Questions

After evacuation of an epidural hematoma, a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter. Which information obtained by the nurse is most important to communicate to the health care provider? a. Pulse 102 beats/min b. Temperature 101.6° F c. Intracranial pressure 15 mm Hg d. Mean arterial pressure 90 mm Hg

b. Temperature 101.6° F infection is serious complication of ICP monitoring

The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the HCP? A. Skin cool and clammy B. HR of 118 C. BP of 92/56 D. O2 sat of 93

A. Skin cool and clammy This indicates progression of shock/deterioration of patient status because in the early stages of septic shock skin is still warm and dry

A 29 year old woman has been prescribed 2 weeks of high dose prednisone therapy. Which information about the prednisone is most important for the nurse to include? A. Weigh yourself daily to monitor for weight gain B. The prednisone dose should be decreased gradually C. A weight-bearing exercise program will help minimize risk for osteoporosis D. Call the HCP if you have mood changes with the prednisone

B. The prednisone dose should be decreased gradually

Which assessment finding should the nurse caring for a patient with thrombocytopenia communicate immediately to the healthcare provider? A. Bruises on the patient's back B. The patient is difficult to arise C. Purpura on the patient's oral mucosa D. The patient's platelet count is 52,000

B. The patient is difficult to arise may indicate cerebral hemorrhage

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

b. Assist the patient onto the bedside commode every 2 hours.

A 62 year old female patient has been hospitalized for 4 days with AKI caused by dehydration. Which information will be most important for the nurse to report to the HCP? A. The creatinine level is 3 B. Urine output over an 8 hour period is 2500 mL C. The BUN is 67 D. The GFR is less than 30

B. Urine output over an 8 hour period is 2500 mL High urine output indicates a need to increase fluid intake to prevent hypovolemia

The nurse is caring for a patient following an adrenalectomy. The highest priority in the immediate postoperative period is to A. protect the patient's skin B. monitor for signs of infection C. balance fluids and electrolytes D. prevent emotional disturbances

C. balance fluids and electrolytes

If a patient is in the diuretic phase of AKI, the nurse must monitor for which serum electrolyte imbalances? A. hyperkalemia and hyponatremia B. hyperkalemia and hypernatremia C. hypokalemia and hyponatremia D. hypokalemia and hypernatremia

C. hypokalemia and hyponatremia

After endotracheal suctioning, the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action should the nurse take first? a. Document the increase in intracranial pressure. b. Ensure that the patient's neck is in neutral position. c. Notify the health care provider about the change in pressure. d. Increase the rate of the prescribed propofol (Diprivan) infusion.

b. Ensure that the patient's neck is in neutral position. nurse should check for factors that may contribute to the transient increase in ICP, observe patient for a few minutes

An early sign of increased ICP that the nurse should assess for is a. Cushing's triad. b. unexpected vomiting. c. decreasing level of consciousness (LOC). d. dilated pupil with sluggish response to light.

c. decreasing level of consciousness (LOC).

After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about a. cerebral aneurysm clipping. b. heparin intravenous infusion. c. oral low-dose aspirin therapy. d. tissue plasminogen activator (tPA).

d. tissue plasminogen activator (tPA). symptoms consistent with TIA -> give tPA after TIA to prevent stroke

A 78-kg patient with septic shock has a pulse rate of 120 beats/min with low central venous pressure and pulmonary artery wedge pressure. Urine output has been 30 mL/hr for the past 3 hours. Which order by the HCP should the nurse question? A. Administer furosemide B. Increase normal saline infusion C. Give hydrocortisone D. Titrate norepinephrine to keep SBP above 90 mmHg

A. Administer furosemide The pt has low pressures, patients in septic shock require large amounts of fluid resuscitation

What are the primary pathophysiologic changes that occur in the injury or exudative phase of ARDS? Select all that apply A. Atelectasis B. SOB C. Interstitial and alveolar edema D. Hyaline membranes line the alveoli E. Influx of neutrophils, monocytes, and lymphocytes

A. Atelectasis C. Interstitial and alveolar edema D. Hyaline membranes line the alveoli

When caring for a patient with a left arm arteriovenous fistula, which action will the nurse include in the plan of care to maintain the patency of the fistula? A. Auscultate for a bruit at the fistula site B. Assess the quality of the left radial pulse C. Compare blood pressures in the left and right arms D. Irrigate the fistula site with saline every 8 to 12 hours

A. Auscultate for a bruit at the fistula site

Sodium polystyrene sulfonate (Kayexalate) is ordered for a patient with hyperkalemia. Before administering the medication, the nurse should assess the A. Bowel sounds B. Blood glucose C. BUN D. LOC

A. Bowel sounds Kayexalate should not be given to a patient with a paralytic ileus because bowel necrosis can occur

A patient is admitted to the emergency department with possible renal trauma after an automobile accident. Which prescribed intervention will the nurse implement first? A. Check BP and HR B. Administer morphine C. Transport to radiology for an intravenous pyelogram D. Insert a urethral catheter and obtain a urine specimen

A. Check BP and HR

A patient with septic shock has a BP of 70/46 mmHg, pulse of 136 beats/min, respirations of 32 breaths/min, temperature of 104, and blood glucose of 246. Which intervention ordered by the healthcare provider should the nurse implement first? A. Give normal saline IV B. Give acetaminophen C. Start insulin drip D. Start norepinephrine

A. Give normal saline IV Fluids are first line. Other actions are appropriate and should be initiated quickly as well

Which factors decrease cerebral blood flow (select all that apply)? A. Increased ICP B. Partial pressure of oxygen in arterial blood (PaO2) of 45 mmHg C. Partial pressure of carbon dioxide in arterial blood (PaCO2) of 30 mmHg D. Arterial blood pH of 7.3 E. Decreased MAP

A. Increased ICP C. Partial pressure of carbon dioxide in arterial blood (PaCO2) of 30 mmHg E. Decreased MAP

A 76 year old with benign prostatic hyperplasia is agitated and confused, with a markedly distended bladder. Which interventions prescribed by the HCP should the nurse implement first? A. Insert a urinary catheter B. Draw blood for a serum creatinine level C. Schedule an IV pyelogram D. Administer lorazepam (ativan)

A. Insert a urinary catheter

Eight months after the delivery of her first child, a 31 yo woman has sought care because of occasional incontinence that she experiences when sneezing or laughing. Which measure should the nurse first recommend in an attempt to resolve the woman's incontinence? A. Kegel exercises B. Use of adult incontinence pads C. Intermittent self-catheterization D. Dietary changes including fluid restriction

A. Kegel exercises

During the change of shift report a nurse is told that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 4 days. Which finding is most important for the nurse to report to the HCP? A. New onset confusion B. Decreased bowel sounds C. HR 112 D. Pale, cool, and dry extremities

A. New onset confusion Indicate patient is in progressive stage of shock and rapid intervention is needed to prevent further deterioration. Other info is consistent with compensatory shock.

A patient has increased ICP. The nursing care plan includes elevating the head of the bed and positioning the patient's head in proper alignment. What is the purpose of these actions? A. Promote venous return B. Increase comfort of the patient C. Improve arterial circulation D. Keep the patient awake

A. Promote venous return

A 70-year-old patient with malnourishment and a history of type 2 diabetes is admitted from the nursing home with pneumonia and tachypnea. Which kind of shock is this patient most likely to develop? A. Septic shock B. Neurogenic shock C. Cardiogenic shock D. Anaphylactic shock

A. Septic shock

The nurse is caring for a patient who arrived in the emergency department with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action? A. The patient's PaO2 is 45 mmHg B. The patient's PaCO2 is 35 mmHg C. The patient's respirations are shallow D. The patient's respiratory rate is 32 breaths/min

A. The patient's PaO2 is 45 mmHg indicates severe hypoxemia and respiratory failure

Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)? A. The patient's serum creatinine level is elevated B. The patient complains of intermittent chest pressure C. The patient's extremities are cool and pulses are weak D. The patient has bilateral crackles throughout the lung fields

A. The patient's serum creatinine level is elevated

Which classification of UTI is described as an infection of the renal parenchyma, renal pelvis, and ureters? A. Upper UTI B. Lower UTI C. Complicated UTI D. Uncomplicated UTI

A. Upper UTI

An older male patient visits his primary care provider because of burning on urination and production of urine that he describes as "foul smelling". The health care provider should assess the patient for what factor that may put him at risk for a urinary tract infection (UTI)? A. benign prostatic hyperplasia B. sedentary lifestyle C. recent use of broad-spectrum ABX D. high purine diet

A. benign prostatic hyperplasia

Which of the following is a risk factor for developing AKI in a patient about to receive intravenous dye contrast? A. dehydration B. hypertension C. female gender D. adolescence

A. dehydration

A patient with hypovolemic shock is receiving Lactated Ringer's solution for fluid replacement therapy. During this therapy, which laboratory result is most important for the nurse to monitor? A. serum pH B. serum sodium C. serum potassium D. hemoglobin and hematocrit

A. serum pH lactate cannot be converted by the liver to bicarb in a shock state, worsens metabolic acidosis

The nurse counsels a 64-year-old man on dietary restrictions to prevent recurrent uric acid renal calculi. Which foods should the nurse teach the patient to avoid? A. venison, crab, and liver B. spinach, cabbage, and tea C. milk, yogurt, and dried fruit D. asparagus, lentils, and chocolate

A. venison, crab, and liver

The nurse teaches a patient about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions? A. "I need to be monitored closely for development of malignant tumors" B. "After a couple of years I will be able to stop taking the cyclosporine" C. "If I develop acute rejection episode, I will need additional types of drugs." D. "The drugs are combined to inhibit different ways the kidney can be rejected."

B. "After a couple of years I will be able to stop taking the cyclosporine"

What causes the anemia of sickle cell disease? A. Intracellular hemolysis of sickled RBCs B. Accelerated breakdown of abnormal RBCs C. Autoimmune antibody destruction of RBCs D. Isoimmune antibody-antigen reactions with RBCs

B. Accelerated breakdown of abnormal RBCs

A patient is admitted to the hospital with acute rejection of a kidney transplant. Which intervention will the nurse prepare for this patient? A. Testing for HLA match B. Administration of immunosuppressant medications C. Insertion of an AV graft for hemodialysis D. Placement of the patient on the transplant waiting list

B. Administration of immunosuppressant medications

The nurse observes scleral jaundice in a patient being admitted with hemolytic anemia. Which laboratory result should the nurse check? A. Schilling test B. Bilirubin level C. Stool occult blood D. Gastric acid analysis

B. Bilirubin level

What is an early indication of increased ICP? A. Increase urine output B. Change in orientation C. Increased blood pressure D. Drop in blood pressure

B. Change in orientation

Which action will the admitting nurse include in the care plan for a patient who has neutropenia? A. Avoid intramuscular injections B. Check temperature every 4 hours C. Place a "no visitors" sign on the door D. Omit fruits and vegetables from the diet

B. Check temperature every 4 hours - can have visitors who are infection free - only avoid fresh fruits and vegetables

A 20-yr-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take? A. Have the patient gently blow the nose B. Check the drainage for glucose content C. Teach the patient that rhinorrhea is expected after head injury D. Obtain a specimen of the fluid to send for culture and sensitivity

B. Check the drainage for glucose content

The patient is experiencing fibrosis and glomerulopathy a year after a kidney transplant. Which type of rejection is occurring? A. Acute B. Chronic C. Delayed D. Hyperacute

B. Chronic

A patient who has been receiving IV heparin infusion and oral warfarin for a DVT is diagnosed with HIT when the platelet level drops to 110,000. Which action will the nurse include in the plan of care? A. Prepare for platelet transfusion B. Discontinue the heparin infusion C. Administer prescribed warfarin D. Give low weight molecular heparin

B. Discontinue the heparin infusion

A patient with respiratory failure has a respiratory rate of 6 breaths/min and an oxygen saturation of 88. The patient is increasingly lethargic. Which intervention will the nurse anticipate? A. Administration of 100% O2 by non rebreather mask B. Endotracheal intubation and positive pressure ventilation C. Insertion of a mini-tracheostomy with frequent suctioning D. Initiation of continuous positive pressure ventilation (CPAP)

B. Endotracheal intubation and positive pressure ventilation

A patient with massive trauma and possible spinal cord injury is admitted to the emergency department. Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock? A. Inspiratory crackles B. Heart rate 45 bpm C. Cool, clammy extremities D. Temperature 101.2

B. Heart rate 45 bpm Neuogenic shock is characterized by hypotension and bradycardia

The nurse admits a patient to the hospital in Addisonian crisis. Which patient statement supports the need to plan additional teaching? A. I frequently eat at restaurants, and my food has a lot of added salt. B. I had the flu earlier this week, so I couldn't take the hydrocortisone C. I always double my dose of hydrocortisone on the days that I go for a long run D. I take twice as much hydrocortisone in the morning dose as I do in the afternoon

B. I had the flu earlier this week, so I couldn't take the hydrocortisone

The nurse is caring for a patient who just returned from the recovery room after undergoing abdominal surgery. The nurse monitors the client for which early sign of hypovolemic shock? A. Lethargy B. Increased pulse rate C. Increased depth of respiration D. Decreased deep tendon reflexes

B. Increased pulse rate

A nurse is caring for a patient whose hemodynamic monitoring indicates a blood pressure of 92/54 mmHg, a pulse of 64 BPM, and an elevated pulmonary artery wedge pressure (indicative of cardiogenic shock). Which intervention ordered by the HCP should the nurse question? A. Elevate HOB to 30 degrees B. Infuse normal saline at 250 mL/hr C. Hold nitroprusside if SBP is less than 90 mmHg D. Titrate dobutamine to keep SBP greater than 90 mmHg

B. Infuse normal saline at 250 mL/hr Do not want to give large amounts of fluid in cardiogenic shock

Vigorous control of fever in the patient with meningitis is required to prevent complications of increased cerebral edema, seizure frequency, neurologic damage, and fluid loss. What nursing care should be included A. Administer analgesics as ordered B. Monitor LOC related to increased brain metabolism C. Rapidly decrease temperature with a cooling blanket D. Assess for peripheral edema from rapid fluid infusion

B. Monitor LOC related to increased brain metabolism

The nurse is caring for a 73 year-old male with a history of benign prostatic hyperplasia and symptoms fo a possible urinary tract infection. Which diagnostic finding would support this diagnosis? A. Glucose, protein, and ketones are present in the urine B. Nitrites and leukocyte esterase are present in the urine C. WBC count is 7500 cells/microL D. Antistreptolexin-O (ASO) titer is 106 Todd units/mL

B. Nitrites and leukocyte esterase are present in the urine

While the nurse performs range of motion (ROM) on an unconscious patient with increased ICP, the patient has severe decerebrate posturing reflexes. What should the nurse do first? A. Use restraints to protect the patient from injury while posturing B. Perform the exercises less often because posturing indicates increased ICP C. Administer CNS depressants to lightly sedate the patient D. Continue the exercises because they are necessary to maintain musculoskeletal function

B. Perform the exercises less often because posturing indicates increased ICP

Which information will the nurse monitor in order to determine the effectiveness of prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease? A. Blood pressure B. Phosphate level C. Neurologic status D. Creatinine clearance

B. Phosphate level

A patient with a head injury has bloody drainage from the ear. What should the nurse do to determine if CSF is present in the drainage? A. Examine the tympanic membrane for a tear B. Test the fluid for a halo sign on a white dressing C. Test the fluid with a glucose-identifying strip or stick D. Collect 5 mL of fluid in a test tube and send it to the laboratory for analysis

B. Test the fluid for a halo sign on a white dressing

A patient with sickle cell anemia asks the nurse why the sickling crisis does not stop when oxygen therapy is started. Which explanation should the nurse give to the patient? A. Sickling occurs in response to decreased blood viscosity, which is not affected by oxygen therapy B. When RBCs sickle, they occlude small vessels, which causes more local hypoxia and more sickling C. The primary problem during a sickle cell crisis is the destruction of the abnormal cells, resulting in fewer RBCs to carry oxygen D. Oxygen therapy does not alter the shape of the abnormal erythrocytes but only allows for increased oxygen concentration in hemoglobin

B. When RBCs sickle, they occlude small vessels, which causes more local hypoxia and more sickling

In teaching the patient with pernicious anemia about the disease, the nurse explains that it results from a lack of A. folic acid B. intrinsic factor C. extrinsic factor D. cobalamin intake

B. intrinsic factor

Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock? A. check temperature every 2 hours B. monitor breath sounds frequently C. maintain patient in supine position D. assess skin for flushing and itching

B. monitor breath sounds frequently

Which of the following are used to determine staging in AKI based on RIFLE classification? A. serum creatinine and BUN B. serum creatinine and urine output C. GFR and BUN D. GFR and cystatin C

B. serum creatinine and urine output (the third is GFR. BUN is not a determinant)

A patient treated with antihypertensive medication is planning to start using meditation to promote relaxation and reduced anxiety. The nurse cautions the patient that A. meditation can be used successfully only if the patient is responsive to suggestion B. the blood pressure should be monitored frequently because the medication might need to be adjusted C. frequent appointments, practice times, and goal setting are necessary for effective use of medication D. meditation can be a good complementary therapy, but medications will always be needed

B. the blood pressure should be monitored frequently because the medication might need to be adjusted

The nurse teaches the female patient with frequent UTIs that she should A. take tub baths with bubble bath B. urinate before and after sexual intercourse C. take prophylactic sulfonamides for the rest of her life D. restrict fluid intake to prevent the need for frequent voiding

B. urinate before and after sexual intercourse

Which is the best indicator that fluid resuscitation for a 90 kg patient with hypovolemic shock has been effective? A. hemoglobin is within normal limits B. urine output is 65 mL over the past hour C. CVP is normal D. MAP is 72

B. urine output is 65 mL over the past hour this is an indicator of end organ perfusion

Which interventions should be used for anaphylactic shock (select all that apply)? A. Antibiotics B. Vasodilators C. Antihistamines D. Oxygen supplementation E. Colloid volume expansion F. Crystalloid volume expansion

C. Antihistamines D. Oxygen supplementation E. Colloid volume expansion F. Crystalloid volume expansion

The RN is planning the client assignments for the day. Which of the following is the most appropriate assignment for the nursing assistant? A. a client requiring a colostomy irrigation B. a client receiving continuous tube feedings C. a client who requires urine specimen collection D. a client with difficulty swallowing food and fluids

C. A client who requires urine specimen collection

Which nursing diagnosis is a priority in the care of a patient with renal calculi? A. Risk for constipation B. Risk for powerlessness C. Acute pain D. Deficient fluid volume

C. Acute pain

The patient has recently experienced a myocardial infarction. Which action by the nurse would help prevent cardiogenic shock? A. Monitor the patient's telemetry B. Turn the patient every two hurs C. Administer oxygen via nasal cannula D. Place the patient in the Trendelenburg position

C. Administer oxygen via nasal cannula

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

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

The nurse observes UAP taking the following actions when caring for a patient with a urethral catheter. Which action requires that the nurse intervene? A. Taping the catheter to the skin on the patient's upper inner thigh B. Cleaning around the patient's urinary meatus with soap and water C. Disconnecting the catheter from the drainage tube to obtain a specimen D. Using an alcohol-based gel hand cleanser before performing catheter care

C. Disconnecting the catheter from the drainage tube to obtain a specimen

When teaching the patient with cancer about chemotherapy, which approach should the nurse take? A. Avoid telling the patient about side effects of the drugs to prevent anticipatory anxiety B. Assure the patient that side effects from chemotherapy are uncomfortable but not life threatening C. Explain that antiemetics, antidiarrheals, and analgesics will be given as needed to control side effects D. Tell the patient that chemotherapy-related alopecia is usually permanent but can be managed with lifelong use of wigs

C. Explain that antiemetics, antidiarrheals, and analgesics will be given as needed to control side effects

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

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

A 55-yr-old patient with end-stage kidney disease (ESKD) is scheduled to receive a prescribed dose of epoetin alfa. Which information should the nurse report to the healthcare provider before giving the medication? A. Creatinine 1.6 B. Oxygen sat 89 C. Hemoglobin 13 D. BP 98/56

C. Hemoglobin 13

The home health nurse teaches a patient with a neurogenic bladder how to use intermittent catheterization for bladder emptying. Which patient statement indicates that the teaching has been effective? A. I will buy seven new catheters weekly and use a new one every day. B. I will use a sterile catheter and gloves for each time I self-catheterize C. I will clean the catheter carefully before and after each catheterization D. I will take prophylactic antibiotics to prevent UTIs

C. I will clean the catheter carefully before and after each catheterization

A patient who is unconscious has ineffective cerebral tissue perfusion and cerebral tissue swelling. Which nursing intervention will be included in the plan of care? A. Encourage coughing and deep breathing B. Position the patient with knees and hips flexed C. Keep HOB elevated to 30 degrees D. Cluster nursing interventions to provide rest periods

C. Keep HOB elevated to 30 degrees

A patient is admitted to the hospital for evaluation and treatment of thrombocytopenia. Which action is most important for the nurse to implement? A. Taking the temperature every 4 hours to assess for fever B. Maintaining the patient on strict bed rest to prevent injury C. Monitoring the patient for headaches, vertigo, or confusion D. Removing the oral crusting and scabs with a soft brush 4 times a day

C. Monitoring the patient for headaches, vertigo, or confusion

A patient is being admitted to the ICU with hypercapnic respiratory failure. Which assessment findings should the nurse expect? Select all that apply. A. Cyanosis B. Metabolic acidosis C. Morning headache D. Respiratory acidosis E. Use of tripod position F. Rapid, shallow respirations

C. Morning headache D. Respiratory acidosis E. Use of tripod position F. Rapid, shallow respirations

A patient is being admitted with a diagnosis of Cushing syndrome. Which findings will the nurse expect during the assessment? A. Chronically low blood pressure B. Bronzed appearance of the skin C. Purplish streaks on the abdomen D. Decreased axillary and pubic hair

C. Purplish streaks on the abdomen

On assessment of the patient with a kidney stone passing down the ureter, what should the nurse expect the patient to report? A. A history of chronic UTIs B. Dull, costovertebral flank pain C. Severe, colicky back pain radiating to the groin D. A feeling of bladder fullness with urgency and frequency

C. Severe, colicky back pain radiating to the groin

The nurse is caring for a patient who has a head injury and fractured right arm. Which assessment information requires rapid action by the nurse? A. The patient reports a headache B. The apical pulse is slightly irregular C. The patient is more difficult to arouse D. The BP increases to 140/62

C. The patient is more difficult to arouse indicator of increased ICP

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

C. The patient reports that the symptoms began with a severe headache could be subarachnoid hemorrhage

The charge nurse observes an inexperienced staff nurse caring for a patient who had a craniotomy. Which action by the nurse requires the charge nurse to intervene? A. The staff nurse assesses neuro status every hour B. The staff nurse elevates HOB to 30 degrees C. The staff nurse suctions the patient routinely every 2 hours D. The staff nurse administers an analgesic before turning the patient

C. The staff nurse suctions the patient routinely every 2 hours suction increases ICP, only do when respiratory condition needs it

The patient has received a bone marrow transplant. Soon after the transplant, there is a rash on the patient's skin. She says her skin is itchy and she has severe abdominal pain. What best summarizes what is happening to the patient and how she will be treated? A. Graft rejection occurring; treat with different immunosuppressive agents B. Dry skin and nausea are side effects of immunosuppressants; decrease the dose C. Transplanted bone marrow is attacking her tissue; prevent with immunosuppressive agents D. Dry skin from the dry air and nausea from the food in the hospital; treat with humidifier and home food

C. Transplanted bone marrow is attacking her tissue; prevent with immunosuppressive agents Graft vs host disease

During change-of-shift report on a medical unit, the nurse learns that a patient with respiratory distress has become increasingly agitated. Which action should the nurse take first? A. Give the prescribed PRN sedative drug B. Offer reassurance and reorient the patient C. Use pulse oximetry to check the patient's oxygen saturation D. Notify the healthcare provider about the patient's status

C. Use pulse oximetry to check the patient's oxygen saturation Agitation may be an early indicator of hypoxemia

While caring for a 77 year old woman who has a urinary catheter, the nurse monitors the patient for the development of a UTI. What clinical manifestations is the patient likely to experience? A. Cloudy urine and fever B. Urethral burning and bloody urine C. Vague abdominal discomfort and disorientation D. Suprapubic pain and slight decline in body temperature

C. Vague abdominal discomfort and disorientation

A patient is admitted to the ED for shock of unknown etiology. The first action by the nurse should be A. obtain the blood pressure B. check the level of orientation C. administer supplemental oxygen D. obtain a 12 lead ECG

C. administer supplemental oxygen

A 46-year-old woman returns to clinic with recurrent dysuria after being treated with trimethoprim and sulfamethoxazole for 3 days. Which action will the nurse plan to take? A. teach the patient to take the prescribed medications for 3 days B. remind the patient about the need to drink 1 liter of fluids a day C. obtain a midstream urine specimen for culture and sensitivity testing D. suggest that the patient use acetaminophen to treat the symptoms

C. obtain a midstream urine specimen for culture and sensitivity testing

The patient with acute respiratory failure has thick secretions that she is having difficulty coughing up. Which intervention would best help mobilize her secretions? A. give more IV fluid B. perform postural drainage C. provide O2 by aerosol mask D. suction nasopharyngeal airways

C. provide O2 by aerosol mask oxygen to help mobilize before attempting to suction thick secretions

Which statement by a patient indicates good understanding of the nurse's teaching about preventing sickle cell crisis? A. "Home oxygen therapy is frequently used to decrease sickling" B. "There are no effective medications that can help prevent sickling" C. "Routine continuous dosage opioids are prescribed to prevent a crisis" D. "Risk for a crisis is decreased by having an annual influenza vaccination.

D. "Risk for a crisis is decreased by having an annual influenza vaccination." infection is most common cause of sickle cell crisis

A patient's wife asks the nurse why her husband did not receive the clot-busting medication tPA she has been reading about. Her husband is diagnosed with a hemorrhagic stroke. What is the best response by the nurse to the patient's wife? A. "He didn't arrive within the time frame for that therapy." B. "Not everyone is eligible for this drug. Has he had surgery lately?" C. "You should discuss the treatment of your husband with his doctor." D. "The medication you are talking about dissolves clots and could cause more bleeding in your husband's brain."

D. "The medication you are talking about dissolves clots and could cause more bleeding in your husband's brain."

Which statement describing SIRS and MODS is accurate? A. MODS may occur independently from SIRS B. All patients with septic shock develop MODs C. The GI system is often the first to show evidence of dysfunction in SIRS and MODS D. A common initial mediator that causes endothelial damage leading to SIRS and MODS is endotoxin

D. A common initial mediator that causes endothelial damage leading to SIRS and MODS is endotoxin

After receiving change-of-shift report on a medical unit, which patient should the nurse assess first? A. A patient with cystic fibrosis who has thick, green-colored sputum B. A patient with pneumonia who has crackles bilaterally in the lung bases C. A patient with emphysema who has an oxygen saturation of 90 to 92 D. A patient with septicemia who has intercostal and suprasternal retractions

D. A patient with septicemia who has intercostal and suprasternal retractions This patient's symptoms suggests the onset of ARDS

A patient is admitted to the hospital with possible bacterial meningitis. During the initial assessment, the nurse questions the patient about a recent history of what? A. Mosquito or tick bites B. Chickenpox or measles C. Cold sores or fever blisters D. An upper respiratory infection

D. An upper respiratory infection

The nurse is caring for a 62 year-old man after a transurethral resection of the prostate (TURP). Which instructions should the nurse include in the teaching plan? A. Restrict fluids to prevent incontinence B. Prostate exams are not needed after surgery C. Sexual functioning will not be affected D. Avoid straining during defecation

D. Avoid straining during defecation

Which diagnostic test would the nurse anticipate scheduling for the patient experiencing recurrent infections from a suspected urinary tract obstruction? A. sensitivity testing B. dipstick urinalysis C. clean-catch urine sample D. CT scan

D. CT scan

The nurse should know that which diagnostic study will be most indicative of chronic kidney disease (CKD) in this patient? A. Serum creatinine B. Serum potassium C. Microalbuminuria D. Calculated glomerular filtration rate (GFR)

D. Calculated glomerular filtration rate (GFR)

Before the patient receives a kidney transplant, a crossmatch is ordered. What does a positive crossmatch indicate? A. Paternity and predicts risk for certain diseases B. Tissue type match for a successful transplantation C. Racial background and predicts risk for certain diseases D. Cytotoxic antibodies to the donor, which contraindicate transplanting this donor's organ

D. Cytotoxic antibodies to the donor, which contraindicate transplanting this donor's organ

What is the most appropriate snack for the nurse to offer a patient with stage 4 CKD? A. Raisins B. Ice cream C. Dill pickles D. Hard candy

D. Hard candy

Which assessment finding is most important for the nurse to obtain when evaluating whether treatment of a patient with anaphylactic shock has been effective? A. Heart rate B. Orientation C. Blood pressure D. Oxygen saturation

D. Oxygen saturation

What indicates to the nurse that a patient with oliguria has prerenal oliguria? A. Urine testing reveals a low specific gravity B. Causative factor is malignant hypertension B. Urine testing reveals a high sodium concentration D. Reversal of oliguria occurs with fluid replacement

D. Reversal of oliguria occurs with fluid replacement

What are the most common immunosuppressive agents initially used to prevent rejection of transplanted organs? A. Cyclosporine, sirolimus,and muromonab-CD3 B. Prednisone, polyclonal antibodies, and cyclosporine C. Azathioprine, mycophenolate mofetil, and sirolimus D. Tacrolimus, prednisone, and mycophenolate mofetil

D. Tacrolimus, prednisone, and mycophenolate mofetil

Which assessment finding of a 42-yr-old patient who had a bilateral adrenalectomy requires the most rapid action by the nurse? A. The blood glucose is 192 B. The lungs have bibasilar crackles C. The patient reports 6/10 incisional pain D. The BP is 88/50

D. The BP is 88/50 indicates possible adrenal insufficiency

Which action by a patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD? A. The patient slows the inflow rate when experiencing pain B. The patient leaves the catheter exist site without a dressing C. The patient plans 30 to 60 minutes for a dialysate exchange D. The patient cleans the catheter while taking a bath every day

D. The patient cleans the catheter while taking a bath every day

When assessing an adult who has bacterial meningitis, the nurse obtains the following data. Which finding requires the most immediate intervention? A. The patient exhibits nuchal rigidity B. The patient has a positive Kernig's sign C. The patient's temperature is 101 D. The patient's blood pressure is 88/42

D. The patient's blood pressure is 88/42 Shock is a serious complication of meningitis

Which description accurately describes the care of the patient with CKD? A. Iron is a nutrient that is commonly supplemented for the patient on dialysis because it is dialyzable B. The syndrome that includes all of the signs and symptoms seen in the various body systems in CKD is azotemia C. The use of morphine is contraindicated in the patient with CKD because accumulation of its metabolites may cause seizures D. The use of calcium-based phosphate binders in the patient with CKD is contraindicated when serum calcium levels are increased

D. The use of calcium-based phosphate binders in the patient with CKD is contraindicated when serum calcium levels are increased

What is a nursing intervention that is indicated for the patient during a sickle cell crisis? A. frequent ambulation B. application of antiembolism hose C. restriction of sodium and oral fluids D. administration of large doses of continuous opioid analgesics

D. administration of large doses of continuous opioid analgesics

What indicates to the nurse that a patient with AKI is in the recovery phase? A. a return to normal weight B. a urine output of 3700 mL/day C. decreasing sodium and potassium levels D. decreasing BUN and creatinine levels

D. decreasing BUN and creatinine levels

Metabolic acidosis occurs in the oliguric phase of AKI as a result of the impairment of A. excretion of sodium B. excretion of bicarbonate C. conservation of potassium D. excretion of hydrogen ions

D. excretion of hydrogen ions

Which nursing interventions included in the care of a mechanically ventilated patient with acute respiratory failure can the RN delegate to an experienced LPN in the intensive care unit? A. assess breath sounds every hour B. monitor CVPs C. place patient in the prone position D. insert an indwelling urinary catheter

D. insert an indwelling urinary catheter repositioning is typically able to be delegated but for an intubated patient who requires proning, it's a multiple person job

The ED receives a report that a seriously injured patient involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 5 minutes. In preparation with the patient's arrival, the nurse will obtain A. a dopamine infusion B. a hypothermia blanket C. lactated Ringer's solution D. two 16-gauge IV catheters

D. two 16-gauge IV catheters

The EMTs deliver a patient to the ER who was in an automobile accident. The patient presents with a heart rate of 45 bpm and a temp of 93. During the assessment, the nurse notices the patient doesn't have sensation below T3. What type of shock is the patient experiencing?

Neurogenic shock

Which factors place a patient at risk for experiencing urinary stasis? Select all that apply. Constipation Urinary Retention Diabetes Mellitus Renal Impairment Urinary Tract Calculi

Urinary Retention Renal Impairment Urinary Tract Calculi

What finding indicates nitroprusside has been effective in treating cardiogenic shock?

Warm, pink, and dry skin Indicates perfusion to tissues is improved

Admission vital signs for a brain-injured patient are blood pressure 128/68, pulse 110, and respirations 26. Which set of vital signs, if taken 1 hour after admission, will be of most concern to the nurse? a. Blood pressure 154/68, pulse 56, respirations 12 b. Blood pressure 134/72, pulse 90, respirations 32 c. Blood pressure 148/78, pulse 112, respirations 28 d. Blood pressure 110/70, pulse 120, respirations 30

a. Blood pressure 154/68, pulse 56, respirations 12 Cushing's triad: systolic HTN with widening pulse pressure, bradycardia, respiratory changes

The nurse determines that teaching about pernicious anemia has been effective when the patient says a. "This condition can kill me unless I take injections of the vitamin for the rest of my life" b. "My symptoms can be completely reversed after I take a cobalamin supplement" c. "If my anemia does not respond to cobalamin therapy, my only other alternative is a bone marrow transplant" d. "The least expensive and most convenient treatment of pernicious anemia is to use a diet with foods high in cobalamin"

a. "This condition can kill me unless I take injections of the vitamin for the rest of my life"

What are prerenal causes of acute kidney injury (AKI) (select all that apply)? a. Anaphylaxis b. Renal stones c. Hypovolemia d. Nephrotoxic drugs e. Decreased cardiac output

a. Anaphylaxis c. Hypovolemia e. Decreased cardiac output

Which menu choice indicates that the patient understands the nurse's teaching about best dietary choices for iron-deficiency anemia? a. Omelet and whole wheat toast b. Cantaloupe and cottage cheese c. Strawberry and banana fruit plate d. Cornmeal muffin and orange juice

a. Omelet and whole wheat toast

The patient has a thoracic spinal cord lesion and incontinence that occurs equally during the day and night. What type of incontinence is this patient experiencing? a. Reflex incontinence b. Overflow incontinence c. Functional incontinence d. Incontinence after trauma

a. Reflex incontinence

Ten days after receiving a bone marrow transplant, a patient develops a skin rash. What would the nurse suspect is the cause of this patient's skin rash? a. The donor T cells are attacking the patient's skin cells. b. The patient's antibodies are rejecting the donor bone marrow. c. The patient is experiencing a delayed hypersensitivity reaction. d. The patient will need treatment to prevent hyperacute rejection.

a. The donor T cells are attacking the patient's skin cells. indicate graft vs host disease

When prone positioning is used for a patient with acute respiratory distress syndrome (ARDS), which information obtained by the nurse indicates that the positioning is effective? a. The patient's PaO2 is 89 mm Hg, and the SaO2 is 91%. b. Endotracheal suctioning results in clear mucous return. c. Sputum and blood cultures show no growth after 48 hours. d. The skin on the patient's back is intact and without redness.

a. The patient's PaO2 is 89 mm Hg, and the SaO2 is 91%.

Which events cause increased ICP (select all that apply)? a. Vasodilation b. Necrotic cerebral tissue c. Blood vessel compression d. Edema from initial brain insult e. Brainstem compression and herniation

a. Vasodilation b. Necrotic cerebral tissue d. Edema from initial brain insult

During the acute phase of a stroke, the nurse assesses the patient's vital signs and neurologic status every 4 hours. A cardiovascular sign that the nurse would see as the body attempts to increase cerebral blood flow is a. hypertension b. fluid overload c. cardiac dysrhythmias d. S3 and S4 heart sounds

a. hypertension

During the oliguric phase of AKI, the nurse monitors the patient for (select all that apply): A. hypotension B. ECG changes C. hypernatremia D. pulmonary edema E. urine with high specific gravity

b. ECG changes d. pulmonary edema

What are the key manifestations of bacterial meningitis? a. Papilledema and psychomotor seizures b. High fever, nuchal rigidity, and severe headache c. Behavioral changes with memory loss and lethargy d. Jerky eye movements, loss of corneal reflex, and hemiparesis

b. High fever, nuchal rigidity, and severe headache

The nurse in the dialysis clinic is reviewing the home medications of a patient with chronic kidney disease (CKD). Which medication reported by the patient indicates that patient teaching is required? a. Multivitamin with iron b. Magnesium hydroxide c. Acetaminophen (Tylenol) d. Calcium phosphate (PhosLo)

b. Magnesium hydroxide

A patient in hypercapnic respiratory failure has a nursing diagnosis of impaired airway clearance caused by increasing exhaustion. What is an appropriate nursing intervention for this patient? A. Inserting an oral airway b. Performing augmented coughing C. Teaching the patient huff coughing D. Teaching the patient slow pursed lip breathing

b. Performing augmented coughing

A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first? a. Document the BP and ICP in the patient's record. b. Report the BP and ICP to the health care provider. c. Elevate the head of the patient's bed to 60 degrees. d. Continue to monitor the patient's vital signs and ICP.

b. Report the BP and ICP to the health care provider. CPP is 56, below normal value, approaching level of ischemia and neuronal death

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.

b. Stop the infusion if swelling is observed at the site.

Which information in a patient's history indicates to the nurse that the patient is not an appropriate candidate for kidney transplantation? a. The patient has type 1 diabetes. b. The patient has metastatic lung cancer. c. The patient has a history of chronic hepatitis C infection. d. The patient is infected with human immunodeficiency virus.

b. The patient has metastatic lung cancer.

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

b. The patient's blood pressure (BP) is 90/50 mm Hg. want higher BP level to prevent cerebral vasospasm and maintain cerebral perfusion, all other signs are typical clinical manifestations of a SAH

The nurse is assessing a patient 4 hours after a kidney transplant. Which information is most important to communicate to the health care provider? a. The urine output is 900 to 1100 mL/hr. b. The patient's central venous pressure (CVP) is decreased. c. The patient has a level 7 (0- to 10-point scale) incisional pain. d. The blood urea nitrogen (BUN) and creatinine levels are elevated.

b. The patient's central venous pressure (CVP) is decreased.

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

b. The patient's visitors bring in some fresh peaches from home.

The nurse is titrating the IV fluid infusion rate immediately after a patient has had kidney transplantation. Which parameter will be most important for the nurse to consider? a. Heart rate b. Urine output c. Creatinine clearance d. Blood urea nitrogen (BUN) level

b. Urine output

A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. The nurse will anticipate teaching the patient about a. alteplase (tPA). b. aspirin (Ecotrin). c. warfarin (Coumadin). d. nimodipine (Nimotop).

b. aspirin (Ecotrin). after a TIA, patients are typically started on aspirin to inhibit platelet function and decrease risk

The nurse uses many precautions during IV administration of vesicant chemotherapeutic agents, primarily to prevent a. septicemia b. extravasation c. catheter occlusion d. anaphylactic shock

b. extravasation

A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of a. iron b. folic acid c. cobalamin (vitamin B12) d. ascorbic acid (vitamin C)

b. folic acid

When a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30, the nurse will expect an assessment finding of a. persistent skin tenting b. rapid, deep respirations. c. bounding peripheral pulses. d. hot, flushed face and neck.

b. rapid, deep respirations. patient has metabolic acidosis - Kussmaul respirations to try to compensate

When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, the nurse reports the response as a. flexion withdrawal. b. localization of pain. c. decorticate posturing. d. decerebrate posturing.

c. decorticate posturing.

A 38-yr-old patient who had a kidney transplant 8 years ago is receiving the immunosuppressants tacrolimus (Prograf), cyclosporine (Sandimmune), and prednisone. Which assessment data will be of most concern to the nurse? a. Skin is thin and fragile. b. Blood pressure is 150/92. c. A nontender axillary lump. d. Blood glucose is 144 mg/dL.

c. A nontender axillary lump.

Which instruction will the nurse plan to include in discharge teaching for the patient admitted with a sickle cell crisis? a. Take a daily multivitamin with iron. b. Limit fluids to 2 to 3 quarts per day. c. Avoid exposure to crowds when possible. d. Drink only two caffeinated beverages daily.

c. Avoid exposure to crowds when possible. crowds increase infection risk

A 52 year old patient has a new diagnosis of pernicious anemia. The nurse determines that the patient understands the teaching about the disorder when the patient states a. I need to start eating more red meat and liver b. I will stop having a glass of wine with dinner c. I could choose nasal spray rather than injections of vitamin B12 d. I will need to take a proton pump inhibitor such as omeprazole

c. I could choose nasal spray rather than injections of vitamin B12

Which assessment finding may indicate that a patient is experiencing adverse effects to a corticosteroid prescribed after kidney transplantation? a. Postural hypotension b. Recurrent tachycardia c. Knee and hip joint pain d. Increased serum creatinine

c. Knee and hip joint pain

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

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

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

c. Poached eggs, whole-wheat toast, and apple juice

After the insertion of an arteriovenous graft (AVG) in the right forearm, a 54-year-old patient complains of pain and coldness of the right fingers. Which action should the nurse take? a. Teach the patient about normal AVG function. b. Remind the patient to take a daily low-dose aspirin tablet. c. Report the patient's symptoms to the health care provider. d. Elevate the patient's arm on pillows to above the heart level.

c. Report the patient's symptoms to the health care provider.

A nurse has obtained donor tissue typing information about a patient who is waiting for a kidney transplant. Which results should be reported to the transplant surgeon? a. Patient is Rh positive and donor is Rh negative b. Six antigen matches are present in HLA typing c. Results of patient-donor cross matching are positive d. Panel of reactive antibodies (PRA) percentage is low

c. Results of patient-donor cross matching are positive positive crossmatching is an absolute contraindication to kidney transplant - hyperacute rejection will occur

Following rectal surgery, a patient voids about 50 mL of urine every 30 to 60 minutes for the first 4 hours. Which nursing action is most appropriate? a. Monitor the patient's intake and output over night. b. Have the patient drink small amounts of fluid frequently. c. Use an ultrasound scanner to check the postvoiding residual volume. d. Reassure the patient that this is normal after rectal surgery because of anesthesia.

c. Use an ultrasound scanner to check the postvoiding residual volume. Symptoms indicate overflow incontinence

The nurse recognizes the presence of Cushing's triad in the patient with a. Increased pulse, irregular respiration, increased BP b. decreased pulse, irregular respiration, increased pulse pressure c. increased pulse, decreased respiration, increased pulse pressure d. decreased pulse, increased respiration, decreased systolic BP

c. increased pulse, decreased respiration, increased pulse pressure

After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first? a. A 20-year-old patient whose cranial x-ray shows a linear skull fracture b. A 30-year-old patient who has an initial Glasgow Coma Scale score of 13 c. A 40-year-old patient who lost consciousness for a few seconds after a fall d. A 50-year-old patient whose right pupil is 10 mm and unresponsive to light

d. A 50-year-old patient whose right pupil is 10 mm and unresponsive to light may indicate intracerebral hemorrhage and increased ICP

A patient being admitted with bacterial meningitis has a temperature of 102.5° F (39.2° C) and a severe headache. Which order for collaborative intervention should the nurse implement first? a. Administer ceftizoxime (Cefizox) 1 g IV. b. Give acetaminophen (Tylenol) 650 mg PO. c. Use a cooling blanket to lower temperature. d. Swab the nasopharyngeal mucosa for cultures.

d. Swab the nasopharyngeal mucosa for cultures. cultures before ABX

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

d. Administer a labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg. elevated BP may be protective response to maintain cerebral perfusion

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

d. Hospitalization will be required for several weeks after the stem cell transplant procedure is performed.

When the nurse educator is evaluating the skills of a new registered nurse (RN) caring for patients experiencing shock, which action by the new RN indicates a need for more education? a. Placing the pulse oximeter on the ear for a patient with septic shock b. Keeping the head of the bed flat for a patient with hypovolemic shock c. Increasing the nitroprusside (Nipride) infusion rate for a patient with a high SVR d. Maintaining a cool room temperature for the patient with neurogenic shock

d. Maintaining a cool room temperature for the patient with neurogenic shock Pts with neurogenic shock have poikilothermia so the temperature should be kept warm to avoid hypothermia

What are intrarenal causes of acute kidney injury (AKI) (select all that apply)? a. Anaphylaxis b. Renal stones c. Bladder cancer d. Nephrotoxic drugs e. Acute glomerulonephritis f. Tubular obstruction by myoglobin

d. Nephrotoxic drugs e. Acute glomerulonephritis f. Tubular obstruction by myoglobin

After receiving change-of-shift report, which patient should the nurse assess first? a. Patient who is scheduled for the drain phase of a peritoneal dialysis exchange b. Patient with stage 4 chronic kidney disease who has an elevated phosphate level c. Patient with stage 5 chronic kidney disease who has a potassium level of 3.4 mEq/L d. Patient who has just returned from having hemodialysis and has a heart rate of 124/min

d. Patient who has just returned from having hemodialysis and has a heart rate of 124/min Tachycardia suggests pt may be bleeding or excessively hypovolemic

While caring for the patient in the oliguric phase of AKI, the nurse monitors the patient for associated collaborative problems. When should the nurse notify the health care provider? a. Urine output is 300 mL/day. b. Edema occurs in the feet, legs, and sacral area. c. Cardiac monitor reveals a depressed T wave and elevated ST segment. d. The patient experiences increasing muscle weakness and abdominal cramping.

d. The patient experiences increasing muscle weakness and abdominal cramping. indicates hyperkalemia

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

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

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 of 30% b. Platelets of 95,000/µL c. Hemoglobin of 10 g/L d. White blood cell (WBC) count of 2700/µL

d. White blood cell (WBC) count of 2700/µL

Which finding by the nurse will be most helpful in determining whether a 67-year-old patient with benign prostatic hyperplasia has an upper urinary tract infection (UTI)? a. Bladder distention b. Foul-smelling urine c. Suprapubic discomfort d. Costovertebral tenderness

d. costovertebral tenderness

The nurse teaches a 64-year-old woman to prevent the recurrence of renal calculi by a. using a filter to strain all urine. b. avoiding dietary sources of calcium. c. choosing diuretic fluids such as coffee. d. drinking 2000 to 3000 mL of fluid a day.

d. drinking 2000 to 3000 mL of fluid a day.

The nurse suspects the presence of an arterial epidural hematoma in the patient who experiences a. failure to regain consciousness following a head injury b. a rapid deterioration of neurologic function within 24 to 48 hours following a head injury c. nonspecific, nonlocalizing progression of alteration in LOC occurring over weeks or months d. unconsciousness at the time of a head injury with a brief period of consciousness followed by a decrease in LOC

d. unconsciousness at the time of a head injury with a brief period of consciousness followed by a decrease in LOC