Med/Surg II Exam 2 TB

A patient in hypertensive urgency is admitted to the hospital. The nurse should be aware of what goal of treatment for a patient in hypertensive urgency? A) Normalizing BP within 2 hours B) Obtaining a BP of less than 110/70 mm Hg within 36 hours C) Obtaining a BP of less than 120/80 mm Hg within 36 hours D) Normalizing BP within 24 to 48 hours

D) Normalizing BP within 24 to 48 hours

An ED nurse is assessing an adult woman for a suspected MI. When planning the assessment, the nurse should be cognizant of what signs and symptoms of MI that are particularly common in female patients? Select all that apply. A) Shortness of breath B) Chest pain C) Anxiety D) Numbness E) Weakness

D) Numbness E) Weakness

A patient calls his cardiologists office and talks to the nurse. He is concerned because he feels he is being defibrillated too often. The nurse tells the patient to come to the office to be evaluated because the nurse knows that the most frequent complication of ICD therapy is what? A) Infection B) Failure to capture C) Premature battery depletion D) Oversensing of dysrhythmias

D) Oversensing of dysrhythmias

The nurse is explaining the safe and effective administration of nasal spray to a patient with seasonal allergies. What information is most important to include in this teaching? A) Finish the bottle of nasal spray to clear the infection effectively. B) Nasal spray can only be shared between immediate family members. C) Nasal spray should be administered in a prone position. D) Overuse of nasal spray may cause rebound congestion.

D) Overuse of nasal spray may cause rebound congestion.

A nurse working in a long-term care facility is performing the admission assessment of a newly admitted, 85-year-old resident. During inspection of the residents feet, the nurse notes that she appears to have early evidence of gangrene on one of her great toes. The nurse knows that gangrene in the elderly is often the first sign of what? A) Chronic venous insufficiency B) Raynauds phenomenon C) VTE D) PAD

D) PAD

The nurse is caring for patient who tells the nurse that he has an angina attack beginning. What is the nurses most appropriate initial action? A) Have the patient sit down and put his head between his knees. B) Have the patient perform pursed-lip breathing. C) Have the patient stand still and bend over at the waist. D) Place the patient on bed rest in a semi-Fowlers position.

D) Place the patient on bed rest in a semi-Fowlers position.

The nurse performing the health interview of a patient with a new onset of periorbital edema has completed a genogram, noting the health history of the patients siblings, parents, and grandparents. This assessment addresses the patients risk of what kidney disorder? A) Nephritic syndrome B) Acute glomerulonephritis C) Nephrotic syndrome D) Polycystic kidney disease (PKD)

D) Polycystic kidney disease (PKD)

A patient in the ICU is status post embolectomy after a pulmonary embolus. What assessment parameter does the nurse monitor most closely on a patient who is postoperative following an embolectomy? A) Pupillary response B) Pressure in the vena cava C) White blood cell differential D) Pulmonary arterial pressure

D) Pulmonary arterial pressure

The home care nurse is monitoring a patient discharged home after resolution of a pulmonary embolus. For what potential complication would the home care nurse be most closely monitoring this patient? A) Signs and symptoms of pulmonary infection B) Swallowing ability and signs of aspiration C) Activity level and role performance D) Residual effects of compromised oxygenation

D) Residual effects of compromised oxygenation

An older adult patient with HF is being discharged home on an ACE inhibitor and a loop diuretic. The patients most recent vital signs prior to discharge include oxygen saturation of 93% on room air, heart rate of 81 beats per minute, and blood pressure of 94/59 mm Hg. When planning this patients subsequent care, what nursing diagnosis should be identified? A) Risk for ineffective tissue perfusion related to dysrhythmia B) Risk for fluid volume excess related to medication regimen C) Risk for ineffective breathing pattern related to hypoxia D) Risk for falls related to hypotension

D) Risk for falls related to hypotension

A patient comes to the ED and is admitted with epistaxis. Pressure has been applied to the patients midline septum for 10 minutes, but the bleeding continues. The nurse should anticipate using what treatment to control the bleeding? A) Irrigation with a hypertonic solution B) Nasopharyngeal suction C) Normal saline application D) Silver nitrate application

D) Silver nitrate application

A 54-year-old man has just been diagnosed with small cell lung cancer. The patient asks the nurse why the doctor is not offering surgery as a treatment for his cancer. What fact about lung cancer treatment should inform the nurses response? A) The cells in small cell cancer of the lung are not large enough to visualize in surgery. B) Small cell lung cancer is self-limiting in many patients and surgery should be delayed. C) Patients with small cell lung cancer are not normally stable enough to survive surgery. D) Small cell cancer of the lung grows rapidly and metastasizes early and extensively.

D) Small cell cancer of the lung grows rapidly and metastasizes early and extensively.

The nurse caring for a patient recently diagnosed with lung disease encourages the patient not to smoke. What is the primary rationale behind this nursing action? A) Smoking decreases the amount of mucus production. B) Smoke particles compete for binding sites on hemoglobin. C) Smoking causes atrophy of the alveoli. D) Smoking damages the ciliary cleansing mechanism.

D) Smoking damages the ciliary cleansing mechanism.

A patient comes to the walk-in clinic complaining of frequent headaches. While assessing the patients vital signs, the nurse notes the BP is 161/101 mm Hg. According to JNC 7, how would this patients BP be defined if a similar reading were obtained at a subsequent office visit? A) High normal B) Normal C) Stage 1 hypertensive D) Stage 2 hypertensive

D) Stage 2 hypertensive

A 15-year-old is admitted to the renal unit with a diagnosis of postinfectious glomerular disease. The nurse should recognize that this form of kidney disease may have been precipitated by what event? A) Psychosocial stress B) Hypersensitivity to an immunization C) Menarche D) Streptococcal infection

D) Streptococcal infection

The nurse is assessing a woman who is pregnant at 27 weeks gestation. The patient is concerned about the recent emergence of varicose veins on the backs of her calves. What is the nurses best response? A) Facilitate a referral to a vascular surgeon. B) Assess the patients ankle-brachial index (ABI) and perform Doppler ultrasound testing. C) Encourage the patient to increase her activity level. D) Teach the patient that circulatory changes during pregnancy frequently cause varicose veins.

D) Teach the patient that circulatory changes during pregnancy frequently cause varicose veins.

A nurse is reviewing the physiological factors that affect a patients cardiovascular health and tissue oxygenation. What is the systemic arteriovenous oxygen difference? A) The average amount of oxygen removed by each organ in the body B) The amount of oxygen removed from the blood by the heart C) The amount of oxygen returning to the lungs via the pulmonary artery D) The amount of oxygen in aortic blood minus the amount of oxygen in the vena caval blood

D) The amount of oxygen in aortic blood minus the amount of oxygen in the vena caval blood

Graduated compression stockings have been prescribed to treat a patients venous insufficiency. What education should the nurse prioritize when introducing this intervention to the patient? A) The need to take anticoagulants concurrent with using compression stockings B) The need to wear the stockings on a one day on, one day off schedule C) The importance of wearing the stockings around the clock to ensure maximum benefit D) The importance of ensuring the stockings are applied evenly with no pressure points

D) The importance of ensuring the stockings are applied evenly with no pressure points

The nurse is assessing an older adult patient with numerous health problems. What assessment datum indicates an increase in the patients risk for heart failure (HF)? A) The patient takes Lasix (furosemide) 20 mg/day. B) The patients potassium level is 4.7 mEq/L. C) The patient is an African American man. D) The patients age is greater than 65

D) The patients age is greater than 65.

The nurse is caring for a patient who has been in a motor vehicle accident and the care team suspects that the patient has developed pleurisy. Which of the nurses assessment findings would best corroborate this diagnosis? A) The patient is experiencing painless hemoptysis. B) The patients arterial blood gases (ABGs) are normal, but he demonstrates increased work of breathing. C) The patients oxygen saturation level is below 88%, but he denies shortness of breath. D) The patients pain intensifies when he coughs or takes a deep breath.

D) The patients pain intensifies when he coughs or takes a deep breath.

A patients recently elevated BP has prompted the primary care provider to prescribe furosemide (Lasix). The nurse should closely monitor which of the following? A) The clients oxygen saturation level B) The patients red blood cells, hematocrit, and hemoglobin C) The patients level of consciousness D) The patients potassium level

D) The patients potassium level

The nurse is providing care to a patient who has just undergone an electrophysiologic (EP) study. The patient states that she is nervous about things going wrong during the procedure. What is the nurses best response? A) This is basically a risk-free procedure. B) Thousands of patients undergo EP every year. C) Remember that this is a step that will bring you closer to enjoying good health. D) The whole team will be monitoring you very closely for the entire procedure.

D) The whole team will be monitoring you very closely for the entire procedure.

A group of nurses are participating in orientation to a telemetry unit. What should the staff educator tell this class about ST segments? A) They are the part of an ECG that reflects systole. B) They are the part of an ECG used to calculate ventricular rate and rhythm. C) They are the part of an ECG that reflects the time from ventricular depolarization through repolarization. D) They are the part of an ECG that represents early ventricular repolarization.

D) They are the part of an ECG that represents early ventricular repolarization.

A nurse is assessing a new patient who is diagnosed with PAD. The nurse cannot feel the pulse in the patients left foot. How should the nurse proceed with assessment? A) Have the primary care provider order a CT. B) Apply a tourniquet for 3 to 5 minutes and then reassess. C) Elevate the extremity and attempt to palpate the pulses. D) Use Doppler ultrasound to identify the pulses.

D) Use Doppler ultrasound to identify the pulses.

A nurse is providing health education to a patient scheduled for cryoablation therapy. The nurse should describe what aspect of this treatment? A) Peeling away the area of endocardium responsible for the dysrhythmia B) Using electrical shocks directly to the endocarduim to eliminate the source of dysrhythmia C) Using high-frequency sound waves to eliminate the source of dysrhythmia D) Using a cooled probe to eliminate the source of dysrhythmia

D) Using a cooled probe to eliminate the source of dysrhythmia

The nurse is providing patient teaching to a young mother who has brought her 3-month-old infant to the clinic for a well-baby checkup. What action should the nurse recommend to the woman to prevent the transmission of organisms to her infant during the cold season? A) Take preventative antibiotics, as ordered. B) Gargle with warm salt water regularly. C) Dress herself and her infant warmly. D) Wash her hands frequently.

D) Wash her hands frequently.

A patient with newly diagnosed hypertension has come to the clinic for a follow-up visit. The patient asks the nurse why she has to come in so often. What would be the nurses best response? A) We do this so you dont suffer a stroke. B) We do this to determine how your blood pressure changes throughout the day. C) We do this to see how often you should change your medication dose. D) We do this to make sure your health is stable. Well then monitor it at routinely scheduled intervals.

D) We do this to make sure your health is stable. Well then monitor it at routinely scheduled intervals.

A nurse in the rehabilitation unit is caring for an older adult patient who is in cardiac rehabilitation following an MI. The nurses plan of care calls for the patient to walk for 10 minutes 3 times a day. The patient questions the relationship between walking and heart function. How should the nurse best reply? A) The arteries in your legs constrict when you walk and allow the blood to move faster and with more pressure on the tissue. B) Walking increases your heart rate and blood pressure. Therefore your heart is under less stress. C) Walking helps your heart adjust to your new arteries and helps build your self-esteem. D) When you walk, the muscles in your legs contract and pump the blood in your veins back toward your heart, which allows more blood to return to your heart.

D) When you walk, the muscles in your legs contract and pump the blood in your veins back toward your heart, which allows more blood to return to your heart.

The nurse is caring for a patient with a history of systemic lupus erythematosus who has been recently diagnosed with end-stage kidney disease (ESKD). The patient has an elevated phosphorus level and has been prescribed calcium acetate to bind the phosphorus. The nurse should teach the patient to take the prescribed phosphorus-binding medication at what time? A) Only when needed B) Daily at bedtime C) First thing in the morning D) With each meal

D) With each meal

The nurse is caring for a patient on telemetry. The patients ECG shows a shortened PR interval, slurring of the initial QRS deflection, and prolonged QRS duration. What does this ECG show? A) Sinus bradycardia B) Myocardial infarction C) Lupus-like syndrome D) Wolf-Parkinson-White (WPW) syndrome

D) Wolf-Parkinson-White (WPW) syndrome

The nurse is reviewing the medication administration record of a patient diagnosed with systolic HF. What medication should the nurse anticipate administering to this patient? A) A beta-adrenergic blocker B) An antiplatelet aggregator C) A calcium channel blocker D) A nonsteroidal anti-inflammatory drug (NSAID)

A) A beta-adrenergic blocker

The home care nurse is assessing the home environment of a patient who will be discharged from the hospital shortly after his laryngectomy. The nurse should inform the patient that he may need to arrange for the installation of which system in his home? A) A humidification system B) An air conditioning system C) A water purification system D) A radiant heating system

A) A humidification system

The nurse at a long-term care facility is assessing each of the residents. Which resident most likely faces the greatest risk for aspiration? A) A resident who suffered a severe stroke several weeks ago B) A resident with mid-stage Alzheimers disease C) A 92-year-old resident who needs extensive help with ADLs D) A resident with severe and deforming rheumatoid arthritis

A) A resident who suffered a severe stroke several weeks ago

The nurse is planning patient teaching for a patient with ESKD who is scheduled for the creation of a fistula. The nurse would include which of the following in teaching the patient about the fistula? A) A vein and an artery in your arm will be attached surgically. B) The arm should be immobilized for 4 to 6 days. C) One needle will be inserted into the fistula for each dialysis treatment. D) The fistula can be used 2 days after the surgery for dialysis treatment

A) A vein and an artery in your arm will be attached surgically.

The nurse providing care for a patient post PTCA knows to monitor the patient closely. For what complications should the nurse monitor the patient? Select all that apply. A) Abrupt closure of the coronary artery B) Venous insufficiency C) Bleeding at the insertion site D) Retroperitoneal bleeding E) Arterial occlusion

A) Abrupt closure of the coronary artery C) Bleeding at the insertion site D) Retroperitoneal bleeding E) Arterial occlusion

A cardiac patients resistance to left ventricular filling has caused blood to back up into the patients circulatory system. What health problem is likely to result? A) Acute pulmonary edema B) Right-sided HF C) Right ventricular hypertrophy D) Left-sided HF

A) Acute pulmonary edema

A patient is brought to the ED and determined to be experiencing symptomatic sinus bradycardia. The nurse caring for this patient is aware the medication of choice for treatment of this dysrhythmia is the administration of atropine. What guidelines will the nurse follow when administering atropine? A) Administer atropine 0.5 mg as an IV bolus every 3 to 5 minutes to a maximum of 3.0 mg. B) Administer atropine as a continuous infusion until symptoms resolve. C) Administer atropine as a continuous infusion to a maximum of 30 mg in 24 hours. D) Administer atropine 1.0 mg sublingually.

A) Administer atropine 0.5 mg as an IV bolus every 3 to 5 minutes to a maximum of 3.0 mg.

The public health nurse is administering Mantoux tests to children who are being registered for kindergarten in the community. How should the nurse administer this test? A) Administer intradermal injections into the childrens inner forearms. B) Administer intramuscular injections into each childs vastus lateralis. C) Administer a subcutaneous injection into each childs umbilical area. D) Administer a subcutaneous injection at a 45-degree angle into each childs deltoid.

A) Administer intradermal injections into the childrens inner forearms.

The nurse is performing a physical assessment on a patient suspected of having HF. The presence of what sound would signal the possibility of impending HF? A) An S3 heart sound B) Pleural friction rub C) Faint breath sounds D) A heart murmur

A) An S3 heart sound

A patient who has undergone a femoral to popliteal bypass graft surgery returns to the surgical unit. Which assessments should the nurse perform during the first postoperative day? A) Assess pulse of affected extremity every 15 minutes at first. B) Palpate the affected leg for pain during every assessment. C) Assess the patient for signs and symptoms of compartment syndrome every 2 hours. D) Perform Doppler evaluation once daily.

A) Assess pulse of affected extremity every 15 minutes at first.

The nurse is caring for a patient who has returned to the postsurgical suite after post-anesthetic recovery from a nephrectomy. The nurses most recent hourly assessment reveals a significant drop in level of consciousness and BP as well as scant urine output over the past hour. What is the nurses best response? A) Assess the patient for signs of bleeding and inform the physician. B) Monitor the patients vital signs every 15 minutes for the next hour. C) Reposition the patient and reassess vital signs. D) Palpate the patients flanks for pain and inform the physician.

A) Assess the patient for signs of bleeding and inform the physician.

The nurse is caring for a patient postoperative day 4 following a kidney transplant. When assessing for potential signs and symptoms of rejection, what assessment should the nurse prioritize? A) Assessment of the quantity of the patients urine output B) Assessment of the patients incision C) Assessment of the patients abdominal girth D) Assessment for flank or abdominal pain

A) Assessment of the quantity of the patients urine output

A patient who is at high risk for developing intracardiac thrombi has been placed on long-term anticoagulation. What aspect of the patients health history creates a heightened risk of intracardiac thrombi? A) Atrial fibrillation B) Infective endocarditis C) Recurrent pneumonia D) Recent surgery

A) Atrial fibrillation

While planning a patients care, the nurse identifies nursing actions to minimize the patients pleuritic pain. Which intervention should the nurse include in the plan of care? A) Avoid actions that will cause the patient to breathe deeply. B) Ambulate the patient at least three times daily. C) Arrange for a soft-textured diet and increased fluid intake. D) Encourage the patient to speak as little as possible

A) Avoid actions that will cause the patient to breathe deeply.

A nurse is creating an education plan for a patient with venous insufficiency. What measure should the nurse include in the plan? A) Avoiding tight-fitting socks. B) Limit activity whenever possible. C) Sleep with legs in a dependent position. D) Avoid the use of pressure stockings.

A) Avoiding tight-fitting socks.

The clinic nurse is caring for a 57-year-old client who reports experiencing leg pain whenever she walks several blocks. The patient has type 1 diabetes and has smoked a pack of cigarettes every day for the past 40 years. The physician diagnoses intermittent claudication. The nurse should provide what instruction about long-term care to the client? A) Be sure to practice meticulous foot care. B) Consider cutting down on your smoking. C) Reduce your activity level to accommodate your limitations. D) Try to make sure you eat enough protein.

A) Be sure to practice meticulous foot care.

A 48-year-old man presents to the ED complaining of severe substernal chest pain radiating down his left arm. He is admitted to the coronary care unit (CCU) with a diagnosis of myocardial infarction (MI). What nursing assessment activity is a priority on admission to the CCU? A) Begin ECG monitoring. B) Obtain information about family history of heart disease. C) Auscultate lung fields. D) Determine if the patient smokes.

A) Begin ECG monitoring.

A patient with HF has met with his primary care provider and begun treatment with an angiotensin converting enzyme (ACE) inhibitor. When the patient begins treatment, the nurse should prioritize what assessment? A) Blood pressure B) Level of consciousness (LOC) C) Assessment for nausea D) Oxygen saturation

A) Blood pressure

The nurse is caring for a patient who has just undergone catheter ablation therapy. The nurse in the stepdown unit should prioritize what assessment? A) Cardiac monitoring B) Monitoring the implanted device signal C) Pain assessment D) Monitoring the patients level of consciousness (LOC)

A) Cardiac monitoring

The nurse is caring for an adult patient with HF who is prescribed digoxin. When assessing the patient for adverse effects, the nurse should assess for which of the following signs and symptoms? A) Confusion and bradycardia B) Uncontrolled diuresis and tachycardia C) Numbness and tingling in the extremities D) Chest pain and shortness of breath

A) Confusion and bradycardia

A patient with ESKD is scheduled to begin hemodialysis. The nurse is working with the patient to adapt the patients diet to maximize the therapeutic effect and minimize the risks of complications. The patients diet should include which of the following modifications? Select all that apply. A) Decreased protein intake B) Decreased sodium intake C) Increased potassium intake D) Fluid restriction E) Vitamin D supplementation

A) Decreased protein intake B) Decreased sodium intake D) Fluid restriction

A nurse is caring for a patient who is exhibiting ventricular tachycardia (VT). Because the patient is pulseless, the nurse should prepare for what intervention? A) Defibrillation B) ECG monitoring C) Implantation of a cardioverter defibrillator D) Angioplasty

A) Defibrillation

The nurse is caring for a patient who is scheduled for a lobectomy for a diagnosis of lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes the clients oxygen saturation rapidly dropping. The patient complains of shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Further assessment findings supporting the presence of a pneumothorax include what? A) Diminished or absent breath sounds on the affected side B) Paradoxical chest wall movement with respirations C) Sudden loss of consciousness D) Muffled heart sounds

A) Diminished or absent breath sounds on the affected side

When assessing venous disease in a patients lower extremities, the nurse knows that what test will most likely be ordered? A) Duplex ultrasonography B) Echocardiography C) Positron emission tomography (PET) D) Radiography

A) Duplex ultrasonography

The nurse is assessing a patient with acute coronary syndrome (ACS). The nurse includes a careful history in the assessment, especially with regard to signs and symptoms. What signs and symptoms are suggestive of ACS? Select all that apply. A) Dyspnea B) Unusual fatigue C) Hypotension D) Syncope E) Peripheral cyanosis

A) Dyspnea B) Unusual fatigue D) Syncope

The nurse is caring for a patient who is in the recovery room following the implantation of an ICD. The patient has developed ventricular tachycardia (VT). What should the nurse assess and document? A) ECG to compare time of onset of VT and onset of devices shock B) ECG so physician can see what type of dysrhythmia the patient has C) Patients level of consciousness (LOC) at the time of the dysrhythmia D) Patients activity at time of dysrhythmia

A) ECG to compare time of onset of VT and onset of devices shock

The perioperative nurse is writing a care plan for a patient who has returned from surgery 2 hours prior. Which measure should the nurse implement to most decrease the patients risk of developing pulmonary emboli (PE)? A) Early ambulation B) Increased dietary intake of protein C) Maintaining the patient in a supine position D) Administering aspirin with warfarin

A) Early ambulation

The nurse is admitting a 32-year-old woman to the presurgical unit. The nurse learns during the admission assessment that the patient takes oral contraceptives. Consequently, the nurses postoperative plan of care should include what intervention? A) Early ambulation and leg exercises B) Cessation of the oral contraceptives until 3 weeks postoperative C) Doppler ultrasound of peripheral circulation twice daily D) Dependent positioning of the patients extremities when at rest

A) Early ambulation and leg exercises

A patient with a diagnosis of HF is started on a beta-blocker. What is the nurses priority role during gradual increases in the patients dose? A) Educating the patient that symptom relief may not occur for several weeks B) Stressing that symptom relief may take up to 4 months to occur C) Making adjustments to each days dose based on the blood pressure trends D) Educating the patient about the potential changes in LOC that may result from the drug

A) Educating the patient that symptom relief may not occur for several weeks

The nurse is evaluating a patients diagnosis of arterial insufficiency with reference to the adequacy of the patients blood flow. On what physiological variables does adequate blood flow depend? Select all that apply. A) Efficiency of heart as a pump B) Adequacy of circulating blood volume C) Ratio of platelets to red blood cells D) Size of red blood cells E) Patency and responsiveness of the blood vessels

A) Efficiency of heart as a pump B) Adequacy of circulating blood volume E) Patency and responsiveness of the blood vessels

A patient with advanced venous insufficiency is confined following orthopedic surgery. How can the nurse best prevent skin breakdown in the patients lower extremities? A) Ensure that the patients heels are protected and supported. B) Closely monitor the patients serum albumin and prealbumin levels. C) Perform gentle massage of the patients lower legs, as tolerated. D) Perform passive range-of-motion exercises once per shift.

A) Ensure that the patients heels are protected and supported.

The nurse and the other members of the team are caring for a patient who converted to ventricular fibrillation (VF). The patient was defibrillated unsuccessfully and the patient remains in VF. According to national standards, the nurse should anticipate the administration of what medication? A) Epinephrine 1 mg IV push B) Lidocaine 100 mg IV push C) Amiodarone 300 mg IV push D) Sodium bicarbonate 1 amp IV push

A) Epinephrine 1 mg IV push

When discussing angina pectoris secondary to atherosclerotic disease with a patient, the patient asks why he tends to experience chest pain when he exerts himself. The nurse should describe which of the following phenomena? A) Exercise increases the hearts oxygen demands. B) Exercise causes vasoconstriction of the coronary arteries. C) Exercise shunts blood flow from the heart to the mesenteric area. D) Exercise increases the metabolism of cardiac medications.

A) Exercise increases the hearts oxygen demands.

The nurse has just admitted a 66-year-old patient for cardiac surgery. The patient tearfully admits to the nurse that she is afraid of dying while undergoing the surgery. What is the nurses best response? A) Explore the factors underlying the patients anxiety. B) Teach the patient guided imagery techniques. C) Obtain an order for a PRN benzodiazepine. D) Describe the procedure in greater detail.

A) Explore the factors underlying the patients anxiety.

The nurse is creating a care plan for a patient diagnosed with HF. When addressing the problem of anxiety, what interventions should the nurse include in the care plan? Select all that apply. A) Facilitate the presence of friends and family whenever possible. B) Teach the patient about the harmful effects of anxiety on cardiac function. C) Provide supplemental oxygen, as needed. D) Provide validation of the patients expressions of anxiety. E) Administer benzodiazepines two to three times daily.

A) Facilitate the presence of friends and family whenever possible. C) Provide supplemental oxygen, as needed. D) Provide validation of the patients expressions of anxiety.

The ED nurse is assessing a young gymnast who fell from a balance beam. The gymnast presents with a clear fluid leaking from her nose. What should the ED nurse suspect? A) Fracture of the cribriform plate B) Rupture of an ethmoid sinus C) Abrasion of the soft tissue D) Fracture of the nasal septum

A) Fracture of the cribriform plate

The nurse is performing an initial assessment of a client diagnosed with HF. The nurse also assesses the patients sensorium and LOC. Why is the assessment of the patients sensorium and LOC important in patients with HF? A) HF ultimately affects oxygen transportation to the brain. B) Patients with HF are susceptible to overstimulation of the sympathetic nervous system. C) Decreased LOC causes an exacerbation of the signs and symptoms of HF. D) The most significant adverse effect of medications used for HF treatment is altered LOC.

A) HF ultimately affects oxygen transportation to the brain.

Renal failure can have prerenal, renal, or postrenal causes. A patient with acute kidney injury is being assessed to determine where, physiologically, the cause is. If the cause is found to be prerenal, which condition most likely caused it? A) Heart failure B) Glomerulonephritis C) Ureterolithiasis D) Aminoglycoside toxicity

A) Heart failure

The nurse is assessing a patient suspected of having developed acute glomerulonephritis. The nurse should expect to address what clinical manifestation that is characteristic of this health problem? A) Hematuria B) Precipitous decrease in serum creatinine levels C) Hypotension unresolved by fluid administration D) Glucosuria

A) Hematuria

A football player is thought to have sustained an injury to his kidneys from being tackled from behind. The ER nurse caring for the patient reviews the initial orders written by the physician and notes that an order to collect all voided urine and send it to the laboratory for analysis. The nurse understands that this nursing intervention is important for what reason? A) Hematuria is the most common manifestation of renal trauma and blood losses may be microscopic, so laboratory analysis is essential. B) Intake and output calculations are essential and the laboratory will calculate the precise urine output produced by this patient. C) A creatinine clearance study may be ordered at a later time and the laboratory will hold all urine until it is determined if the test will be necessary. D) There is great concern about electrolyte imbalances and the laboratory will monitor the urine for changes in potassium and sodium concentrations.

A) Hematuria is the most common manifestation of renal trauma and blood losses may be microscopic, so laboratory analysis is essential.

A 45-year-old man with diabetic nephropathy has ESKD and is starting dialysis. What should the nurse teach the patient about hemodialysis? A) Hemodialysis is a treatment option that is usually required three times a week. B) Hemodialysis is a program that will require you to commit to daily treatment. C) This will require you to have surgery and a catheter will need to be inserted into your abdomen. D) Hemodialysis is a treatment that is used for a few months until your kidney heals and starts to produce urine again.

A) Hemodialysis is a treatment option that is usually required three times a week.

The nurse is caring for a patient whose recent unexplained weight loss and history of smoking have prompted diagnostic testing for cancer. What symptom is most closely associated with the early stages of laryngeal cancer? A) Hoarseness B) Dyspnea C) Dysphagia D) Frequent nosebleeds

A) Hoarseness

The nurse is planning the care of a patient with HF. The nurse should identify what overall goals of this patients care? SELECT ALL THAT APPLY. A) Improve functional status B) Prevent endocarditis. C) Extend survival. D) Limit physical activity. E) Relieve patient symptoms.

A) Improve functional status C) Extend survival. E) Relieve patient symptoms.

A patient admitted to the medical unit with HF is exhibiting signs and symptoms of pulmonary edema. The nurse is aware that positioning will promote circulation. How should the nurse best position the patient? A) In a high Fowlers position B) On the left side-lying position C) In a flat, supine position D) In the Trendelenburg position

A) In a high Fowlers position

The nurse is caring for a patient at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the patient. What is an example of a first-line measure to minimize atelectasis? A) Incentive spirometry B) Intermittent positive-pressure breathing (IPPB) C) Positive end-expiratory pressure (PEEP) D) Bronchoscopy

A) Incentive spirometry

The nurse is caring for a patient who has undergone percutaneous transluminal coronary angioplasty (PTCA). What is the major indicator of success for this procedure? A) Increase in the size of the arteries lumen B) Decrease in arterial blood flow in relation to venous flow C) Increase in the patients resting heart rate D) Increase in the patients level of consciousness (LOC)

A) Increase in the size of the arteries lumen

A critical-care nurse is caring for a patient diagnosed with pneumonia as a surgical complication. The nurses assessment reveals that the patient has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the patient to do? A) Increase oral fluids unless contraindicated. B) Call the nurse for oral suctioning, as needed. C) Lie in a low Fowlers or supine position. D) Increase activity.

A) Increase oral fluids unless contraindicated.

A patient with ESKD receives continuous ambulatory peritoneal dialysis. The nurse observes that the dialysate drainage fluid is cloudy. What is the nurses most appropriate action? A) Inform the physician and assess the patient for signs of infection. B) Flush the peritoneal catheter with normal saline. C) Remove the catheter promptly and have the catheter tip cultured. D) Administer a bolus of IV normal saline as ordered.

A) Inform the physician and assess the patient for signs of infection.

The nurse is caring for a patient with severe left ventricular dysfunction who has been identified as being at risk for sudden cardiac death. What medical intervention can be performed that may extend the survival of the patient? A) Insertion of an implantable cardioverter defibrillator B) Insertion of an implantable pacemaker C) Administration of a calcium channel blocker D) Administration of a beta-blocker

A) Insertion of an implantable cardioverter defibrillator

The nurse is caring for a patient who needs education on his medication therapy for allergic rhinitis. The patient is to take cromolyn (Nasalcrom) daily. In providing education for this patient, how should the nurse describe the action of the medication? A) It inhibits the release of histamine and other chemicals. B) It inhibits the action of proton pumps. C) It inhibits the action of the sodium-potassium pump in the nasal epithelium. D) It causes bronchodilation and relaxes smooth muscle in the bronchi.

A) It inhibits the release of histamine and other chemicals.

The triage nurse in the ED assesses a 66-year-old male patient who presents to the ED with complaints of midsternal chest pain that has lasted for the last 5 hours. If the patients symptoms are due to an MI, what will have happened to the myocardium? A) It may have developed an increased area of infarction during the time without treatment. B) It will probably not have more damage than if he came in immediately. C) It may be responsive to restoration of the area of dead cells with proper treatment. D) It has been irreparably damaged, so immediate treatment is no longer necessary.

A) It may have developed an increased area of infarction during the time without treatment.

The nurse is providing patient education prior to a patients discharge home after treatment for HF. The nurse gives the patient a home care checklist as part of the discharge teaching. What should be included on this checklist? A) Know how to recognize and prevent orthostatic hypotension. B) Weigh yourself weekly at a consistent time of day. C) Measure everything you eat and drink until otherwise instructed. D) Limit physical activity to only those tasks that are absolutely necessary.

A) Know how to recognize and prevent orthostatic hypotension.

The nurse is assessing a patient who has a 35 pack-year history of cigarette smoking. In light of this known risk factor for lung cancer, what statement should prompt the nurse to refer the patient for further assessment? A) Lately, I have this cough that just never seems to go away. B) I find that I dont have nearly the stamina that I used to. C) I seem to get nearly every cold and flu that goes around my workplace. D) I never used to have any allergies, but now I think Im developing allergies to dust and pet hair.

A) Lately, I have this cough that just never seems to go away.

The nurse is caring for a patient who has been diagnosed with an elevated cholesterol level. The nurse is aware that plaque on the inner lumen of arteries is composed chiefly of what? A) Lipids and fibrous tissue B) White blood cells C) Lipoproteins D) High-density cholesterol

A) Lipids and fibrous tissue

The nurse has performed a thorough nursing assessment of the care of a patient with chronic leg ulcers. The nurses assessment should include which of the following components? Select all that apply. A) Location and type of pain B) Apical heart rate C) Bilateral comparison of peripheral pulses D) Comparison of temperature in the patients legs E) Identification of mobility limitations

A) Location and type of pain C) Bilateral comparison of peripheral pulses D) Comparison of temperature in the patients legs E) Identification of mobility limitations

The nurse has identified the nursing diagnosis of risk for infection in a patient who undergoes peritoneal dialysis. What nursing action best addresses this risk? A) Maintain aseptic technique when administering dialysate. B) Wash the skin surrounding the catheter site with soap and water prior to each exchange. C) Add antibiotics to the dialysate as ordered. D) Administer prophylactic antibiotics by mouth or IV as ordered.

A) Maintain aseptic technique when administering dialysate.

The nurse is caring for an adult patient who has gone into ventricular fibrillation. When assisting with defibrillating the patient, what must the nurse do? A) Maintain firm contact between paddles and patient skin. B) Apply a layer of water as a conducting agent. C) Call all clear once before discharging the defibrillator. D) Ensure the defibrillator is in the sync mode.

A) Maintain firm contact between paddles and patient skin.

A patient is undergoing preoperative teaching before his cardiac surgery and the nurse is aware that a temporary pacemaker will be placed later that day. What is the nurses responsibility in the care of the patients pacemaker? A) Monitoring for pacemaker malfunction or battery failure B) Determining when it is appropriate to remove the pacemaker C) Making necessary changes to the pacemaker settings D) Selecting alternatives to future pacemaker use

A) Monitoring for pacemaker malfunction or battery failure

A nurse is teaching an adult female patient about the risk factors for hypertension. What should the nurse explain as risk factors for primary hypertension? A) Obesity and high intake of sodium and saturated fat B) Diabetes and use of oral contraceptives C) Metabolic syndrome and smoking D) Renal disease and coarctation of the aorta

A) Obesity and high intake of sodium and saturated fat

A patient has been prescribed antihypertensives. After assessment and analysis, the nurse has identified a nursing diagnosis of risk for ineffective health maintenance related to nonadherence to therapeutic regimen. When planning this patients care, what desired outcome should the nurse identify? A) Patient takes medication as prescribed and reports any adverse effects. B) Patients BP remains consistently below 140/90 mm Hg. C) Patient denies signs and symptoms of hypertensive urgency. D) Patient is able to describe modifiable risk factors for hypertension

A) Patient takes medication as prescribed and reports any adverse effects.

The nurse is developing a nursing care plan for a patient who is being treated for hypertension. What is a measurable patient outcome that the nurse should include? A) Patient will reduce Na+ intake to no more than 2.4 g daily. B) Patient will have a stable BUN and serum creatinine levels. C) Patient will abstain from fat intake and reduce calorie intake. D) Patient will maintain a normal body weight.

A) Patient will reduce Na+ intake to no more than 2.4 g daily.

A nurse practitioner has provided care for three different patients with chronic pharyngitis over the past several months. Which patients are at greatest risk for developing chronic pharyngitis? A) Patients who are habitual users of alcohol and tobacco B) Patients who are habitual users of caffeine and other stimulants C) Patients who eat a diet high in spicy foods D) Patients who have gastrointestinal reflux disease (GERD)

A) Patients who are habitual users of alcohol and tobacco

Cardiopulmonary resuscitation has been initiated on a patient who was found unresponsive. When performing chest compressions, the nurse should do which of the following? A) Perform at least 100 chest compressions per minute. B) Pause to allow a colleague to provide a breath every 10 compressions. C) Pause chest compressions to allow for vital signs monitoring every 4 to 5 minutes. D) Perform high-quality chest compressions as rapidly as possible.

A) Perform at least 100 chest compressions per minute.

The nurse is providing patient teaching to a patient diagnosed with acute rhinosinusitis. For what possible complication should the nurse teach the patient to seek immediate follow-up? A) Periorbital edema B) Headache unrelieved by OTC medications C) Clear drainage from nose D) Blood-tinged mucus when blowing the nose

A) Periorbital edema

The nurse is assessing an adult patient following a motor vehicle accident. The nurse observes that the patient has an increased use of accessory muscles and is complaining of chest pain and shortness of breath. The nurse should recognize the possibility of what condition? A) Pneumothorax B) Anxiety C) Acute bronchitis D) Aspiration

A) Pneumothorax

A patient has been brought to the ED by the paramedics. The patient is suspected of having ARDS. What intervention should the nurse first anticipate? A) Preparing to assist with intubating the patient B) Setting up oxygen at 5 L/minute by nasal cannula C) Performing deep suctioning D) Setting up a nebulizer to administer corticosteroids

A) Preparing to assist with intubating the patient

A patient presents to the ED in distress and complaining of crushing chest pain. What is the nurses priority for assessment? A) Prompt initiation of an ECG B) Auscultation of the patients point of maximal impulse (PMI) C) Rapid assessment of the patients peripheral pulses D) Palpation of the patients cardiac apex

A) Prompt initiation of an ECG

The nurse is caring for a patient with a large venous leg ulcer. What intervention should the nurse implement to promote healing and prevent infection? A) Provide a high-calorie, high-protein diet. B) Apply a clean occlusive dressing once daily and whenever soiled. C) Irrigate the wound with hydrogen peroxide once daily. D) Apply an antibiotic ointment on the surrounding skin with each dressing change.

A) Provide a high-calorie, high-protein diet.

The nurse is caring for a patient status after a motor vehicle accident. The patient has developed AKI. What is the nurses role in caring for this patient? Select all that apply. A) Providing emotional support for the family B) Monitoring for complications C) Participating in emergency treatment of fluid and electrolyte imbalances D) Providing nursing care for primary disorder (trauma) E) Directing nutritional interventions

A) Providing emotional support for the family B) Monitoring for complications C) Participating in emergency treatment of fluid and electrolyte imbalances D) Providing nursing care for primary disorder (trauma)

The nurse is caring for a patient who has just returned to the post-surgical unit following renal surgery. When assessing the patients output from surgical drains, the nurse should assess what parameters? Select all that apply. A) Quantity of output B) Color of the output C) Visible characteristics of the output D) Odor of the output E) pH of the output

A) Quantity of output B) Color of the output C) Visible characteristics of the output

A cardiovascular patient with a previous history of pulmonary embolism (PE) is experiencing a sudden onset of dyspnea, rapid breathing, and chest pain. The nurse recognizes the characteristic signs and symptoms of a PE. What is the nurses best action? A) Rapidly assess the patients cardiopulmonary status. B) Arrange for an ECG. C) Increase the height of the patients bed. D) Manage the patients anxiety.

A) Rapidly assess the patients cardiopulmonary status.

The nurse is caring for a patient who has had an ECG. The nurse notes that leads I, II, and III differ from one another on the cardiac rhythm strip. How should the nurse best respond? A) Recognize that the view of the electrical current changes in relation to the lead placement. B) Recognize that the electrophysiological conduction of the heart differs with lead placement. C) Inform the technician that the ECG equipment has malfunctioned. D) Inform the physician that the patient is experiencing a new onset of dysrhythmia

A) Recognize that the view of the electrical current changes in relation to the lead placement.

A patient with cardiovascular disease is being treated with amlodipine (Norvasc), a calcium channel blocking agent. The therapeutic effects of calcium channel blockers include which of the following? A) Reducing the hearts workload by decreasing heart rate and myocardial contraction B) Preventing platelet aggregation and subsequent thrombosis C) Reducing myocardial oxygen consumption by blocking adrenergic stimulation to the heart D) Increasing the efficiency of myocardial oxygen consumption, thus decreasing ischemia and relieving pain

A) Reducing the hearts workload by decreasing heart rate and myocardial contraction

A patient newly diagnosed with hypertension asks the nurse what happens when uncontrolled hypertension is prolonged. The nurse explains that a patient with prolonged, uncontrolled hypertension is at risk for developing what health problem? A) Renal failure B) Right ventricular hypertrophy C) Glaucoma D) Anemia

A) Renal failure

The nurse is caring for a patient who has had a biventricular pacemaker implanted. When planning the patients care, the nurse should recognize what goal of this intervention? A) Resynchronization B) Defibrillation C) Angioplasty D) Ablation

A) Resynchronization

A patient with primary hypertension comes to the clinic complaining of a gradual onset of blurry vision and decreased visual acuity over the past several weeks. The nurse is aware that these symptoms could be indicative of what? A) Retinal blood vessel damage B) Glaucoma C) Cranial nerve damage D) Hypertensive emergency

A) Retinal blood vessel damage

A patient with primary hypertension complains of dizziness with ambulation. The patient is currently on an alpha-adrenergic blocker and the nurse assesses characteristic signs and symptoms of postural hypotension. When teaching this patient about risks associated with postural hypotension, what should the nurse emphasize? A) Rising slowly from a lying or sitting position B) Increasing fluids to maintain BP C) Stopping medication if dizziness persists D) Taking medication first thing in the morning

A) Rising slowly from a lying or sitting position

The nurse is caring for a patient who returned from the tropics a few weeks ago and who sought care with signs and symptoms of lymphedema. The nurses plan of care should prioritize what nursing diagnosis? A) Risk for infection related to lymphedema B) Disturbed body image related to lymphedema C) Ineffective health maintenance related to lymphedema D) Risk for deficient fluid volume related to lymphedema

A) Risk for infection related to lymphedema

A patient with secondary hypertension has come into the clinic for a routine check-up. The nurse is aware that the difference between primary hypertension and secondary hypertension is which of the following? A) Secondary hypertension has a specific cause. B) Secondary hypertension has a more gradual onset than primary hypertension. C) Secondary hypertension does not cause target organ damage. D) Secondary hypertension does not normally respond to antihypertensive drug therapy.

A) Secondary hypertension has a specific cause.

A patient has had a nasogastric tube in place for 6 days due to the development of paralytic ileus after surgery. In light of the prolonged presence of the nasogastric tube, the nurse should prioritize assessments related to what complication? A) Sinus infections B) Esophageal strictures C) Pharyngitis D) Laryngitis

A) Sinus infections

A nurse in the CCU is caring for a patient with HF who has developed an intracardiac thrombus. This creates a high risk for what sequela? A) Stroke B) Myocardial infarction (MI) C) Hemorrhage D) Peripheral edema

A) Stroke

An x-ray of a trauma patient reveals rib fractures and the patient is diagnosed with a small flail chest injury. Which intervention should the nurse include in the patients plan of care? A) Suction the patients airway secretions. B) Immobilize the ribs with an abdominal binder. C) Prepare the patient for surgery. D) Immediately sedate and intubate the patient.

A) Suction the patients airway secretions.

A nurse on the renal unit is caring for a patient who will soon begin peritoneal dialysis. The family of the patient asks for education about the peritoneal dialysis catheter that has been placed in the patients peritoneum. The nurse explains the three sections of the catheter and talks about the two cuffs on the dialysis catheter. What would the nurse explain about the cuffs? Select all that apply. A) The cuffs are made of Dacron polyester. B) The cuffs stabilize the catheter. C) The cuffs prevent the dialysate from leaking. D) The cuffs provide a barrier against microorganisms. E) The cuffs absorb dialysate

A) The cuffs are made of Dacron polyester. B) The cuffs stabilize the catheter. C) The cuffs prevent the dialysate from leaking. D) The cuffs provide a barrier against microorganisms.

An adult patient has tested positive for tuberculosis (TB). While providing patient teaching, what information should the nurse prioritize? A) The importance of adhering closely to the prescribed medication regimen B) The fact that the disease is a lifelong, chronic condition that will affect ADLs C) The fact that TB is self-limiting, but can take up to 2 years to resolve D) The need to work closely with the occupational and physical therapists

A) The importance of adhering closely to the prescribed medication regimen

The nurse is working with a patient who had an MI and is now active in rehabilitation. The nurse should teach this patient to cease activity if which of the following occurs? A) The patient experiences chest pain, palpitations, or dyspnea. B) The patient experiences a noticeable increase in heart rate during activity. C) The patients oxygen saturation level drops below 96%. D) The patients respiratory rate exceeds 30 breaths/min.

A) The patient experiences chest pain, palpitations, or dyspnea.

The school nurse is presenting a class on smoking cessation at the local high school. A participant in the class asks the nurse about the risk of lung cancer in those who smoke. What response related to risk for lung cancer in smokers is most accurate? A) The younger you are when you start smoking, the higher your risk of lung cancer. B) The risk for lung cancer never decreases once you have smoked, which is why smokers need annual chest x-rays. C) The risk for lung cancer is determined mostly by what type of cigarettes you smoke. D) The risk for lung cancer depends primarily on the other risk factors for cancer that you have.

A) The younger you are when you start smoking, the higher your risk of lung cancer.

The occupational health nurse is assessing new employees at a company. What would be important to assess in employees with a potential occupational respiratory exposure to a toxin? Select all that apply. A) Time frame of exposure B) Type of respiratory protection used C) Immunization status D) Breath sounds E) Intensity of exposure

A) Time frame of exposure B) Type of respiratory protection used D) Breath sounds E) Intensity of exposure

A patient who is a candidate for an implantable cardioverter defibrillator (ICD) asks the nurse about the purpose of this device. What would be the nurses best response? A) To detect and treat dysrhythmias such as ventricular fibrillation and ventricular tachycardia B) To detect and treat bradycardia, which is an excessively slow heart rate C) To detect and treat atrial fibrillation, in which your heart beats too quickly and inefficiently D) To shock your heart if you have a heart attack at home

A) To detect and treat dysrhythmias such as ventricular fibrillation and ventricular tachycardia

The nurse is teaching a patient about some of the health consequences of uncontrolled hypertension. What health problems should the nurse describe? Select all that apply. A) Transient ischemic attacks B) Cerebrovascular accident C) Retinal hemorrhage D) Venous insufficiency E) Right ventricular hypertrophy

A) Transient ischemic attacks B) Cerebrovascular accident C) Retinal hemorrhage

A patient has come to the clinic for a follow-up assessment that will include a BP reading. To ensure an accurate reading, the nurse should confirm that the patient has done which of the following? A) Tried to rest quietly for 5 minutes before the reading is taken B) Refrained from smoking for at least 8 hours C) Drunk adequate fluids during the day prior D) Avoided drinking coffee for 12 hours before the visit

A) Tried to rest quietly for 5 minutes before the reading is taken

A patient the nurse is caring for has a permanent pacemaker implanted with the identification code beginning with VVI. What does this indicate? A) Ventricular paced, ventricular sensed, inhibited B) Variable paced, ventricular sensed, inhibited C) Ventricular sensed, ventricular situated, implanted D) Variable sensed, variable paced, inhibited

A) Ventricular paced, ventricular sensed, inhibited

The nurse is working on the renal transplant unit. To reduce the risk of infection in a patient with a transplanted kidney, it is imperative for the nurse to do what? A) Wash hands carefully and frequently. B) Ensure immediate function of the donated kidney. C) Instruct the patient to wear a face mask. D) Bar visitors from the patients room.

A) Wash hands carefully and frequently.

The nurse is caring for a patient who is scheduled for cardiac surgery. What should the nurse include in preoperative care? A) With the patient, clarify the surgical procedure that will be performed. B) Withhold the patients scheduled medications for at least 12 hours preoperatively. C) Inform the patient that health teaching will begin as soon as possible after surgery. D) Avoid discussing the patients fears as not to exacerbate them.

A) With the patient, clarify the surgical procedure that will be performed.

The nurse is planning the care of a patient who has been diagnosed with hypertension, but who otherwise enjoys good health. When assessing the response to an antihypertensive drug regimen, what blood pressure would be the goal of treatment? A) 156/96 mm Hg or lower B) 140/90 mm Hg or lower C) Average of 2 BP readings of 150/80 mm Hg D) 120/80 mm Hg or lower

B) 140/90 mm Hg or lower

The nurse coming on shift on the medical unit is taking a report on four patients. What patient does the nurse know is at the greatest risk of developing ESKD? A) A patient with a history of polycystic kidney disease B) A patient with diabetes mellitus and poorly controlled hypertension C) A patient who is morbidly obese with a history of vascular disorders Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1019 D) A patient with severe chronic obstructive pulmonary disease

B) A patient with diabetes mellitus and poorly controlled hypertension

A patient with thoracic trauma is admitted to the ICU. The nurse notes the patients chest and neck are swollen and there is a crackling sensation when palpated. The nurse consequently identifies the presence of subcutaneous emphysema. If this condition becomes severe and threatens airway patency, what intervention is indicated? A) A chest tube B) A tracheostomy C) An endotracheal tube D) A feeding tube

B) A tracheostomy

The critical care nurse is monitoring the patients urine output and drains following renal surgery. What should the nurse promptly report to the physician? A) Increased pain on movement B) Absence of drain output C) Increased urine output D) Blood-tinged serosanguineous drain output

B) Absence of drain output

The nurse is caring for a 72-year-old patient who is in cardiac rehabilitation following heart surgery. The patient has been walking on a regular basis for about a week and walks for 15 minutes 3 times a day. The patient states that he is having a cramp-like pain in the legs every time he walks and that the pain gets better when I rest. The patients care plan should address what problem? A) Decreased mobility related to VTE B) Acute pain related to intermittent claudication C) Decreased mobility related to venous insufficiency D) Acute pain related to vasculitis

B) Acute pain related to intermittent claudication

A patient presents to the ED complaining of increasing shortness of breath. The nurse assessing the patient notes a history of left-sided HF. The patient is agitated and occasionally coughing up pink-tinged, foamy sputum. The nurse should recognize the signs and symptoms of what health problem? A) Right-sided heart failure B) Acute pulmonary edema C) Pneumonia D) Cardiogenic shock

B) Acute pulmonary edema

The nurse is creating a plan of care for a patient with acute coronary syndrome. What nursing action should be included in the patients care plan? A) Facilitate daily arterial blood gas (ABG) sampling. B) Administer supplementary oxygen, as needed. C) Have patient maintain supine positioning when in bed. D) Perform chest physiotherapy, as indicated

B) Administer supplementary oxygen, as needed

A hospital has been the site of an increased incidence of hospital-acquired pneumonia (HAP). What is an important measure for the prevention of HAP? A) Administration of prophylactic antibiotics B) Administration of pneumococcal vaccine to vulnerable individuals C) Obtaining culture and sensitivity swabs from all newly admitted patients D) Administration of antiretroviral medications to patients over age 65

B) Administration of pneumococcal vaccine to vulnerable individuals

The nurse is caring for a patient with acute glomerular inflammation. When assessing for the characteristic signs and symptoms of this health problem, the nurse should include which assessments? Select all that apply. A) Percuss for pain in the right lower abdominal quadrant. B) Assess for the presence of peripheral edema. C) Auscultate the patients apical heart rate for dysrhythmias. D) Assess the patients BP. E) Assess the patients orientation and judgment.

B) Assess for the presence of peripheral edema. D) Assess the patients BP.

A perioperative nurse is caring for a postoperative patient. The patient has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the patients increased risk for what complication? A) Acute respiratory distress syndrome (ARDS) B) Atelectasis C) Aspiration D) Pulmonary embolism

B) Atelectasis

The nurse is performing the health interview of a patient with chronic rhinosinusitis who experiences frequent nose bleeds. The nurse asks the patient about her current medication regimen. Which medication would put the patient at a higher risk for recurrent epistaxis? A) Afrin B) Beconase C) Sinustop Pro D) Singulair

B) Beconase

A patient with an occluded coronary artery is admitted and has an emergency percutaneous transluminal coronary angioplasty (PTCA). The patient is admitted to the cardiac critical care unit after the PTCA. For what complication should the nurse most closely monitor the patient? A) Hyperlipidemia B) Bleeding at insertion site C) Left ventricular hypertrophy D) Congestive heart failure

B) Bleeding at insertion site

A patient has returned to the cardiac care unit after having a permanent pacemaker implantation. For which potential complication should the nurse most closely assess this patient? A) Chest pain B) Bleeding at the implantation site C) Malignant hyperthermia D) Bradycardia

B) Bleeding at the implantation site

The nurse is caring for a patient suspected of having ARDS. What is the most likely diagnostic test ordered in the early stages of this disease to differentiate the patients symptoms from those of a cardiac etiology? A) Carboxyhemoglobin level B) Brain natriuretic peptide (BNP) level C) C-reactive protein (CRP) level D) Complete blood count

B) Brain natriuretic peptide (BNP) level

A nurse has taken on the care of a patient who had a coronary artery stent placed yesterday. When reviewing the patients daily medication administration record, the nurse should anticipate administering what drug? A) Ibuprofen B) Clopidogrel C) Dipyridamole D) Acetaminophen

B) Clopidogrel

A patient converts from normal sinus rhythm at 80 bpm to atrial fibrillation with a ventricular response at 166 bpm. Blood pressure is 162/74 mm Hg. Respiratory rate is 20 breaths per minute with normal chest expansion and clear lungs bilaterally. IV heparin and Cardizem are given. The nurse caring for the patient understands that the main goal of treatment is what? A) Decrease SA node conduction B) Control ventricular heart rate C) Improve oxygenation D) Maintain anticoagulation

B) Control ventricular heart rate

The nurse is reviewing the medication administration record of a patient who takes a variety of medications for the treatment of hypertension. What potential therapeutic benefits of antihypertensives should the nurse identify? Select all that apply. A) Increased venous return B) Decreased peripheral resistance C) Decreased blood volume D) Decreased strength and rate of myocardial contractions E) Decreased blood viscosity

B) Decreased peripheral resistance C) Decreased blood volume D) Decreased strength and rate of myocardial contractions

A nurse in a long-term care facility is caring for an 83-year-old woman who has a history of HF and peripheral arterial disease (PAD). At present the patient is unable to stand or ambulate. The nurse should implement measures to prevent what complication? A) Aoritis B) Deep vein thrombosis C) Thoracic aortic aneurysm D) Raynauds disease

B) Deep vein thrombosis

The nurse is conducting a presurgical interview for a patient with laryngeal cancer. The patient states that he drinks approximately six to eight shots of vodka per day. It is imperative that the nurse inform the surgical team so the patient can be assessed for what? A) Increased risk for infection B) Delirium tremens C) Depression D) Nonadherence to postoperative care

B) Delirium tremens

New nurses on the telemetry unit have been paired with preceptors. One new nurse asks her preceptor to explain depolarization. What would be the best answer by the preceptor? A) Depolarization is the mechanical contraction of the heart muscles. B) Depolarization is the electrical stimulation of the heart muscles. C) Depolarization is the electrical relaxation of the heart muscles. D) Depolarization is the mechanical relaxation of the heart muscles

B) Depolarization is the electrical stimulation of the heart muscles.

A patient is scheduled for catheter ablation therapy. When describing this procedure to the patients family, the nurse should address what aspect of the treatment? A) Resetting of the hearts contractility B) Destruction of specific cardiac cells C) Correction of structural cardiac abnormalities D) Clearance of partially occluded coronary arteries

B) Destruction of specific cardiac cells

The nurse is assessing a patient who is known to have right-sided HF. What assessment finding is most consistent with this patients diagnosis? A) Pulmonary edema B) Distended neck veins C) Dry cough D) Orthopnea

B) Distended neck veins

A nurse has written a plan of care for a man diagnosed with peripheral arterial insufficiency. One of the nursing diagnoses in the care plan is altered peripheral tissue perfusion related to compromised circulation. What is the most appropriate intervention for this diagnosis? A) Elevate his legs and arms above his heart when resting. B) Encourage the patient to engage in a moderate amount of exercise. C) Encourage extended periods of sitting or standing. D) Discourage walking in order to limit pain.

B) Encourage the patient to engage in a moderate amount of exercise.

The ED nurse is caring for a patient who has gone into cardiac arrest. During external defibrillation, what action should the nurse perform? A) Place gel pads over the apex and posterior chest for better conduction. B) Ensure no one is touching the patient at the time shock is delivered. C) Continue to ventilate the patient via endotracheal tube during the procedure. D) Allow at least 3 minutes between shocks.

B) Ensure no one is touching the patient at the time shock is delivered.

The nurse is addressing exercise and physical activity during discharge education with a patient diagnosed with HF. What should the nurse teach this patient about exercise? A) Do not exercise unsupervised. B) Eventually aim to work up to 30 minutes of exercise each day. C) Slow down if you get dizzy or short of breath. D) Start your exercise program with high-impact activities.

B) Eventually aim to work up to 30 minutes of exercise each day.

A patient is being treated for AKI and the patient daily weights have been ordered. The nurse notes a weight gain of 3 pounds over the past 48 hours. What nursing diagnosis is suggested by this assessment finding? A) Imbalanced nutrition: More than body requirements B) Excess fluid volume C) Sedentary lifestyle D) Adult failure to thrive

B) Excess fluid volume

A patient has been diagnosed as being prehypertensive. What should the nurse encourage this patient to do to aid in preventing a progression to a hypertensive state? A) Avoid excessive potassium intake. B) Exercise on a regular basis. C) Eat less protein and more vegetables. D) Limit morning activity.

B) Exercise on a regular basis.

The critical care nurse is caring for a patient who is in cardiogenic shock. What assessments must the nurse perform on this patient? Select all that apply. A) Platelet level B) Fluid status C) Cardiac rhythm D) Action of medications E) Sputum volume

B) Fluid status C) Cardiac rhythm D) Action of medications

The nurse is providing care for a patient with a new diagnosis of hypertension. How can the nurse best promote the patients adherence to the prescribed therapeutic regimen? A) Screen the patient for visual disturbances regularly. B) Have the patient participate in monitoring his or her own BP. C) Emphasize the dire health outcomes associated with inadequate BP control. D) Encourage the patient to lose weight and exercise regularly.

B) Have the patient participate in monitoring his or her own BP.

When planning the care of a patient with an implanted pacemaker, what assessment should the nurse prioritize? A) Core body temperature B) Heart rate and rhythm C) Blood pressure D) Oxygen saturation level

B) Heart rate and rhythm

The nurse is caring for a patient who is admitted to the medical unit for the treatment of a venous ulcer in the area of her lateral malleolus that has been unresponsive to treatment. What is the nurse most likely to find during an assessment of this patients wound? A) Hemorrhage B) Heavy exudate C) Deep wound bed D) Pale-colored wound bed

B) Heavy exudate

The perioperative nurse has admitted a patient who has just underwent a tonsillectomy. The nurses postoperative assessment should prioritize which of the following potential complications of this surgery? A) Difficulty ambulating B) Hemorrhage C) Infrequent swallowing D) Bradycardia

B) Hemorrhage

A patient with HF is placed on a low-sodium diet. Which statement by the patient indicates that the nurses nutritional teaching plan has been effective? A) I will have a ham and cheese sandwich for lunch. B) I will have a baked potato with broiled chicken for dinner. C) I will have a tossed salad with cheese and croutons for lunch. D) I will have chicken noodle soup with crackers and an apple for lunch.

B) I will have a baked potato with broiled chicken for dinner.

A mother calls the clinic asking for a prescription for Amoxicillin for her 2-year-old son who has what the nurse suspects to be viral rhinitis. What should the nurse explain to this mother? A) I will relay your request promptly to the doctor, but I suspect that she wont get back to you if its a cold. B) Ill certainly inform the doctor, but if it is a cold, antibiotics wont be used because they do not affect the virus. C) Ill phone in the prescription for you since it can be prescribed by the pharmacist. D) Amoxicillin is not likely the best antibiotic, but Ill call in the right prescription for you.

B) Ill certainly inform the doctor, but if it is a cold, antibiotics wont be used because they do not affect the virus.

In preparation for cardiac surgery, a patient was taught about measures to prevent venous thromboembolism. What statement indicates that the patient clearly understood this education? A) Ill try to stay in bed for the first few days to allow myself to heal. B) Ill make sure that I dont cross my legs when Im resting in bed. C) Ill keep pillows under my knees to help my blood circulate better. D) Ill put on those compression stockings if I get pain in my calves.

B) Ill make sure that I dont cross my legs when Im resting in bed.

While assessing a patient the nurse notes that the patients ankle-brachial index (ABI) of the right leg is 0.40. How should the nurse best respond to this assessment finding? A) Assess the patients use of over-the-counter dietary supplements. B) Implement interventions relevant to arterial narrowing. C) Encourage the patient to increase intake of foods high in vitamin K. D) Adjust the patients activity level to accommodate decreased coronary output.

B) Implement interventions relevant to arterial narrowing.

The nurse is doing discharge teaching in the ED with a patient who had a nosebleed. What should the nurse include in the discharge teaching of this patient? A) Avoid blowing the nose for the next 45 minutes. B) In case of recurrence, apply direct pressure for 15 minutes. C) Do not take aspirin for the next 2 weeks. D) Seek immediate medical attention if the nosebleed recurs.

B) In case of recurrence, apply direct pressure for 15 minutes.

A patients medication regimen for the treatment of hypertension includes hydrochlorothiazide. Following administration of this medication, the nurse should anticipate what effect? A) Drowsiness or lethargy B) Increased urine output C) Decreased heart rate D) Mild agitation

B) Increased urine output

You are caring for a patient who is diagnosed with Raynauds phenomenon. The nurse should plan interventions to address what nursing diagnosis? A) Chronic pain B) Ineffective tissue perfusion C) Impaired skin integrity D) Risk for injury

B) Ineffective tissue perfusion

A postsurgical patient has illuminated her call light to inform the nurse of a sudden onset of lower leg pain. On inspection, the nurse observes that the patients left leg is visibly swollen and reddened. What is the nurses most appropriate action? A) Administer a PRN dose of subcutaneous heparin. B) Inform the physician that the patient has signs and symptoms of VTE. C) Mobilize the patient promptly to dislodge any thrombi in the patients lower leg. D) Massage the patients lower leg to temporarily restore venous return.

B) Inform the physician that the patient has signs and symptoms of VTE.

The nurse is taking a health history of a new patient. The patient reports experiencing pain in his left lower leg and foot when walking. This pain is relieved with rest. The nurse notes that the left lower leg is slightly edematous and is hairless. When planning this patients subsequent care, the nurse should most likely address what health problem? A) Coronary artery disease (CAD) B) Intermittent claudication C) Arterial embolus D) Raynauds disease

B) Intermittent claudication

The nurse recognizes that aspiration is a potential complication of a laryngectomy. How should the nurse best manage this risk? A) Facilitate total parenteral nutrition (TPN). B) Keep a complete suction setup at the bedside. C) Feed the patient several small meals daily. D) Refer the patient for occupational therapy.

B) Keep a complete suction setup at the bedside.

A 71-year-old patient with ESKD has been told by the physician that it is time to consider hemodialysis until a transplant can be found. The patient tells the nurse she is not sure she wants to undergo a kidney transplant. What would be an appropriate response for the nurse to make? A) The decision is certainly yours to make, but be sure not to make a mistake. B) Kidney transplants in patients your age are as successful as they are in younger patients. C) I understand your hesitancy to commit to a transplant surgery. Success is comparatively rare. D) Have you talked this over with your family?

B) Kidney transplants in patients your age are as successful as they are in younger patients.

A patient is brought to the ED by ambulance after a motor vehicle accident in which the patient received blunt trauma to the chest. The patient is in acute respiratory failure, is intubated, and is transferred to the ICU. What parameters of care should the nurse monitor most closely? Select all that apply. A) Coping B) Level of consciousness C) Oral intake D) Arterial blood gases E) Vital signs

B) Level of consciousness D) Arterial blood gases E) Vital signs

A patient is brought to the renal unit from the PACU status post resection of a renal tumor. Which of the following nursing actions should the nurse prioritize in the care of this patient? A) Increasing oral intake B) Managing postoperative pain C) Managing dialysis D) Increasing mobility

B) Managing postoperative pain

Which assessment would be most appropriate for a patient who is receiving a loop diuretic for HF? A) Monitor liver function studies B) Monitor for hypotension C) Assess the patients vitamin D intake D) Assess the patient for hyperkalemia

B) Monitor for hypotension

A patient is receiving thrombolytic therapy for the treatment of pulmonary emboli. What is the best way for the nurse to assess the patients oxygenation status at the bedside? A) Obtain serial ABG samples. B) Monitor pulse oximetry readings. C) Test pulmonary function. D) Monitor incentive spirometry volumes

B) Monitor pulse oximetry readings.

An adult patient is admitted to the ED with chest pain. The patient states that he had developed unrelieved chest pain that was present for approximately 20 minutes before coming to the hospital. To minimize cardiac damage, the nurse should expect to administer which of the following interventions? A) Thrombolytics, oxygen administration, and nonsteroidal anti-inflammatories B) Morphine sulphate, oxygen, and bed rest C) Oxygen and beta-adrenergic blockers D) Bed rest, albuterol nebulizer treatments, and oxygen

B) Morphine sulphate, oxygen, and bed rest

The hospital nurse cares for many patients who have hypertension. What nursing diagnosis is most common among patients who are being treated for this health problem? A) Deficient knowledge regarding the lifestyle modifications for management of hypertension B) Noncompliance with therapeutic regimen related to adverse effects of prescribed therapy C) Deficient knowledge regarding BP monitoring D) Noncompliance with treatment regimen related to medication costs

B) Noncompliance with therapeutic regimen related to adverse effects of prescribed therapy

A firefighter was trapped in a fire and is admitted to the ICU for smoke inhalation. After 12 hours, the firefighter is exhibiting signs of ARDS and is intubated. What other supportive measures are initiated in a patient with ARDS? A) Psychological counseling B) Nutritional support C) High-protein oral diet D) Occupational therapy

B) Nutritional support

The nurse is caring for an older adult with a diagnosis of hypertension who is being treated with a diuretic and beta-blocker. Which of the following should the nurse integrate into the management of this clients hypertension? A) Ensure that the patient receives a larger initial dose of antihypertensive medication due to impaired absorption. B) Pay close attention to hydration status because of increased sensitivity to extracellular volume depletion. C) Recognize that an older adult is less likely to adhere to his or her medication regimen than a younger patient. D) Carefully assess for weight loss because of impaired kidney function resulting from normal aging

B) Pay close attention to hydration status because of increased sensitivity to extracellular volume depletion.

The nurse is caring for a 68-year-old patient the nurse suspects has digoxin toxicity. In addition to physical assessment, the nurse should collect what assessment datum? A) Skin turgor B) Potassium level C) White blood cell count D) Peripheral pulses

B) Potassium level

During an adult patients last two office visits, the nurse obtained BP readings of 122/84 mm Hg and 130/88 mm Hg, respectively. How would this patients BP be categorized? A) Normal B) Prehypertensive C) Stage 1 hypertensive D) Stage 2 hypertensive

B) Prehypertensive

A patient is scheduled for a CT scan of the abdomen with contrast. The patient has a baseline creatinine level of 2.3 mg/dL. In preparing this patient for the procedure, the nurse anticipates what orders? A) Monitor the patients electrolyte values every hour before the procedure. B) Preprocedure hydration and administration of acetylcysteine C) Hemodialysis immediately prior to the CT scan D) Obtain a creatinine clearance by collecting a 24-hour urine specimen.

B) Preprocedure hydration and administration of acetylcysteine

The nurses comprehensive assessment of a patient who has HF includes evaluation of the patients hepatojugular reflux. What action should the nurse perform during this assessment? A) Elevate the patients head to 90 degrees. B) Press the right upper abdomen. C) Press above the patients symphysis pubis. D) Lay the patient flat in bed.

B) Press the right upper abdomen.

The nurse is performing an assessment on a patient who has been diagnosed with cancer of the larynx. Part of the nurses assessment addresses the patients general state of nutrition. Which laboratory values would be assessed when determining the nutritional status of the patient? Select all that apply. A) White blood cell count B) Protein level C) Albumin level D) Platelet count E) Glucose level

B) Protein level C) Albumin level E) Glucose level

The nurse is caring for a patient with refractory atrial fibrillation who underwent the maze procedure several months ago. The nurse reviews the result of the patients most recent cardiac imaging, which notes the presence of scarring on the atria. How should the nurse best respond to this finding? A) Recognize that the procedure was unsuccessful. B) Recognize this as a therapeutic goal of the procedure. C) Liaise with the care team in preparation for repeating the maze procedure. D) Prepare the patient for pacemaker implantation.

B) Recognize this as a therapeutic goal of the procedure.

A patient on the critical care unit is postoperative day 1 following kidney transplantation from a living donor. The nurses most recent assessments indicate that the patient is producing copious quantities of dilute urine. What is the nurses most appropriate response? A) Assess the patient for further signs or symptoms of rejection. B) Recognize this as an expected finding. C) Inform the primary care provider of this finding. D) Administer exogenous antidiuretic hormone as ordered.

B) Recognize this as an expected finding.

A patient with chronic kidney disease is completing an exchange during peritoneal dialysis. The nurse observes that the peritoneal fluid is draining slowly and that the patients abdomen is increasing in girth. What is the nurses most appropriate action? A) Advance the catheter 2 to 4 cm further into the peritoneal cavity. B) Reposition the patient to facilitate drainage. C) Aspirate from the catheter using a 60-mL syringe. D) Infuse 50 mL of additional dialysate.

B) Reposition the patient to facilitate drainage.

A patient who involved in a workplace accident suffered a penetrating wound of the chest that led to acute respiratory failure. What goal of treatment should the care team prioritize when planning this patients care? A) Facilitation of long-term intubation B) Restoration of adequate gas exchange C) Attainment of effective coping D) Self-management of oxygen therapy

B) Restoration of adequate gas exchange

The nurse is analyzing a rhythm strip. What component of the ECG corresponds to the resting state of the patients heart? A) P wave B) T wave C) U wave D) QRS complex

B) T wave

The nurse is caring for a patient who is believed to have just experienced an MI. The nurse notes changes in the ECG of the patient. What change on an ECG most strongly suggests to the nurse that ischemia is occurring? A) P wave inversion B) T wave inversion C) Q wave changes with no change in ST or T wave D) P wave enlargement

B) T wave inversion

The nurse is educating an 80-year-old patient diagnosed with HF about his medication regimen. What should the nurse to teach this patient about the use of oral diuretics? A) Avoid drinking fluids for 2 hours after taking the diuretic. B) Take the diuretic in the morning to avoid interfering with sleep. C) Avoid taking the medication within 2 hours consuming dairy products. D) Take the diuretic only on days when experiencing shortness of breath.

B) Take the diuretic in the morning to avoid interfering with sleep.

The nurse is caring for a patient who has just been diagnosed with chronic rhinosinusitis. While being admitted to the clinic, the patient asks, Will this chronic infection hurt my new kidney? What should the nurse know about chronic rhinosinusitis in patients who have had a transplant? A) The patient will have exaggerated symptoms of rhinosinusitis due to immunosuppression. B) Taking immunosuppressive drugs can contribute to chronic rhinosinusitis. C) Chronic rhinosinusitis can damage the transplanted organ. D) Immunosuppressive drugs can cause organ rejection.

B) Taking immunosuppressive drugs can contribute to chronic rhinosinusitis.

The nursing lab instructor is teaching student nurses how to take blood pressure. To ensure accurate measurement, the lab instructor would teach the students to avoid which of the following actions? A) Measuring the BP after the patient has been seated quietly for more than 5 minutes B) Taking the BP at least 10 minutes after nicotine or coffee ingestion C) Using a cuff with a bladder that encircles at least 80% of the limb D) Using a bare forearm supported at heart level on a firm surface

B) Taking the BP at least 10 minutes after nicotine or coffee ingestion

During a CPR class, a participant asks about the difference between cardioversion and defibrillation. What would be the instructors best response? A) Cardioversion is done on a beating heart; defibrillation is not. B) The difference is the timing of the delivery of the electric current. C) Defibrillation is synchronized with the electrical activity of the heart, but cardioversion is not. D) Cardioversion is always attempted before defibrillation because it has fewer risks.

B) The difference is the timing of the delivery of the electric current.

The nurse overseeing care in the ICU reviews the shift report on four patients. The nurse recognizes which patient to be at greatest risk for the development of cardiogenic shock? A) The patient admitted with acute renal failure B) The patient admitted following an MI C) The patient admitted with malignant hypertension D) The patient admitted following a stroke

B) The patient admitted following an MI

The nurse is providing care for a patient who has just been admitted to the postsurgical unit following a laryngectomy. What assessment should the nurse prioritize? A) The patients swallowing ability B) The patients airway patency C) The patients carotid pulses D) Signs and symptoms of infection

B) The patients airway patency

A patient on the medical unit has a documented history of polycystic kidney disease (PKD). What principle should guide the nurses care of this patient? A) The disease is self-limiting and cysts usually resolve spontaneously in the fifth or sixth decade of life. B) The patients disease is incurable and the nurses interventions will be supportive. C) The patient will eventually require surgical removal of his or her renal cysts. D) The patient is likely to respond favorably to lithotripsy treatment of the cysts.

B) The patients disease is incurable and the nurses interventions will be supportive.

When assessing a patient diagnosed with angina pectoris it is most important for the nurse to gather what information? A) The patients activities limitations and level of consciousness after the attacks B) The patients symptoms and the activities that precipitate attacks C) The patients understanding of the pathology of angina D) The patients coping strategies surrounding the attacks

B) The patients symptoms and the activities that precipitate attacks

A patient states that her family has had several colds during this winter and spring despite their commitment to handwashing. The high communicability of the common cold is attributable to what factor? A) Cold viruses are increasingly resistant to common antibiotics. B) The virus is shed for 2 days prior to the emergence of symptoms. C) A genetic predisposition to viral rhinitis has recently been identified. D) Overuse of OTC cold remedies creates a rebound susceptibility to future colds.

B) The virus is shed for 2 days prior to the emergence of symptoms.

A patient has just been diagnosed with squamous cell carcinoma of the neck. While the nurse is doing health education, the patient asks, Does this kind of cancer tend to spread to other parts of the body? What is the nurses best response? A) In many cases, this type of cancer spreads to other parts of the body. B) This cancer usually does not spread to distant sites in the body. C) You will have to speak to your oncologist about that. D) Squamous cell carcinoma is nothing to be concerned about, so try to focus on your health.

B) This cancer usually does not spread to distant sites in the body.

A patient with angina has been prescribed nitroglycerin. Before administering the drug, the nurse should inform the patient about what potential adverse effects? A) Nervousness or paresthesia B) Throbbing headache or dizziness C) Drowsiness or blurred vision D) Tinnitus or diplopia

B) Throbbing headache or dizziness

A 40-year-old male newly diagnosed with hypertension is discussing risk factors with the nurse. The nurse talks about lifestyle changes with the patient and advises that the patient should avoid tobacco use. What is the primary rationale behind that advice to the patient? A) Quitting smoking will cause the patients hypertension to resolve. B) Tobacco use increases the patients concurrent risk of heart disease. C) Tobacco use is associated with a sedentary lifestyle. D) Tobacco use causes ventricular hypertrophy.

B) Tobacco use increases the patients concurrent risk of heart disease.

The nurse is caring for a patient with a severe nosebleed. The physician inserts a nasal sponge and tells the patient it may have to remain in place up to 6 days before it is removed. The nurse should identify that this patient is at increased risk for what? A) Viral sinusitis B) Toxic shock syndrome C) Pharyngitis D) Adenoiditis

B) Toxic shock syndrome

The nurse caring for a patient whose sudden onset of sinus bradycardia is not responding adequately to atropine. What might be the treatment of choice for this patient? A) Implanted pacemaker B) Transcutaneous pacemaker C) ICD D) Asynchronous defibrillator

B) Transcutaneous pacemaker

The nurse is providing care for a patient who has just been diagnosed with peripheral arterial occlusive disease (PAD). What assessment finding is most consistent with this diagnosis? A) Numbness and tingling in the distal extremities B) Unequal peripheral pulses between extremities C) Visible clubbing of the fingers and toes D) Reddened extremities with muscle atrophy

B) Unequal peripheral pulses between extremities

The staff educator is teaching a CPR class. Which of the following aspects of defibrillation should the educator stress to the class? A) Apply the paddles directly to the patients skin. B) Use a conducting medium between the paddles and the skin. C) Always use a petroleum-based gel between the paddles and the skin. D) Any available liquid can be used between the paddles and the skin.

B) Use a conducting medium between the paddles and the skin.

An occupational health nurse is providing an educational event and has been asked by an administrative worker about the risk of varicose veins. What should the nurse suggest as a proactive preventative measure for varicose veins? A) Sit with crossed legs for a few minutes each hour to promote relaxation. B) Walk for several minutes every hour to promote circulation. C) Elevate the legs when tired. D) Wear snug-fitting ankle socks to decrease edema.

B) Walk for several minutes every hour to promote circulation.

A new employee asks the occupational health nurse about measures to prevent inhalation exposure of the substances. Which statement by the nurse will decrease the patients exposure risk to toxic substances? A) Position a fan blowing on the toxic substances to prevent the substance from becoming stagnant in the air. B) Wear protective attire and devices when working with a toxic substance. C) Make sure that you keep your immunizations up to date to prevent respiratory diseases resulting from toxins. D) Always wear a disposable paper face mask when you are working with inhalable toxins

B) Wear protective attire and devices when working with a toxic substance.

The prevention of VTE is an important part of the nursing care of high-risk patients. When providing patient teaching for these high-risk patients, the nurse should advise lifestyle changes, including which of the following? Select all that apply. A) High-protein diet B) Weight loss C) Regular exercise D) Smoking cessation E) Calcium and vitamin D supplementation

B) Weight loss C) Regular exercise D) Smoking cessation

A nurse is performing blood pressure screenings at a local health fair. While obtaining subjective assessment data from a patient with hypertension, the nurse learns that the patient has a family history of hypertension and she herself has high cholesterol and lipid levels. The patient says she smokes one pack of cigarettes daily and drinks about a pack of beer every day. The nurse notes what nonmodifiable risk factor for hypertension? A) Hyperlipidemia B) Excessive alcohol intake C) A family history of hypertension D) Closer adherence to medical regimen

C) A family history of hypertension

A patient is being treated for bacterial pharyngitis. Which of the following should the nurse recommend when promoting the patients nutrition during treatment? A) A 1.5 L/day fluid restriction B) A high-potassium, low-sodium diet C) A liquid or soft diet D) A high-protein diet

C) A liquid or soft diet

A medical nurse has admitted four patients over the course of a 12-hour shift. For which patient would assessment of ankle-brachial index (ABI) be most clearly warranted? A) A patient who has peripheral edema secondary to chronic heart failure B) An older adult patient who has a diagnosis of unstable angina C) A patient with poorly controlled type 1 diabetes who is a smoker D) A patient who has community-acquired pneumonia and a history of COPD

C) A patient with poorly controlled type 1 diabetes who is a smoker

A nurse is working with a patient who has been scheduled for a percutaneous coronary intervention (PCI) later in the week. What anticipatory guidance should the nurse provide to the patient? A) He will remain on bed rest for 48 to 72 hours after the procedure. B) He will be given vitamin K infusions to prevent bleeding following PCI. C) A sheath will be placed over the insertion site after the procedure is finished. D) The procedure will likely be repeated in 6 to 8 weeks to ensure success.

C) A sheath will be placed over the insertion site after the procedure is finished.

A group of student nurses are practicing taking blood pressure. A 56-year-old male student has a blood pressure reading of 146/96 mm Hg. Upon hearing the reading, he exclaims, My pressure has never been this high. Do you think my doctor will prescribe medication to reduce it? Which of the following responses by the nursing instructor would be best? A) Yes. Hypertension is prevalent among men; it is fortunate we caught this during your routine examination. B) We will need to reevaluate your blood pressure because your age places you at high risk for hypertension. C) A single elevated blood pressure does not confirm hypertension. You will need to have your blood pressure reassessed several times before a diagnosis can be made. D) You have no need to worry. Your pressure is probably elevated because you are being tested.

C) A single elevated blood pressure does not confirm hypertension. You will need to have your blood pressure reassessed several times before a diagnosis can be made.

A patient presents to the ED stating she was in a boating accident about 3 hours ago. Now the patient has complaints of headache, fatigue, and the feeling that he just cant breathe enough. The nurse notes that the patient is restless and tachycardic with an elevated blood pressure. This patient may be in the early stages of what respiratory problem? A) Pneumoconiosis B) Pleural effusion C) Acute respiratory failure D) Pneumonia

C) Acute respiratory failure

An 84-year-old woman diagnosed with cancer is admitted to the oncology unit for surgical treatment. The patient has been on chemotherapeutic agents to decrease the tumor size prior to the planned surgery. The nurse caring for the patient is aware that what precipitating factors in this patient may contribute to AKI? Select all that apply. A) Anxiety B) Low BMI C) Age-related physiologic changes D) Chronic systemic disease E) NPO status

C) Age-related physiologic changes D) Chronic systemic disease

A nurse on a medical unit is caring for a patient who has been diagnosed with lymphangitis. When reviewing this patients medication administration record, the nurse should anticipate which of the following? A) Coumadin (warfarin) B) Lasix (furosemide) C) An antibiotic D) An antiplatelet aggregator

C) An antibiotic

The triage nurse in the ED is assessing a patient who has presented with complaint of pain and swelling in her right lower leg. The patients pain became much worse last night and appeared along with fever, chills, and sweating. The patient states, I hit my leg on the car door 4 or 5 days ago and it has been sore ever since. The patient has a history of chronic venous insufficiency. What intervention should the nurse anticipate for this patient? A) Platelet transfusion to treat thrombocytopenia B) Warfarin to treat arterial insufficiency C) Antibiotics to treat cellulitis D) Heparin IV to treat VTE

C) Antibiotics to treat cellulitis

The nurse is providing discharge teaching for a patient who developed a pulmonary embolism after total knee surgery. The patient has been converted from heparin to sodium warfarin (Coumadin) anticoagulant therapy. What should the nurse teach the client? A) Coumadin will continue to break up the clot over a period of weeks B) Coumadin must be taken concurrent with ASA to achieve anticoagulation. C) Anticoagulant therapy usually lasts between 3 and 6 months. D) He should take a vitamin supplement containing vitamin K

C) Anticoagulant therapy usually lasts between 3 and 6 months.

You are writing a care plan for a patient who has been diagnosed with angina pectoris. The patient describes herself as being distressed and shocked by her new diagnosis. What nursing diagnosis is most clearly suggested by the womans statement? A) Spiritual distress related to change in health status B) Acute confusion related to prognosis for recovery C) Anxiety related to cardiac symptoms D) Deficient knowledge related to treatment of angina pectoris

C) Anxiety related to cardiac symptoms

A 79-year-old man is admitted to the medical unit with digital gangrene. The man states that his problems first began when he stubbed his toe going to the bathroom in the dark. In addition to this trauma, the nurse should suspect that the patient has a history of what health problem? A) Raynauds phenomenon B) CAD C) Arterial insufficiency D) Varicose veins

C) Arterial insufficiency

When assessing for substances that are known to harm workers lungs, the occupational health nurse should assess their potential exposure to which of the following? A) Organic acids B) Propane C) Asbestos D) Gypsum

C) Asbestos

The nurse is caring for a patient who is receiving oxygen therapy for pneumonia. How should the nurse best assess whether the patient is hypoxemic? A) Assess the patients level of consciousness (LOC). B) Assess the patients extremities for signs of cyanosis. C) Assess the patients oxygen saturation level. D) Review the patients hemoglobin, hematocrit, and red blood cell levels

C) Assess the patients oxygen saturation level.

The nurse is providing care for a patient with a diagnosis of hypertension. The nurse should consequently assess the patient for signs and symptoms of which other health problem? A) Migraines B) Atrial-septal defect C) Atherosclerosis D) Thrombocytopenia

C) Atherosclerosis

The triage nurse in the ED is assessing a patient with chronic HF who has presented with worsening symptoms. In reviewing the patients medical history, what is a potential primary cause of the patients heart failure? A) Endocarditis B) Pleural effusion C) Atherosclerosis D) Atrial-septal defect

C) Atherosclerosis

During a patients care conference, the team is discussing whether the patient is a candidate for cardiac conduction surgery. What would be the most important criterion for a patient to have this surgery? A) Angina pectoris not responsive to other treatments B) Decreased activity tolerance related to decreased cardiac output C) Atrial and ventricular tachycardias not responsive to other treatments D) Ventricular fibrillation not responsive to other treatments

C) Atrial and ventricular tachycardias not responsive to other treatments

The nurse is planning discharge teaching for a patient with a newly inserted permanent pacemaker. What is the priority teaching point for this patient? A) Start lifting the arm above the shoulder right away to prevent chest wall adhesion. B) Avoid cooking with a microwave oven. C) Avoid exposure to high-voltage electrical generators. D) Avoid walking through store and library antitheft devices.

C) Avoid exposure to high-voltage electrical generators.

The nurse is participating in the care conference for a patient with ACS. What goal should guide the care teams selection of assessments, interventions, and treatments? A) Maximizing cardiac output while minimizing heart rate B) Decreasing energy expenditure of the myocardium C) Balancing myocardial oxygen supply with demand D) Increasing the size of the myocardial muscle

C) Balancing myocardial oxygen supply with demand

The nurse is caring for an 84-year-old man who has just returned from the OR after inguinal hernia repair. The OR report indicates that the patient received large volumes of IV fluids during surgery and the nurse recognizes that the patient is at risk for left-sided heart failure. What signs and symptoms would indicate left-sided heart failure? A) Jugular vein distention B) Right upper quadrant pain C) Bibasilar fine crackles D) Dependent edema

C) Bibasilar fine crackles

Diagnostic imaging reveals that the quantity of fluid in a clients pericardial sac is dangerously increased. The nurse should collaborate with the other members of the care team to prevent the development of what complication? A) Pulmonary edema B) Pericardiocentesis C) Cardiac tamponade D) Pericarditis

C) Cardiac tamponade

The nurse is caring for a patient who has had a dysrhythmic event. The nurse is aware of the need to assess for signs of diminished cardiac output (CO). What change in status may signal to the nurse a decrease in cardiac output? A) Increased blood pressure B) Bounding peripheral pulses C) Changes in level of consciousness D) Skin flushing

C) Changes in level of consciousness

A nurse is admitting a 45-year-old man to the medical unit who has a history of PAD. While providing his health history, the patient reveals that he smokes about two packs of cigarettes a day, has a history of alcohol abuse, and does not exercise. What would be the priority health education for this patient? A) The lack of exercise, which is the main cause of PAD. B) The likelihood that heavy alcohol intake is a significant risk factor for PAD. C) Cigarettes contain nicotine, which is a powerful vasoconstrictor and may cause or aggravate PAD. D) Alcohol suppresses the immune system, creates high glucose levels, and may cause PAD.

C) Cigarettes contain nicotine, which is a powerful vasoconstrictor and may cause or aggravate PAD.

The nurse is caring for a patient with systolic HF whose previous adverse reactions preclude the safe use of ACE inhibitors. The nurse should anticipate that the prescriber may choose what combination of drugs? A) Loop diuretic and antiplatelet aggregator B) Loop diuretic and calcium channel blocker C) Combination of hydralazine and isosorbide dinitrate D) Combination of digoxin and normal saline

C) Combination of hydralazine and isosorbide dinitrate

A patient who is postoperative day 1 following a CABG has produced 20 mL of urine in the past 3 hours and the nurse has confirmed the patency of the urinary catheter. What is the nurses most appropriate action? A) Document the patients low urine output and monitor closely for the next several hours. B) Contact the dietitian and suggest the need for increased oral fluid intake. C) Contact the patients physician and suggest assessment of fluid balance and renal function. D) Increase the infusion rate of the patients IV fluid to prompt an increase in renal function.

C) Contact the patients physician and suggest assessment of fluid balance and renal function.

A patient is admitted to the ICU after a motor vehicle accident. On the second day of the hospital admission, the patient develops acute kidney injury. The patient is hemodynamically unstable, but renal replacement therapy is needed to manage the patients hypervolemia and hyperkalemia. Which of the following therapies will the patients hemodynamic status best tolerate? A) Hemodialysis B) Peritoneal dialysis C) Continuous venovenous hemodialysis (CVVHD) D) Plasmapheresis

C) Continuous venovenous hemodialysis (CVVHD)

A patient in a hypertensive emergency is admitted to the ICU. The nurse anticipates that the patient will be treated with IV vasodilators, and that the primary goal of treatment is what? A) Lower the BP to reduce onset of neurologic symptoms, such as headache and vision changes. B) Decrease the BP to a normal level based on the patients age. C) Decrease the mean arterial pressure between 20% and 25% in the first hour of treatment. D) Reduce the BP to 120/75 mm Hg as quickly as possible.

C) Decrease the mean arterial pressure between 20% and 25% in the first hour of treatment.

A nurse is caring for a patient who is in the diuresis phase of AKI. The nurse should closely monitor the patient for what complication during this phase? A) Hypokalemia B) Hypocalcemia C) Dehydration D) Acute flank pain

C) Dehydration

A patient is admitted to the cardiac care unit for an electrophysiology (EP) study. What goal should guide the planning and execution of the patients care? A) Ablate the area causing the dysrhythmia. B) Freeze hypersensitive cells. C) Diagnose the dysrhythmia. D) Determine the nursing plan of care.

C) Diagnose the dysrhythmia.

A newly diagnosed patient with hypertension is prescribed Diuril, a thiazide diuretic. What patient education should the nurse provide to this patient? A) Eat a banana every day because Diuril causes moderate hyperkalemia. B) Take over-the-counter potassium pills because Diuril causes your kidneys to lose potassium. C) Diuril can cause low blood pressure and dizziness, especially when you get up suddenly. D) Diuril increases sodium levels in your blood, so cut down on your salt.

C) Diuril can cause low blood pressure and dizziness, especially when you get up suddenly.

How should the nurse best position a patient who has leg ulcers that are venous in origin? A) Keep the patients legs flat and straight. B) Keep the patients knees bent to 45-degree angle and supported with pillows. C) Elevate the patients lower extremities. D) Dangle the patients legs over the side of the bed.

C) Elevate the patients lower extremities.

The nurse is creating a plan of car for a patient diagnosed with acute laryngitis. What intervention should be included in the patients plan of care? A) Place warm cloths on the patients throat, as needed. B) Have the patient inhale warm steam three times daily. C) Encourage the patient to limit speech whenever possible. D) Limit the patients fluid intake to 1.5 L/day.

C) Encourage the patient to limit speech whenever possible.

An adult patient with third-degree AV block is admitted to the cardiac care unit and placed on continuous cardiac monitoring. What rhythm characteristic will the ECG most likely show? A) PP interval and RR interval are irregular. B) PP interval is equal to RR interval. C) Fewer QRS complexes than P waves D) PR interval is constant.

C) Fewer QRS complexes than P waves

The nurse is caring for a patient in the ED for epistaxis. What information should the nurse include in patient discharge teaching as a way to prevent epistaxis? A) Keep nasal passages clear. B) Use decongestants regularly. C) Humidify the indoor environment. D) Use a tissue when blowing the nose.

C) Humidify the indoor environment.

The nurse is caring for a patient in acute kidney injury. Which of the following complications would most clearly warrant the administration of polystyrene sulfonate (Kayexalate)? A) Hypernatremia B) Hypomagnesemia C) Hyperkalemia D) Hypercalcemia

C) Hyperkalemia

The nurse is caring for a patient in the ICU admitted with ARDS after exposure to toxic fumes from a hazardous spill at work. The patient has become hypotensive. What is the cause of this complication to the ARDS treatment? A) Pulmonary hypotension due to decreased cardiac output B) Severe and progressive pulmonary hypertension C) Hypovolemia secondary to leakage of fluid into the interstitial spaces D) Increased cardiac output from high levels of PEEP therapy

C) Hypovolemia secondary to leakage of fluid into the interstitial spaces

The nurse is planning the care of a patient who is scheduled for a laryngectomy. The nurse should assign the highest priority to which postoperative nursing diagnosis? A) Anxiety related to diagnosis of cancer B) Altered nutrition related to swallowing difficulties C) Ineffective airway clearance related to airway alterations D) Impaired verbal communication related to removal of the larynx

C) Ineffective airway clearance related to airway alterations

The nurse is caring for an adult patient who had symptoms of unstable angina upon admission to the hospital. What nursing diagnosis underlies the discomfort associated with angina? A) Ineffective breathing pattern related to decreased cardiac output B) Anxiety related to fear of death C) Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD) D) Impaired skin integrity related to CAD

C) Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD)

The nurse is assessing a patient who was admitted to the critical care unit 3 hours ago following cardiac surgery. The nurses most recent assessment reveals that the patients left pedal pulses are not palpable and that the right pedal pulses are rated at +2. What is the nurses best response? A) Document this expected assessment finding during the initial postoperative period. B) Reposition the patient with his left leg in a dependent position. C) Inform the patients physician of this assessment finding. D) Administer an ordered dose of subcutaneous heparin.

C) Inform the patients physician of this assessment finding.

The nurse is creating an education plan for a patient who underwent a nephrectomy for the treatment of a renal tumor. What should the nurse include in the teaching plan? A) The importance of increased fluid intake B) Signs and symptoms of rejection C) Inspection and care of the incision D) Techniques for preventing metastasis

C) Inspection and care of the incision

The nurse is preparing to administer warfarin (Coumadin) to a client with deep vein thrombophlebitis (DVT). Which laboratory value would most clearly indicate that the patients warfarin is at therapeutic levels? A) Partial thromboplastin time (PTT) within normal reference range B) Prothrombin time (PT) eight to ten times the control C) International normalized ratio (INR) between 2 and 3 D) Hematocrit of 32%

C) International normalized ratio (INR) between 2 and 3

The occupational health nurse is obtaining a patient history during a pre-employment physical. During the history, the patient states that he has hereditary angioedema. The nurse should identify what implication of this health condition? A) It will result in increased loss of work days. B) It may cause episodes of weakness due to reduced cardiac output. C) It can cause life-threatening airway obstruction. D) It is unlikely to interfere with the individuals health.

C) It can cause life-threatening airway obstruction.

The nurse is assessing a patient new to the clinic. Records brought to the clinic with the patient show the patient has hypertension and that her current BP readings approximate the readings from when she was first diagnosed. What contributing factor should the nurse first explore in an effort to identify the cause of the clients inadequate BP control? A) Progressive target organ damage B) Possibility of medication interactions C) Lack of adherence to prescribed drug therapy D) Possible heavy alcohol use or use of recreational drugs

C) Lack of adherence to prescribed drug therapy

The nurse is caring for a patient after kidney surgery. The nurse is aware that bleeding is a major complication of kidney surgery and that if it goes undetected and untreated can result in hypovolemia and hemorrhagic shock in the patient. When assessing for bleeding, what assessment parameter should the nurse evaluate? A) Oral intake B) Pain intensity C) Level of consciousness D) Radiation of pain

C) Level of consciousness

The nurse is caring for an acutely ill patient who is on anticoagulant therapy. The patient has a comorbidity of renal insufficiency. How will this patients renal status affect heparin therapy? A) Heparin is contraindicated in the treatment of this patient. B) Heparin may be administered subcutaneously, but not IV. C) Lower doses of heparin are required for this patient. D) Coumadin will be substituted for heparin.

C) Lower doses of heparin are required for this patient.

The nurse is writing a plan of care for a patient with a cardiac dysrhythmia. What would be the most appropriate goal for the patient? A) Maintain a resting heart rate below 70 bpm. B) Maintain adequate control of chest pain. C) Maintain adequate cardiac output. D) Maintain normal cardiac structure.

C) Maintain adequate cardiac output.

The nurse is providing discharge education to a patient diagnosed with HF. What should the nurse teach this patient to do to assess her fluid balance in the home setting? A) Monitor her blood pressure daily B) Assess her radial pulses daily C) Monitor her weight daily D) Monitor her bowel movements

C) Monitor her weight daily

The ED nurse is caring for a patient with a suspected MI. What drug should the nurse anticipate administering to this patient? A) Oxycodone B) Warfarin C) Morphine D) Acetaminophen

C) Morphine

The nurse is providing an educational workshop about coronary artery disease (CAD) and its risk factors. The nurse explains to participants that CAD has many risk factors, some that can be controlled and some that cannot. What risk factors would the nurse list that can be controlled or modified? A) Gender, obesity, family history, and smoking B) Inactivity, stress, gender, and smoking C) Obesity, inactivity, diet, and smoking D) Stress, family history, and obesity

C) Obesity, inactivity, diet, and smoking

A 45-year-old obese man arrives in a clinic with complaints of daytime sleepiness, difficulty going to sleep at night, and snoring. The nurse should recognize the manifestations of what health problem? A) Adenoiditis B) Chronic tonsillitis C) Obstructive sleep apnea D) Laryngeal cancer

C) Obstructive sleep apnea

A gerontologic nurse is teaching a group of medical nurses about the high incidence and mortality of pneumonia in older adults. What is a contributing factor to this that the nurse should describe? A) Older adults have less compliant lung tissue than younger adults. B) Older adults are not normally candidates for pneumococcal vaccination. C) Older adults often lack the classic signs and symptoms of pneumonia. D) Older adults often cannot tolerate the most common antibiotics used to treat pneumonia.

C) Older adults often lack the classic signs and symptoms of pneumonia.

A patient is recovering in the hospital from cardiac surgery. The nurse has identified the diagnosis of risk for ineffective airway clearance related to pulmonary secretions. What intervention best addresses this risk? A) Administration of bronchodilators by nebulizer B) Administration of inhaled corticosteroids by metered dose inhaler (MDI) C) Patients consistent performance of deep breathing and coughing exercises D) Patients active participation in the cardiac rehabilitation program

C) Patients consistent performance of deep breathing and coughing exercises

The nurse is caring for an 82-year-old patient with a diagnosis of tracheobronchitis. The patient begins complaining of right-sided chest pain that gets worse when he coughs or breathes deeply. Vital signs are within normal limits. What would you suspect this patient is experiencing? A) Traumatic pneumothorax B) Empyema C) Pleuritic pain D) Myocardial infarction

C) Pleuritic pain

The nurse is reviewing the electronic health record of a patient with an empyema. What health problem in the patients history is most likely to have caused the empyema? A) Smoking B) Asbestosis C) Pneumonia D) Lung cancer

C) Pneumonia

The nurse is performing preoperative teaching with a patient who has cancer of the larynx. After completing patient teaching, what would be most important for the nurse to do? A) Give the patient his or her cell phone number. B) Refer the patient to a social worker or psychologist. C) Provide the patient with audiovisual materials about the surgery. D) Reassure the patient and family that everything will be alright.

C) Provide the patient with audiovisual materials about the surgery.

The nurse notes that a patient has developed a cough productive for mucoid sputum, is short of breath, has cyanotic hands, and has noisy, moist-sounding, rapid breathing. These symptoms and signs are suggestive of what health problem? A) Pericarditis B) Cardiomyopathy C) Pulmonary edema D) Right ventricular hypertrophy

C) Pulmonary edema

The nursing educator is presenting a case study of an adult patient who has abnormal ventricular depolarization. This pathologic change would be most evident in what component of the ECG? A) P wave B) T wave C) QRS complex D) U wave

C) QRS complex

The nurse has noted the emergence of a significant amount of fresh blood at the drain site of a patient who is postoperative day 1 following total laryngectomy. How should the nurse respond to this development? A) Remove the patients drain and apply pressure with a sterile gauze. B) Assess the patient, reposition the patient supine, and apply wall suction to the drain. C) Rapidly assess the patient and notify the surgeon about the patients bleeding. D) Administer a STAT dose of vitamin K to aid coagulation.

C) Rapidly assess the patient and notify the surgeon about the patients bleeding.

The nurse is teaching a patient with allergic rhinitis about the safe and effective use of his medications. What would be the most essential information to give this patient about preventing possible drug interactions? A) Prescription medications can be safely supplemented with OTC medications. B) Use only one pharmacy so the pharmacist can check drug interactions. C) Read drug labels carefully before taking OTC medications. D) Consult the Internet before selecting an OTC medication.

C) Read drug labels carefully before taking OTC medications.

The nurse is collaborating with the dietitian and a patient with hypertension to plan dietary modifications. These modifications should include which of the following? A) Reduced intake of protein and carbohydrates B) Increased intake of calcium and vitamin D C) Reduced intake of fat and sodium D) Increased intake of potassium, vitamin B12 and vitamin D

C) Reduced intake of fat and sodium

A patient has undergone diagnostic testing and received a diagnosis of sinus bradycardia attributable to sinus node dysfunction. When planning this patients care, what nursing diagnosis is most appropriate? A) Acute pain B) Risk for unilateral neglect C) Risk for activity intolerance D) Risk for fluid volume excess

C) Risk for activity intolerance

The nurse is providing a health education workshop to a group of adults focusing on cancer prevention. The nurse should emphasize what action in order to reduce participants risks of renal carcinoma? A) Avoiding heavy alcohol use B) Control of sodium intake C) Smoking cessation D) Adherence to recommended immunization schedules

C) Smoking cessation

The critical care nurse is caring for a patient just admitted in a hypertensive emergency. The nurse should anticipate the administration of what medication? A) Warfarin (Coumadin) B) Furosemide (Lasix) C) Sodium nitroprusside (Nitropress) D) Ramipril (Altace)

C) Sodium nitroprusside (Nitropress)

A patient has a glomerular filtration rate (GFR) of 43 mL/min/1.73 m2. Based on this GFR, the nurse interprets that the patients chronic kidney disease is at what stage? A) Stage 1 B) Stage 2 C) Stage 3 D) Stage 4

C) Stage 3

The nurse is caring for a patient who has developed obvious signs of pulmonary edema. What is the priority nursing action? A) Lay the patient flat. B) Notify the family of the patients critical state. C) Stay with the patient. D) Update the physician.

C) Stay with the patient.

A student nurse is taking care of an elderly patient with hypertension during a clinical experience. The instructor asks the student about the relationships between BP and age. What would be the best answer by the student? A) Because of reduced smooth muscle tone in blood vessels, blood pressure tends to go down with age, not up. B) Decreases in the strength of arteries and the presence of venous insufficiency cause hypertension in the elderly. C) Structural and functional changes in the cardiovascular system that occur with age contribute to increases in blood pressure. D) The neurologic system of older adults is less efficient at monitoring and regulating blood pressure.

C) Structural and functional changes in the cardiovascular system that occur with age contribute to increases in blood pressure.

A nurse is closely monitoring a patient who has recently been diagnosed with an abdominal aortic aneurysm. What assessment finding would signal an impending rupture of the patients aneurysm? A) Sudden increase in blood pressure and a decrease in heart rate B) Cessation of pulsating in an aneurysm that has previously been pulsating visibly C) Sudden onset of severe back or abdominal pain D) New onset of hemoptysis

C) Sudden onset of severe back or abdominal pain

The nurse is caring for a 46-year-old patient recently diagnosed with the early stages of lung cancer. The nurse is aware that the preferred method of treating patients with nonsmall cell tumors is what? A) Chemotherapy B) Radiation C) Surgical resection D) Bronchoscopic opening of the airway

C) Surgical resection

A nursing student is discussing a patient with viral pharyngitis with the preceptor at the walk-in clinic. What should the preceptor tell the student about nursing care for patients with viral pharyngitis? A) Teaching focuses on safe and effective use of antibiotics. B) The patient should be preliminarily screened for surgery. C) Symptom management is the main focus of medical and nursing care. D) The focus of care is resting the voice to prevent chronic hoarseness.

C) Symptom management is the main focus of medical and nursing care.

The nurse is caring for a patient receiving hemodialysis three times weekly. The patient has had surgery to form an arteriovenous fistula. What is most important for the nurse to be aware of when providing care for this patient? A) Using a stethoscope for auscultating the fistula is contraindicated. B) The patient feels best immediately after the dialysis treatment. C) Taking a BP reading on the affected arm can damage the fistula. D) The patient should not feel pain during initiation of dialysis.

C) Taking a BP reading on the affected arm can damage the fistula.

The nurse is caring for acutely ill patient. What assessment finding should prompt the nurse to inform the physician that the patient may be exhibiting signs of acute kidney injury (AKI)? A) The patient is complains of an inability to initiate voiding. B) The patients urine is cloudy with a foul odor. C) The patients average urine output has been 10 mL/hr for several hours. D) The patient complains of acute flank pain.

C) The patients average urine output has been 10 mL/hr for several hours.

Family members bring a patient to the ED with pale cool skin, sudden midsternal chest pain unrelieved with rest, and a history of CAD. How should the nurse best interpret these initial data? A) The symptoms indicate angina and should be treated as such. B) The symptoms indicate a pulmonary etiology rather than a cardiac etiology. C) The symptoms indicate an acute coronary episode and should be treated as such. D) Treatment should be determined pending the results of an exercise stress test.

C) The symptoms indicate an acute coronary episode and should be treated as such.

A patient has just been diagnosed with lung cancer. After the physician discusses treatment options and leaves the room, the patient asks the nurse how the treatment is decided upon. What would be the nurses best response? A) The type of treatment depends on the patients age and health status. B) The type of treatment depends on what the patient wants when given the options. C) The type of treatment depends on the cell type of the cancer, the stage of the cancer, and the patients health status. D) The type of treatment depends on the discussion between the patient and the physician of which treatment is best.

C) The type of treatment depends on the cell type of the cancer, the stage of the cancer, and the patients health status.

A client presents to the walk-in clinic complaining of a dry, irritating cough and production of a minute amount of mucus-like sputum. The patient complains of soreness in her chest in the sternal area. The nurse should suspect that the primary care provider will assess the patient for what health problem? A) Pleural effusion B) Pulmonary embolism C) Tracheobronchitis D) Tuberculosis

C) Tracheobronchitis

The nurse is creating a care plan for a patient who is status post-total laryngectomy. Much of the plan consists of a long-term postoperative communication plan for alaryngeal communication. What form of alaryngeal communication will likely be chosen? A) Esophageal speech B) Electric larynx C) Tracheoesophageal puncture D) American sign language (ASL)

C) Tracheoesophageal puncture

A patient presents to the clinic complaining of the inability to grasp objects with her right hand. The patients right arm is cool and has a difference in blood pressure of more than 20 mm Hg compared with her left arm. The nurse should expect that the primary care provider may diagnose the woman with what health problem? A) Lymphedema B) Raynauds phenomenon C) Upper extremity arterial occlusive disease D) Upper extremity VTE

C) Upper extremity arterial occlusive disease

An older adult is newly diagnosed with primary hypertension and has just been started on a beta-blocker. The nurses health education should include which of the following? A) Increasing fluids to avoid extracellular volume depletion from the diuretic effect of the betablocker B) Maintaining a diet high in dairy to increase protein necessary to prevent organ damage C) Use of strategies to prevent falls stemming from postural hypotension D) Limiting exercise to avoid injury that can be caused by increased intracranial pressure

C) Use of strategies to prevent falls stemming from postural hypotension

It is cold season and the school nurse been asked to provide an educational event for the parent teacher organization of the local elementary school. What should the nurse include in teaching about the treatment of pharyngitis? A) Pharyngitis is more common in children whose immunizations are not up to date. B) There are no effective, evidence-based treatments for pharyngitis. C) Use of warm saline gargles or throat irrigations can relieve symptoms. D) Heat may increase the spasms in pharyngeal muscles.

C) Use of warm saline gargles or throat irrigations can relieve symptoms.

The nurse is caring for a patient who has just had an implantable cardioverter defibrillator (ICD) placed. What is the priority area for the nurses assessment? A) Assessing the patients activity level B) Facilitating transthoracic echocardiography C) Vigilant monitoring of the patients ECG D) Close monitoring of the patients peripheral perfusion

C) Vigilant monitoring of the patients ECG

An older adult patient has been treated for a venous ulcer and a plan is in place to prevent the occurrence of future ulcers. What should the nurse include in this plan? A) Use of supplementary oxygen to aid tissue oxygenation B) Daily use of normal saline compresses on the lower limbs C) Daily administration of prophylactic antibiotics D) A high-protein diet that is rich in vitamins

D) A high-protein diet that is rich in vitamins

When assessing the patient with pericardial effusion, the nurse will assess for pulsus paradoxus. Pulsus paradoxus is characterized by what assessment finding? A) A diastolic blood pressure that is lower during exhalation B) A diastolic blood pressure that is higher during inhalation C) A systolic blood pressure that is higher during exhalation D) A systolic blood pressure that is lower during inhalation

D) A systolic blood pressure that is lower during inhalation

The nurse has entered a patients room and found the patient unresponsive and not breathing. What is the nurses next appropriate action? A) Palpate the patients carotid pulse. B) Illuminate the patients call light. C) Begin performing chest compressions. D) Activate the Emergency Response System (ERS).

D) Activate the Emergency Response System (ERS).

A patient in hypertensive emergency is being cared for in the ICU. The patient has become hypovolemic secondary to natriuresis. What is the nurses most appropriate action? A) Add sodium to the patients IV fluid, as ordered. B) Administer a vasoconstrictor, as ordered. C) Promptly cease antihypertensive therapy. D) Administer normal saline IV, as ordered.

D) Administer normal saline IV, as ordered.

A 42-year-old patient is admitted to the ED after an assault. The patient received blunt trauma to the face and has a suspected nasal fracture. Which of the following interventions should the nurse perform? A) Administer nasal spray and apply an occlusive dressing to the patients face. B) Position the patients head in a dependent position. C) Irrigate the patients nose with warm tap water. D) Apply ice and keep the patients head elevated.

D) Apply ice and keep the patients head elevated.

A patient with chronic kidney disease has been hospitalized and is receiving hemodialysis on a scheduled basis. The nurse should include which of the following actions in the plan of care? A) Ensure that the patient moves the extremity with the vascular access site as little as possible. B) Change the dressing over the vascular access site at least every 12 hours. C) Utilize the vascular access site for infusion of IV fluids. D) Assess for a thrill or bruit over the vascular access site each shift.

D) Assess for a thrill or bruit over the vascular access site each shift.

The nurse is caring for a patient who is postoperative day 2 following a total laryngectomy for supraglottic cancer. The nurse should prioritize what assessment? A) Assessment of body image B) Assessment of jugular venous pressure C) Assessment of carotid pulse D) Assessment of swallowing ability

D) Assessment of swallowing ability

The cardiac monitor alarm alerts the critical care nurse that the patient is showing no cardiac rhythm on the monitor. The nurses rapid assessment suggests cardiac arrest. In providing cardiac resuscitation documentation, how will the nurse describe this initial absence of cardiac rhythm? A) Pulseless electrical activity (PEA) B) Ventricular fibrillation C) Ventricular tachycardia D) Asystole

D) Asystole

The nurse is reviewing a newly admitted patients electronic health record, which notes a history of orthopnea? What nursing action is most clearly indicated? A) Teach the patient deep breathing and coughing exercises. B) Administer supplemental oxygen at all times. C) Limit the patients activity level. D) Avoid positioning the patient supine.

D) Avoid positioning the patient supine.

A community health nurse teaching a group of adults about preventing and treating hypertension. The nurse should encourage these participants to collaborate with their primary care providers and regularly monitor which of the following? A) Heart rate B) Sodium levels C) Potassium levels D) Blood lipid levels

D) Blood lipid levels

A patient in the cardiac step-down unit has begun bleeding from the percutaneous coronary intervention (PCI) access site in her femoral region. What is the nurses most appropriate action? A) Call for assistance and initiate cardiopulmonary resuscitation. B) Reposition the patients leg in a nondependent position. C) Promptly remove the femoral sheath. D) Call for help and apply pressure to the access site.

D) Call for help and apply pressure to the access site.

The OR nurse is explaining to a patient that cardiac surgery requires the absence of blood from the surgical field. At the same time, it is imperative to maintain perfusion of body organs and tissues. What technique for achieving these simultaneous goals should the nurse describe? A) Coronary artery bypass graft (CABG) B) Percutaneous transluminal coronary angioplasty (PTCA) C) Atherectomy D) Cardiopulmonary bypass

D) Cardiopulmonary bypass

An 87-year-old patient has been hospitalized with pneumonia. Which nursing action would be a priority in this patients plan of care? A) Nasogastric intubation B) Administration of probiotic supplements C) Bedrest D) Cautious hydration

D) Cautious hydration

A patient presents to the walk-in clinic complaining of intermittent chest pain on exertion, which is eventually attributed to angina. The nurse should inform the patient that angina is most often attributable to what cause? A) Decreased cardiac output B) Decreased cardiac contractility C) Infarction of the myocardium D) Coronary arteriosclerosis

D) Coronary arteriosclerosis

A patient has presented with signs and symptoms that are characteristic of acute kidney injury, but preliminary assessment reveals no obvious risk factors for this health problem. The nurse should recognize the need to interview the patient about what topic? A) Typical diet B) Allergy status C) Psychosocial stressors D) Current medication use

D) Current medication use

The public health nurse is participating in a health fair and interviews a patient with a history of hypertension, who is currently smoking one pack of cigarettes per day. She denies any of the most common manifestations of CAD. Based on these data, the nurse would expect the focuses of CAD treatment most likely to be which of the following? A) Drug therapy and smoking cessation B) Diet and drug therapy C) Diet therapy only D) Diet therapy and smoking cessation

D) Diet therapy and smoking cessation

The nurse working on the coronary care unit is caring for a patient with ACS. How can the nurse best meet the patients psychosocial needs? A) Reinforce the fact that treatment will be successful. B) Facilitate a referral to a chaplain or spiritual leader. C) Increase the patients participation in rehabilitation activities. D) Directly address the patients anxieties and fears.

D) Directly address the patients anxieties and fears.

The home health nurse is caring for a patient who has a comorbidity of hypertension. What assessment question most directly addresses the possibility of worsening hypertension? A) Are you eating less salt in your diet? B) How is your energy level these days? C) Do you ever get chest pain when you exercise? D) Do you ever see spots in front of your eyes?

D) Do you ever see spots in front of your eyes?

Following cardiac resuscitation, a patient has been placed in a state of mild hypothermia before being transferred to the cardiac intensive care unit. The nurses assessment reveals that the patient is experiencing neuromuscular paralysis. How should the nurse best respond? A) Administer hypertonic IV solution. B) Administer a bolus of warned normal saline. C) Reassess the patient in 15 minutes. D) Document this as an expected assessment finding.

D) Document this as an expected assessment finding.

A patient admitted with nephrotic syndrome is being cared for on the medical unit. When writing this patients care plan, based on the major clinical manifestation of nephrotic syndrome, what nursing diagnosis should the nurse include? A) Constipation related to immobility B) Risk for injury related to altered thought processes C) Hyperthermia related to the inflammatory process D) Excess fluid volume related to generalized edema

D) Excess fluid volume related to generalized edema

As a clinic nurse, you are caring for a patient who has been prescribed an antibiotic for tonsillitis and has been instructed to take the antibiotic for 10 days. When you do a follow-up call with this patient, you are informed that the patient is feeling better and is stopping the medication after taking it for 4 days. What information should you provide to this patient? A) Keep the remaining tablets for an infection at a later time. B) Discontinue the medications if the fever is gone. C) Dispose of the remaining medication in a biohazard receptacle. D) Finish all the antibiotics to eliminate the organism completely.

D) Finish all the antibiotics to eliminate the organism completely.

A patients total laryngectomy has created a need for alaryngeal speech which will be achieved through the use of tracheoesophageal puncture. What action should the nurse describe to the patient when teaching him about this process? A) Training on how to perform controlled belching B) Use of an electronically enhanced artificial pharynx C) Insertion of a specialized nasogastric tube D) Fitting for a voice prosthesis

D) Fitting for a voice prosthesis

An ECG has been ordered for a newly admitted patient. What should the nurse do prior to electrode placement? A) Clean the skin with providone-iodine solution. B) Ensure that the area for electrode placement is dry. C) Apply tincture of benzoin to the electrode sites and wait for it to become tacky. D) Gently abrade the skin by rubbing the electrode sites with dry gauze or cloth.

D) Gently abrade the skin by rubbing the electrode sites with dry gauze or cloth.

The triage nurse in the ED is performing a rapid assessment of a man with complaints of severe chest pain and shortness of breath. The patient is diaphoretic, pale, and weak. When the patient collapses, what should the nurse do first? A) Check for a carotid pulse. B) Apply supplemental oxygen. C) Give two full breaths. D) Gently shake and shout, Are you OK?

D) Gently shake and shout, Are you OK?

An OR nurse is preparing to assist with a coronary artery bypass graft (CABG). The OR nurse knows that the vessel most commonly used as source for a CABG is what? A) Brachial artery B) Brachial vein C) Femoral artery D) Greater saphenous vein

D) Greater saphenous vein

A community health nurse is planning an educational campaign addressing hypertension. The nurse should anticipate that the incidence and prevalence of hypertension are likely to be highest among members of what ethnic group? A) Pacific Islanders B) African Americans C) Asian-Americans D) Hispanics

D) Hispanics

A 55-year-old patient comes to the clinic for a routine check-up. The patients BP is 159/100 mm Hg and the physician diagnoses hypertension after referring to previous readings. The patient asks why it is important to treat hypertension. What would be the nurses best response? A) Hypertension can cause you to develop dangerous blood clots in your legs that can migrate to your lungs. B) Hypertension puts you at increased risk of type 1 diabetes and cancer in your age group. C) Hypertension is the leading cause of death in people your age. D) Hypertension greatly increases your risk of stroke and heart disease.

D) Hypertension greatly increases your risk of stroke and heart disease.

The staff educator is teaching ED nurses about hypertensive crisis. The nurse educator should explain that hypertensive urgency differs from hypertensive emergency in what way? A) The BP is always higher in a hypertensive emergency. B) Vigilant hemodynamic monitoring is required during treatment of hypertensive emergencies. C) Hypertensive urgency is treated with rest and benzodiazepines to lower BP. D) Hypertensive emergencies are associated with evidence of target organ damage.

D) Hypertensive emergencies are associated with evidence of target organ damage.

The nurse caring for a patient with a leg ulcer has finished assessing the patient and is developing a problem list prior to writing a plan of care. What major nursing diagnosis might the care plan include? A) Risk for disuse syndrome B) Ineffective health maintenance C) Sedentary lifestyle D) Imbalanced nutrition: less than body requirements

D) Imbalanced nutrition: less than body requirements

A patient visiting the clinic is diagnosed with acute sinusitis. To promote sinus drainage, the nurse should instruct the patient to perform which of the following? A) Apply a cold pack to the affected area. B) Apply a mustard poultice to the forehead. C) Perform postural drainage. D) Increase fluid intake.

D) Increase fluid intake.

A cardiac care nurse is aware of factors that result in positive chronotropy. These factors would affect a patients cardiac function in what way? A) Exacerbating an existing dysrhythmia B) Initiating a new dysrhythmia C) Resolving ventricular tachycardia D) Increasing the heart rate

D) Increasing the heart rate

The nurse is assessing a patient who had a pacemaker implanted 4 weeks ago. During the patients most recent follow-up appointment, the nurse identifies data that suggest the patient may be socially isolated and depressed. What nursing diagnosis is suggested by these data? A) Decisional conflict related to pacemaker implantation B) Deficient knowledge related to pacemaker implantation C) Spiritual distress related to pacemaker implantation D) Ineffective coping related to pacemaker implantation

D) Ineffective coping related to pacemaker implantation

The campus nurse at a university is assessing a 21-year-old student who presents with a severe nosebleed. The site of bleeding appears to be the anterior portion of the nasal septum. The nurse instructs the student to tilt her head forward and the nurse applies pressure to the nose, but the students nose continues to bleed. Which intervention should the nurse next implement? A) Apply ice to the bridge of her nose B) Lay the patient down on a cot C) Arrange for transfer to the local ED D) Insert a tampon in the affected nare

D) Insert a tampon in the affected nare

Preoperative education is an important part of the nursing care of patients having coronary artery revascularization. When explaining the pre- and postoperative regimens, the nurse would be sure to include education about which subject? A) Symptoms of hypovolemia B) Symptoms of low blood pressure C) Complications requiring graft removal D) Intubation and mechanical ventilation

D) Intubation and mechanical ventilation

The nurse is screening a number of adults for hypertension. What range of blood pressure is considered normal? A) Less than 140/90 mm Hg B) Less than 130/90 mm Hg C) Less than 129/89 mm Hg D) Less than 120/80 mm Hg

D) Less than 120/80 mm Hg

The nurse is providing care for a patient with high cholesterol and triglyceride values. In teaching the patient about therapeutic lifestyle changes such as diet and exercise, the nurse realizes that the desired goal for cholesterol levels is which of the following? A) High HDL values and high triglyceride values B) Absence of detectable total cholesterol levels C) Elevated blood lipids, fasting glucose less than 100 D) Low LDL values and high HDL values

D) Low LDL values and high HDL values

A patient comes to the walk-in clinic with complaints of pain in his foot following stepping on a roofing nail 4 days ago. The patient has a visible red streak running up his foot and ankle. What health problem should the nurse suspect? A) Cellulitis B) Local inflammation C) Elephantiasis D) Lymphangitis

D) Lymphangitis