More NCLEX Prep Questions
Which of the following is a sympathetic-adrenal medullary response to stress? Decreased blood glucose level Mental confusion Increased heart rate Constricted pupils
Increased heart rate
The nurse stresses to the patient with sickle cell anemia that one of the most elementary home interventions to help prevent sickle cell crisis is to: A.) engage in daily exercise B.) take iron supplements daily C.) maintain adequate fluid intake D.) eat leafy green vegetables
Maintain adequate fluid intake
A patient in surgery receives a neuromuscular blocking agent as an adjunct to general anesthesia. While in the postanesthesia care unit (PACU), what assessment finding is most important for the nurse to report? Weak chest wall movement Right sided weakness Complaint of nausea Patient unable to recall the correct date
Weak chest wall movement
A patient who takes a diuretic and a β-blocker to control blood pressure is scheduled for breast reconstruction surgery. Which patient information is most important to communicate to the health care provider before surgery? Hematocrit 36% Blood pressure 144/82 Pulse rate 62 beats/minute Serum potassium 3.2 mEq/L
Serum potassium 3.2 mEq/L
A patient in the emergency department has several broken ribs. What care measure will best promote comfort? - providing warmed blankets -offering frequent, small drinks of water -allowing the patient to choose the position in bed -humidifying the supplemental oxygen
allowing the patient to choose the position in bed
A patient has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)? - dangle both legs on the side of the bed - ambulate the patient - apply a warm moist pack - massage the patient's leg
apply a warm moist pack
An older adult in the family practice clinic reports a decrease in hearing over a week. What action by the nurse is most appropriate? assess for cerumen buildup facilitate audiological testing perform tuning fork tests review the medication list
assess for cerumen buildup
A nurse teaches a patient who has very dry skin. Which statement should the nurse include in this patient's education? "Take a cold shower instead of soaking in the bathtub." "After you bathe, put lotion on before your skin is totally dry." "Use antimicrobial soap to avoid infection of cracked skin." "Use lots of moisturizer several times a day to minimize dryness."
"After you bathe, put lotion on before your skin is totally dry."
A nurse supervises an unlicensed assistive personnel (UAP) applying electrocardiographic monitoring. Which statement should the nurse provide to the UAP related to this procedure? -"Add gel to the electrodes prior to applying them." - "Clean the skin and clip hairs if needed." - "Place the electrodes on the posterior chest." - "Turn off oxygen prior to monitoring the patient."
"Clean the skin and clip hairs if needed."
A patient undergoing external radiation has developed a dry desquamation of the skin in the treatment area. The nurse teaches the patient about management of the skin reaction. Which statement, if made by the patient, indicates the teaching was effective? "I will scrub the area with warm water to remove the scales "I can use ice packs to relieve itching in the treatment area." "I can buy some aloe vera gel to use on the area." "I will expose the treatment area to a sun lamp daily."
"I can buy some aloe vera gel to use on the area."
A nurse cares for a patient with chronic obstructive pulmonary disease (COPD). The patient states that he no longer enjoys going out with his friends. How should the nurse respond? -"I will ask your provider to prescribe you with an antianxiety agent." -"Friends can be a good support system for patients with chronic disorders." -"Share any thoughts and feelings that cause you to limit social activities." -"There are a variety of support groups for people who have COPD."
"Share any thoughts and feelings that cause you to limit social activities."
The patient with angina asks what to do if the first Nitroglycerin tablet (NTG) does not relieve the pain. What instruction by the nurse is correct? "Take 2 more tablets 5 minutes apart and notify the physician if your pain is not relieved." "Take a second tablet 15 minutes after the first dose and call the physician if you are still having pain." "Take 2 tablets 10 minutes after the first dose and go to the ER if you are still having pain." "Take 2 more tablets 30 minutes apart, and then rest for 20 minutes."
"Take 2 more tablets 5 minutes apart and notify the physician if your pain is not relieved."
The nurse is caring for a postoperative patient with an indwelling urinary catheter. The hourly urinary output at 9 am is 80 mL. The nurse assesses the hourly urinary output at 10 am at 20 mL. What is the highest priority action by the nurse? a. Irrigate the catheter with sterile normal saline. b. Document the findings. c. Reassess the output at 11 am. d. Notify the physician.
d. Notify the physician
A nurse in a family practice clinic is preparing discharge instructions for a patient reporting facial pain that is worse when bending over, tenderness across the cheeks, and postnasal discharge. What instruction will be most helpful? -"Over the counter remedies will manage your symptoms better than prescribed medications." -"We will schedule you for a computed tomography scan this week." -"Try warm, moist heat packs on your face." -"Limit fluids to dry out your sinuses."
"Try warm, moist heat packs on your face."
The patient voices feeling very stressed regarding her immune deficiency diagnosis and the care regimen. Which response by the nurse is most beneficial in addressing the patient's stress? "What worries you the most about your immune disorder?" "I can't imagine how it must feel to have this disorder and all of the treatment regimen that goes along with it." "Light exercise and relaxation techniques may really help alleviate your stress." "Maybe you should talk to your doctor about your stress so he can prescribe some antianxiety medication."
"What worries you the most about your immune disorder?"
After teaching an asthmatic patient who is prescribed a long-acting beta 2 agonist medication, a nurse assesses the patient's understanding. Which statement indicates the patient comprehends the teaching? - "I will take this medication every morning to help prevent an acute attack." - "I will be weaned off this medication when I no longer need it." - "I will take this medication when I start to experience an asthma attack." - "I will carry this medication with me at all times in case I need it."
- "I will take this medication every morning to help prevent an acute attack."
A 79-year-old patient with bacterial pneumonia becomes increasingly restless and confused. Temperature is 100° F and pulse, blood pressure, and respirations are elevated since the last assessment 6 hours ago. The initial intervention by the nurse should be to: -administer an NSAID for discomfort - take the patient off oral fluids -give the ordered mild sedative - assess oxygen saturation
- assess oxygen saturation
A nurse is caring for an older adult patient who has a pulmonary infection. Which action should the nurse take first? - assess the patient's level of consciousness - provide the patient with humidified oxygen - encourage the patient to increase fluid intake - raise the head of the bed to at least 45 degrees
- assess the patient's level of consciousness
A nurse admits a patient who is experiencing an exacerbation of heart failure. Which action should the nurse take first? -administer intravenous Furosemide (Lasix) -ask the patient about current medications -draw blood to assess the patient's serum electrolytes - assess the patient's respiratory status
- assess the patient's respiratory status
A patient with emphysema enters the emergency room with severe dyspnea; O2 saturation is 74%, pulse is 120, and respirations are 26. After positioning the patient in high Fowler's, the nurse should: -coach in pursed-lip breathing - give oxygen at 2 L/min by nasal cannula - reposition patient in orthopneic position -attempt to help the patient slow her respirations
- give oxygen at 2 L/min by nasal cannula
A patient is on intravenous Heparin to treat a pulmonary embolism. The patient's most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate? - decrease the Heparin rate - no change in the Heparin rate - stop Heparin, begin Coumadin - increase the Heparin rate
- increase the Heparin rate
A nurse cares for a patient with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions should the nurse implement to address this patient's concerns? - ask unlicensed assistive personnel to help bathe the patient - provide the patient with a sleeping pill to stimulate rest - schedule periods of exercise and rest during the day - administer oxygen therapy at 2 liters per nasal cannula
- schedule periods of exercise and rest during the day
A nurse is assessing a patient who has suffered a nasal fracture. Which is the nurse's initial concern? -facial pain -airway patency -vital signs -bone displacement
-airway patency
A patient with long-term obstructive pulmonary disease has a pH of 7, HCO3 of 18 mEq/L, and a PaCO2 of 40 mm Hg. From this laboratory information, the nurse concludes that the patient is in: metabolic acidosis respiratory acidosis metabolic alkalosis respirator alkalosis
metabolic acidosis
The Parkland fluid resuscitation calculation calls for a total 8000 mL. The burn occurred at noon. The present time is 2:00 PM. According to the formula's fluid administration guidelines, the fluid should be set to deliver _____ mL by _____ PM. 7000, 9:00 3000, 7:00 4000, 8:00 2000, 6:00
4000, 8:00
A patient admitted for pneumonia has been tachypneic for several days. When the nurse starts an IV to give fluids, the patient questions this action, saying "I have been drinking tons of water. How am I dehydrated?" What response by the nurse is best? A.) "Breathing so quickly can be dehydrating." B.) "We always hang fluids when administering antibiotics." C.) "Why do you think you are so dehydrated?" D.) "Everyone with pneumonia is dehydrated."
A.) "Breathing so quickly can be dehydrating."
The nurse is caring for four hypertensive patients. Which drug-laboratory value combination should the nurse report immediately to the health care provider? A.) Furosemide (Lasix)/potassium: 2.9 mEq/L B.) Spironolactone (Aldactone)/potassium: 5.1 mEq/L C.) Hydrochlorothiazide (Hydrodiuril)/potassium: 4.2 mEq/L D.) Torsemide (Demadex)/sodium: 142 mEq/L
A.) Furosemide (Lasix)/potassium: 2.9 mEq/L
A patient with terminal cancer-related pain and a history of opioid abuse complains of breakthrough pain 2 hours before the next dose of sustained-release morphine sulfate (MS Contin) is due. Which action should the nurse take first? Administer the prescribed PRN immediate-acting morphine. Consult with the doctor about increasing the MS Contin dose. Use distraction by talking about things the patient enjoys Suggest the use of alternative therapies such as heat or cold.
Administer the prescribed PRN immediate-acting morphine.
A patient who is near blind is admitted to the hospital. What action by the nurse is most important? allow the patient to feel his or her way around speak loudly and slowing when talking to the patient orient the patient to the room using a focal point let the patient arrange objects on the bedside table
orient the patient to the room using a focal point
A patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU) is restless and shouting at the nurse. The patient's oxygen saturation is 96%, and recent laboratory results are all normal. Which action by the nurse is most appropriate? Assess for bladder distention. Demonstrate the use of the nurse call bell button. Notify the anesthesia care provider (ACP). Increase the IV fluid rate.
Assess for bladder distention.
The client arrives at the emergency room reporting symptoms of heart palpitations, tightness in the chest, and epigastric pain. The nurse asks the client what was happening when these symptoms first appeared. The client states a stressful event. The nurse is correct to correlate that the symptoms experienced stem from which system? Central nervous system Autonomic nervous system Cardiopulmonary system Sympathetic nervous system
Autonomic nervous system
The nurse is explaining to a patient how telemetry will be used during his time in the hospital to help in diagnosing his heart disorder. Which patient statement indicates understanding of teaching? a.) "This test will help determine if I have a blockage in my arteries." b.) "The nurses will be able to monitor my heart rate and rhythm." c.) "If there is a problem with my heart valves it will show up with telemetry." d.) "I will need to stay in bed when the monitor is reading my heart waves."
B.) "The nurse will be able to monitor my heart rate and rhythm"
Heart disease in women is manifested by a variety of subtle signs. Which sign is typically seen in women? A.) dizziness B.) fatigue C.) chest pain D.) fainting
B.) fatigue
A nurse is preparing a teaching plan for a 29 year old patient recently diagnosed with Stage 3 Breast Cancer..What nursing diagnosis would be most important to include with the information that you have been provided above? Impaired coping related to medical diagnosis. Change in body image related to radical mascectomy Acute pain related to surgical procedure Fatigue related to medical diagnosis.
Change in body image related to radical mascectomy
The nurse is caring for a 1-day postoperative patient who is receiving morphine through patient-controlled analgesia (PCA). What action by the nurse is a priority? Perform a complete cardiac assessment Assess for nausea after eating. Check the respiratory rate Inspect the abdomen and auscultate bowel sounds.
Check the respiratory rate
In the postanesthesia care unit (PACU), a patient's vital signs are blood pressure 116/72, pulse 74, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take first? Encourage the patient to take deep breaths. Immediately apply oxygen by mask at 10 liters. Place the patient in a side-lying position. Increase the rate of the postoperative IV fluids.
Encourage the patient to take deep breaths.
Which action should the perioperative nurse take to best protect the patient from burn injury during surgery? Ensure correct placement of the grounding pad. Verify that a fire extinguisher is available during surgery. Check all emergency sprinklers in the operating room. Confirm that all electrosurgical equipment has been properly serviced.
Ensure correct placement of the grounding pad.
A nurse cares for a patient who is prescribed Vancomycin (Vancocin) 500 mg IV every 6 hours for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which action should the nurse take? ensure that the patient has increased oral intake during therapy administer it over 30 minutes using an IV pump assess the IV site at least every 2 hours for thrombophlebitis give the patient diphenhydramine (Benadryl) before the drug
assess the IV site at least every 2 hours for thrombophlebitis
Five minutes after receiving the ordered preoperative midazolam (Versed) by IV injection, the patient asks to get up to go to the bathroom to urinate. Which action by the nurse is most appropriate? Offer a urinal or bedpan and position the patient in bed to promote voiding. Ask the patient to wait because catheterization is performed just before the surgery. Allow the patient up to the bathroom because medication onset is 10 minutes. Assist the patient to the bathroom and stay with the patient to prevent falls.
Offer a urinal or bedpan and position the patient in bed to promote voiding.
A nurse assesses a patient 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. Which action should the nurse take? - increase the flow rate of intravenous fluids -document the finding as "left pedal pulse of +1" -assess the color and temperature of the left leg -elevate the leg and apply a sandbag to the entrance site
assess the color and temperature of the left leg
A nurse is assessing an older patient for the presence of infection. The patient's temperature is 98.6° F (37.0° C). Which response by the nurse is best? document findings and continue to monitor conclude that an infection is not present assess the patient for more specific signs request that the provider order blood cultures
assess the patient for more specific signs
After receiving change-of-shift report about these postoperative patients, which patient should the nurse assess first? Patient who has bibasilar crackles and a temperature of 100°F (37.8°C) on the first postoperative day after chest surgery Patient who has 30 mL of sanguineous drainage in the wound drain 10 hours after hip replacement surgery Patient who continues to have incisional pain 15 minutes after hydrocodone and acetaminophen (Vicodin) administration Patient complaining of 10/10 chest pain after a right total knee replacement.
Patient complaining of 10/10 chest pain after a right total knee replacement.
An older adult patient who has colorectal cancer is receiving IV fluids at 175 mL/hour in conjunction with the prescribed chemotherapy. Which finding by the nurse is most important to report to the health care provider? Patient needs to void every hour during the day. Patient complains of severe fatigue. Patient complains of weakness. Patient has audible crackles to the midline posterior chest.
Patient has audible crackles to the midline posterior chest.
A postoperative patient has not voided for 8 hours after return to the clinical unit. Which action should the nurse take first? Assist the patient to ambulate to the bathroom. Perform a bladder scan. Insert a straight catheter as indicated on the PRN order. Encourage increased oral fluid intake.
Perform a bladder scan.
A nurse is caring for a patient who has a pressure ulcer on the right ankle. Which action should the nurse take first? draw blood for albumin, prealbumin, and total protein place the patient in bed and instruct the patient to elevate the foot assess the right leg for pulses, skin color, and temperature prepare for and assist with obtaining a wound culture
assess the right leg for pulses, skin color, and temperature
A patient who is using a fentanyl (Duragesic) patch for the first time and immediate-release morphine for chronic cancer pain develops new-onset confusion, dizziness, and a decrease in respiratory rate. Which action should the nurse take first? Notify the health care provider. Remove the fentanyl patch. Administer the prescribed PRN naloxone (Narcan). Perform a complete respiratory assessment.
Remove the fentanyl patch.
The nurse administers an IV vesicant chemotherapeutic agent to a patient. Which action is most important for the nurse to take? Hold the medication unless a central venous line is available. Stop the infusion if swelling is observed at the site. Infuse the medication over a short period of time. Administer the chemotherapy through a small-bore catheter.
Stop the infusion if swelling is observed at the site.
The nurse is caring for a patient the first postoperative day following a laparotomy for a small bowel obstruction. The nurse notices new bright-red drainage about 5 cm in diameter on the dressing. Which action should the nurse take first? Reinforce the dressing. Apply an abdominal binder. Take the patient's vital signs and perform an assessment. Recheck the dressing in 1 hour for increased drainage.
Take the patient's vital signs and perform an assessment.
A patient is 89 years old and weighs 48kgs. The patient is scheduled for a right hip replacement. Which data identified during the perioperative assessment alert the nurse that special protection techniques should be implemented during surgery? Having a sip of water 3 hours previously Stated allergy to cats and dogs Verbalization of anxiety by the patient History of spinal and hip arthritis
History of spinal and hip arthritis
The nurse reviews the medication administration record in order to choose the most appropriate pain medication for a patient with cancer who describes the pain as "deep, aching and at a level 8 on a 0 to 10 scale". Which medication should the nurse administer? - Fentanyl (Duragesic) patch - Ketorolac (Toradol) tablets - Acetaminophen (Tylenol) suppository - Hydromorphone (Dilaudid) IV
Hydromorphone (Dilaudid) IV
Which statement by a patient scheduled for surgery is most important to report to the health care provider? "I have a strong family history of breast cancer." "I had a heart valve replacement last year." "I had bacterial pneumonia last year" "I have knee pain whenever I walk or jog."
I had a heart valve replacement last year.
A patient who has fibromyalgia tells the nurse, "I feel depressed because I ache too much to play golf." "I really love to play golf."The patient says the pain is usually at a level 7 (0 to 10 scale). Which patient goal has the highest priority when the nurse is developing the treatment plan? The patient will say that the aching has decreased. The patient will be able to play 1 to 2 rounds of golf. The patient will exhibit fewer signs of depression. The patient will state that pain is at a level 2 of 10.
The patient will be able to play 1 to 2 rounds of golf.
A patient who has severe pain associated with terminal pancreatic cancer is being cared for at home by family members. Which finding by the nurse indicates that teaching regarding pain management has been effective? The patient takes opioids around the clock on a regular schedule and uses additional doses when breakthrough pain occurs. The patient states that nonopioid analgesics may be used when the maximal dose of the opioid is reached without adequate pain relief. The patient uses the ordered opioid pain medication whenever the pain is greater than 5 (0 to 10 scale). The patient agrees to take the medications by the IV route in order to improve analgesic effectiveness.
The patient takes opioids around the clock on a regular schedule and uses additional doses when breakthrough pain occurs.
A hospice patient is manifesting a decrease in all body system functions except for a heart rate of 124 and a respiratory rate of 28. Which statement, if made by the nurse to the patient's family member, is most appropriate? "These symptoms will continue to increase until death finally occurs." These symptoms are a normal response before these functions decrease." "These symptoms may be associated with an improvement in the patient's condition. "These symptoms indicate a reflex response to the slowing of other body systems."
These symptoms are a normal response before these functions decrease."
When visiting a hospice patient, the nurse assesses that the patient has a respiratory rate of 11 breaths/minute and complains of severe pain. Which action is best for the nurse to take? Administer a nonopioid analgesic, such as a nonsteroidal antiinflammatory drug (NSAID), to improve patient pain control. Inform the patient that increasing the morphine will cause the respiratory drive to fail. Tell the patient that additional morphine can be administered when the respirations are 12. Titrate the prescribed morphine dose upward until the patient indicates adequate pain relief.
Titrate the prescribed morphine dose upward until the patient indicates adequate pain relief.
An emergency department nurse triages patients who present with chest discomfort. Which patient should the nurse plan to assess first? -a 42-year-old female who describes her pain as a dull ache with numbness in her fingers -a 58-year-old male who describes his pain as intense stabbing that spreads across his chest -a 53-year-old female who reports substernal pain that radiates to her abdomen -a 49-year-old male who reports moderate pain that is worse on inspiration
a 58-year-old male who describes his pain as intense stabbing that spreads across his chest
A nurse teaches patients at a community center about risks for dehydration. Which patient is at greatest risk for dehydration? a 36-year-old who is prescribed long-term steroid therapy a 64-year-old who is disoriented a 55-year-old receiving hypertonic intravenous fluids an 83-year-old with congestive heart failure
a 64-year-old who is disoriented
A nurse assesses patients on a medical-surgical unit. Which patient is at greatest risk for pressure ulcer development? a 44-year-old prescribed IV antibiotics for pneumonia a 26-year-old who is bedridden with a fractured leg a 78-year-old requiring assistance to ambulate with a walker a 65-year-old with hemi-paralysis and incontinence
a 65-year-old with hemi-paralysis and incontinence
The nurse is aware that infection is a potential complication of surgery. Which intervention should the nurse implement to prevent infection? Select all that apply. a. Avoid touching sterile items unless necessary. b. Keep artificial nails clean and in good repair. c. Alert the surgical team of any breaches of sterile technique. d. Wear a long-sleeved, sterile gown and gloves. e. Remove hair from the surgical site using a razor.
a. Avoid touching sterile items unless necessary. c. Alert the surgical team of any breaches of sterile technique. d. Wear a long-sleeved, sterile gown and gloves.
A patient has an autosomal recessive inherited condition. For what type of disorder does the nurse anticipate the patient will be treated? a. Cystic fibrosis b. Hereditary breast cancer c. Huntington disease d. Familial hypercholesterolemia
a. Cystic fibrosis
A client has learned of a terminal illness and impending death. The client asks the nurse to explain the concepts and care that are provided under the definition of palliative care. Which of the following would the nurse include in the explanation for this client? Select all that apply. a. Provides pain relief b. Includes chemotherapy c. Integrates spirituality d. Hastens death e. Offers a team approach to care f. Enhances quality of life
a. Provides pain relief c. Integrates spirituality e. Offers a team approach to care f. Enhances quality of life
A nurse suspects malignant hyperthermia in a patient who underwent surgery approximately 18 hours ago. Which of the following would the nurse identify as a late, ominous sign? a. Rapid rise in body temperature b. Oliguria c. Tachycardia d. Muscle rigidity
a. Rapid rise in body temperature
The nurse recognizes that the client who takes hydrochlorothiazide (HydroDIURIL) to manage hypertension is predisposed for which interaction with anesthesia? a. Respiratory depression b. Hypotension c. Increased risk of bleeding d. Seizures
a. Respiratory depression
A patient who is receiving care for osteosarcoma has been experiencing severe pain since being diagnosed. As a result, the patient has been receiving analgesics on both a scheduled and PRN basis. For the past several hours, however, the patient's level of consciousness has declined and she is now unresponsive. How should the patient's pain control regimen be affected? a. The patient's pain control regimen should be continued. b. The pain control regimen should be placed on hold until the patient's level of consciousness improves. c. IV analgesics should be withheld and replaced with transdermal analgesics. d. The patient's analgesic dosages should be reduced by approximately one half.
a. The patient's pain control regimen should be continued.
A client who has undergone extensive fracture repair continues to request opioid pain medication with increasing frequency. The initial surgeries occurred more than 2 months ago, and the nurse is concerned about the repeated requests. What does the nurse suspect to be the cause of the client's frequent appeals for pain medication? a. Tolerance b. Addiction c. Drug allergy d. Poor quality control by the drug manufacturer
a. Tolerance
A nurse receives new orders for a patient with severe burn injuries who is receiving fluid resuscitation per the Parkland formula. The patient's urine output continues to range from 10-20mL/hr. Which order should the nurse question? increase intravenous fluids by 100 mL/hr continue to monitor urine output hourly draw blood for serum electrolytes STAT administer furosemide (Lasix) 40 mg IV push
administer furosemide (Lasix) 40 mg IV push
A nurse admits a patient from the emergency department. Patient data are listed below: History: 70 years of age History of diabetes On insulin twice a day Physical Assessment: Reports new-onset dyspnea and productive cough, crackles and rhonchi heard throughout the lungs, dullness to percussion LLL, afebrile, oriented to person only Laboratory Values: WBC: 5,200/mm3 PaO2 on room air 65 mm Hg What action by the nurse is the priority? - administer oxygen at 2-4 liters per nasal cannula - collect a sputum sample for culture - begin broad-spectrum antibiotics - start an IV of normal saline at 50 mL/hr
administer oxygen at 2-4 liters per nasal cannula
A nurse cares for a patient who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. Which action should the nurse take? - administer pain medication and encourage the patient to take deep breaths - encourage the patient to take shallow breaths to help with the pain - ambulate the patient in the hallway to promote deep breathing - auscultate the patient's posterior lung fields before auscultating anterior lung fields
administer pain medication and encourage the patient to take deep breaths
A new scrub technician is being orientated to the operating room. The scrub technician states to the nurse, "You can skip the fire safety information because I have worked in hospitals for the last 10 years." What is the best response by the nurse? a. "I know this information is not exciting but I'm required to cover this information with you." b. "The operating room has some unique circumstances that increases the chances of fire." c. "OK, but you will be required to review the hospital's policy on fire safety on your own." d. "This is a requirement of your job, just tough through it."
b. "The operating room has some unique circumstances that increases the chances of fire."
Following surgery for adenocarcinoma, the client learns the tumor stage is T3, N1, M0. What treatment mode will the nurse anticipate? a. No further treatment is indicated. b. Adjuvant therapy is likely. c. Palliative care is likely. d. Repeat biopsy is needed before treatment begins.
b. Adjuvant therapy is likely.
The nurse is conducting a community education class on genetics and genomics. The nurse explains that a chromosomal difference that most likely involves an extra or missing chromosome is known as which of the following? a. Haploidy b. Aneuploidy c. Monosomy d. Trisomy
b. Aneuploidy
A nurse correctly instructs a client with peripheral vascular disease that stress-reduction technique: a. Are helpful only because they assist in smoking cessation. b. Are helpful because stress stimulates the release of vasoconstricting catecholamines. c. Are helpful because they distract the client from focusing on claudication pain. d. Haven't proven useful in clients with peripheral vascular disease.
b. Are helpful because stress stimulates the release of vasoconstricting catecholamines.
After completing a history and physical assessment of a client who has just found out that she is pregnant, the nurse determines the need for a referral for a genetic evaluation based on which of the following? Select all that apply. a. Age of 30 at expected time of delivery b. History of diabetes c. Brother with mental retardation d. Negative alpha-fetoprotein screening e. Two previous unexplained miscarriages
b. History of diabetes c. Brother with mental retardation e. Two previous unexplained miscarriages
A postanesthesia care unit (PACU) nurse is caring for a patient with the following assessment data: pale, cool, moist skin; thready pulse of 122; blood pressure 78/60; urine output of 25 mL/h; temperature 99.2°F. What interventions by the nurse are appropriate? Select all that apply. a. Raise the head of the bed 30 degrees. b. Maintain a patent airway. c. Frequently monitor neurological status. d. Administer blood products per orders. e. Apply oxygen per orders. f. Apply a warming blanket.
b. Maintain a patent airway. c. Frequently monitor neurological status. d. Administer blood products per orders. e. Apply oxygen per orders
The nurse would identify which of the following vitamin deficiencies to prevent the complication of hemorrhaging during surgery? a. Zinc b. Vitamin K c. Vitamin A d. Magnesium
b. Vitamin K
The nurse caring for a patient with congestive heart failure (CHF) will include which intervention in the plan of care? a.) perform all care at one time to allow more time to rest b.) alternate rest with activity c.) encourage eating large meals at regular times d.) keep the patient as flat as possible to prevent venous pooling
b.) alternate rest with activity
The nurse is performing a preoperative assessment on a patient going to surgery. The patient informs the nurse that he drinks approximately two bottles of wine each day and has for the last several years. What postoperative difficulties can the nurse anticipate for this patient? a. Alcohol withdrawal syndrome 1 week after his last alcohol drink b. Alcohol withdrawal syndrome upon administration of general anesthesia c. Alcohol withdrawal syndrome 2 to 4 days after his last alcohol drink d. Alcohol withdrawal syndrome immediately following surgery
c. Alcohol withdrawal syndrome 2 to 4 days after his last alcohol drink
The clinic nurse is doing a preoperative assessment of a patient who will be undergoing outpatient cataract surgery with lens implantation in 1 week. While taking the patient's medical history, the nurse notes that this patient had a kidney transplant 8 years ago and that the patient is taking immunosuppressive drugs. For what is this patient at increased risk when having surgery? a. Rejection of the kidney b. Rejection of the implanted lens c. Infection d. Adrenal storm
c. Infection
The intraoperative nurse is transferring a patient from the OR to the PACU after replacement of the right knee. The patient is a 73-year-old woman. The nurse should prioritize which of the following actions? a. Keeping the patient sterile b. Keeping the patient restrained c. Keeping the patient warm d. Keeping the patient hydrated
c. Keeping the patient warm
Which cardiovascular findings indicate to the nurse that the condition of the dying client is worsening? a. Pulse 60 beats/minute, blood pressure 90/42mm Hg, difficult to arouse b. Pulse 100 beats/minute, blood pressure 100/60 mm Hg, pale with poor skin turgor c. Pulse 104 beats/minute in the morning, 62 beats/minute in the afternoon with mottled feet and ankles d. Pulse 72 beats/minute, irregular; patient confused and agitated
c. Pulse 104 beats/minute in the morning, 62 beats/minute in the afternoon with mottled feet and ankles
A nurse works in an allergy clinic. What task performed by the nurse takes priority? providing educational materials in several languages ensuring informed consent is obtained as needed checking emergency equipment each morning teaching patients how to manage their allergies
checking emergency equipment each morning
A patient is hospitalized and on multiple antibiotics. The patient develops frequent diarrhea. What action by the nurse is most important? place the patient on NPO status until the diarrhea resolves consult with the provider about obtaining stool cultures delegate frequent perianal care to unlicensed assistive personnel request an order for an anti-diarrheal medication
consult with the provider about obtaining stool cultures
Which of the following terms is an example of an X-linked recessive condition? a. Osteoarthritis b. Huntington disease c. Sickle cell anemia d. Duchenne muscular dystrophy
d. Duchenne muscular dystrophy
A nurse is planning the care of a woman who has been admitted to the medical unit following an ischemic cerebrovascular accident. What would the nurse recognize as the longest-acting phase of the woman's physiologic response to stress and its cause? a. Sympathetic-adrenal-medullary response caused by persistent stress b. Hypothalamic-pituitary response caused by acute stress c. Sympathetic-adrenal-medullary response caused by acute stress d. Hypothalamic-pituitary response caused by persistent stress
d. Hypothalamic-pituitary response caused by persistent stress
The PACU nurse is caring for a male patient who had a hernia repair. The patient's blood pressure is now 164/92 mm Hg; he has no history of hypertension prior to surgery and his preoperative blood pressure was 112/68 mm Hg. The nurse should assess for what potential causes of hypertension following surgery? a. Dysrhythmias, blood loss, and hyperthermia b. A parasympathetic reaction and low blood volumes c. Electrolyte imbalances and neurologic changes d. Pain, hypoxia, or bladder distention
d. Pain, hypoxia, or bladder distention
A nurse is caring for a client with a terminal illness. The client asks the nurse to help him end his own life to alleviate his suffering and that of his family. When responding to the client, the nurse integrates knowledge of which of the following? a. Most states have enacted laws that allow for physician-assisted suicide. b. A client has the right to make independent decisions about the timing of his or her death. c. Nurses may administer medications prescribed by physicians to hasten end of life. d. Participating in assisted suicide violates the Code of Ethics for Nurses.
d. Participating in assisted suicide violates the Code of Ethics for Nurses.
A patient in hospice has end-stage renal failure. He says that, of late, he has lost his appetite and feels like everyday situations have become more stressful. He reports feeling restless. In addition, his wife notices that he is more and more confused. What is the most important nursing intervention that needs to be carried out at this point? a. Make arrangements for the patient to have nutritional counseling. b. Immediately administer drug therapy to restore renal function. c. Make arrangements with the physician to administer immunosuppressants. d. Provide the wife with an emergency kit with small doses of oral morphine liquid.
d. Provide the wife with an emergency kit with small doses of oral morphine liquid.
A male client has been unable to return to work for 10 days following chemotherapy as the result of ongoing fatigue and inability to perform usual activities. Laboratory test results are WBCs 2000/mm³, RBCs 3.2 x 10¹²/L, and platelets 85,000/mm³. The nurse notes that the client is anxious. Which of the following is the priority nursing diagnosis? a. Anxiety related to change in role function b. Activity intolerance related to side effects of chemotherapy c. Fatigue related to deficient blood cells d. Risk for infection related to inadequate defenses
d. Risk for infection related to inadequate defenses
When evaluating the response to treatment for a patient with a fluid imbalance, the most important assessment to include is: daily weight skin turgor presence of edema hourly urine output
daily weight
A nurse reviews the following data in the chart of a patient with burn injuries: Admission Note: 36-year-old female with bilateral leg burns Health history of asthma and seasonal allergies NKDA Wound Assessment: Bilateral leg burns present with a white and leather-like appearance.No blisters or bleeding present. Patient rates pain 2/10 on a scale of 0-10. Based on the data provided, how should the nurse categorize this patient's injuries? partial thickness deep partial-thickness superficial full-thickness superficial
full-thickness
A nurse assesses a patient with diabetes mellitus who is admitted with an acid-base imbalance. The patient's arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L. Which manifestation should the nurse identify as an example of the patient's compensation mechanism? increased thirst and hunger increased release of acids from the kidneys increased rate and depth of respirations increased urinary output
increased rate and depth of respirations
A nurse performs a skin screening for a patient who has numerous skin lesions. Which lesion does the nurse evaluate first? irregular blue mole with white specks on the lower leg thick, reddened papules covered by white scales large cluster of pustules in the right axilla beige freckles on the backs of both hands
irregular blue mole with white specks on the lower leg
A patient is receiving an isotonic IV solution (0.9% NS). During administration of the solution, what is the most important assessment for the nurse to monitor? peripheral edema bounding peripheral pulses urinary output lung sounds
lung sounds
A nurse is assessing patients on a medical-surgical unit. Which patient is at risk for hypokalemia? patient in a motor vehicle crash who is receiving 6 units of packed red blood cells patient who is prescribed an angiotensin-converting enzyme (ACE) inhibitor patient with uncontrolled diabetes and a serum pH level of 7.33 patent with pancreatitis who has continuous nasogastric suctioning
patent with pancreatitis who has continuous nasogastric suctioning
The nurse admitting a patient with significant burns to the emergency department notes the presence of symptoms consistent with an inhalation burn. Which finding is the nurse most likely noting? agitation hypotension persistent coughing full-thickness burns to the chest
persistent coughing
A nurse assesses a patient who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. Which action should the nurse take next? document and reassess in an hour perform chest physiotherapy place the patient in an upright position administer furosemide (Lasix)
place the patient in an upright position
A nurse evaluates the following data in a patient's chart: Admission Note: 66-year-old male with a health history of a cerebral vascular accident and left-side paralysis Laboratory Results: White blood cell count: 8000/mm3 Prealbumin: 15.2 mg/dL Albumin: 4.2 mg/dL Lymphocyte count: 2000/mm3 Wound Care Note: Sacral ulcer - 4 cm × 2 cm × 1.5 cm Based on this information, which action should the nurse take? perform a neuromuscular assessment request a dietary consult assess the patent's vital signs initiate Contact Precautions
request a dietary consult
The nurse is assessing a patient with renal failure and notes fatigue, muscle cramps, confusion, and headache. The nurse will monitor the patient's _____ level. potassium sodium calcium chloride
sodium
Which teaching point is most important for the patient with bacterial pharyngitis? - take all antibiotics as prescribed - use a humidifier in the bedroom - wash hands frequently - gargle with warm salt water
take all antibiotics as prescribed
The nurse caring for the patient with lymphedema of the left arm will implement what intervention? keep the arm below the level of the heart to minimize edema clean the arm with mild soap and massage gently encourage patient to keep the arms as inactive as possible to reduce further injury take blood pressure and give injections in the right arm
take blood pressure and give injections in the right arm
