NURS 355 Exam 1

A patient who is scheduled for a therapeutic abortion tells the nurse, "Having an abortion is wrong." Which functional health pattern should the nurse further assess? a. Value-belief b. Cognitive-perceptual c. Sexuality-reproductive d. Coping-stress tolerance

Value-belief

A patient has a magnesium level of 1.3 mg/dL. Which assessment would help the nurse identify a likely cause of this value? a. Daily alcohol intake b. Dietary protein intake c. Multivitamin with minerals d. Over-the-counter (OTC) laxative

daily alcohol intake

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

"Can you tell me what has been helpful when coping with past stressful events?"

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

"I can buy some aloe vera gel to use on my skin."

Which statement by a patient scheduled for knee surgery is most important to report to the health care provider before surgery? a. "I have a strong family history of cancer." b. "I had a heart valve replacement last year." c. "I had bacterial pneumonia 3 months ago." d. "I have knee pain whenever I walk or jog." ANS: B

"I had a heart valve replacement last year."

Which statement, if made by a new circulating nurse, reflects understanding of the circulating nurse role? a. "I will assist in preparing the operating room for the patient." b. "I will don sterile gloves to obtain items from the unsterile field." c. "I will assist with suturing of incisions and maintaining hemostasis." d. "I will remain gloved while performing activities in the sterile field."

"I will assist in preparing the operating room for the patient."

A patient scheduled to undergo total knee replacement surgery under general anesthesia asks the nurse, "Will the doctor put me to sleep with a mask over my face?" Which response by the nurse is most appropriate? a. "Only your surgeon can tell you what method of anesthesia will be used." b. "I will check with the anesthesia care provider to find out what is planned." c. "General anesthesia is given by injecting drugs into your veins, so you will not need a mask over your face." d. "Masks are no longer used for anesthesia. A tube inserted into your throat will deliver gas that puts you to sleep."

"I will check with the anesthesia care provider to find out what is planned."

Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective? a. "I will try to drink at least 8 glasses of water every day." b. "I will use a salt substitute to decrease my sodium intake." c. "I will increase my intake of potassium-containing foods." d. "I will drink apple juice instead of orange juice for breakfast."

"I will drink apple juice instead of orange juice for breakfast

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

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

The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give this patient related to fluid intake? a. "Drink more fluids in the late evening." b. "More fluids are needed if you feel thirsty." c. "Increase the fluids if your mouth feels dry." d. "If you feel confused, you need more fluids." ANS: C

"Increase the fluids if your mouth feels dry."

A patient scheduled for an elective hysterectomy tells the nurse, "I am afraid that I will die in surgery like my mother did!" Which initial response by the nurse is most appropriate? a. "Tell me more about what happened to your mother." b. "Surgical techniques have improved in recent years." c. "You will receive medication to reduce your anxiety." d. "You should talk to the doctor again about the surgery."

"Tell me more about what happened to your mother"

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

"The biopsy will help decide the treatment for my enlarged prostate."

A student asks the nurse why a peripherally inserted central catheter is needed for a patient receiving parenteral nutrition with 25% dextrose. Which response by the nurse is accurate? a. "The prescribed infusion can be given more rapidly when the patient has a central line." b. "The hypertonic solution will be more rapidly diluted when given through a central line." c. "There is a decreased risk for infection when 25% dextrose is infused through a central line." d. "The required blood glucose monitoring is based on samples obtained from a central line."

"The hypertonic solution will be more rapidly diluted when given through a central line."

The sister of a patient diagnosed with BRCA gene-related breast cancer asks the nurse, "Do you think I should be tested for the gene?" Which response by the nurse is most appropriate? a. "In most cases, breast cancer is not caused by having the BRCA gene." b. "It depends on how you will feel if the test is positive for the BRCA gene." c. "There are many things to consider before deciding to have genetic testing." d. "First you should decide whether you are willing to have a bilateral mastectomy."

"There are many things to consider before deciding to have genetic testing."

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

"Would you like to talk about options for the care of your children?"

A male patient with hemophilia asks the nurse if his future children will have hemophilia. Which response by the nurse is accurate? a. "All of your children will be at risk for hemophilia." b. "Hemophilia is a multifactorial inherited condition." c. "Only your male children are at risk for hemophilia." d. "Your female children will be carriers for hemophilia."

"Your female children will be carriers for hemophilia."

Which nursing actions will the nurse take to assess for possible malnutrition in an older adult patient? (Select all that apply.) a. Assess for depression. b. Review laboratory results. c. Determine food preferences. d. Inspect teeth and oral mucosa. e. Ask about transportation needs.

-Assess for depression -Review laboratory results -Inspect teeth and oral mucosa -Ask about transportation needs

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

-Cook food thoroughly before eating -Avoid public transportation such as buses -Talk to the oncologist before having any dental work

When caring for a preoperative patient on the day of surgery, which actions can the nurse delegate to unlicensed assistive personnel (UAP)? (Select all that apply.) a. Teach incentive spirometer use. b. Explain routine preoperative care. c. Obtain and document baseline vital signs. d. Remove nail polish and apply pulse oximeter. e. Transport the patient by stretcher to the operating room.

-Obtain and document baseline vital signs -Remove nail polish and apply pulse oximeter -Transport the patient by stretcher to the operating room

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

-Pap testing -Sunscreen use -Mammography -Colorectal screening

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

200 mL sanguineous fluid in the wound drain

Which patient is most likely to need long-term nursing care management? a. 72-yr-old who had a hip replacement after a fall at home b. 64-yr-old who developed sepsis after a ruptured peptic ulcer c. 76-yr-old who had a cholecystectomy and bile duct drainage d. 63-yr-old with bilateral knee osteoarthritis who weighs 350 lb (159 kg)

63-yr-old with bilateral knee osteoarhtritis who weighs 350 lb (159 kg)

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

A 24-yr-old patient who received neck radiation and has blood oozing from the neck

The nurse in the outpatient clinic has obtained health histories for these new patients. Which patient may need referral for genetic testing? a. A 30-yr-old patient who has a sibling with polycystic kidney disease b. A 30-yr-old patient with dyspnea who has a history of cigarette smoking c. A 20-yr-old patient whose maternal grandparent died after a stroke at age 80 d. A 20-yr-old patient with a positive pregnancy test whose first child has cerebral palsy

A 30-yr-old patient who has a sibling with polycystic kidney disease

While ambulating in the room, a patient reports feeling dizzy. In what order will the nurse accomplish the following activities? (Put a comma and a space between each answer choice [A, B, C, D].) a. Have the patient sit down in a chair. b. Give the patient something to drink. c. Take the patient's blood pressure (BP). d. Inform the patient's health care provider.

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

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

A. Increase the IV infusion rate C. Increase the oxygen flowrate B. Assess the patient's dressing D. Check the patient's temperature

A patient undergoing an emergency appendectomy has been using St. John's wort to prevent depression. Which complication should the nurse expect in the postanesthesia care unit? a. Increased blood pressure b. Increased physical discomfort c. Increased anesthesia recovery time d. Increased postoperative wound bleeding

Increased anesthesia recovery time

A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications. The patient seems confused and short of breath with peripheral edema. Which assessment should the nurse complete first? a. Skin turgor b. Heart sounds c. Mental status d. Capillary refill

Mental status

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

Administer prescribed analgesic medications before the activities

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

Administer the prescribed PRN IV morphine sulfate

A patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take? a. Give the prescribed PRN lorazepam (Ativan). b. Encourage the patient to take deep slow breaths. c. Start the prescribed PRN oxygen at 2 to 4 L/min. d. Administer the prescribed fluid bolus and insulin.

Administer the prescribed fluid bolus and insulin

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

Albumin level 2.2 g/dL

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

Metabolic acidosis

While in the holding area, a patient reveals to the nurse that his father had a high fever after surgery. What action by the nurse is a priority? a. Place a medical alert sticker on the front of the patient's chart. b. Alert the anesthesia care provider of the family member's reaction to surgery. c. Give 650 mg of acetaminophen (Tylenol) per rectum as a preventive measure. d. Reassure the patient that his temperature will be monitored closely after surgery.

Alert the anesthesia care provider of the family member's reaction to surgery

A patient who has not had any prior surgeries tells the nurse doing the preoperative assessment about allergies to avocados and bananas. Which action is most important for the nurse to take? a. Notify the dietitian about the specific food allergies. b. Alert the surgery center about a possible latex allergy. c. Reassure the patient that all allergies are noted on the health record. d. Ask whether the patient uses antihistamines to reduce allergic reactions.

Alert the surgery center about a possible latex allergy.

The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action should the nurse expect to take first? a. Monitor ionized calcium level. b. Give oral calcium citrate tablets. c. Check parathyroid hormone level. d. Administer vitamin D supplements.

Monitor ionized calcium level

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

Anxiety

The family of an older patient with chronic health problems and increasing weakness is considering placement in a long-term care (LTC) facility. Which action by the nurse will be most helpful in assisting the patient to make this transition? a. Have the family select an LTC facility that is relatively new. b. Ask the patient's preference for the choice of an LTC facility. c. Explain the reasons for the need to live in LTC to the patient. d. Request that the patient be placed in a private room at the facility.

Ask the patient's preference for the choice of an LTC facility

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

Assess for bladder distention

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

Assess for sensation and strength in the legs

A patient with new-onset confusion and hyponatremia is being admitted. Which action should the charge nurse take when making room assignments? a. Assign the patient to a semiprivate room. b. Assign the patient to a room near the nurse's station. c. Place the patient in a room nearest to the water fountain. d. Place the patient on telemetry to monitor for peaked T waves.

Assign the patient to a room near the nurse's station

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

Assist the patient to ambulate

The surgical unit nurse has just received a patient with a history of smoking from the postanesthesia care unit. Which action is most important at this time? a. Auscultate for adventitious breath sounds. b. Obtain the blood pressure and temperature. c. Teach the patient about harmful effects of smoking. d. Ask the health care provider to prescribe a nicotine patch.

Auscultate for adventitious breath sounds.

After placement of a centrally inserted IV catheter, a patient reports acute chest pain and dyspnea. Which action should the nurse take first? a. Notify the health care provider. b. Offer reassurance to the patient. c. Auscultate the patient's breath sounds. d. Give prescribed PRN morphine sulfate IV.

Auscultate the patient's breath sounds

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

Avoid giving the patient foods that are strongly disliked

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

Baked chicken

The nurse is caring for a patient who has a massive burn injury and possible hypovolemia. Which assessment data should be of most concern to the nurse? a. Urine output is 30 mL/hr. b. Blood pressure is 90/40 mm Hg. c. Oral fluid intake is 100 mL for 8 hours. d. Skin tenting over the sternum is prolonged. ANS: B

Blood pressure is 90/40 mm Hg

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

Blueberry yogurt

. A young male patient with paraplegia who has a stage 2 sacral pressure injury is being cared for at home by his family. To prevent further tissue damage, what instructions are most important for the nurse to teach the patient and family? a. Change the patient's bedding frequently. b. Apply a hydrocolloid dressing over the injury. c. Change the patient's position every 1 to 2 hours. d. Record the size and appearance of the injury weekly.

Change the patient's position every 1 to 2 hours

Which action describes how the scrub nurse protects the patient with aseptic technique during surgery? a. Uses waterproof shoe covers. b. Wears personal protective equipment. c. Changes gloves after touching the upper arm of the surgeon's gown. d. Requires that all operating room (OR) staff perform a surgical scrub.

Changes gloves after touching the upper arm of the surgeon's gown

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

Check the oxygen (O2) saturation

A patient who comes to the clinic reports frequent, watery stools for 2 days. Which action should the nurse take first? a. Obtain the baseline weight. b. Check the patient's blood pressure. c. Draw blood for serum electrolyte levels. d. Ask about extremity numbness or tingling.

Check the patient's blood pressure

A young adult patient receiving antibiotics for an infected leg wound has a temperature of 101.8° F (38.7° C). The patient denies any discomfort. Which action by the nurse is appropriate? a. Apply a cooling blanket. b. Notify the health care provider. c. Check the patient's temperature again in 4 hours. d. Give acetaminophen prescribed as-needed for pain. ANS: C

Check the patient's temperature again in 4 hours

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

Clean the perianal area carefully after very bowel movement

The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan? a. Maintain the patient on bed rest. b. Auscultate lung sounds every 4 hours. c. Encourage fluid intake up to 4000 mL daily. d. Monitor for Trousseau's and Chvostek's signs.

Encourage fluid intake up to 4000 mL daily

Which intervention should the nurse implement to provide optimal care for an older patient who is hospitalized with pneumonia? a. Use a standardized geriatric care plan. b. Plan for transfer to a long-term care facility. c. Consider the preadmission functional abilities. d. Minimize physical activity during hospitalization.

Consider the preadmission functional abilities

The outpatient surgery nurse reviews the complete blood cell (CBC) count results for a patient who is scheduled for surgery. The results are white blood cell (WBC) count 10.2 × 103/µL; hemoglobin 15 g/dL; hematocrit 45%; platelets 150 × 103/µL. Which action should the nurse take? a. Notify the surgeon and anesthesiologist immediately. b. Ask the patient about any symptoms of a recent infection. c. Continue to prepare the patient for the surgical procedure. d. Discuss the possibility of blood transfusion with the patient.

Continue to prepare the patient for the surgical procedure

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

Continue to take vital signs every 15 minutes

Which action should the nurse include in the plan of care for a hospitalized patient who uses culturally based treatments? a. Encourage the use of additional diagnostic procedures. b. Teach the patient that folk remedies will interfere with prescribed orders. c. Ask the patient to discontinue the cultural treatments during hospitalization. d. Coordinate the use of requested treatments with prescribed medical therapies.

Coordinate the use of requested treatments with prescribed medical therapies

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

Cover the patient with a warm blanket

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

Crackles at the lung bases

A patient with multiple draining wounds is admitted for hypovolemia. What would be the most accurate way for the nurse to evaluate fluid balance? a. Skin turgor b. Daily weight c. Urine output d. Edema presence

Daily weight

A patient who has been hospitalized for 2 days has a nasogastric tube to low suction and is receiving normal saline IV at 100 mL/hr. Which assessment finding would be a priority for the nurse to report to the health care provider? a. Oral temperature of 100.1° F b. Decreased alertness since admission c. Weight gain of 2 pounds (1 kg) over 2 days d. Serum sodium level of 138 mEq/L (138 mmol/L)

Decreased alertness since admission

The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patient's condition has improved? a. Hematocrit 28% b. Absence of skin tenting c. Decreased peripheral edema d. Blood pressure 110/72 mm Hg

Decreased peripheral edema

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

Decreasing the tumor size will improve the effects of other therapy

Which topic should the nurse discuss preoperatively with a patient who is scheduled for an open cholecystectomy? a. Care for the surgical incision b. Deep breathing and coughing c. Oral antibiotic therapy after discharge d. Medications to be used during surgery

Deep breathing and coughing

The nurse is obtaining a health history from a new patient. Which data will be the focus of patient teaching? a. Family history b. Age and genders c. Dietary fat intake d. Race and ethnicity

Dietary fat intake

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

Difficulty coping

A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication? a. Digoxin (Lanoxin) 0.25 mg/day b. Ibuprofen 400 mg every 6 hours c. Lantus insulin 24 U every evening d. Metoprolol (Lopressor) 12.5 mg/day

Digoxin (Lanoxin) 0.25 mg/day

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

Discuss patient concerns regarding self-care

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

Discuss risks associated with cigarettes during each patient encounter

The nurse obtains a health history from a patient who is scheduled for elective hip surgery in 1 week. The patient reports use of garlic and Ginkgo biloba. Which action by the nurse is appropriate? a. Teach the patient that these products may be continued preoperatively. b. Advise the patient to stop the use of herbs and supplements at this time. c. Discuss the herb and supplement use with the patient's health care provider. d. Reassure the patient that there will be no interactions with anesthetic agents.

Discuss the herb and supplement use with the patient's health care provider

The nurse assesses a patient's surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is appropriate? a. Obtain wound cultures. b. Document the assessment. c. Notify the health care provider. d. Assess the wound every 2 hours.

Document the assessment

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

Document the drainage characteristics

An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. Which clinical manifestation should the nurse expect? a. Pallor b. Edema c. Confusion d. Restlessness

Edema

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

Encourage the patient to purchase a wig or hat to war when hair loss begins.

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

Encourage the patient to take deep breaths

Which action should the perioperative nurse take to protect the patient from burn injury during surgery? a. Ensure correct placement of the grounding pad. b. Check emergency sprinklers in the operating room. c. Verify that a fire extinguisher is available during surgery. d. Confirm that all electrosurgical equipment is working properly.

Ensure correct placement of the grounding pad

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

Establish time to take a short walk almost every day

A patient has received atropine before surgery and reports a dry mouth. Which action by the nurse is appropriate? a. Check for skin tenting. b. Notify the health care provider. c. Ask the patient about any weakness or dizziness. d. Explain that dry mouth is an expected side effect. ANS: D

Explain that dry mouth as an expected side effect

Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines and medications delegate to a licensed practical/vocational nurse (LPN/VN)? a. Titrate vasoactive IV medications. b. Flush a saline lock with normal saline. c. Remove the patient's central venous catheter. d. Verify blood products prior to administration.

Flush a saline lock with normal saline

Which strategy should the nurse prioritize when planning care for a patient with diabetes who is uninsured? a. Obtain less expensive medications. b. Follow evidence-based practice guidelines. c. Assist with dietary changes as the first action. d. Teach about the impact of exercise on diabetes.

Follow evidence-based practice guidelines

A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction. The patient reports anxiety and incisional pain. The patient's respiratory rate is 32 breaths/min, and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first? a. Check to make sure the nasogastric tube is patent. b. Give the patient the PRN IV morphine sulfate 4 mg. c. Notify the health care provider about the ABG results. d. Teach the patient to take slow, deep breaths when anxious.

Give the patient the PRN IV morphine sulfate 4 mg

A patient who has just relocated to a long-term care facility is exhibiting signs of stress related to the move. Which action should the nurse include in the plan of care? a. Remind the patient that making changes is usually stressful. b. Discuss the reason for the move to the facility with the patient. c. Restrict family visits until the patient is accustomed to the facility. d. Have staff members write notes welcoming the patient to the facility.

Have staff members write notes welcoming the patient to the facility

. An older adult patient presents with a broken arm and visible scattered bruises healing at different stages. Which action should the nurse take first? a. Notify an elder protective services agency about possible abuse. b. Make a referral for a home assessment visit by the home health nurse. c. Have the family member stay in the waiting area while the patient is assessed. d. Ask the patient how the injury occurred and observe the family member's reaction. ANS: C

Have the family member stay in the waiting area while the patient is assessed

Which actions will the nurse include in the surgical time-out procedure before surgery (Select all that apply.)? a. Check for patency of IV lines. b. Have the surgeon identify the patient. c. Have the patient state name and date of birth. d. Verify the patient identification band number. e. Ask the patient to state the surgical procedure.

Have the patient state name and date of birth Verify the patient identification band number Ask the patient to state the surgical procedure

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

Have the patient use the incentive spirometer

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

Help to transfer the patient onto a stretcher

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

Hematuria

Which data identified during the preoperative assessment alerts the nurse that special protection techniques should be implemented during surgery? a. Stated allergy to cats and dogs b. History of spinal and hip arthritis c. Verbalization of anxiety by the patient d. Having a sip of water 3 hours previously

History of spinal and hip arthritis

. A patient's 4 × 3-cm leg wound has a 0.4-cm black area in the center of the wound surrounded by yellow-green semiliquid material. Which dressing should the nurse apply to the wound? a. Dry gauze dressing b. Nonadherent dressing c. Hydrocolloid dressing d. Transparent film dressing

Hydrocolloid dressing

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

Increased carcinoembryonic antigen (CEA)

A patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient's serum sodium level is 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question? a. Infuse 5% dextrose in water intravenously at 125 mL/hr. b. Administer IV morphine sulfate 4 mg every 2 hours PRN. c. Give IV metoclopramide 10 mg every 6 hours PRN for nausea. d. Administer 3% saline intravenously at 50 mL/hr for a total of 200

Infuse 5 % dextrose in water intravenously at 125 mL/hr

IV potassium chloride (KCl) 60 mEq is prescribed for a patient with severe hypokalemia. Which action should the nurse take? a. Administer the KCl as a rapid IV bolus. b. Infuse the KCl at a maximum rate of 10 mEq/hr. c. Discontinue cardiac monitoring during the infusion. d. Refuse to give the KCl through a peripheral venous line.

Infuse the KCI at a maximum rate of 10 mEq/hr

The operating room nurse is providing orientation to a student nurse. Which action would the nurse describe as a routine responsibility of a scrub nurse? a. Document all patient care accurately. b. Label all specimens to send to the laboratory. c. Keep both hands above the operating table level. d. Take the patient to the postanesthesia recovery area.

Keep both hands above the operating table level

Postoperatively, the nurse should monitor the patient who received inhalation anesthesia for which complication? a. Tachypnea b. Myoclonus c. Hypertension d. Laryngospasm

Laryngospasm

Which finding is most important for the nurse to communicate to the health care provider when caring for a patient who is receiving negative-pressure wound therapy? a. Low serum albumin level b. Serosanguineous drainage c. Deep red and moist wound bed d. Cobblestone wound appearance

Low serum albumin level

. A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor while the patient is receiving this infusion? a. Lung sounds b. Urinary output c. Peripheral pulses d. Peripheral edema

Lung sounds

A patient who has diabetes and acute abdominal pain is admitted for an exploratory laparotomy. When planning postoperative interventions to promote wound healing, what is the nurse's highest priority? a. Maintaining the patient's blood glucose within a normal range b. Ensuring that the patient has an adequate dietary protein intake c. Giving antipyretics to keep the temperature less than 102° F (38.9° C) d. Redressing the surgical incision with a dry, sterile dressing twice daily

Maintaining the patient's blood glucose within a normal range

Which nursing action should the operating room (OR) nurse manager delegate to the registered nurse first assistant (RNFA) when caring for a surgical patient? a. Adjust the doses of administered anesthetics. b. Make surgical incisions and suture as needed. c. Provide postoperative teaching about coughing. d. Coordinate transfer of the patient to the operating table.

Make surgical incisions and suture as needed

An older adult patient receiving iso-osmolar continuous enteral nutrition develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately? a. K+3.4 mEq/L (3.4 mmol/L) b. Ca+2 7.8 mg/dL (1.95 mmol/L) c. Na+154 mEq/L (154 mmol/L) d. PO4?2-34.8 mg/dL (1.55 mmol/L)

Na+ 154 mEq/L (154 mmol/L)

When caring for a patient who has received a general anesthetic, the circulating nurse notes red, raised wheals on the patient's arms. Which action should the nurse take? a. Apply lotion to the affected areas. b. Cover the arms with sterile drapes. c. Recheck the patient's arms during surgery. d. Notify the anesthesia care practitioner (ACP).

Notify the anesthesia care practitioner (ACP)

A patient with renal failure who arrives for outpatient hemodialysis is unresponsive to questions and has decreased deep tendon reflexes. Family members report that the patient has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. Which action should the nurse take first? a. Notify the patient's health care provider. b. Obtain an order to draw a potassium level. c. Review the last magnesium level on the patient's chart. d. Teach the patient about magnesium-containing antacids.

Notify the patient's health care provider

The nurse is preparing to witness the patient signing the operative consent form when the patient says, "I don't understand what the doctor said about the surgery." Which action should the nurse take next? a. Provide a thorough explanation of the planned surgical procedure. b. Notify the surgeon that the informed consent process is not complete. c. Give the prescribed preoperative antibiotics and withhold sedative medications. d. Notify the operating room nurse to give a complete explanation of the procedure.

Notify the surgeon that the informed consent process is not complete

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

Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating

. The nurse is caring for an Asian patient who is being admitted to the hospital. Which action would be most appropriate for the nurse to take when interviewing this patient? a. Avoid eye contact with the patient. b. Observe the patient's use of eye contact. c. Look directly at the patient when interacting. d. Ask a family member about the patient's cultural beliefs.

Observe the patient's use of eye contact

A patient who has diabetes and uses insulin to control blood glucose has been NPO since midnight before having a knee replacement surgery. Which action should the nurse take? a. Withhold the usual scheduled insulin dose because the patient is NPO. b. Obtain a blood glucose measurement before any insulin administration. c. Give the patient the usual insulin dose because stress will increase the blood glucose. d. Give half the usual dose of insulin because there will be no oral intake before surgery.

Obtain a blood glucose measurement before any insulin

A patient with an open leg lesion has a white blood cell (WBC) count of 13,500/µL and a band count of 11%. What prescribed action should the nurse take first? a. Obtain cultures of the wound. b. Begin antibiotic administration. c. Continue to monitor the wound for drainage. d. Redress the wound with wet-to-dry dressings.

Obtain cultures of the wound

The nurse cares for an older adult patient who lives in a rural area. Which intervention should the nurse plan to implement to meet this patient's needs? a. Suggest that the patient move closer to health care providers. b. Obtain extra medications for the patient to last for 4 to 6 months. c. Ensure transportation to appointments with the health care provider. d. Assess the patient for chronic diseases that are unique to rural areas.

Obtain extra medications for the patient to last for 4 to 6 months

Five minutes after receiving the ordered preoperative midazolam by IV injection, the patient asks to get up to go to the bathroom to urinate. Which action by the nurse is most appropriate? a. Perform a straight catheterization. b. Assist the patient to the bathroom. c. Offer the patient a urinal or bedpan. d. Tell the patient that a catheter will be placed in the operating room.

Offer the patient a urinal or bedpan

Which action in the perioperative patient plan of care can the charge nurse delegate to a surgical technologist? a. Teach the patient about what to expect in the operating room (OR). b. Pass sterile instruments and supplies to the surgeon and scrub technician. c. Monitor and interpret the patient's echocardiogram (ECG) during surgery. d. Give the postoperative report to the postanesthesia care unit (PACU) nurse

Pass sterile instruments and supplies to the surgeon and scrub technician

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

Patient has crackles up to the midline posterior chest

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

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

After receiving change-of-shift report, which patient should the nurse assess first? a. Patient with serum sodium level of 145 mEq/L who is asking for water b. Patient with serum potassium level of 5.0 mEq/L who reports abdominal cramping c. Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive reflexes d. Patient with serum phosphorus level of 4.5 mg/dL who has soft tissue calcium-phosphate precipitates

Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive reflexes

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

Patient's breath sounds are clear to auscultation

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

Perform a bladder scan

The nurse is admitting an acutely ill, older patient to the hospital. Which action should the nurse take? a. Speak slowly and loudly while facing the patient. b. Perform a physical assessment before interviewing the patient. c. Ask a family member to go home and retrieve the patient's cane. d. Begin care by obtaining a detailed medical history from the patient.

Perform a physical assessment before interviewing the patient

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

Perform the jaw-thrust maneuver

Which action will the perioperative nurse take after surgery is completed for a patient who received ketamine as an anesthetic agent? a. Question the order for giving a benzodiazepine. b. Ensure that atropine is available in case of bradycardia. c. Provide a quiet environment in the postanesthesia care unit. d. Anticipate the need for higher than usual doses of analgesic agents.

Provide a quiet environment in the postanesthesia care unit

The nurse plans to provide preoperative teaching to an alert older man who has hearing and vision deficits. His wife answers most questions that are directed to the patient. Which action should the nurse take when doing the teaching? a. Use printed materials for instruction so that the patient will have more time to review the material. b. Direct all the teaching toward the wife because she is the obvious support and caregiver for the patient c. Provide additional time for the patient to understand preoperative instructions and carry out procedures. d. Ask the patient's wife to wait in the hall in order to focus preoperative teaching with the patient himself.

Provide additional time for the patient to understand preoperative instructions and carry out procedures

A patient with a family history of cystic fibrosis (CF) asks for information about genetic testing. Which response by the nurse is most appropriate?' a. Refer the patient to a qualified genetic counselor. b. Ask the patient why genetic testing seems necessary. c. Remind the patient that genetic testing has many social implications. d. Tell the patient that cystic fibrosis is an autosomal recessive disorder.

Refer the patient to a qualified genetic counselor

Which statement best describes the role of the certified registered nurse anesthetist (CRNA) on the surgical care team? a. Performs the same responsibilities as the anesthesiologist. b. Gives intraoperative anesthetics ordered by the anesthesiologist. c. Releases or discharges patients from the postanesthesia care area. d. Manages a patient's airway with direct supervision of the anesthesiologist

Releases or discharges patients from the postanesthesia care area.

The nurse will assess an older patient who takes diuretics and has a possible urinary tract infection (UTI). Which action should the nurse take first? a. Palpate over the suprapubic area. b. Inspect for abdominal distention. c. Question the patient about hematuria. d. Request the patient empty the bladder.

Request the patient empty the bladder

A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

Respiratory alkalosis

The nurse is preparing a patient on the morning of surgery. The patient prefers not to remove a wedding ring, saying, "I've never taken it off since the day I was married." How should the nurse respond? a. Have the patient sign a release form and leave the ring on. b. Tell the patient that the hospital is not liable for loss of the ring. c. Suggest that the patient give the ring to a family member to hold. d. Inform the operating room personnel that the patient is wearing a ring.

Suggest that the patient give the ring to a family member to hold

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

Suggest use of a daily planner and encourage adequate sleep

The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider? a. Blood glucose of 136 mg/dL b. Separation of proximal wound edges c. Oral temperature of 101° F (38.3° C) d. Patient reports increased incisional pain

Separation of proximal wound edges

A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse? a. Arterial blood pH is 7.32. b. Serum calcium is 18 mg/dL. c. Serum potassium is 5.1 mEq/L. d. Arterial oxygen saturation is 91%. ANS: B

Serum calcium is 18 mg/dL

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? a. Hematocrit 36% b. Blood pressure 144/82 c. Serum potassium 3.2 mEq/L d. Pulse rate 54-58 beats/minute

Serum potassium 3.2 mEq/L

A patient who has a small cell cancer of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding? a. Serum hematocrit of 42% b. Serum sodium of 120 mg/dL c. Urinary output of 280 mL in 8 hours d. Reported weight gain of 2.2 pounds (1 kg)

Serum sodium of 120 mg/dL

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

Serum sodium of 126 mEq/L

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

Shortness of breath

A patient with renal failure is on a low phosphate diet. Which food should the nurse instruct unlicensed assistive personnel (UAP) to remove from the patient's food tray? a. Skim milk b. Grape juice c. Mixed green salad d. Fried chicken breast

Skim milk

A patient from a long-term care facility is admitted to the hospital with a sacral pressure injury. The base of the wound involves subcutaneous tissue. How should the nurse classify this pressure injury? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

Stage 3

Monitored anesthesia care (MAC) is going to be used for a closed, manual reduction of a patient's dislocated shoulder. What action does the nurse anticipate? a. Starting an IV in the patient's unaffected arm b. Securing an airtight fit for the inhalation mask c. Preparing for placement of an epidural catheter d. Giving deep sedation under physician supervision

Starting an IV in the patient's unaffected arm

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

Stop the infusion if swelling is observed at the site

A patient who is taking a potassium-wasting diuretic for treatment of hypertension reports generalized weakness. Which action is appropriate for the nurse to take? a. Assess for facial muscle spasms. b. Ask the patient about loose stools. c. Recommend the patient avoid drinking orange juice with meals. d. Suggest that the health care provider order a basic metabolic panel.

Suggest that the health care provider order a basic metabolic panel

When caring for an older patient with hypertension who has been hospitalized after a transient ischemic (TIA), which topic is the most important for the nurse to include in the discharge teaching? a. Mechanism of action of anticoagulant therapy b. Effect of atherosclerosis on cerebral blood vessels c. Symptoms indicating that the patient should contact the health care provider d. Impact of the patient's family history on likelihood of developing a serious stroke

Symptoms indicating that the patient should contact the health care provider

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

Take the patient's vital signs

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

Take the patient's vital signs

Following a thyroidectomy, a patient reports "a tingling feeling around my mouth." Which assessment should the nurse complete first? a. Verify the serum potassium level. b. Test for presence of Chvostek's sign. c. Observe for blood on the neck dressing. d. Confirm a prescription for thyroid replacement.

Test for presence of Chvostek's sign

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

The UAP stands by the patient's bed for 30 minutes talking with the patient.

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

Venous thromboembolism

After the home health nurse teaches a patient's family member about how to care for a sacral pressure injury, which finding indicates that additional teaching is needed? a. The family member uses a lift sheet to reposition the patient. b. The family member uses clean tap water to clean the wound. c. The family member dries the wound using a hair dryer on a low setting. d. The family member places contaminated dressings in a plastic grocery bag.

The family member dries the wound using a hair dryer on a low setting

A new nurse performs a dressing change on a patient's stage 2 left heel pressure injury. Which action by the new nurse indicates a need for further teaching about pressure injury care? a. The new nurse cleans the injury with half-strength peroxide. b. The new nurse applies a hydrocolloid dressing on the injury. c. The new nurse irrigates the pressure injury with saline using a 30-mL syringe. d. The new nurse inserts a sterile cotton-tipped applicator into the pressure injury.

The new nurse cleans the injury with half-strength peroxide

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

The new nurse positions an unconscious patient on the side upon arrival in the PACU

A female staff nurse is assessing a male patient of Arab descent who is admitted with complaints of severe headaches. It is important for the charge nurse to intervene if the nurse takes which action? a. The nurse explains the 0 to 10 intensity pain scale. b. The nurse asks the patient when the headaches started. c. The nurse approaches the bedside and closes the privacy curtain. d. The nurse calls for a male nurse to bring a hospital gown to the room.

The nurse approaches the bedside and closes the privacy curtain

During an admission assessment, the nurse notices that the patient pauses before answering questions about the health history. Which action by the nurse is appropriate? a. Wait for the patient to answer the questions. b. Give the patient an assessment form and a pen. c. Interview a family member instead of the patient. d. Remind the patient that other patients also need care.

Wait for the patient to answer the questions

The nurse interviews a patient scheduled to undergo general anesthesia for a bilateral hernia repair. Which information is most important to communicate to the surgeon and anesthesiologist before surgery? a. The patient drinks 3 cups of coffee every day. b. The patient stopped taking aspirin 10 days ago. c. The patient's father died after general anesthesia for abdominal surgery. d. The patient drank 4 ounces of apple juice 6 hours before coming to the hospital.

The patient's father died after general anesthesia for abdominal surgery

The nurse could delegate care of which patient to a licensed practical/vocational nurse (LPN/VN)? a. The patient who was just admitted after suturing of a full-thickness arm wound. b. The patient who just reported increased tenderness and swelling in a leg wound. c. The patient who requires teaching about home care for an open draining abdominal wound. d. The patient who needs a hydrocolloid dressing change for a stage 3 sacral pressure injury.

The patient who needs a hydrocolloid dressing change for a stage 3 sacral pressure injury

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

The patient's calf is swollen and warm to touch

A pregnant patient with eclampsia is receiving IV magnesium sulfate. Which finding should the nurse report to the health care provider immediately? a. The bibasilar breath sounds are decreased. b. The patellar and triceps reflexes are absent. c. The patient has been sleeping most of the day. d. The patient reports feeling "sick to my stomach."

The patellar and triceps reflexes are absent

The home health nurse visits an older patient with mild forgetfulness. Which new information is of most concern to the nurse in planning care? a. The patient has lost 10 lb (4.5 kg) during the past month. b. The patient tells the nurse that a close friend recently died. c. The patient is cared for by a daughter during the day and stays with a son at night. d. The patient's son uses a marked pillbox to set up the patient's medications weekly.

The patient has lost 10 lb (4.5 kg) during the past month

A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider? a. The patient is experiencing stridor. b. The patient reports generalized fatigue. c. The patient's bowels have not moved for 4 days. d. The patient has numbness and tingling of the lips.

The patient is experiencing stridor

A patient arrives at the outpatient surgical center for a scheduled laparoscopy under general anesthesia. Which information requires the nurse's preoperative intervention to maintain patient safety? a. The patient has never had general anesthesia. b. The patient is planning to drive home after surgery. c. The patient drank a sip of water 4 hours before arriving. d. The patient's insurance does not cover outpatient surgery.

The patient is planning to drive home after surgery

Which information in the preoperative patient's medication history is most important to communicate to the health care provider before surgery? a. The patient takes garlic capsules every day. b. The patient quit using cocaine 10 years ago. c. The patient uses acetaminophen for aches and pains. d. The patient took a prescribed sedative the previous night.

The patient takes garlic capsules every day

A 38-yr-old woman is admitted for an elective surgical procedure. Which information obtained by the nurse during the preoperative assessment must be communicated to the anesthesiologist and surgeon before surgery? a. The patient's lack of knowledge about postoperative pain control b. The patient's history of an infection following a cholecystectomy c. The patient's report that her last menstrual period was 8 weeks ago d. The patient's concern about being able to resume lifting heavy items

The patient's report that her last menstrual period was 8 weeks ago

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

The patient's visitors bring in fresh peaches.

The nurse facilitates student clinical experiences in the surgical suite. Which action, if performed by a student, would require the nurse to intervene? a .The student wears a mask in the semirestricted area. b .The student wears a hair cover in the semirestricted area. c. The student wears street clothes in the semirestricted area. d. The student wears surgical scrubs in the semirestricted area.

The student wears street clothes in the semirestricted area

A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse? a. The patient's radial pulse is 105 beats/min. b. There are crackles throughout both lung fields. c. There is sediment and blood in the patient's urine. d. The patient's blood pressure increases to 142/94 mm Hg.

There are crackles throughout both lung fields

An older adult being admitted is assessed at high risk for falls. Which action should the nurse take first? a. Use a bed alarm system on the patient's bed. b. Administer the prescribed PRN sedative medication. c. Ask the health care provider to order a vest restraint. d. Position the patient in a geriatric recliner with locking tray.

Use a bed alarm system on the patient's bed

The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate? a. Avoid using friction when cleaning around the CVAD insertion site. b. Use the push-pause method to flush the CVAD after giving medications. c. Position the patient's face toward the CVAD during injection cap changes. d. Obtain a prescription from the health care provider to change CVAD dressing.

Use the push-pause method to flush the CVAD after giving medications

A patient in the surgical holding area is being prepared for a spinal fusion. Which action by a member of the surgical team requires immediate intervention by the charge nurse? a. Wearing street clothes into the nursing station b. Wearing a surgical mask into the holding room c. Walking into the hallway outside the operating room with hair uncovered d. Putting on a surgical mask, cap, and scrubs before entering the operating room

Walking into the hallway outside the operating room with hair uncovered

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? a. Lethargy b. Report of nausea c. Disorientation to time d. Weak chest movement

Weak chest movement

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

White blood cells (WBC) 2700/µL

. The nurse plans health care for a community with a large number of recent immigrants from Vietnam. Which intervention is the most important for the nurse to implement? a. Hepatitis testing b. Tuberculosis screening c. Contraceptive teaching d. Colonoscopy information

tuberculosis screenin

The nurse notes that a patient's open abdominal wound widens as it extends deeper into the abdomen. How would the nurse document this characteristic? a. Eschar b. Slough c. Maceration d. Undermining

undermining

. What information should the nurse collect when assessing the health status of a community? a. Air pollution levels b. Number of healthy food stores c. Most common causes of death d. Education level of the individuals

Most common causes of death

The nurse performs a comprehensive assessment of an older patient who is considering admission to an assisted living facility. Which question is the most important for the nurse to ask? a. "Have you had any recent infections?" b. "How frequently do you see a doctor?" c. "Do you have a history of heart disease?" d. "Are you able to prepare your own meals?"

"Are you able to prepare your own meals?"

A patient with rheumatoid arthritis has been taking oral corticosteroids for 2 years. Which nursing action is most likely to detect early signs of infection in this patient? a. Monitor white blood cell counts. b. Check the skin for areas of redness. c. Measure the temperature every 2 hours. d. Ask about feelings of fatigue or malaise.

Ask about feelings of fatigue or malaise

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

Administer prescribed antiemetics 1 hour before the treatments

A staff nurse expresses frustration that a Native American patient always has several family members at the bedside. Which action by the charge nurse is appropriate? a. Request that family members leave until a different nurse can be assigned. b. Ask about the nurse's beliefs regarding family support during hospitalization. c. Have the nurse explain to the family that too many visitors will tire the patient. d. Suggest that the nurse ask family members to leave the room during patient care.

Ask about the nurse's beliefs regarding family support during hospitalization

The nurse performs a cultural assessment with a patient from a different culture. Which action should the nurse take first? a. Request an interpreter before interviewing the patient. b. Wait until a family member is available to help with the assessment. c. Ask the patient about any affiliation with a particular cultural group. d. Tell the patient what the nurse already knows about the patient's culture.

Ask the patient about any affiliation with a particular cultural group

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

Hospitalization is required for several weeks after the stem cell transplant.

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

IL-2 enhances the body's immunologic response to tumor cells.

The nurse cares for an alert, homeless older adult patient who was admitted to the hospital with a chronic foot infection. Which intervention is the priority for the nurse to include in the discharge plan for this patient? a. Teach the patient how to assess and care for the foot infection. b. Refer the patient to social services for assessment of resources. c. Schedule the patient to return to outpatient services for foot care. d. Give the patient written information about shelters and meal sites.

Refer the patient to social services for assessment of resources

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

Rinse the mouth before and after each meal and at bedtime with a saline solution

The nurse works in a clinic located in a community where many of the residents are Hispanic. Which strategy, if implemented by the nurse, would decrease health care disparities and promote health equity for this community? a. Improve public transportation to the clinic. b. Update equipment and supplies at the clinic. c. Teach clinic staff about cultural health beliefs. d. Obtain low-cost medications for clinic patients.

Teach clinic staff about cultural health beliefs

When caring for a young adult patient who has abnormalities in the cytochrome P450 (CYP 450) gene, which action will the nurse include in the patient's plan of care? a. Teach that some medications may not work effectively. b. Teach about genetic risk for cystic fibrosis in any children. c. Encourage scheduling screening mammograms starting at age 30. d. Encourage the patient to watch for early symptoms of heart disease.

Teach that some medications may not work effectively

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

The patient takes opioids around the clock on a regular schedule and uses additional doses when breakthrough pain occurs.

When admitting a patient with stage 3 pressure injuries on both heels, which information obtained by the nurse will have the most impact on wound healing? a. The patient has had the injuries for 6 months. b. The patient takes oral hypoglycemic agents daily. c. The patient states that the injuries are very painful. d. The patient has several incisions that formed keloids.

The patient takes oral hypoglycemic agents daily

The nurse should plan to use a wet-to-dry dressing for which patient? a. A patient who has a pressure injury with pink granulation tissue. b. A patient who has a surgical incision with pink, approximated edges. c. A patient who has a full-thickness burn filled with dry, black material. d. A patient who has a wound with purulent drainage and dry brown areas.

A patient who has a wound with purulent drainage and dry brown areas

A family caregiver tells the home health nurse, "I feel like I can never get away to do anything for myself." Which action by the nurse would directly address this concern? a. Assist the caregiver in finding respite services. b. Assure the caregiver that the work is appreciated. c. Encourage the caregiver to discuss feelings openly with the nurse. d. Tell the caregiver that family members provide excellent patient care.

Assist the caregiver in finding respite services

The nurse will perform which action for a wet-to-dry dressing change on a patient's stage 3 sacral pressure injury? a. Pour sterile saline onto the new dry dressings after packing the wound. b. Administer a prescribed PRN oral analgesic 30 minutes before the change. c. Apply antimicrobial ointment before repacking the wound with moist dressings. d. Soak the old dressings with sterile saline 30 minutes before the dressing change.

Administer a prescribed PRN oral analgesic 30 minutes before the change

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

Obtain more information about the patient's relatives

A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect next? a. Skin flushing b. Muscle cramps c. Rising body temperature d. Decreasing blood pressure

Rising body temperature

An alert older patient who takes multiple medications for chronic cardiac and pulmonary diseases lives with a daughter who works during the day. During a clinic visit, the patient tells the nurse that she has a strained relationship with her daughter and does not enjoy being alone all day. In planning care for this patient, which problem should the nurse consider as the priority? a. Risk for injury b. Social isolation c. Caregiver strain d. Difficulty coping

Risk for injury

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

The UAP assists the patient to use dental floss after eating.

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

The patient swims several days each week

. The nurse is performing an admission assessment for a patient from China who does not speak English. Which actions could the nurse take to enhance communication? (Select all that apply.) a. Ask the patient's young child to interpret. b. Use a telephone-based medical interpreter. c. Wait until an agency interpreter is available. d. Use exaggerated gestures to convey information. e. Use an electronic translation software application.

Use a telephone-based medical interpreter Wait until an agency interpreter is available Use an electronic translation software application

The nurse is caring for a patient who speaks a different language. If an interpreter is not available, which action by the nurse is appropriate? a. Talk slowly so that each word is clearly heard. b. Use gestures or pictures to demonstrate meaning. c. Speak loudly in close proximity to the patient's ears. d. Repeat important words so that the patient recognizes their significance.

Use gestures or pictures to demonstrate meaning

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

Apply prescribed anesthetic gel to oral lesions before meals.

An older patient reports having "no energy" and feeling increasingly weak. The patient has lost 12 pounds over the past year. Which action should the nurse take initially? a. Ask the patient about daily dietary intake. b. Schedule regular range-of-motion exercise. c. Describe normal changes associated with aging. d. Discuss long-term care placement with the patient.

Ask the patient about daily dietary intake

A patient tells the nurse, "I would like to use a home genetic test to see if I will develop breast cancer." Which is the nurse's best initial response? a. "Home genetic testing can be very expensive." b. "Are you prepared to cope with a positive result?" c. "Are you concerned about developing breast cancer?" d. "Genetic testing only determines if you are at higher risk for breast cancer."

"Are you concerned about developing breast cancer?"

. When counseling a couple in which the man has an autosomal recessive disorder and the woman has no gene for the disorder, the nurse uses Punnett squares to show the couple the probability of their having a child with the disorder. Which statement by the nurse is accurate? a. "Each child would be a carrier of the disorder." b. "Each child would have 50% chance of having the disorder." c. "Your male children would display characteristics of the disorder." d. "Your female children would display characteristics of the disorder."

"Each child would be a carrier of the disorder."

Which statement, if made by an older adult patient, would be of most concern to the nurse in planning care? a. "I prefer to manage my life without much help from other people." b. "I take three different medications for my heart and joint problems." c. "I don't go on daily walks anymore since I had pneumonia 3 months ago." d. "I set up my medications in a marked pillbox so I don't forget to take them."

"I don't go on daily walks anymore since I had pneumonia 3 months ago."

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

"I rarely have the energy to get out of bed."

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

"The cancer involves only the cervix."

. A patient who has an infected abdominal wound develops a temperature of 104° F (40° C). All the following interventions are included in the patient's plan of care. In which order should the nurse perform the following actions? (Put a comma and a space between each answer choice [A, B, C, D]). a. Administer IV antibiotics. b. Sponge patient with cool water. c. Perform wet-to-dry dressing change. d. Administer acetaminophen (Tylenol).

A. Administer IV antibiotics D. Administer acetaminophen (Tylenol) B. Sponge patient with cool water C. Perform wet-to-dry dressing change

An older Asian American patient tells the nurse that she has lived in the United States for 50 years. The patient speaks English and lives in a predominantly Asian neighborhood. Which initial action by the nurse is appropriate? a. Include a shaman when planning the patient's care. b. Avoid direct eye contact with the patient during care. c. Ask the patient about any special cultural beliefs or practices. d. Involve the patient's oldest son to assist with health care decisions.

Ask the patient about any special cultural beliefs or practices

Which nursing action will be most helpful in decreasing the risk for drug-drug interactions in an older adult? a. Teach the patient to have all prescriptions filled at the same pharmacy. b. Make a schedule for the patient as a reminder of when to take each medication. c. Ask the patient to bring all medications, supplements, and herbs to each appointment. d. Instruct the patient to avoid taking over-the-counter (OTC) medications or supplements.

Ask the patient to bring all medications, supplements, and herbs to each appointment

A Hispanic patient reports abdominal cramping caused by empacho. Which action should the nurse take first? a. Ask the patient what treatments are likely to help. b. Massage the patient's abdomen until the pain is gone. c. Offer to contact a curandero(a) to make a visit to the patient. d. Administer prescribed medications to decrease the cramping.

Ask the patient what treatments are likely to help

The nurse is caring for a patient who has traditional Native American beliefs about health and illness. Which action by the nurse is most appropriate? a. Avoid asking questions unless the patient initiates the conversation. b. Ask the patient whether it is important that cultural healers are contacted. c. Explain the usual hospital routines for meal times, care, and family visits. d. Obtain information about the patient's cultural beliefs from a family member.

Ask the patient whether it is important that cultural healers are contacted

The nurse working in a clinic in a primarily black community notes a higher incidence of uncontrolled hypertension in the patients. To address this health disparity and promote health equity, which action should the nurse take first? a. Initiate a regular home-visit program by nurses working at the clinic. b. Schedule teaching sessions about low-salt diets at community events. c. Assess the perceptions of community members about the care at the clinic. d. Obtain low-cost antihypertensive drugs using funding from government grants.

Assess the perceptions of community members about the care at the clinic

A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which action by the nurse is appropriate? a. Elevate the ankle above heart level. b. Apply a warm moist pack to the ankle. c. Ask the patient to try bearing weight on the ankle. d. Assess the ankle's passive range of motion (ROM).

Elevate the ankle above heart level

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

Malignant tumors may spread to other tissues or organs

The nurse manages the care of older adults in an adult health day care center. Which action can the nurse delegate to unlicensed assistive personnel (UAP)? a. Plan daily activities based on the individual patient needs and desires. b. Obtain information about food and medication allergies from patients. c. Take blood pressures daily and document in individual patient records. d. Teach family members how to cope with patients who are cognitively impaired.

Take blood pressures daily and document in individual patient records

After receiving a change-of-shift report, which patient should the nurse assess first? a. The patient who has multiple leg wounds with eschar to be debrided. b. The patient receiving chemotherapy who has a temperature of 102° F. c. The patient who requires analgesics before a scheduled dressing change. d. The newly admitted patient with a stage 4 pressure injury on the coccyx.

The patient receiving chemotherapy who has a temperature of 102 F

Which method should the nurse use to obtain a complete assessment of an older patient? a. Review the patient's health record for previous assessments. b. Use a geriatric assessment instrument to evaluate the patient. c. Ask the patient to write down medical problems and medications. d. Interview both the patient and the primary caregiver for the patient.

Use a geriatric assessment instrument to evaluate the patient

The home health nurse cares for an older adult patient who lives alone and takes several different prescribed medications for chronic health problems. Which intervention, if implemented by the nurse, would support both the patient's self-management and the goal of medication adherence? a. Use a marked pillbox to set up the patient's medications. b. Discuss the option of moving to an assisted living facility. c. Remind the patient about the importance of taking medications. d. Visit the patient daily to administer the prescribed medications.

Use a marked pillbox to set up the patient's medications