Medsurg2 quiz session 7 quiz
A patient got a sliver of glass in his eye when a glass container at work fell and shattered. The glass had to be surgically removed and the patient is about to be discharged home. The patient asks the nurse for a topical anesthetic for the pain in his eye. What should the nurse respond? A) "Overuse of these drops could soften your cornea and damage your eye." B) "You could lose the peripheral vision in your eye if you used these drops too much." C) "I'm sorry, this medication is considered a controlled substance and patients cannot take it home." D) "I know these drops will make your eye feel better, but I can't let you take them home."
A) "Overuse of these drops could soften your cornea and damage your eye."
A patient with a recent diagnosis of ITP has asked the nurse why the care team has not chosen to administer platelets, stating, "I have low platelets, so why not give me a transfusion of exactly what I'm missing?" How should the nurse best respond? A) "Transfused platelets usually aren't beneficial because they're rapidly destroyed in the body." B) "A platelet transfusion often blunts your body's own production of platelets even further." C) "Finding a matching donor for a platelet transfusion is exceedingly difficult." D) "A very small percentage of the platelets in a transfusion are actually functional."
A) "Transfused platelets usually aren't beneficial because they're rapidly destroyed in the body."
The nurse should recognize the greatest risk for the development of blindness in which of the following patients? A) A 58-year-old Caucasian woman with macular degeneration B) A 28-year-old Caucasian man with astigmatism C) A 58-year-old African American woman with hyperopia D) A 28-year-old African American man with myopia
A) A 58-year-old Caucasian woman with macular degeneration
The nurse is preparing to administer a unit of platelets to an adult patient. When administering this blood product, which of the following actions should the nurse perform? A) Administer the platelets as rapidly as the patient can tolerate. B) Establish IV access as soon as the platelets arrive from the blood bank. C) Ensure that the patient has a patent central venous catheter. D) Aspirate 10 to 15 mL of blood from the patient's IV immediately following the transfusion.
A) Administer the platelets as rapidly as the patient can tolerate.
A patient is scheduled for enucleation and the nurse is providing anticipatory guidance about postoperative care. What aspects of care should the nurse describe to the patient? Select all that apply. A) Application of topical antibiotic ointment B) Maintenance of a supine position for the first 48 hours postoperative C) Fluid restriction to prevent orbital edema D) Administration of loop diuretics to prevent orbital edema E) Use of an ocular pressure dressing
A) Application of topical antibiotic ointment E) Use of an ocular pressure dressing
A public health nurse is teaching a health promotion workshop that focuses on vision and eye health. What should this nurse cite as the most common causes of blindness and visual impairment among adults over the age of 40? Select all that apply. A) Diabetic retinopathy B) Trauma C) Macular degeneration D) Cytomegalovirus E) Glaucoma
A) Diabetic retinopathy C) Macular degeneration E) Glaucoma
A patient's ocular tumor has necessitated enucleation and the patient will be fitted with a prosthesis. The nurse should address what nursing diagnosis when planning the patient's discharge education? A) Disturbed body image B) Chronic pain C) Ineffective protection D) Unilateral neglect
A) Disturbed body image
The nurse has taken shift report on her patients and has been told that one patient has an ocular condition that has primarily affected the rods in his eyes. Considering this information, what should the nurse do while caring for the patient? A) Ensure adequate lighting in the patient's room. B) Provide a dimly lit room to aid vision by limiting contrast. C) Carefully point out color differences for the patient. D) Carefully point out fine details for the patient.
A) Ensure adequate lighting in the patient's room.
A patient has had a sudden loss of vision after head trauma. How should the nurse best describe the placement of items on the dinner tray? A) Explain the location of items using clock cues. B) Explain that each of the items on the tray is clearly separated. C) Describe the location of items from the bottom of the plate to the top. D) Ask the patient to describe the location of items before confirming their location.
A) Explain the location of items using clock cues.
The nurse is admitting a 55-year-old male patient diagnosed with a retinal detachment in his left eye. While assessing this patient, what characteristic symptom would the nurse expect to find? A) Flashing lights in the visual field B) Sudden eye pain C) Loss of color vision D) Colored halos around lights
A) Flashing lights in the visual field
A 6-year-old child is brought to the pediatric clinic for the assessment of redness and discharge from the eye and is diagnosed with viral conjunctivitis. What is the most important information to discuss with the parents and child? A) Handwashing can prevent the spread of the disease to others. B) The importance of compliance with antibiotic therapy C) Signs and symptoms of complications, such as meningitis and septicemia D) The likely need for surgery to prevent scarring of the conjunctiva
A) Handwashing can prevent the spread of the disease to others.
28. A nurse at a blood donation clinic has completed the collection of blood from a woman. The woman states that she feels lightheaded and she appears visibly pale. What is the nurse's most appropriate action? A) Help her into a sitting position with her head lowered below her knees. B) Administer supplementary oxygen by nasal prongs. C) Obtain a full set of vital signs. D) Inform a physician or other primary care provider.
A) Help her into a sitting position with her head lowered below her knees.
The results of a patient's most recent blood work and physical assessment are suggestive of immune thrombocytopenic purpura (ITP). This patient should undergo testing for which of the following potential causes? Select all that apply. A) Hepatitis B) Acute renal failure C) HIV D) Malignant melanoma E) Cholecystitis
A) Hepatitis C) HIV
A nurse is teaching a patient with glaucoma how to administer eye drops to achieve maximum absorption. The nurse should teach the patient to perform what action? A) Instill the medication in the conjunctival sac. B) Maintain a supine position for 10 minutes after administration. C) Keep the eyes closed for 1 to 2 minutes after administration. D) Apply the medication evenly to the sclera
A) Instill the medication in the conjunctival sac.
A patient comes to the clinic complaining of fatigue and the health interview is suggestive of pica. Laboratory findings reveal a low serum iron level and a low ferritin level. With what would the nurse suspect that the patient will be diagnosed? A) Iron deficiency anemia B) Pernicious anemia C) Sickle cell anemia D) Hemolytic anemia
A) Iron deficiency anemia
Through the process of hematopoiesis, stem cells differentiate into either myeloid or lymphoid stem cells. Into what do myeloid stem cells further differentiate? Select all that apply. A) Leukocytes B) Natural killer cells C) Cytokines D) Platelets E) Erythrocytes
A) Leukocytes D) Platelets E) Erythrocytes
A patient's absolute neutrophil count (ANC) is 440/mm3. But the nurse's assessment reveals no apparent signs or symptoms of infection. What action should the nurse prioritize when providing care for this patient? A) Meticulous hand hygiene B) Timely administration of antibiotics C) Provision of a nutrient-dense diet D) Maintaining a sterile care environment
A) Meticulous hand hygiene
A patient with a history of cirrhosis is admitted to the ICU with a diagnosis of bleeding esophageal varices; an attempt to stop the bleeding has been only partially successful. What would the critical care nurse expect the care team to order for this patient? A) Packed red blood cells (PRBCs) B) Vitamin K C) Oral anticoagulants D) Heparin infusion
A) Packed red blood cells (PRBCs)
A nurse is caring for a patient with severe anemia. The patient is tachycardic and complains of dizziness and exertional dyspnea. The nurse knows that in an effort to deliver more blood to hypoxic tissue, the workload on the heart is increased. What signs and symptoms might develop if this patient goes into heart failure? A) Peripheral edema B) Nausea and vomiting C) Migraine D) Fever
A) Peripheral edema
A patient has been diagnosed with a lymphoid stem cell defect. This patient has the potential for a problem involving which of the following? A) Plasma cells B) Neutrophils C) Red blood cells D) Platelets
A) Plasma cells
A patient's most recent blood work reveals low levels of albumin. This assessment finding should suggest the possibility of what nursing diagnosis? A) Risk for imbalanced fluid volume related to low albumin B) Risk for infection related to low albumin C) Ineffective tissue perfusion related to low albumin D) Impaired skin integrity related to low albumin
A) Risk for imbalanced fluid volume related to low albumin
A man suffers a leg wound that causes minor blood loss. As a result of bleeding, the process of primary hemostasis is activated. What occurs in primary hemostasis? A) Severed blood vessels constrict. B) Thromboplastin is released. C) Prothrombin is converted to thrombin. D) Fibrin is lysed.
A) Severed blood vessels constrict.
A patient is receiving a blood transfusion and complains of a new onset of slight dyspnea. The nurse's rapid assessment reveals bilateral lung crackles and elevated BP. What is the nurse's most appropriate action? A) Slow the infusion rate and monitor the patient closely. B) Discontinue the transfusion and begin resuscitation. C) Pause the transfusion and administer a 250 mL bolus of normal saline. D) Discontinue the transfusion and administer a beta-blocker, as ordered.
A) Slow the infusion rate and monitor the patient closely.
An older adult client is exhibiting many of the characteristic signs and symptoms of iron deficiency. In addition to a complete blood count, what diagnostic assessment should the nurse anticipate? A) Stool for occult blood B) Bone marrow biopsy C) Lumbar puncture D) Urinalysis
A) Stool for occult blood
A patient's low prothrombin time (PT) was attributed to a vitamin K deficiency and the patient's PT normalized after administration of vitamin K. When performing discharge education in an effort to prevent a recurrence, what should the nurse emphasize? A) The need for adequate nutrition B) The need to avoid NSAIDs C) The need for constant access to factor concentrate D) The need for meticulous hygiene
A) The need for adequate nutrition
The nurse's brief review of a patient's electronic health record indicates that the patient regularly undergoes therapeutic phlebotomy. Which of the following rationales for this procedure is most plausible? A) The patient may chronically produce excess red blood cells. B) The patient may frequently experience a low relative plasma volume. C) The patient may have impaired stem cell function. D) The patient may previously have undergone bone marrow biopsy.
A) The patient may chronically produce excess red blood cells.
A patient with glaucoma has presented for a scheduled clinic visit and tells the nurse that she has begun taking an herbal remedy for her condition that was recommended by a work colleague. What instruction should the nurse provide to the patient? A) The patient should discuss this new remedy with her ophthalmologist promptly. B) The patient should monitor her IOP closely for the next several weeks. C) The patient should do further research on the herbal remedy. D) The patient should report any adverse effects to her pharmacist.
A) The patient should discuss this new remedy with her ophthalmologist promptly.
A patient comes to the ophthalmology clinic for an eye examination. The patient tells the nurse that he often sees floaters in his vision. How should the nurse best interpret this subjective assessment finding? A) This is a normal aging process of the eye. B) Glasses will minimize this phenomenon. C) The patient may be exhibiting signs of glaucoma. D) This may be a result of weakened ciliary muscles.
A) This is a normal aging process of the eye.
The public health nurse is planning a health promotion campaign that reflects current epidemiologic trends. The nurse should know that hemorrhagic stroke currently accounts for what percentage of total strokes in the United States? A. 13% B. 33% C. 43% D. 23%
A. 13%
Level C personal protective equipment has been deemed necessary in the response to an unknown substance. The nurse is aware that the equipment will include what? A. An air-purified respirator B. A uniform only C. A self-contained breathing apparatus D. A vapor-tight, chemical-resistant suit
A. An air-purified respirator
A nurse is teaching preventative measures for otitis externa to a group of older adults. What action should the nurse encourage? A. Avoiding the use of cotton swabs B. Rinsing the ears with normal saline after swimming C. Avoiding loud environmental noises D. Instilling antibiotic ointments on a regular basis
A. Avoiding the use of cotton swabs
Following a motorcycle accident, a 17-year-old man is brought to the ED. What physical assessment findings related to the ear should be reported by the nurse immediately? A. Clear, watery fluid is draining from the patient's ear. B. The malleus can be visualized during an otoscopic examination. C. Tenderness is reported by the patient when the mastoid area is palpated. D. The tympanic membrane is pearly gray.
A. Clear, watery fluid is draining from the patient's ear.
The physician has ordered a somatosensory evoked responses (SERs) test for a patient for whom the nurse is caring. The nurse is justified in suspecting that this patient may have a history of what type of neurologic disorder? A. Demyelinating disease B. Diabetic neuropathy C. Hypothalamic disorder D. Brainstem deficit
A. Demyelinating disease
A patient who presents for an eye examination is diagnosed as having a visual acuity of 20/40. The patient asks the nurse what these numbers specifically mean. What is a correct response by the nurse? A) "A person whose vision is 20/40 can see an object from 40 feet away that a person with 20/20 vision can see from 20 feet away." B) "A person whose vision is 20/40 can see an object from 20 feet away that a person with 20/20 vision can see from 40 feet away." C) "A person whose vision is 20/40 can see an object from 40 inches away that a person with 20/20 vision can see from 20 inches away." D) "A person whose vision is 20/40 can see an object from 20 inches away that a person with 20/20 vision can see from 40 inches away."
B) "A person whose vision is 20/40 can see an object from 20 feet away that a person with 20/20 vision can see from 40 feet away."
A patient has been diagnosed with glaucoma and the nurse is preparing health education regarding the patient's medication regimen. The patient states that she is eager to "beat this disease" and looks forward to the time when she will no longer require medication. How should the nurse best respond? A) "You have a great attitude. This will likely shorten the amount of time that you need medications." B) "In fact, glaucoma usually requires lifelong treatment with medications." C) "Most people are treated until their intraocular pressure goes below 50 mm Hg." D) "You can likely expect a minimum of 6 months of treatment."
B) "In fact, glaucoma usually requires lifelong treatment with medications."
A patient with a documented history of glucose-6-phosphate dehydrogenase deficiency has presented to the emergency department with signs and symptoms including pallor, jaundice, and malaise. Which of the nurse's assessment questions relates most directly to this patient's hematologic disorder? A) "When did you last have a blood transfusion?" B) "What medications have taken recently?" C) "Have you been under significant stress lately?" D) "Have you suffered any recent injuries?"
B) "What medications have taken recently?"
A patient with renal failure has decreased erythropoietin production. Upon analysis of the patient's complete blood count, the nurse will expect which of the following results? A) An increased hemoglobin and decreased hematocrit B) A decreased hemoglobin and hematocrit C) A decreased mean corpuscular volume (MCV) and red cell distribution width (RDW) D) An increased MCV and RDW
B) A decreased hemoglobin and hematocrit
A nurse has participated in organizing a blood donation drive at a local community center. Which of the following individuals would most likely be disallowed from donating blood? A) A man who is 81 years of age B) A woman whose blood pressure is 88/51 mm Hg C) A man who donated blood 4 months ago D) A woman who has type 1 diabetes
B) A woman whose blood pressure is 88/51 mm Hg
The nurse is describing the role of plasminogen in the clotting cascade. Where in the body is plasminogen present? A) Myocardial muscle tissue B) All body fluids C) Cerebral tissue D) Venous and arterial vessel walls
B) All body fluids
A group of nurses are learning about the high incidence and prevalence of anemia among different populations. Which of the following individuals is most likely to have anemia? A) A 50-year-old African-American woman who is going through menopause B) An 81-year-old woman who has chronic heart failure C) A 48-year-old man who travels extensively and has a high-stress job D) A 13-year-old girl who has just experienced menarche
B) An 81-year-old woman who has chronic heart failure
A client's health history reveals daily consumption of two to three bottles of wine. The nurse should plan assessments and interventions in light of the patient's increased risk for what hematologic disorder? A) Leukemia B) Anemia C) Thrombocytopenia D) Lymphoma
B) Anemia
The nurse is providing discharge education to an adult patient who will begin a regimen of ocular medications for the treatment of glaucoma. How can the nurse best determine if the patient is able to self-administer these medications safely and effectively? A) Assess the patient for any previous inability to self-manage medications. B) Ask the patient to demonstrate the instillation of her medications. C) Determine whether the patient can accurately describe the appropriate method of administering her medications. D) Assess the patient's functional status.
B) Ask the patient to demonstrate the instillation of her medications.
During discharge teaching, the nurse realizes that the patient is not able to read medication bottles accurately and has not been taking her medications consistently at home. How should the nurse intervene most appropriately in this situation? A) Ask the social worker to investigate alternative housing arrangements. B) Ask the social worker to investigate community support agencies. C) Encourage the patient to explore surgical corrections for the vision problem. D) Arrange for referral to a rehabilitation facility for vision training.
B) Ask the social worker to investigate community support agencies.
A patient has lost most of her vision as a result of macular degeneration. When attempting to meet this patient's psychosocial needs, what nursing action is most appropriate? A) Encourage the patient to focus on her use of her other senses. B) Assess and promote the patient's coping skills during interactions with the patient. C) Emphasize that her lifestyle will be unchanged once she adapts to her vision loss. D) Promote the patient's hope for recovery.
B) Assess and promote the patient's coping skills during interactions with the patient.
The nurse is providing health education to a patient newly diagnosed with glaucoma. The nurse teaches the patient that this disease has a familial tendency. The nurse should encourage the patient's immediate family members to undergo clinical examinations how often? A) At least monthly B) At least once every 2 years C) At least once every 5 years D) At least once every 10 years
B) At least once every 2 years
A nurse is providing discharge education to a patient who has recently been diagnosed with a bleeding disorder. What topic should the nurse prioritize when teaching this patient? A) Avoiding buses, subways, and other crowded, public sites B) Avoiding activities that carry a risk for injury C) Keeping immunizations current D) Avoiding foods high in vitamin K
B) Avoiding activities that carry a risk for injury
The nurse on the medical-surgical unit is reviewing discharge instructions with a patient who has a history of glaucoma. The nurse should anticipate the use of what medications? A) Potassium-sparing diuretics B) Cholinergics C) Antibiotics D) Loop diuretics
B) Cholinergics Feedback: Cholinergics are used in the treatment of glaucoma. The action of this medication is to increase aqueous fluid outflow by contracting the ciliary muscle and causing miosis and opening the trabecular meshwork. Diuretics and antibiotics are not used in the management of glaucoma
A night nurse is reviewing the next day's medication administration record (MAR) of a patient who has hemophilia. The nurse notes that the MAR specifies both oral and subcutaneous options for the administration of a PRN antiemetic. What is the nurse's best action? A) Ensure that the day nurse knows not to give the antiemetic. B) Contact the prescriber to have the subcutaneous option discontinued. C) Reassess the patient's need for antiemetics. D) Remove the subcutaneous route from the patient's MAR.
B) Contact the prescriber to have the subcutaneous option discontinued.
The nurse's assessment of a patient with significant visual losses reveals that the patient cannot count fingers. How should the nurse proceed with the assessment of the patient's visual acuity? A) Assess the patient's vision using a Snellen chart. B) Determine whether the patient is able to see the nurse's hand motion. C) Perform a detailed examination of the patient's external eye structures. D) Palpate the patient's periocular regions.
B) Determine whether the patient is able to see the nurse's hand motion.
A patient on the medical unit is receiving a unit of PRBCs. Difficult IV access has necessitated a slow infusion rate and the nurse notes that the infusion began 4 hours ago. What is the nurse's most appropriate action? A) Apply an icepack to the blood that remains to be infused. B) Discontinue the remainder of the PRBC transfusion and inform the physician. C) Disconnect the bag of PRBCs, cool for 30 minutes, and then administer. D) Administer the remaining PRBCs by the IV direct (IV push) route.
B) Discontinue the remainder of the PRBC transfusion and inform the physician.
A patient is receiving the first of two ordered units of PRBCs. Shortly after the initiation of the transfusion, the patient complains of chills and experiences a sharp increase in temperature. What is the nurse's priority action? A) Position the patient in high Fowler's. B) Discontinue the transfusion. C) Auscultate the patient's lungs. D) Obtain a blood specimen from the patient.
B) Discontinue the transfusion. Feedback: Stopping the transfusion is the first step in any suspected transfusion reaction. This must precede other assessments and interventions, including repositioning, chest auscultation, and collecting specimens
A nurse is caring for a patient who has sickle cell anemia and the nurse's assessment reveals the possibility of substance abuse. What is the nurse's most appropriate action? A) Encourage the patient to rely on complementary and alternative therapies. B) Encourage the patient to seek care from a single provider for pain relief. C) Teach the patient to accept chronic pain as an inevitable aspect of the disease. D) Limit the reporting of emergency department visits to the primary health care provider.
B) Encourage the patient to seek care from a single provider for pain relief.
A patient with poorly controlled diabetes has developed end-stage renal failure and consequent anemia. When reviewing this patient's treatment plan, the nurse should anticipate the use of what drug? A) Magnesium sulfate B) Epoetin alfa C) Low-molecular weight heparin D) Vitamin K
B) Epoetin alfa
A patient has just returned to the surgical floor after undergoing a retinal detachment repair. The postoperative orders specify that the patient should be kept in a prone position until otherwise ordered. What should the nurse do? A) Call the physician and ask for the order to be confirmed. B) Follow the order because this position will help keep the retinal repair intact. C) Instruct the patient to maintain this position to prevent bleeding. D) Reposition the patient after the first dressing change
B) Follow the order because this position will help keep the retinal repair intact.
A patient presents at the ED after receiving a chemical burn to the eye. What would be the nurse's initial intervention for this patient? A) Generously flush the affected eye with a dilute antibiotic solution. B) Generously flush the affected eye with normal saline or water. C) Apply a patch to the affected eye. D) Apply direct pressure to the affected eye.
B) Generously flush the affected eye with normal saline or water.
The nurse is describing normal RBC physiology to a patient who has a diagnosis of anemia. The nurse should explain that the RBCs consist primarily of which of the following? A) Plasminogen B) Hemoglobin C) Hematocrit D) Fibrin
B) Hemoglobin
A patient's electronic health record states that the patient receives regular transfusions of factor IX. The nurse would be justified in suspecting that this patient has what diagnosis? A) Leukemia B) Hemophilia C) Hypoproliferative anemia D) Hodgkin's lymphoma
B) Hemophilia
The nurse is providing care for an older adult who has a hematologic disorder. What age-related change in hematologic function should the nurse integrate into care planning? A) Bone marrow in older adults produces a smaller proportion of healthy, functional blood cells. B) Older adults are less able to increase blood cell production when demand suddenly increases. C) Stem cells in older adults eventually lose their ability to differentiate. D) The ratio of plasma to erythrocytes and lymphocytes increases with age.
B) Older adults are less able to increase blood cell production when demand suddenly increases.
A patient's blood work reveals a platelet level of 17,000/mm3. When inspecting the patient's integumentary system, what finding would be most consistent with this platelet level? A) Dermatitis B) Petechiae C) Urticaria D) Alopecia
B) Petechiae
An individual has accidentally cut his hand, immediately initiating the process of hemostasis. Following vasoconstriction, what event in the process of hemostasis will take place? A) Fibrin will be activated at the bleeding site. B) Platelets will aggregate at the injury site. C) Thromboplastin will form a clot. D) Prothrombin will be converted to thrombin.
B) Platelets will aggregate at the injury site.
A patient undergoing a hip replacement has autologous blood on standby if a transfusion is needed. What is the primary advantage of autologous transfusions? A) Safe transfusion for patients with a history of transfusion reactions B) Prevention of viral infections from another person's blood C) Avoidance of complications in patients with alloantibodies D) Prevention of alloimmunization
B) Prevention of viral infections from another person's blood
The nurse caring for a patient receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the patient is having difficulty breathing and complains of severe chest tightness. What is the most appropriate initial action for the nurse to take? A) Notify the patient's physician. B) Stop the transfusion immediately. C) Remove the patient's IV access. D) Assess the patient's chest sounds and vital signs.
B) Stop the transfusion immediately.
A hospitalized patient with impaired vision must get a picture in his or her mind of the hospital room and its contents in order to mobilize independently and safely. What must the nurse monitor in the patient's room? A) That a commode is always available at the bedside B) That all furniture remains in the same position C) That visitors do not leave items on the bedside table D) That the patient's slippers stay under the bed
B) That all furniture remains in the same position
A patient is being treated in the ICU after a medical error resulted in an acute hemolytic transfusion reaction. What was the etiology of this patient's adverse reaction? A) Antibodies to donor leukocytes remained in the blood. B) The donor blood was incompatible with that of the patient. C) The patient had a sensitivity reaction to a plasma protein in the blood. D) The blood was infused too quickly and overwhelmed the patient's circulatory system.
B) The donor blood was incompatible with that of the patient.
A patient is scheduled for a splenectomy. During discharge education, what teaching point should the nurse prioritize? A) The importance of adhering to prescribed immunosuppressant therapy B) The need to report any signs or symptoms of infection promptly C) The need to ensure adequate folic acid, iron, and vitamin B12 intake D) The importance of limiting activity postoperatively to prevent hemorrhage
B) The need to report any signs or symptoms of infection promptly
A patient's electronic health record notes that he has previously undergone treatment for secondary polycythemia. How should this aspect of the patient's history guide the nurse's subsequent assessment? A) The nurse should assess for recent blood donation. B) The nurse should assess for evidence of lung disease. C) The nurse should assess for a history of venous thromboembolism. D) The nurse should assess the patient for impaired renal function.
B) The nurse should assess for evidence of lung disease.
A patient is being treated for the effects of a longstanding vitamin B12 deficiency. What aspect of the patient's health history would most likely predispose her to this deficiency? A) The patient has irregular menstrual periods. B) The patient is a vegan. C) The patient donated blood 60 days ago. D) The patient frequently smokes marijuana.
B) The patient is a vegan. Feedback: Because vitamin B12 is only found in foods of animal origin, strict vegetarians may ingest little vitamin B12. Irregular menstrual periods, marijuana use, and blood donation would not precipitate a vitamin B12 deficiency.
A patient newly diagnosed with thrombocytopenia is admitted to the medical unit. After the admission assessment, the patient asks the nurse to explain the disease. What should the nurse explain to this patient? A) There could be an attack on the platelets by antibodies. B) There could be decreased production of platelets. C) There could be impaired communication between platelets. D) There could be an autoimmune process causing platelet malfunction.
B) There could be decreased production of platelets.
A patient is admitted to the hospital with pernicious anemia. The nurse should prepare to administer which of the following medications? A) Folic acid B) Vitamin B12 C) Lactulose D) Magnesium sulfate
B) Vitamin B12 Feedback: Pernicious anemia is characterized by vitamin B12 deficiency. Magnesium sulfate, lactulose, and folic acid do not address the pathology of this type of anemia.
An elderly patient is being discharged home. The patient lives alone and has atrophy of his olfactory organs. The nurse tells the patient's family that it is essential that the patient have what installed in the home? A. Nonslip mats B. A smoke detector C. Baseboard heaters D. Grab bars
B. A smoke detector
The nurse is caring for a patient who exhibits abnormal results of the Weber test and Rinne test. The nurse should suspect dysfunction involving what cranial nerve? A. Trigeminal B. Acoustic C. Trochlear D. Hypoglossal
B. Acoustic
A nurse is planning discharge education for a patient who underwent a cervical diskectomy. What strategies would the nurse assess that would aid in planning discharge teaching? A. Techniques for restoring nerve function B. Care of the cervical collar C. Technique for performing neck ROM exercises D. Home assessment of ABGs
B. Care of the cervical collar
A 13-year-old is being admitted to the ED after falling from a roof and sustaining blunt abdominal injuries. To assess for internal injury in the patient's peritoneum, the nurse should anticipate what diagnostic test? A. Complete blood count (CBC) B. Computed tomography (CT) scan C. Radiograph D. Barium swallow
B. Computed tomography (CT) scan
A patient who has been diagnosed with cholecystitis is being discharged home from the ED to be scheduled for surgery later. The patient received morphine during the present ED admission and is visibly drowsy. When providing health education to the patient, what would be the most appropriate nursing action? A. Give verbal instructions to one of the patient's family members. B. Give verbal and written instructions to the patient and a family member. C. Telephone the patient the next day with verbal instructions. D. Give written instructions to the patient.
B. Give verbal and written instructions to patient and a family member.
A patient has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the patient's ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following? A. Dry mucous membranes B. Loss of brain stem reflexes C. Hemiplegia D. Signs of internal bleeding
B. Loss of brain stem reflexes
The advanced practice nurse is attempting to examine the patient's ear with an otoscope. Because of impacted cerumen, the tympanic membrane cannot be visualized. The nurse irrigates the patient's ear with a solution of hydrogen peroxide and water to remove the impacted cerumen. What nursing intervention is most important to minimize nausea and vertigo during the procedure? A. Follow the procedure with the insertion of a cerumen curette to extract missed ear wax. B. Maintain the irrigation fluid at a warm temperature. C. Have the patient stand during the procedure. D. Instill short, sharp bursts of fluid into the ear canal.
B. Maintain the irrigation fluid at a warm temperature.
A male patient with multiple injuries is brought to the ED by ambulance. He has had his airway stabilized and is breathing on his own. The ED nurse does not see any active bleeding, but should suspect internal hemorrhage based on what finding? A. Sudden diaphoresis B. Rapid pulse and decreased capillary refill C. Absence of bruising at contusion sites D. Increased BP with narrowed pulse pressure
B. Rapid pulse and decreased capillary refill
A patient has been scheduled for a bone marrow biopsy and admits to the nurse that she is worried about the pain involved with the procedure. What patient education is most accurate? A) "You'll be given painkillers before the test, so there won't likely be any pain?" B) "You'll feel some pain when the needle enters your skin, but none when the needle enters the bone because of the absence of nerves in bone." C) "Most people feel some brief, sharp pain when the needle enters the bone." D) "I'll be there with you, and I'll try to help you keep your mind off the pain."
C) "Most people feel some brief, sharp pain when the needle enters the bone."
A 56-year-old patient has come to the clinic for his routine eye examination and is told he needs bifocals. The patient asks the nurse what change in his eyes has caused his need for bifocals. How should the nurse respond? A) "You know, you are getting older now and we change as we get older." B) "The parts of our eyes age, just like the rest of us, and this is nothing to cause you to worry." C) "There is a gradual thickening of the lens of the eye and it can limit the eye's ability for accommodation." D) "The eye gets shorter, back to front, as we age and it changes how we see things."
C) "There is a gradual thickening of the lens of the eye and it can limit the eye's ability for accommodation."
A patient has informed the home health nurse that she has recently noticed distortions when she looks at the Amsler grid that she has mounted on her refrigerator. What is the nurse's most appropriate action? A) Reassure the patient that this is an age-related change in vision. B) Arrange for the patient to have her visual acuity assessed. C) Arrange for the patient to be assessed for macular degeneration. D) Facilitate tonometry testing.
C) Arrange for the patient to be assessed for macular degeneration.
An older adult patient has been diagnosed with macular degeneration and the nurse is assessing him for changes in visual acuity since his last clinic visit. When assessing the patient for recent changes in visual acuity, the patient states that he sees the lines on an Amsler grid as being distorted. What is the nurse's most appropriate response? A) Ask if the patient has been using OTC vasoconstrictors. B) Instruct the patient to repeat the test at different times of the day when at home. C) Arrange for the patient to visit his ophthalmologist. D) Encourage the patient to adhere to his prescribed drug regimen.
C) Arrange for the patient to visit his ophthalmologist.
A client with several chronic health problems has been newly diagnosed with a qualitative platelet defect. What component of the patient's previous medication regimen may have contributed to the development of this disorder? A) Calcium carbonate B) Vitamin B12 C) Aspirin D) Vitamin D
C) Aspirin
29. A patient's low hemoglobin level has necessitated transfusion of PRBCs. Prior to administration, what action should the nurse perform? A) Have the patient identify his or her blood type in writing. B) Ensure that the patient has granted verbal consent for transfusion. C) Assess the patient's vital signs to establish baselines. D) Facilitate insertion of a central venous catheter.
C) Assess the patient's vital signs to establish baselines.
A patient has just arrived on the floor after an enucleation procedure following a workplace accident in which his left eye was irreparably damaged. Which of the following should the nurse prioritize during the patient's immediate postoperative recovery? A) Teaching the patient about options for eye prostheses B) Teaching the patient to estimate depth and distance with the use of one eye C) Assessing and addressing the patient's emotional needs D) Teaching the patient about his post-discharge medication regimen
C) Assessing and addressing the patient's emotional needs
A woman who is in her third trimester of pregnancy has been experiencing an exacerbation of iron-deficiency anemia in recent weeks. When providing the patient with nutritional guidelines and meal suggestions, what foods would be most likely to increase the woman's iron stores? A) Salmon accompanied by whole milk B) Mixed vegetables and brown rice C) Beef liver accompanied by orange juice D) Yogurt, almonds, and whole grain oats
C) Beef liver accompanied by orange juice
Cytomegalovirus (CMV) is the most common cause of retinal inflammation in patients with AIDS. What drug, surgically implanted, is used for the acute stage of CMV retinitis? A) Pilocarpine B) Penicillin C) Ganciclovir D) Gentamicin
C) Ganciclovir
A nurse in a long-term care facility is admitting a new resident who has a bleeding disorder. When planning this resident's care, the nurse should include which of the following? A) Housing the resident in a private room B) Implementing a passive ROM program to compensate for activity limitation C) Implementing a plan for fall prevention D) Providing the patient with a high-fiber diet
C) Implementing a plan for fall prevention
A patient with a hematologic disorder asks the nurse how the body forms blood cells. The nurse should describe a process that takes place where? A) In the spleen B) In the kidneys C) In the bone marrow D) In the liver
C) In the bone marrow
The nurse on the pediatric unit is caring for a 10-year-old boy with a diagnosis of hemophilia. The nurse knows that a priority nursing diagnosis for a patient with hemophilia is what? A) Hypothermia B) Diarrhea C) Ineffective coping D) Imbalanced nutrition: Less than body requirements
C) Ineffective coping
A nurse is planning the care of a patient with a diagnosis of sickle cell disease who has been admitted for the treatment of an acute vaso-occlusive crisis. What nursing diagnosis should the nurse prioritize in the patient's plan of care? A) Risk for disuse syndrome related to ineffective peripheral circulation B) Functional urinary incontinence related to urethral occlusion C) Ineffective tissue perfusion related to thrombosis D) Ineffective thermoregulation related to hypothalamic dysfunction
C) Ineffective tissue perfusion related to thrombosis
A patient has come to the OB/GYN clinic due to a recent heavy menstrual flow. Because of the patient's consequent increase in RBC production, the nurse knows that the patient may need to increase her daily intake of what substance? A) Vitamin E B) Vitamin D C) Iron D) Magnesium
C) Iron
A nurse is providing education to a patient with iron deficiency anemia who has been prescribed iron supplements. What should the nurse include in health education? A) Take the iron with dairy products to enhance absorption. B) Increase the intake of vitamin E to enhance absorption. C) Iron will cause the stools to darken in color. D) Limit foods high in fiber due to the risk for diarrhea.
C) Iron will cause the stools to darken in color.
The nurse is assessing a new patient with complaints of overwhelming fatigue and a sore tongue that is visibly smooth and beefy red. This patient is demonstrating signs and symptoms associated with what form of what hematologic disorder? A) Sickle cell anemia B) Hemophilia C) Megaloblastic anemia D) Thrombocytopenia
C) Megaloblastic anemia
When administering a patient's eye drops, the nurse recognizes the need to prevent absorption by the nasolacrimal duct. How can the nurse best achieve this goal? A) Ensure that the patient is well hydrated at all times. B) Encourage self-administration of eye drops. C) Occlude the puncta after applying the medication. D) Position the patient supine before administering eye drops.
C) Occlude the puncta after applying the medication.
A young man with a diagnosis of hemophilia A has been brought to emergency department after suffering a workplace accident resulting in bleeding. Rapid assessment has revealed the source of the patient's bleeding and established that his vital signs are stable. What should be the nurse's next action? A) Position the patient in a prone position to minimize bleeding. B) Establish IV access for the administration of vitamin K. C) Prepare for the administration of factor VIII. D) Administer a normal saline bolus to increase circulatory volume.
C) Prepare for the administration of factor VIII. Feedback: Injuries in clients with hemophilia necessitate prompt administration of clotting factors. Vitamin K is not a treatment modality and a prone position will not be appropriate for all types and locations of wounds. A normal saline bolus is not indicated.
Fresh-frozen plasma (FFP) has been ordered for a hospital patient. Prior to administration of this blood product, the nurse should prioritize what patient education? A) Infection risks associated with FFP administration B) Physiologic functions of plasma C) Signs and symptoms of a transfusion reaction D) Strategies for managing transfusion-associated anxiety
C) Signs and symptoms of a transfusion reaction
The nurse's review of a patient's most recent blood work reveals a significant increase in the number of band cells. The nurse's subsequent assessment should focus on which of the following? A) Respiratory function B) Evidence of decreased tissue perfusion C) Signs and symptoms of infection D) Recent changes in activity tolerance
C) Signs and symptoms of infection
A nurse is admitting a patient with immune thrombocytopenic purpura to the unit. In completing the admission assessment, the nurse must be alert for what medications that potentially alter platelet function? Select all that apply. A) Antihypertensives B) Penicillins C) Sulfa-containing medications D) Aspirin-based drugs E) NSAIDs
C) Sulfa-containing medications D) Aspirin-based drugs E) NSAIDs
The nurse is teaching a patient to care for her new ocular prosthesis. What should the nurse emphasize during the patient's health education? A) The need to limit exposure to bright light B) The need to maintain a low Fowler's position when removing the prosthesis C) The need to perform thorough hand hygiene before handling the prosthesis D) The need to apply antiviral ointment to the prosthesis daily
C) The need to perform thorough hand hygiene before handling the prosthesis
Which of the following circumstances would most clearly warrant autologous blood donation? A) The patient has type-O blood. B) The patient has sickle cell disease or a thalassemia. C) The patient has elective surgery pending. D) The patient has hepatitis C.
C) The patient has elective surgery pending.
A patient with a history of atrial fibrillation has contacted the clinic saying that she has accidentally overdosed on her prescribed warfarin (Coumadin). The nurse should recognize the possible need for what antidote? A) IVIG B) Factor X C) Vitamin K D) Factor VIII
C) Vitamin K
The nurse is reviewing the health history of a newly admitted patient and reads that the patient has been previously diagnosed with exostoses. How should the nurse accommodate this fact into the patient's plan of care? A. The nurse should perform the Rinne and Weber tests. B. The nurse should arrange for audiometry testing as soon as possible. C. No specific assessments or interventions are necessary to address exostoses. D. The nurse should collaborate with the pharmacist to assess for potential ototoxic medications.
C. No specific assessments or interventions are necessary to address exostoses.
A patient who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the patient's current health status is most likely to have precipitated this event? A. The patient was not repositioned during the night shift. B. The patient received a blood transfusion. C. The patient's urinary catheter became occluded. D. The patient's analgesia regimen was recently changed.
C. The patient's urinary catheter became occluded
A patient is ready to be discharged home after cataract extraction with intraocular lens implant and the nurse is reviewing signs and symptoms that need to be reported to the ophthalmologist immediately. Which of the patient's statements best demonstrates an adequate understanding? A) "I need to call the doctor if I get nauseated." B) "I need to call the doctor if I have a light morning discharge." C) "I need to call the doctor if I get a scratchy feeling." D) "I need to call the doctor if I see flashing lights."
D) "I need to call the doctor if I see flashing lights."
The public health nurse is addressing eye health and vision protection during an educational event. What statement by a participant best demonstrates an understanding of threats to vision? A) "I'm planning to avoid exposure to direct sunlight on my next vacation." B) "I've never exercised regularly, but I'm going to start working out at the gym daily." C) "I'm planning to talk with my pharmacist to review my current medications." D) "I'm certainly going to keep a close eye on my blood pressure from now on."
D) "I'm certainly going to keep a close eye on my blood pressure from now on."
Two units of PRBCs have been ordered for a patient who has experienced a GI bleed. The patient is highly reluctant to receive a transfusion, stating, "I'm terrified of getting AIDS from a blood transfusion." How can the nurse best address the patient's concerns? A) "All the donated blood in the United States is treated with antiretroviral medications before it is used." B) "That did happen in some high-profile cases in the twentieth century, but it is no longer a possibility." C) "HIV was eradicated from the US blood supply in the early 2000s." D) "The chances of contracting AIDS from a blood transfusion in the United States are exceedingly low."
D) "The chances of contracting AIDS from a blood transfusion in the United States are exceedingly low."
The nurse is administering eye drops to a patient with glaucoma. After instilling the patient's first medication, how long should the nurse wait before instilling the patient's second medication into the same eye? A) 30 seconds B) 1 minute C) 3 minutes D) 5 minutes
D) 5 minutes
A patient comes into the clinic complaining of fatigue. Blood work shows an increased bilirubin concentration and an increased reticulocyte count. What would the nurse suspect the patient has? A) A hypoproliferative anemia B) A leukemia C) Thrombocytopenia D) A hemolytic anemia
D) A hemolytic anemia
A patient is being discharged home from the ambulatory surgical center after cataract surgery. In reviewing the discharge instructions with the patient, the nurse instructs the patient to immediately call the office if the patient experiences what? A) Slight morning discharge from the eye B) Any appearance of redness of the eye C) A "scratchy" feeling in the eye D) A new floater in vision
D) A new floater in vision
An intensive care nurse is aware of the need to identify patients who may be at risk of developing disseminated intravascular coagulation (DIC). Which of the following ICU patients most likely faces the highest risk of DIC? A) A patient with extensive burns B) A patient who has a diagnosis of acute respiratory distress syndrome C) A patient who suffered multiple trauma in a workplace accident D) A patient who is being treated for septic shock
D) A patient who is being treated for septic shock
The nurse is planning the care of a patient with a nutritional deficit and a diagnosis of megaloblastic anemia. The nurse should recognize that this patient's health problem is due to what? A) Production of inadequate quantities of RBCs B) Premature release of immature RBCs C) Injury to the RBCs in circulation D) Abnormalities in the structure and function RBCs
D) Abnormalities in the structure and function RBCs
A nurse is educating a patient about the role of B lymphocytes. The nurse's description will include which of the following physiologic processes? A) Stem cell differentiation B) Cytokine production C) Phagocytosis D) Antibody production
D) Antibody production
A patient has been living with a diagnosis of anemia for several years and has experienced recent declines in her hemoglobin levels despite active treatment. What assessment finding would signal complications of anemia? A) Venous ulcers and visual disturbances B) Fever and signs of hyperkalemia C) Epistaxis and gastroesophageal reflux D) Ascites and peripheral edema
D) Ascites and peripheral edema
The medical nurse is aware that patients with sickle cell anemia benefit from understanding what situations can precipitate a sickle cell crisis. When teaching a patient with sickle cell anemia about strategies to prevent crises, what measures should the nurse recommend? A) Using prophylactic antibiotics and performing meticulous hygiene B) Maximizing physical activity and taking OTC iron supplements C) Limiting psychosocial stress and eating a high-protein diet D) Avoiding cold temperatures and ensuring sufficient hydration
D) Avoiding cold temperatures and ensuring sufficient hydration
An interdisciplinary team has been commissioned to create policies and procedures aimed at preventing acute hemolytic transfusion reactions. What action has the greatest potential to reduce the risk of this transfusion reaction? A) Ensure that blood components are never infused at a rate greater than 125 ml/hr. B) Administer prophylactic antihistamines prior to all blood transfusions. C) Establish baseline vital signs for all patients receiving transfusions. D) Be vigilant in identifying the patient and the blood component.
D) Be vigilant in identifying the patient and the blood component. Feedback: The most common causes of acute hemolytic reaction are errors in blood component labeling and client identification that results in the administration of an ABO-incompatible transfusion. Actions to address these causes are necessary for all healthcare settings. Prophylactic antihistamines are not normally given, and would not prevent acute hemolytic reactions. Similarly, baseline vital signs and slow administration will not prevent this reaction.
A patient is being treated for DIC and the nurse has prioritized the nursing diagnosis of Risk for Deficient Fluid Volume Related to Bleeding. How can the nurse best determine if goals of care relating to this diagnosis are being met? A) Assess for edema. B) Assess skin integrity frequently. C) Assess the patient's level of consciousness frequently. D) Closely monitor intake and output.
D) Closely monitor intake and output.
A patient with chronic open-angle glaucoma is being taught to self-administer pilocarpine. After the patient administers the pilocarpine, the patient states that her vision is blurred. Which nursing action is most appropriate? A) Holding the next dose and notifying the physician B) Treating the patient for an allergic reaction C) Suggesting that the patient put on her glasses D) Explaining that this is an expected adverse effect
D) Explaining that this is an expected adverse effect
An adult patient has been diagnosed with iron-deficiency anemia. What nursing diagnosis is most likely to apply to this patient's health status? A) Risk for deficient fluid volume related to impaired erythropoiesis B) Risk for infection related to tissue hypoxia C) Acute pain related to uncontrolled hemolysis D) Fatigue related to decreased oxygen-carrying capacity
D) Fatigue related to decreased oxygen-carrying capacity
A patient, 25 years of age, comes to the emergency department complaining of excessive bleeding from a cut sustained when cleaning a knife. Blood work shows a prolonged PT but a vitamin K deficiency is ruled out. When assessing the patient, areas of ecchymosis are noted on other areas of the body. Which of the following is the most plausible cause of the patient's signs and symptoms? A) Lymphoma B) Leukemia C) Hemophilia D) Hepatic dysfunction
D) Hepatic dysfunction
The nurse educating a patient with anemia is describing the process of RBC production. When the patient's kidneys sense a low level of oxygen in circulating blood, what physiologic response is initiated? A) Increased stem cell synthesis B) Decreased respiratory rate C) Arterial vasoconstriction D) Increased production of erythropoietin
D) Increased production of erythropoietin
A patient is being treated on the medical unit for a sickle cell crisis. The nurse's most recent assessment reveals an oral temperature of 100.5F and a new onset of fine crackles on lung auscultation. What is the nurse's most appropriate action? A) Apply supplementary oxygen by nasal cannula. B) Administer bronchodilators by nebulizer. C) Liaise with the respiratory therapist and consider high-flow oxygen. D) Inform the primary care provider that the patient may have an infection.
D) Inform the primary care provider that the patient may have an infection.
A patient lives with a diagnosis of sickle cell anemia and receives frequent blood transfusions. The nurse should recognize the patient's consequent risk of what complication of treatment? A) Hyopvolemia B) Vitamin B12 deficiency C) Thrombocytopenia D) Iron overload
D) Iron overload
Several residents of a long-term care facility have developed signs and symptoms of viral conjunctivitis. What is the most appropriate action of the nurse who oversees care in the facility? A) Arrange for the administration of prophylactic antibiotics to unaffected residents. B) Instill normal saline into the eyes of affected residents two to three times daily. C) Swab the conjunctiva of unaffected residents for culture and sensitivity testing. D) Isolate affected residents from residents who have not developed conjunctivitis.
D) Isolate affected residents from residents who have not developed conjunctivitis. Feedback: To prevent spread during outbreaks of conjunctivitis, health care facilities must set aside specified areas for treating clients diagnosed with or suspected of having conjunctivitis. Antibiotics and saline flushes are ineffective and normally there is no need to perform testing of individuals lacking symptoms.
The nurse is caring for a patient who has developed scar tissue in many of the areas that normally produce blood cells. What organs can become active in blood cell production by the process of extramedullary hematopoiesis? A) Spleen and kidneys B) Kidneys and pancreas C) Pancreas and liver D) Liver and spleen
D) Liver and spleen
A nurse is planning the care of a patient who has a diagnosis of hemophilia A. When addressing the nursing diagnosis of Acute Pain Related to Joint Hemorrhage, what principle should guide the nurse's choice of interventions? A) Gabapentin (Neurontin) is effective because of the neuropathic nature of the patient's pain. B) Opioids partially inhibit the patient's synthesis of clotting factors. C) Opioids may cause vasodilation and exacerbate bleeding. D) NSAIDs are contraindicated due to the risk of bleeding.
D) NSAIDs are contraindicated due to the risk of bleeding.
A patient's wound has begun to heal and the blood clot which formed is no longer necessary. When a blood clot is no longer needed, the fibrinogen and fibrin will be digested by which of the following? A) Plasminogen B) Thrombin C) Prothrombin D) Plasmin
D) Plasmin
A patient's diagnosis of atrial fibrillation has prompted the primary care provider to prescribe warfarin (Coumadin), an anticoagulant. When assessing the therapeutic response to this medication, what is the nurse's most appropriate action? A) Assess for signs of myelosuppression. B) Review the patient's platelet level. C) Assess the patient's capillary refill time. D) Review the patient's international normalized ratio (INR).
D) Review the patient's international normalized ratio (INR).
A nurse is caring for a patient who undergoing preliminary testing for a hematologic disorder. What sign or symptom most likely suggests a potential hematologic disorder? A) Sudden change in level of consciousness (LOC) B) Recurrent infections C) Anaphylaxis D) Severe fatigue
D) Severe fatigue
A patient with a diagnosis of retinal detachment has undergone a vitreoretinal procedure on an outpatient basis. What subject should the nurse prioritize during discharge education? A) Risk factors for postoperative cytomegalovirus (CMV) B) Compensating for vision loss for the next several weeks C) Non-pharmacologic pain management strategies D) Signs and symptoms of increased intraocular pressure
D) Signs and symptoms of increased intraocular pressure
A critical care nurse is caring for a patient with autoimmune hemolytic anemia. The patient is not responding to conservative treatments, and his condition is now becoming life-threatening. The nurse is aware that a treatment option, in this case, may include what? A) Hepatectomy B) Vitamin K administration C) Platelet transfusion D) Splenectomy
D) Splenectomy
The registered nurse taking shift report learns that an assigned patient is blind. How should the nurse best communicate with this patient? A) Provide instructions in simple, clear terms. B) Introduce herself in a firm, loud voice at the doorway of the room. C) Lightly touch the patient's arm and then introduce herself. D) State her name and role immediately after entering the patient's room.
D) State her name and role immediately after entering the patient's room.
A patient is exploring treatment options after being diagnosed with age-related cataracts that affect her vision. What treatment is most likely to be used in this patient's care? A) Antioxidant supplements, vitamin C and E, beta-carotene, and selenium B) Eyeglasses or magnifying lenses C) Corticosteroid eye drops D) Surgical intervention
D) Surgical intervention
A patient with Von Willebrand disease (VWD) has experienced recent changes in bowel function that suggest the need for a screening colonoscopy. What intervention should be performed in anticipation of this procedure? A) The patient should not undergo the normal bowel cleansing protocol prior to the procedure. B) The patient should receive a unit of fresh-frozen plasma 48 hours before the procedure. C) The patient should be admitted to the surgical unit on the day before the procedure. D) The patient should be given necessary clotting factors before the procedure.
D) The patient should be given necessary clotting factors before the procedure.
A patient with a pulmonary embolism is being treated with a heparin infusion. What diagnostic finding suggests to the nurse that treatment is effective? A) The patient's PT is within reference ranges. B) Arterial blood sampling tests positive for the presence of factor XIII. C) The patient's platelet level is below 100,000/mm3. D) The patient's activated partial thromboplastin time (aPTT) is 1.5 to 2.5 times the control value.
D) The patient's activated partial thromboplastin time (aPTT) is 1.5 to 2.5 times the control value.
A family member brings the patient to the clinic for a follow-up visit after a stroke. The family member asks the nurse what he can do to decrease his chance of having another stroke. What would be the nurse's best answer? A. "Get medication to bring down your sodium levels." B. "Have your heart checked regularly." C. "Eat a nutritious diet." D. "Stop smoking as soon as possible."
D. "Stop smoking as soon as possible."
The nurse is caring for a patient who is hospitalized with an exacerbation of MS. To ensure the patient's safety, what nursing action should be performed? A. Provide several small meals each day. B. Pad the patient's bed rails. C. Maintain bed rest whenever possible. D. Ensure that suction apparatus is set up at the bedside.
D. Ensure that suction apparatus is set up at the bedside.
A patient presents to the ED complaining of a sudden onset of incapacitating vertigo, with nausea and vomiting, and tinnitus. The patient mentions to the nurse that she suddenly cannot hear very well. What would the nurse suspect the patient's diagnosis will be? A. Ménière's disease B. Ototoxicity C. Ossiculitis D. Labyrinthitis
D. Labyrinthitis
A nurse is giving an educational class to members of the local disaster team. What should the nurse instruct members of the disaster team to do in a chemical bioterrorist attack? A. Crawl to an exit. B. Cover their eyes. C. Put on a personal protective equipment mask. D. Stand up.
D. Stand up.
A patient who has experienced an ischemic stroke has been admitted to the medical unit. The patient's family is adamant that she remain on bed rest to hasten her recovery and to conserve energy. What principle of care should inform the nurse's response to the family? A. To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks. B. The patient should remain on bed rest until she expresses a desire to mobilize. C. Lack of mobility will greatly increase the patient's risk of stroke recurrence. D. The patient should mobilize as soon as she is physically able.
D. The patient should mobilize as soon as she is physically able.
