an over bed table

ANS: D d. Sitting upright with the arms supported on an over bed table

A patient with a left-brain stroke suddenly bursts into tears when family members visit. How should the nurse respond? a. Use a calm voice to ask the patient to stop the crying behavior. b. Explain to the family that depression is normal following a stroke. c. Have the family members leave the patient alone for a few minutes. d. Teach the family that emotional outbursts are common after strokes.

ANS: D d. Teach the family that emotional outbursts are common after strokes.

The nurse analyzes the results of a patient's arterial blood gases (ABGs). Which finding requires immediate action? a. The bicarbonate level (HCO3?2-) is 31 mEq/L. b. The arterial oxygen saturation (SaO2) is 92%. c. The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg. d. The partial pressure of oxygen in arterial blood (PaO2) is 62 mm Hg.

ANS: D d. The partial pressure of oxygen in arterial blood (PaO2) is 62 mm Hg.

A patient is admitted to the outpatient testing area for an ultrasound of the gallbladder. Which information obtained by the nurse indicates that the ultrasound may need to be rescheduled? a. The patient took a laxative the previous evening. b. The patient had a high-fat meal the previous evening. c. The patient has a permanent gastrostomy tube in place. d. The patient ate a low-fat bagel 4 hours ago for breakfast.

ANS: D d. The patient ate a low-fat bagel 4 hours ago for breakfast.

The nurse is caring for a patient who is living with human immunodeficiency virus (HIV) and taking antiretroviral therapy (ART). Which information is most important for the nurse to address when planning care? a. The patient reports feeling "constantly tired." b. The patient reports having no side effects from the medications. c. The patient is unable to explain the effects of atorvastatin (Lipitor). d. The patient reports missing doses of tenofovir AF/emtricitabine (Descovy).

ANS: D d. The patient reports missing doses of tenofovir AF/emtricitabine (Descovy).

A patient with human immunodeficiency virus (HIV) infection has developed Cryptosporidium parvum infection. Which outcome would be appropriate for the nurse to include in the plan of care? a. The patient will be free from injury. b. The patient will receive immunizations. c. The patient will have adequate oxygenation. d. The patient will maintain intact perineal skin.

ANS: D d. The patient will maintain intact perineal skin.

A patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. Health records show a history of several transient ischemic attacks (TIAs). What should the nurse anticipate for this patient? a. Surgical endarterectomy b. Transluminal angioplasty c. Intravenous heparin drip administration d. Tissue plasminogen activator (tPa) infusion

ANS: D d. Tissue plasminogen activator (tPa) infusion

The nurse interviews a patient while completing the health history and physical examination. What is the purpose of the assessment phase of the nursing process? a. To teach interventions that relieve health problems b. To use patient data to evaluate patient care outcomes c. To help the patient identify realistic outcomes for health problems d. To obtain data with which to diagnose patient strengths and problems

ANS: D d. To obtain data with which to diagnose patient strengths and problems

Which information will the nurse include in the teaching plan for a patient newly diagnosed with asthma? a. Use the inhaled corticosteroid when shortness of breath occurs. b. Inhale slowly and deeply when using the dry powder inhaler (DPI). c. Hold your breath for 5 seconds after using the bronchodilator inhaler. d. Tremors are an expected side effect of rapidly acting bronchodilators.

ANS: D d. Tremors are an expected side effect of rapidly acting bronchodilators.

A patient is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease. Which assessment finding should indicate to the nurse that a change in the medication or dosage may be needed? a. Shuffling gait b. Tremor at rest c. Cogwheel rigidity of limbs d. Uncontrolled head movement

ANS: D d. Uncontrolled head movement

Which risk factor should the nurse focus on when teaching a patient who has a 5-cm abdominal aortic aneurysm? a. Male gender b. Turner syndrome c. Abdominal trauma history d. Uncontrolled hypertension

ANS: D d. Uncontrolled hypertension

The nurse reviews the laboratory results of a patient who is receiving chemotherapy. Which laboratory result is most important to report to the health care provider? a. Hematocrit 30% b. Platelets 95,000/μL c. Hemoglobin 10 g/L d. White blood cells (WBC) 2700/μL

ANS: D d. White blood cells (WBC) 2700/μL

A young adult arrives in the emergency department with ankle swelling and severe pain after twisting an ankle playing basketball. Which prescribed action will the nurse implement first? a. Send the patient for ankle x-rays. b. Administer naproxen (Naprosyn). c. Give acetaminophen with codeine. d. Wrap the ankle and apply an ice pack.

ANS: D d. Wrap the ankle and apply an ice pack.

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? a. captopril (Capoten) 25 mg b. furosemide (Lasix) 60 mg c. digoxin (Lanoxin) 0.125 mg d. carvedilol (Coreg) 3.125 mg

ANS: D d. carvedilol (Coreg) 3.125 mg

The laboratory technician calls with arterial blood gas (ABG) results on four patients. Which result is most important for the nurse to report immediately to the health care provider? a. pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97% b. pH 7.35, PaO2 85 mm Hg, PaCO2 50 mm Hg, and O2 sat 95% c. pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98% d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%

ANS: D d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%

A patient's blood pressure in the postanesthesia care unit (PACU) has dropped from an admission blood pressure of 140/86 to 102/60 mm Hg with a pulse change of 70 to 96 beats/min. SpO2 is 92% on 3 L of oxygen. In which order should the nurse take these actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Increase the IV infusion rate. b. Assess the patient's dressing. c. Increase the oxygen flowrate. d. Check the patient's temperature.

ANS: a, C, B, D a. Increase the IV infusion rate. c. Increase the oxygen flowrate. b. Assess the patient's dressing. d. Check the patient's temperature.

Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires the most immediate action by the nurse? a. O2 saturation of 88% b. Weight gain of 1 kg (2.2 lb) c. Heart rate of 106 beats/min d. Urine output of 50 mL over 2 hours

ANS:A

A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan. Which information obtained by the nurse is a priority to communicate to the health care provider before the CT? a. Allergy to shellfish b. Apical pulse of 104 c. Respiratory rate of 30 d. O2 saturation of 90%

ANS:A a. Allergy to shellfish

The nurse receives the following information about a patient who is scheduled for a colonoscopy. Which information should be communicated to the health care provider before sending the patient for the procedure? a. The patient declined to drink the prescribed laxative solution. b. The patient has had an allergic reaction to shellfish and iodine. c. The patient has a permanent pacemaker to prevent bradycardia. d. The patient is worried about discomfort during the examination.

ANS:A a. The patient declined to drink the prescribed laxative solution.

After receiving change-of-shift report, which patient admitted to the emergency department should the nurse assess first? a. A 67-yr-old patient who has a gangrenous foot ulcer with a weak pedal pulse b. A 50-yr-old patient who is reporting sudden sharp and severe upper back pain c. A 39-yr-old patient who has right calf tenderness and swelling after a plane ride d. A 58-yr-old patient taking anticoagulants for atrial fibrillation who has black stools

ANS:B b. A 50-yr-old patient who is reporting sudden sharp and severe upper back pain

After receiving change-of-shift report on four patients admitted to a heart failure unit, which patient should the nurse assess first? a. A patient who reported dizziness after receiving the first dose of captopril. b. A patient who has new-onset confusion and restlessness and cool, clammy skin. c. A patient who is receiving oxygen and has crackles bilaterally in the lung bases. d. A patient who is receiving IV nesiritide (Natrecor), with a blood pressure of 100/62.

ANS:B b. A patient who has new-onset confusion and restlessness and cool, clammy skin.

A patient seen in the emergency department for severe headache and acute confusion has a serum sodium level of 118 mEq/L. The nurse should anticipate the need for which diagnostic test? a. Urinary 17-ketosteroids b. Antidiuretic hormone level c. Growth hormone stimulation test d. Adrenocorticotropic hormone level

ANS:B b. Antidiuretic hormone level

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. What is the nurse's priority action? a. Teach the patient about restricting dietary sodium. b. Assess the patient for manifestations of acute heart failure. c. Ask the patient about the use of the prescribed medications. d. Have the patient recall the dietary intake for the past 3 days.

ANS:B b. Assess the patient for manifestations of acute heart failure.

Which topic will the nurse plan to include in discharge teaching for a patient who has heart failure with reduced ejection fraction (HFrEF)? a. Need to begin an aerobic exercise program several times weekly b. Benefits and effects of angiotensin-converting enzyme (ACE) inhibitors c. Use of salt substitutes to replace table salt when cooking and at the table d. Importance of making an annual appointment with the health care provider

ANS:B b. Benefits and effects of angiotensin-converting enzyme (ACE) inhibitors

An older patient with a history of an abdominal aortic aneurysm arrives at the emergency department (ED) with severe back pain and absent pedal pulses. Which action should the nurse take first? a. Draw blood for laboratory testing. b. Check the patient's blood pressure. c. Assess the patient for an abdominal bruit. d. Determine any family history of heart disease.

ANS:B b. Check the patient's blood pressure.

During the physical examination, the nurse cannot feel the patient's thyroid gland. What action should the nurse take? a. Palpate the patient's neck more deeply. b. Document that the thyroid was nonpalpable. c. Notify the health care provider immediately. d. Teach the patient about thyroid hormone testing.

ANS:B b. Document that the thyroid was nonpalpable.

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? a. Urinary urgency b. Left-sided flank pain c. Intermittent hematuria d. Burning with urination

ANS:B b. Left-sided flank pain

The nurse is planning care for a patient with severe heart failure who has developed increased blood urea nitrogen (BUN) and creatinine levels. What will be the primary treatment goal in the plan? a. Augmenting fluid volume b. Maintaining cardiac output c. Diluting nephrotoxic substances d. Preventing systemic hypertension

ANS:B b. Maintaining cardiac output

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? a. Increased calories are needed because glucose is lost during hemodialysis. b. More protein is allowed because urea and creatinine are removed by dialysis. c. Dietary potassium is not restricted because the level is normalized by dialysis. d. Unlimited fluids are allowed because retained fluid is removed during dialysis.

ANS:B b. More protein is allowed because urea and creatinine are removed by dialysis.

After change-of-shift report, which patient should the nurse assess first? a. Patient who has cloudy urine after bladder reconstruction. b. Patient with a urethral stricture who has not voided for 12 hours. c. Patient who voided bright red urine after returning from lithotripsy. d. Patient with polycystic kidney disease whose blood pressure is 186/98 mm Hg.

ANS:B b. Patient with a urethral stricture who has not voided for 12 hours.

Which is the correct technique for the nurse to palpate the liver during a head-to-toe physical assessment? a. Place one hand on top of the other and use the upper fingers to apply pressure and the bottom fingers to feel for the liver edge. b. Place one hand on the patient's back and press upward and inward with the other hand below the patient's right costal margin. c. Press slowly and firmly over the right costal margin with one hand and withdraw the fingers quickly after the liver edge is felt. d. Place one hand under the patient's lower ribs and press the left lower rib cage forward, palpating below the costal margin with the other hand.

ANS:B b. Place one hand on the patient's back and press upward and inward with the other hand below the patient's right costal margin.

A registered nurse (RN) is caring for a patient with a goiter and possible hyperthyroidism. Which action by the RN indicates that the charge nurse needs to provide the RN with additional teaching? a. The RN checks the blood pressure in both arms. b. The RN palpates the neck to assess thyroid size. c. The RN orders saline eyedrops to lubricate the patient's bulging eyes. d. The RN lowers the thermostat to decrease the temperature in the room.

ANS:B b. The RN palpates the neck to assess thyroid size.

A patient has been newly diagnosed with type 2 diabetes. Which information about the patient will be most useful to the nurse who is helping the patient develop strategies for successful adaptation to this disease? a. Ideal weight b. Value system c. Activity level d. Visual changes

ANS:B b. Value system

The nurse is caring for a patient who was admitted to the coronary care unit following an acute myocardial infarction (AMI) and percutaneous coronary intervention the previous day. What should teaching for this patient include today? a. Typical emotional responses to AMI b. When cardiac rehabilitation will begin c. Pathophysiology of coronary artery disease d. Information regarding discharge medications

ANS:B b. When cardiac rehabilitation will begin

A patient is scheduled in the outpatient clinic for blood cortisol testing. Which instruction should the nurse provide? a. "Avoid adding any salt to your foods for 24 hours before the test." b. "You will need to lie down for 30 minutes before the blood is drawn." c. "Come to the laboratory to have the blood drawn early in the morning." d. "Do not have anything to eat or drink before the blood test is obtained."

ANS:C c. "Come to the laboratory to have the blood drawn early in the morning."

Which question from the nurse during a patient interview will provide focused information about a possible thyroid disorder? a. "What methods do you use to help cope with stress?" b. "Have you experienced any blurring or double vision?" c. "Have you had a recent unplanned weight gain or loss?" d. "Do you have to get up at night to empty your bladder?"

ANS:C c. "Have you had a recent unplanned weight gain or loss?"

A patient who has a history of chronic obstructive pulmonary disease (COPD) was hospitalized for increasing shortness of breath and chronic hypoxemia (SaO2 levels of 89% to 90%). In planning for discharge, which action by the nurse will be most effective in improving compliance with discharge teaching? a. Have the patient repeat the instructions immediately after teaching. b. Accomplish the patient teaching just before the scheduled discharge. c. Arrange for the patient's caregiver to be present during the teaching. d. Start giving the patient discharge teaching during the admission process.

ANS:C c. Arrange for the patient's caregiver to be present during the teaching.

A patient who has chest pain is admitted to the emergency department (ED), and all of the following items are prescribed. Which one should the nurse arrange to be completed first? a. Chest x-ray b. Troponin level c. Electrocardiogram (ECG) d. Insertion of a peripheral IV

ANS:C c. Electrocardiogram (ECG)

A patient is taking spironolactone (Aldactone), a drug that blocks the action of aldosterone on the kidney, for hypertension. What additional effect of the medication should the nurse monitor? a. Increased serum sodium b. Decreased urinary output c. Elevated serum potassium d. Evidence of fluid overload

ANS:C c. Elevated serum potassium

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? a. Creatinine 1.6 mg/dL b. Oxygen saturation 89% c. Hemoglobin level 13 g/dL d. Blood pressure 98/56 mm Hg

ANS:C c. Hemoglobin level 13 g/dL

A patient is admitted with tetany. Which laboratory value should the nurse plan to monitor? a. Total protein b. Blood glucose c. Ionized calcium d. Serum phosphate

ANS:C c. Ionized calcium

A licensed practical/vocational nurse (LPN/VN) is caring for a patient with stage 2 chronic kidney disease. Which observation by the RN requires an intervention? a. The LPN/VN assists the patient to ambulate in the hallway. b. The LPN/VN administers the erythropoietin subcutaneously. c. The LPN/VN administers the iron supplement and phosphate binder with lunch. d. The LPN/VN carries a tray containing low-protein foods into the patient's room.

ANS:C c. The LPN/VN administers the iron supplement and phosphate binder with lunch.

Which action by a patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD? a. The patient leaves the catheter exit site without a dressing. b. The patient plans 30 to 60 minutes for a dialysate exchange. c. The patient cleans the catheter while in the bathtub each day. d. The patient slows the inflow rate when experiencing abdominal pain.

ANS:C c. The patient cleans the catheter while in the bathtub each day.

After receiving change-of-shift report about the following four patients on the cardiac care unit, which patient should the nurse assess first? a. A 39-year-old patient with pericarditis who is complaining of sharp, stabbing chest pain. b. A 56-year-old patient with variant angina who is scheduled to receive nifedipine (Procardia). c. A 65-year-old patient who had a myocardial infarction (MI) 4 days ago and is anxious about today's planned discharge. d. A 59-year-old patient with unstable angina who has just returned after a percutaneous coronary intervention (PCI).

ANS:D d. A 59-year-old patient with unstable angina who has just returned after a percutaneous coronary intervention (PCI).

The nurse palpates the posterior chest and notes absent fremitus while the patient says "99". Which action should the nurse take next? a. Palpate the anterior chest and observe for barrel chest. b. Encourage the patient to turn, cough, and deep breathe. c. Review the chest x-ray report for evidence of pneumonia. d. Auscultate anterior and posterior breath sounds bilaterally.

ANS:D d. Auscultate anterior and posterior breath sounds bilaterally.

A patient admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI) is restless and anxious. The blood pressure is 86/40 mm Hg, and heart rate is 132 beats/min. Based on this information, which patient problem is the priority? a. Anxiety b. Acute pain c. Stress management d. Decreased cardiac output

ANS:D d. Decreased cardiac output