Sem 3 Final Review

The oncologist ordered external radiation post-surgery for stage 1 NSCLC. What should the nurse include in the teaching? A. Radiation will take 1 week to complete B. Careful skin care to the radiated area will be necessary C. Visitors are restricted until radiation treatment is complete D. Wigs may be used until hair regrows after radiation treatment

B. Careful skin care to the radiated area will be necessary

Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate? a. "I will call my health care provider if my stools turn black." b. "I will take a stool softener if I feel constipated occasionally." c. "I should take the iron with orange juice about an hour before eating." d. "I should increase my fluid and fiber intake while I am taking iron tablets."

ANS: A It is normal for the stools to appear black when a patient is taking iron, and the patient should not call the health care provider about this. The other patient statements are correct.

A woman is 6 weeks pregnant. She has had a previous spontaneous abortion at 14 weeks of gestation and a pregnancy that ended at 38 weeks with the birth of a stillborn girl. What is her gravidity and parity using the GTPAL system?

3-1-0-1-0 Using the GPTAL system, this woman's gravidity and parity information is calculated as follows:G: Total number of times the woman has been pregnant (she is pregnant for the third time) T: Number of pregnancies carried to term (she has one stillborn) P: Number of pregnancies that resulted in a preterm birth (she has none) A: Abortions or miscarriages before the period of viability (she has had one) L: Number of children born who are currently living (she has no living children)

A patient is diagnosed with left side systolic HF. Which are expected findings? A. Echocardiogram shows an ejection fraction of 38% B. Echocardiogram shoes an ejection fraction of 65% C. Echocardiogram shows an ejection fractionof 20% D. Jugular vein distention and ascites

A. Echocardiogram shows an ejection fraction of 38%

Which of the following are NOT a sign and symptom of acute glomerulonephritis (poststreptococcal)? Select all that apply. A. Hypotension B. Increased glomerular filtration rate C. Cola colored urine D. Massive proteinuria E. Elevated BUN and creatinine F. Mild swelling in the face or eyes

A. Hypotension B. Increased glomerular filtration rate D. Massive proteinuria The patient with AGN may experience HYPERtension, (not hypotension), DECREASED GFR (NOT increased), MILD (not massive) proteinuria. Massive proteinuria is a classic sign and symptom in nephrotic syndrome which doesn't present with hematuria.

The patient with chest pain had an ECG done which showed a STEMI. The patient is taken to the cath lab for a PCI. Nurse's responsibility to assess? Select all that apply. A. PT/PTT B. Liver function test C. Creatinine D. Allergies to Iodine/contrast dye

A. PT/PTT C. Creatinine D. Allergies to Iodine/contrast dye

Clinical manifestations of glomerulonephritis includes: (select all that apply) A. Pink/cola colored urine B. Low BP C. Fluid retention D. Decrease protein in urine E. Urine positive for nitrates

A. Pink/cola colored urine C. Fluid retention

A nurse caring for a woman in labor understands that moderate variability of the fetal heart rate might be caused by: a. narcotics. b. barbiturates. c. methamphetamines. d. tranquilizers.

ANS. C methamphetamines. Maternal ingestion of narcotics may be the cause of absent or minimal variability. The use of barbiturates may also result in a significant decrease in variability as these are known to cross the placental barrier. The use of illicit drugs, such as cocaine or methamphetamines, might cause moderate variability. Tranquilizer use is a possible cause of absent or minimal variability in the fetal heart rate.

A woman who has completed one pregnancy with a fetus (or fetuses) reaching the stage of fetal viability is called a: a. primipara. b. primigravida. c. multipara. d. nulligravida.

ANS. A primipara. A primipara is a woman who has completed one pregnancy with a viable fetus. To remember terms, keep in mind that gravida is a pregnant woman; para comes from parity, meaning a viable fetus; primi means first; multi means many; and null means none. A primigravida is a woman pregnant for the first time. A multipara is a woman who has completed two or more pregnancies with a viable fetus. A nulligravida is a woman who has never been pregnant.

Fetal well-being during labor is assessed by: a. the response of the fetal heart rate (FHR) to uterine contractions (UCs). b. maternal pain control. c. accelerations in the FHR. d. an FHR greater than 110 beats/min.

ANS. A the response of the fetal heart rate (FHR) to uterine contractions (UCs). Fetal well-being during labor can be measured by the response of fetal heart rate (FHR) to uterine contractions (UCs). In general, reassuring FHR patterns are characterized by an FHR baseline in the range of 110 to 160 beats/min with no periodic changes, a moderate baseline variability, and accelerations with fetal movement. Maternal pain control is not the measure used to determine fetal well-being in labor. Although FHR accelerations are a reassuring pattern, they are only one component of the criteria by which fetal well-being is assessed. Although an FHR greater than 110 beats/min may be reassuring, it is only one component of the criteria by which fetal well-being is assessed. More information is needed to determine fetal well-being.

Which hematocrit (Hct) and hemoglobin (Hgb) results represent(s) the lowest acceptable values for a woman in the third-trimester of pregnancy? a. 38% Hct; 14 g/dL Hgb b. 35% Hct; 13 g/dL Hgb c. 33% Hct; 11 g/dL Hgb d. 32% Hct; 10.5 g/dL Hgb

ANS. B 35% Hct; 13 g/dL Hgb This is within normal limits in the nonpregnant woman. This is within normal limits for a nonpregnant woman. Represents the lowest acceptable value during the first and the third trimesters. This represents the lowest acceptable value for the second trimester when the hemodilution effect of blood volume expansion is at its peak.

Cardiovascular system changes occur during pregnancy. Which finding would be considered normal for a woman in her second trimester? a. Less audible heart sounds (S1, S2) b. Increased pulse rate c. Increased blood pressure d. Decreased red blood cell (RBC) production

ANS. B Increased pulse rate Splitting of S1 and S2 is more audible. Between 14 and 20 weeks of gestation, the pulse increases about 10 to 15 beats/min, which persists to term. In the first-trimester blood pressure usually remains the same as the prepregnancy level, but it gradually decreases up to about 20 weeks of gestation. During the second trimester both the systolic and diastolic pressures decrease by about 5 to 10 mm Hg. Production of RBCs accelerates during pregnancy.

When assessing the fetal heart rate (FHR) of a woman at 30 weeks of gestation, the nurse counts a rate of 82 beats/min. Initially the nurse should: a. recognize that the rate is within normal limits and record it. b. assess the woman's radial pulse. c. notify the physician. d. allow the woman to hear the heartbeat.

ANS. B assess the woman's radial pulse. The expected fetal heart rate (FHR) is 120 to 160 beats/min. The nurse may have inadvertently counted the uterine souffle, the beat-like sound of blood flowing through the uterine blood vessels, which corresponds to the mother's heartbeat. The physician should be notified if the FHR is confirmed to be 82 beats/min. Allow the woman to hear the heartbeat as soon as a full assessment is made.

When assessing a fetal heart rate (FHR) tracing, the nurse notes a decrease in the baseline rate from 155 to 110. The rate of 110 persists for more than 10 minutes. The nurse could attribute this decrease in baseline to: a. maternal hyperthyroidism. b. initiation of epidural anesthesia that resulted in maternal hypotension. c. maternal infection accompanied by fever. d. alteration in maternal position from semirecumbent to lateral.

ANS. B initiation of epidural anesthesia that resulted in maternal hypotension. Hyperthyroidism would result in baseline tachycardia. Fetal bradycardia is the pattern described and results from the hypoxia that would occur when uteroplacental perfusion is reduced by maternal hypotension. The woman receiving epidural anesthesia needs to be well hydrated before and during induction of the anesthesia to maintain an adequate cardiac output and blood pressure. A maternal fever could cause fetal tachycardia. Assumption of a lateral position enhances placental perfusion and should result in a reassuring fetal heart rate (FHR) pattern.

Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of Pitocin. The woman is in a side-lying position, and her vital signs are stable and fall within a normal range. Contractions are intense, last 90 seconds, and occur every 1½ to 2 minutes. The nurse's IMMEDIATE action would be to: a. change the woman's position. b. stop the Pitocin. c. elevate the woman's legs. d. administer oxygen via a tight mask at 8 to 10 L/min.

ANS. B stop the Pitocin. The woman is already in an appropriate position for uteroplacental perfusion. Late deceleration patterns noted are most likely related to alteration in uteroplacental perfusion associated with the strong contractions described. The immediate action would be to stop the Pitocin infusion since Pitocin is an oxytocic that stimulates the uterus to contract. Elevation of her legs would be appropriate if hypotension were present. Oxygen is appropriate but not the immediate action.

Which statement about acute kidney injury is correct? a. Parenchymal damage occurs in prerenal oliguria. b. Prerenal azotemia results in increased sodium excretion. c. Prerenal oliguria is caused by decreased circulatory volume. d. Prerenal causes of AKI increase the glomerular filtration rate.

ANS. C Prerenal oliguria is caused by a decrease in the circulatory volume due to dehydration and congestive cardiac failure. Parenchymal damage does not occur in prerenal oliguria. Prerenal azotemia results in decreased sodium excretion.

The nurse's priority action when observing early deceleration indicating expected head compression during contractions is to: a. notify the health care provider. b. assist with vaginal examination to assess for cord prolapse. c. change maternal position. d. assist with amnioinfusion.

ANS. C change maternal position. The usual priority is as follows:1. Change maternal position (side to side, knee chest).2. Discontinue oxytocin if infusing.3. Administer oxygen at 8 to 10 L/min by nonrebreather face mask.4. Notify physician or nurse-midwife.5. Assist with vaginal or speculum examination to assess for cord prolapse.6. Assist with amnioinfusion if ordered.7. Assist with birth (vaginal assisted or cesarean) if pattern cannot be corrected

You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly you see the fetal heart rate (FHR) drop from its baseline of 125 down to 80. You reposition the mother, provide oxygen, increase intravenous (IV) fluid, and perform a vaginal examination. The cervix has not changed. Five minutes have passed, and the FHR remains in the 80s. What additional nursing measures should you take? a. Notify nursery nurse of imminent delivery. b. Perform a straight cath at this time. c. Start oxytocin (Pitocin). d. Notify the primary health care provider immediately (HCP).

ANS. D Notify the primary health care provider immediately (HCP). Although delivery is a priority, notification of the nursery nurse is not the most important nursing measure at this time. The patient needs to be evaluated by the HCP immediately to determine whether delivery is warranted at this time. If the FHR were to continue in an abnormal or nonreassuring pattern, a cesarean section may be warranted. Performing a straight cath at this time would not be prudent as it is more likely that a foley catheter will have to be inserted if a cesarean section becomes the mode of delivery. Oxytocin may put additional stress on the fetus. To relieve an FHR deceleration, the nurse can reposition the mother, increase intravenous (IV) fluid, and provide oxygen. Also, if oxytocin is infusing, it should be discontinued. If the FHR does not resolve, the primary health care provider should be notified immediately.

Which finding meets the criteria of a reassuring fetal heart rate (FHR) pattern? a. FHR does not change as a result of fetal activity. b. Average baseline rate ranges between 100 and 140 beats/min. c. Mild late deceleration patterns occur with some contractions. d. Variability averages between 6 and 10 beats/min.

ANS. D Variability averages between 6 and 10 beats/min. Fetal heart rate (FHR) should accelerate with fetal movement. Baseline range for the FHR is 120 to 160 beats/min. Late deceleration patterns are never reassuring, although early and mild variable decelerations are expected, reassuring findings. Variability indicates a well oxygenated fetus with a functioning autonomic nervous system.

In order to reassure and educate pregnant clients about changes in their blood pressure, maternity nurses should be aware that: a. a blood pressure cuff that is too small produces a reading that is too low; a cuff that is too large produces a reading that is too high. b. shifting the client's position and changing from arm to arm for different measurements produces the most accurate composite blood pressure reading at each visit. c. the systolic blood pressure increases slightly as pregnancy advances; the diastolic pressure remains constant. d. compression of the iliac veins and inferior vena cava by the uterus contributes to hemorrhoids in the latter stage of term pregnancy.

ANS. D compression of the iliac veins and inferior vena cava by the uterus contributes to hemorrhoids in the latter stage of term pregnancy. The tightness of a cuff that is too small produces a reading that is too high; similarly, the looseness of a cuff that is too large results in a reading that is too low. Because maternal positioning affects readings, blood pressure measurements should be obtained in the same arm and with the woman in the same position. The systolic blood pressure generally remains constant but may decline slightly as pregnancy advances. The diastolic blood pressure first drops and then gradually increases. This compression also leads to varicose veins in the legs and vulva.

After the nurse gives IV atropine to a patient with symptomatic type 1, second-degree atrioventricular (AV) block, which finding indicates that the drug has been effective? a. Increase in the patient's heart rate b. Increase in strength of peripheral pulses c. Decrease in premature atrial contractions d. Decrease in premature ventricular contractions

ANS: A Atropine will increase the heart rate and conduction through the AV node. Because the drug increases electrical conduction, not cardiac contractility, the quality of the peripheral pulses is not used to evaluate the drug effectiveness. The patient does not have premature atrial or ventricular contractions.

When admitting a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI) to the intensive care unit, which action should the nurse perform first? a. Attach the heart monitor. b. Obtain the blood pressure. c. Assess the peripheral pulses. d. Auscultate the breath sounds.

ANS: A Because dysrhythmias are the most common complication of myocardial infarction (MI), the first action should be to place the patient on a heart monitor. The other actions are also important and should be accomplished as quickly as possible.

The nurse is caring for a patient who was admitted to the coronary care unit following an acute myocardial infarction (AMI) and percutaneous coronary intervention the previous day. Teaching for this patient would include a. when cardiac rehabilitation will begin. b. the typical emotional responses to AMI. c. information regarding discharge medications. d. the pathophysiology of coronary artery disease.

ANS: A Early after an AMI, the patient will want to know when resumption of usual activities can be expected. At this time, the patient's anxiety level or denial will interfere with good understanding of complex information such as the pathophysiology of coronary artery disease. Teaching about discharge medications should be done closer to discharge. The nurse should support the patient by decreasing anxiety rather than discussing the typical emotional responses to myocardial infarction.

A patient who has elevated blood urea nitrogen (BUN) and serum creatinine levels is scheduled for a renal arteriogram. Which bowel preparation order would the nurse question for this patient? a. Fleet enema c. Senna/docusate (Senokot-S) b. Tap-water enema d. Bisacodyl (Dulcolax) tablets

ANS: A High-phosphate enemas, such as Fleet enemas, should be avoided in patients with elevated BUN and creatinine because phosphate cannot be excreted by patients with renal failure. The other medications for bowel evacuation are more appropriate.

The nurse hears a murmur between the S1 and S2 heart sounds at the patient's left fifth intercostal space and midclavicular line. How will the nurse record this information? a. Systolic murmur heard at mitral area b. Systolic murmur heard at Erb's point c. Diastolic murmur heard at aortic area d. Diastolic murmur heard at the point of maximal impulse

ANS: A The S1 signifies the onset of ventricular systole. S2 signifies the onset of diastole. A murmur occurring between these two sounds is a systolic murmur. The mitral area is the intersection of the left fifth intercostal space and the midclavicular line. The other responses describe murmurs heard at different landmarks on the chest and/or during the diastolic phase of the cardiac cycle.

What glomerular filtration rate (GFR) would the nurse estimate for a 30-yr-old patient with a creatinine clearance result of 60 mL/min? a. 60 mL/min c. 120 mL/min b. 90 mL/min d. 180 mL/min

ANS: A The creatinine clearance approximates the GFR. The other responses are not accurate.

The standard policy on the cardiac unit states, "Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg." The nurse will need to call the health care provider about the a. postoperative patient with a BP of 116/42 mm Hg. b. newly admitted patient with a BP of 150/87 mm Hg. c. patient with left ventricular failure who has a BP of 110/70 mm Hg. d. patient with a myocardial infarction who has a BP of 140/86 mm Hg.

ANS: A The mean arterial pressure (MAP) is calculated using the formula MAP = (systolic BP + 2 diastolic BP)/3. The MAP for the postoperative patient in answer 3 is 67. The MAP in the other three patients is higher than 70 mm Hg.

A few days after experiencing a myocardial infarction (MI) and successful percutaneous coronary intervention, the patient states, "It was just a little chest pain. As soon as I get out of here, I'm going for my vacation as planned." Which reply would be most appropriate for the nurse to make? a. "What do you think caused your chest pain?" b. "Where are you planning to go for your vacation?" c. "Sometimes plans need to change after a heart attack." d. "Recovery from a heart attack takes at least a few weeks."

ANS: A When the patient is experiencing denial, the nurse should assist the patient in testing reality until the patient has progressed beyond this step of the emotional adjustment to MI. Asking the patient about vacation plans reinforces the patient's plan, which is not appropriate in the immediate post-MI period. Reminding the patient in denial about the MI is likely to make the patient angry and lead to distrust of the nursing staff.

Which of the nurse's assigned patients should be referred to the dietitian for a complete nutritional assessment (select all that apply)? a. A 48-yr-old patient with rheumatoid arthritis who takes prednisone daily b. A 23-yr-old patient who has a history of fluctuating weight gains and losses c. A 35-yr-old patient who complains of intermittent nausea for the past 2 days d. A 64-yr-old patient who is admitted for débridement of an infected surgical wound e. A 52-yr-old patient admitted with chest pain and possible myocardial infarction (MI)

ANS: A, B, D Weight fluctuations, use of corticosteroids, and draining or infected wounds all suggest that the patient may be at risk for malnutrition. Patients with chest pain or MI are not usually poorly nourished. Although vomiting that lasts 5 days places a patient at risk, nausea that has persisted for 2 days does not always indicate poor nutritional status or risk for health problems caused by poor nutrition.

When auscultating over the patient's abdominal aorta, the nurse hears a loud humming sound. The nurse documents this finding as a a. thrill. b. bruit. c. murmur. d. normal finding.

ANS: B A bruit is the sound created by turbulent blood flow in an artery. Thrills are palpable vibrations felt when there is turbulent blood flow through the heart or in a blood vessel. A murmur is the sound caused by turbulent blood flow through the heart. Auscultating a bruit in an artery is not normal and indicates pathology.

Which nursing action is essential for a patient immediately after a renal biopsy? a. Insert a urinary catheter and test urine for microscopic hematuria. b. Apply a pressure dressing and keep the patient on the affected side. c. Check blood glucose to assess for hyperglycemia or hypoglycemia. d. Monitor blood urea nitrogen (BUN) and creatinine to assess renal function.

ANS: B A pressure dressing is applied, and the patient is kept on the affected side for 30 to 60 minutes to put pressure on the biopsy side and decrease the risk for bleeding. The blood glucose and BUN/creatinine will not be affected by the biopsy. Although monitoring for hematuria is needed, there is no need for catheterization.

A patient who has been receiving IV heparin infusion and oral warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when the platelet level drops to 110,000/μL. 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 (Coumadin). d. Use low-molecular-weight heparin (LMWH).

ANS: B All heparin is discontinued when HIT is diagnosed. The patient should be instructed to never receive heparin or LMWH. Warfarin is usually not given until the platelet count has returned to 150,000/μL. The platelet count does not drop low enough in HIT for a platelet transfusion, and platelet transfusions increase the risk for thrombosis.

The nurse is caring for a patient who has cirrhosis. Which data obtained by the nurse during the assessment will be of most concern? a. The patient complains of right upper-quadrant pain with palpation. b. The patient's hands flap back and forth when the arms are extended. c. The patient has ascites and a 2-kg weight gain from the previous day. d. The patient's abdominal skin has multiple spider-shaped blood vessels.

ANS: B Asterixis indicates that the patient has hepatic encephalopathy, and hepatic coma may occur. The spider angiomas and right upper quadrant abdominal pain are not unusual for the patient with cirrhosis and do not require a change in treatment. The ascites and weight gain indicate the need for treatment but not as urgently as the changes in neurologic status.

How will the nurse assess for flank tenderness in a patient with suspected pyelonephritis? a. Palpate along both sides of the lumbar vertebral column. b. Strike a flat hand covering the costovertebral angle (CVA). c. Push fingers upward into the two lowest intercostal spaces. d. Percuss between the iliac crest and ribs at the midaxillary line.

ANS: B Checking for flank pain is best performed by percussion of the CVA and asking about pain. The other techniques would not assess for flank pain.

The nurse identifies the nursing diagnosis of decreased cardiac output related to valvular insufficiency for the patient with infective endocarditis (IE) based on which assessment finding(s)? a. Fever, chills, and diaphoresis b. Urine output less than 30 mL/hr c. Petechiae on the inside of the mouth and conjunctiva d. Increase in heart rate of 15 beats/minute with walking

ANS: B Decreased renal perfusion caused by inadequate cardiac output will lead to decreased urine output. Petechiae, fever, chills, and diaphoresis are symptoms of IE but are not caused by decreased cardiac output. An increase in pulse rate of 15 beats/min is normal with exercise.

Which action should the nurse take to evaluate treatment effectiveness for a patient who has hepatic encephalopathy? a. Request that the patient stand on one foot. b. Ask the patient to extend both arms forward. c. Request that the patient walk with eyes closed. d. Ask the patient to perform the Valsalva maneuver.

ANS: B Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic encephalopathy. The other tests might also be done as part of the neurologic assessment but would not be diagnostic for hepatic encephalopathy.

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."

ANS: B Fatigue can be a dose-limiting toxicity for use of immunotherapy. Flulike symptoms, such as muscle aches and chills, are common side effects with interferon use. Patients are advised to use acetaminophen every 4 hours.

The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia. The nurse will plan to check the laboratory results for the a. Schilling test. c. gastric analysis. b. bilirubin level. d. stool occult blood.

ANS: B Jaundice is caused by the elevation of bilirubin level associated with red blood cell hemolysis. The other tests would not be helpful in monitoring or treating a hemolytic anemia.

The nurse suspects that the patient with stable angina is experiencing a side effect of the prescribed drug metoprolol (Lopressor) if the a. patient is restless and agitated. b. blood pressure is 90/54 mm Hg. c. patient complains about feeling anxious. d. heart monitor shows normal sinus rhythm.

ANS: B Patients taking b-adrenergic blockers should be monitored for hypotension and bradycardia. Because this class of medication inhibits the sympathetic nervous system, restlessness, agitation, hypertension, and anxiety will not be side effects. Normal sinus rhythm is a normal and expected heart rhythm.

After the nurse teaches the patient about the use of carvedilol (Coreg) in preventing anginal episodes, which statement by a patient indicates that the teaching has been effective? a. "Carvedilol will help my heart muscle work harder." b. "It is important not to suddenly stop taking the carvedilol." c. "I can expect to feel short of breath when taking carvedilol." d. "Carvedilol will increase the blood flow to my heart muscle."

ANS: B Patients who have been taking b-adrenergic blockers can develop intense and frequent angina if the medication is suddenly discontinued. Carvedilol (Coreg) decreases myocardial contractility. Shortness of breath that occurs when taking b-adrenergic blockers for angina may be due to bronchospasm and should be reported to the health care provider. Carvedilol works by decreasing myocardial O2 demand, not by increasing blood flow to the coronary arteries.

A young adult who has von Willebrand disease is admitted to the hospital for minor knee surgery. The nurse will review the coagulation survey to check the a. platelet count. c. thrombin time. b. bleeding time. d. prothrombin time.

ANS: B The bleeding time is affected by von Willebrand disease. Platelet count, prothrombin time, and thrombin time are normal in von Willebrand disease.

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. Omit fruits or vegetables from the diet. d. Place a "No Visitors" sign on the door.

ANS: B The earliest sign of infection in a neutropenic patient is an elevation in temperature. Although unpeeled fresh fruits and vegetables should be avoided, fruits and vegetables that are peeled or cooked are acceptable. Injections may be required for administration of medications such as filgrastim (Neupogen). The number of visitors may be limited and visitors with communicable diseases should be avoided, but a "no visitors" policy is not needed.

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.

ANS: B The incisional redness and warmth are indicators of the normal initial (inflammatory) stage of wound healing by primary intention. The nurse should document the wound appearance and continue to monitor the wound. Notification of the health care provider, assessment every 2 hours, and obtaining wound cultures are not indicated because the healing is progressing normally.

A patient is being treated for bleeding esophageal varices with balloon tamponade. Which nursing action will be included in the plan of care? a. Instruct the patient to cough every hour. b. Monitor the patient for shortness of breath. c. Verify the position of the balloon every 4 hours. d. Deflate the gastric balloon if the patient reports nausea.

ANS: B The most common complication of balloon tamponade is aspiration pneumonia. In addition, if the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway. Coughing increases the pressure on the varices and increases the risk for bleeding. Balloon position is verified after insertion and does not require further verification. Balloons may be deflated briefly every 8 to 12 hours to avoid tissue necrosis, but if only the gastric balloon is deflated, the esophageal balloon may occlude the airway. Balloons are not deflated for nausea.

Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute shortness of breath has heart failure? a. Serum troponin b. Arterial blood gases c. B-type natriuretic peptide d. 12-lead electrocardiogram

ANS: C B-type natriuretic peptide (BNP) is secreted when ventricular pressures increase, as they do with heart failure. Elevated BNP indicates a probable or very probable diagnosis of heart failure. A 12-lead electrocardiogram, arterial blood gases, and troponin may also be used in determining the causes or effects of heart failure but are not as clearly diagnostic of heart failure as BNP.

A patient who has acute myelogenous leukemia develops an absolute neutrophil count of 850/μL while receiving outpatient chemotherapy. Which action by the outpatient clinic nurse is most appropriate? a. Discuss the need for hospital admission to treat the neutropenia. b. Teach the patient to administer filgrastim (Neupogen) injections. c. Plan to discontinue the chemotherapy until the neutropenia resolves. d. Order a high-efficiency particulate air (HEPA) filter for the patient's home.

ANS: B The patient may be taught to self-administer filgrastim injections. Although chemotherapy may be stopped with severe neutropenia (neutrophil count <500/μL), administration of filgrastim usually allows the chemotherapy to continue. Patients with neutropenia are at higher risk for infection when exposed to other patients in the hospital. HEPA filters are expensive and are used in the hospital, where the number of pathogens is much higher than in the patient's home environment.

A patient has a body mass index (BMI) of 31 kg/m2, a normal C-reactive protein level, and low serum transferrin and albumin levels. The nurse will plan patient teaching to increase the patient's intake of foods that are high in a. iron. b. protein. c. calories. d. carbohydrate.

ANS: B The patient's C-reactive protein and transferrin levels indicate low protein stores. The BMI is in the obese range, so increasing caloric intake is not indicated. The data do not indicate a need for increased carbohydrate or iron intake.

A patient's heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious, apneic, and pulseless. Which action should the nurse take first? a. Give epinephrine (Adrenalin) IV. b. Perform immediate defibrillation. c. Prepare for endotracheal intubation. d. Ventilate with a bag-valve-mask device.

ANS: B The patient's rhythm and assessment indicate ventricular fibrillation and cardiac arrest; the initial action should be to defibrillate. If a defibrillator is not immediately available or is unsuccessful in converting the patient to a better rhythm, begin chest compressions. The other actions may also be appropriate but not first.

A female patient with a suspected urinary tract infection (UTI) is to provide a clean-catch urine specimen for culture and sensitivity testing. To obtain the specimen, the nurse will a. have the patient empty the bladder completely; then obtain the next urine specimen that the patient is able to void. b. teach the patient to clean the urethral area, void a small amount into the toilet, and then void into a sterile specimen cup. c. insert a short sterile "mini" catheter attached to a collecting container into the urethra and bladder to obtain the specimen. d. clean the area around the meatus with a povidone-iodine (Betadine) swab and then have the patient void into a sterile container.

ANS: B This answer describes the technique for obtaining a clean-catch specimen. The answer beginning, "insert a short, small, 'mini' catheter attached to a collecting container" describes a technique that would result in a sterile specimen, but a health care provider's order for a catheterized specimen would be required. Using Betadine before obtaining the specimen is not necessary and might result in suppressing the growth of some bacteria. The technique described in the answer beginning "have the patient empty the bladder completely" would not result in a sterile specimen.

Which action should the nurse perform when preparing a patient with supraventricular tachycardia for cardioversion who is alert and has a blood pressure of 110/66 mm Hg? a. Turn the synchronizer switch to the "off" position. b. Give a sedative before cardioversion is implemented. c. Set the defibrillator/cardioverter energy to 360 joules. d. Provide assisted ventilations with a bag-valve-mask device.

ANS: B When a patient has a nonemergency cardioversion, sedation is used just before the procedure. The synchronizer switch is turned "on" for cardioversion. The initial level of joules for cardioversion is low (e.g., 50). Assisted ventilations are not indicated for this patient.

A patient admitted with an abrupt onset of jaundice and nausea has abnormal liver function studies but serologic testing is negative for viral causes of hepatitis. Which question by the nurse is appropriate? a. "Do you have a history of IV drug use?" b. "Do you use any over-the-counter drugs?" c. "Have you used corticosteroids for any reason?" d. "Have you recently traveled to a foreign country?"

ANS: B The patient's symptoms, lack of antibodies for hepatitis, and the abrupt onset of symptoms suggest toxic hepatitis, which can be caused by commonly used over-the-counter drugs such as acetaminophen (Tylenol). Travel to a foreign country and a history of IV drug use are risk factors for viral hepatitis. Corticosteroid use does not cause the symptoms listed.

To detect possible complications in a patient with severe cirrhosis who has bleeding esophageal varices, it is most important for the nurse to monitor a. bilirubin levels. b. ammonia levels. c. potassium levels. d. prothrombin time.

ANS: B The protein in the blood in the gastrointestinal tract will be absorbed and may result in an increase in the ammonia level because the liver cannot metabolize protein very well. The prothrombin time, bilirubin, and potassium levels should also be monitored, but they will not be affected by the bleeding episode.

A patient is scheduled for a cardiac catheterization with coronary angiography. Before the test, the nurse informs the patient that a. it will be important not to move at all during the procedure. b. monitored anesthesia care will be provided during the procedure. c. a flushed feeling may be noticed when the contrast dye is injected. d. arterial pressure monitoring will be required for 24 hours after the test.

ANS: C A sensation of warmth or flushing is common when the contrast material is injected, which can be anxiety producing unless it has been discussed with the patient. The patient may receive a sedative drug before the procedure, but monitored anesthesia care is not used. Arterial pressure monitoring is not routinely used after the procedure to monitor blood pressure. The patient is not immobile during cardiac catheterization and may be asked to cough or take deep breaths.

Which laboratory test result will the nurse monitor when evaluating the effects of therapy for a patient who has acute pancreatitis? a. Calcium b. Bilirubin c. Amylase d. Potassium

ANS: C Amylase is elevated in acute pancreatitis. Although changes in the other values may occur, they would not be useful in evaluating whether the prescribed therapies have been effective.

A patient who is on the telemetry unit develops atrial flutter, rate 150, with associated dyspnea and chest pain. Which action that is included in the hospital dysrhythmia protocol should the nurse do first? a. Obtain a 12-lead electrocardiogram (ECG). b. Notify the health care provider of the change in rhythm. c. Give supplemental O2 at 2 to 3 L/min via nasal cannula. d. Assess the patient's vital signs including O2 saturation.

ANS: C Because this patient has dyspnea and chest pain in association with the new rhythm, the nurse's initial actions should be to address the patient's airway, breathing, and circulation (ABC) by starting with O2 administration. The other actions are also important and should be implemented rapidly.

A patient with heart failure has a new order for captopril 12.5 mg PO. After giving the first dose and teaching the patient about the drug, which statement by the patient indicates that teaching has been effective? a. "I will be sure to take the medication with food." b. "I will need to eat more potassium-rich foods in my diet." c. "I will call for help when I need to get up to use the bathroom." d. "I will expect to feel more short of breath for the next few days."

ANS: C Captopril can cause hypotension, especially after the initial dose, so it is important that the patient not get up out of bed without assistance until the nurse has had a chance to evaluate the effect of the first dose. The angiotensin-converting enzyme (ACE) inhibitors are potassium sparing, and the nurse should not teach the patient to purposely increase sources of dietary potassium. Increased shortness of breath is expected with the initiation of b-adrenergic blocker therapy for heart failure, not for ACE inhibitor therapy. ACE inhibitors are best absorbed when taken an hour before eating.

Which information about a patient who has been receiving thrombolytic therapy for an acute myocardial infarction is most important for the nurse to communicate to the health care provider? a. An increase in troponin levels from baseline b. A large bruise at the patient's IV insertion site c. No change in the patient's reported level of chest pain d. A decrease in ST-segment elevation on the electrocardiogram

ANS: C Continued chest pain suggests that the thrombolytic therapy is not effective and that other interventions such as percutaneous coronary intervention may be needed. Bruising is a possible side effect of thrombolytic therapy, but it is not an indication that therapy should be discontinued. The decrease of the ST-segment elevation indicates that thrombolysis is occurring and perfusion is returning to the injured myocardium. An increase in troponin levels is expected with reperfusion and is related to the washout of cardiac biomarkers into the circulation as the blocked vessel is opened.

A 76-yr-old woman with a body mass index (BMI) of 17 kg/m2 and a low serum albumin level is being admitted by the nurse. Which assessment finding will the nurse expect to find? a. Restlessness c. Pitting edema b. Hypertension d. Food allergies

ANS: C Edema occurs when serum albumin levels and plasma oncotic pressure decrease. The blood pressure and level of consciousness are not directly affected by malnutrition. Food allergies are not an indicator of nutritional status.

A young adult patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8° F (38.7° C) The patient reports having no 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 (Tylenol) prescribed PRN for pain.

ANS: C Mild to moderate temperature elevations (<103° F) do not harm young adult patients and may benefit host defense mechanisms. The nurse should continue to monitor the temperature. Antipyretics are not indicated unless the patient is complaining of fever-related symptoms, and the patient does not require analgesics if not reporting discomfort. There is no need to notify the patient's health care provider or to use a cooling blanket for a moderate temperature elevation.

Which information from a patient's urinalysis requires that the nurse notify the health care provider? a. pH 6.2 b. Trace protein c. WBC 20 to 26/hpf d. Specific gravity 1.021

ANS: C The increased number of white blood cells (WBCs) indicates the presence of urinary tract infection or inflammation. The other findings are normal.

When assessing a new patient at the outpatient clinic, the nurse notes dry, scaly skin; thin hair; and thick, brittle nails. What is the nurse's most important action? a. Instruct the patient about the importance of nutrition for skin health. b. Make a referral to a podiatrist so that the nails can be safely trimmed. c. Consult with the health care provider about the need for further diagnostic testing. d. Teach the patient about using moisturizing creams and lotions to decrease dry skin.

ANS: C The patient has clinical manifestations that could be caused by systemic problems such as malnutrition or hypothyroidism, so further diagnostic evaluation is indicated. Patient teaching about nutrition, addressing the patient's dry skin, and referral to a podiatrist may also be needed, but the priority is to rule out underlying disease that may be causing these manifestations.

To prepare a patient with ascites for paracentesis, the nurse a. places the patient on NPO status. b. assists the patient to lie flat in bed. c. asks the patient to empty the bladder. d. positions the patient on the right side.

ANS: C The patient should empty the bladder to decrease the risk of bladder perforation during the procedure. The patient would be positioned in Fowler's position and would not be able to lie flat without compromising breathing. Because no sedation is required for paracentesis, the patient does not need to be NPO.

A transesophageal echocardiogram (TEE) is ordered for a patient with possible endocarditis. Which action included in the standard TEE orders will the nurse need to accomplish first? a. Start an IV line. b. Start O2 per nasal cannula. c. Place the patient on NPO status. d. Give lorazepam (Ativan) 1 mg IV.

ANS: C The patient will need to be NPO for 6 hours preceding the TEE, so the nurse should place the patient on NPO status as soon as the order is received. The other actions also will need to be accomplished but not until just before or during the procedure.

A patient recovering from a myocardial infarction (MI) develops chest pain on day 3 that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take as focused follow-up on this symptom? a. Assess the feet for pedal edema. b. Palpate the radial pulses bilaterally. c. Auscultate for a pericardial friction rub. d. Check the heart monitor for dysrhythmias.

ANS: C The patient's symptoms are consistent with the development of pericarditis, a possible complication of MI. The other assessments listed are not consistent with the description of the patient's symptoms.

A patient with diabetes mellitus and chronic stable angina has a new order for captopril . The nurse should teach the patient that the primary purpose of captopril is to a. decrease the heart rate. b. control blood glucose levels. c. prevent changes in heart muscle. d. reduce the frequency of chest pain.

ANS: C The purpose for angiotensin-converting enzyme (ACE) inhibitors in patients with chronic stable angina who are at high risk for a cardiac event is to decrease ventricular remodeling. ACE inhibitors do not directly impact angina frequency, blood glucose, or heart rate.

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."

ANS: C The risk of recurrence varies by the type of cancer. Some cancers are considered cured after a shorter time span or after surgery, but stage III breast cancer will require additional therapies and ongoing follow-up.

Diltiazem (Cardizem) is ordered for a patient with newly diagnosed Prinzmetal's (variant) angina. When teaching the patient, the nurse will include the information that diltiazem will a. reduce heart palpitations. b. prevent coronary artery plaque. c. decrease coronary artery spasms. d. increase contractile force of the heart.

ANS: C Prinzmetal's angina is caused by coronary artery spasm. Calcium channel blockers (e.g., diltiazem, amlodipine [Norvasc]) are a first-line therapy for this type of angina. Lipid-lowering drugs help reduce atherosclerosis (i.e., plaque formation), and b-adrenergic blockers decrease sympathetic stimulation of the heart (i.e., palpitations). Medications or activities that increase myocardial contractility will increase the incidence of angina by increasing O2 demand.

Which electrocardiographic (ECG) change is most important for the nurse to report to the health care provider when caring for a patient with chest pain? a. Inverted P wave b. Sinus tachycardia c. ST-segment elevation d. First-degree atrioventricular block

ANS: C The patient is likely to be experiencing an ST-segment-elevation myocardial infarction. Immediate therapy with percutaneous coronary intervention or thrombolytic medication is indicated to minimize myocardial damage. The other ECG changes may also suggest a need for therapy but not as rapidly.

The nurse assessing the urinary system of a 45-yr-old patient would use palpation to a. determine kidney function. c. check for ureteral peristalsis. b. identify renal artery bruits. d. assess for bladder distention.

ANS: D A distended bladder may be palpable above the symphysis pubis. Palpation would not be helpful in assessing for the other listed urinary tract information.

A patient who has just been admitted with pulmonary edema is scheduled to receive the following medications. Which medication should the nurse question before giving? a. captopril 25 mg b. furosemide (Lasix) 60 mg c. digoxin (Lanoxin) 0.125 mg d. carvedilol (Coreg) 3.125 mg

ANS: D Although carvedilol is appropriate for the treatment of chronic heart failure, it is not used for patients with acute decompensated heart failure (ADHF) because of the risk of worsening the heart failure. The other drugs are appropriate for the patient with ADHF.

A hospitalized patient with possible renal insufficiency after coronary artery bypass surgery is scheduled for a creatinine clearance test. Which item will the nurse need to obtain? a. Urinary catheter b. Sterile specimen cup c. Cleansing towelettes d. Large urine container

ANS: D Because creatinine clearance testing involves a 24-hour urine specimen, the nurse should obtain a large container for the urine collection. Catheterization, cleaning of the perineum with antiseptic towelettes, and a sterile specimen cup are not needed for this test.

Which information from a patient helps the nurse confirm the previous diagnosis of chronic stable angina? a. "The pain wakes me up at night." b. "The pain is level 3 to 5 (0 to 10 scale)." c. "The pain has gotten worse over the last week." d. "The pain goes away after a nitroglycerin tablet."

ANS: D Chronic stable angina is typically relieved by rest or nitroglycerin administration. The level of pain is not a consistent indicator of the type of angina. Pain occurring at rest or with increased frequency is typical of unstable angina.

A young adult who is employed as a hairdresser and has a 15 pack-year history of cigarette smoking is scheduled for an annual physical examination. The nurse will plan to teach the patient about the increased risk for a. renal failure. b. kidney stones. c. pyelonephritis. d. bladder cancer.

ANS: D Exposure to the chemicals involved with working as a hairdresser and in smoking both increase the risk of bladder cancer, and the nurse should assess whether the patient understands this risk. The patient is not at increased risk for renal failure, pyelonephritis, or kidney stones.

Which laboratory test will the nurse use to determine whether filgrastim (Neupogen) is effective for a patient with acute lymphocytic leukemia who is receiving chemotherapy? a. Platelet count c. Total lymphocyte count b. Reticulocyte count d. Absolute neutrophil count

ANS: D Filgrastim increases the neutrophil count and function in neutropenic patients. Although total lymphocyte, platelet, and reticulocyte counts are also important to monitor in this patient, the absolute neutrophil count is used to evaluate the effects of filgrastim.

When working in the urology/nephrology clinic, which patient could the nurse delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Patient who is scheduled for a renal biopsy after a recent kidney transplant b. Patient who will need monitoring for several hours after a renal arteriogram c. Patient who requires teaching about possible post-cystoscopy complications d. Patient who will have catheterization to check for residual urine after voiding

ANS: D LPN/LVN education includes common procedures such as catheterization of stable patients. The other patients require more complex assessments or patient teaching that are included in registered nurse (RN) education and scope of practice.

Which laboratory result will the nurse expect to show a decreased value if a patient develops heparin-induced thrombocytopenia (HIT)? a. Prothrombin time b. Erythrocyte count c. Fibrinogen degradation products d. Activated partial thromboplastin time

ANS: D Platelet aggregation in HIT causes neutralization of heparin, so the activated partial thromboplastin time will be shorter, and more heparin will be needed to maintain therapeutic levels. The other data will not be affected by HIT.

A 74-yr-old patient has just arrived in the emergency department. After assessment reveals a pulse deficit of 46 beats, the nurse will anticipate that the patient may require a. emergent cardioversion. b. a cardiac catheterization. c. hourly blood pressure (BP) checks. d. electrocardiographic (ECG) monitoring.

ANS: D Pulse deficit is a difference between simultaneously obtained apical and radial pulses. It indicates that there may be a cardiac dysrhythmia that would best be detected with ECG monitoring. Frequent BP monitoring, cardiac catheterization, and emergent cardioversion are used for diagnosis and/or treatment of cardiovascular disorders but would not be as helpful in determining the immediate reason for the pulse deficit.

A serum potassium level of 3.2 mEq/L (3.2 mmol/L) is reported for a patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix) due. Which action should the nurse take? a. Withhold both drugs. b. Administer both drugs c. Administer the furosemide. d. Administer the spironolactone.

ANS: D Spironolactone is a potassium-sparing diuretic and will help increase the patient's potassium level. The nurse does not need to talk with the doctor before giving the spironolactone, although the health care provider should be notified about the low potassium value. The furosemide will further decrease the patient's potassium level and should be held until the nurse talks with the health care provider.

To determine whether there is a delay in impulse conduction through the ventricles, the nurse will measure the duration of the patient's a. P wave. b. Q wave. c. PR interval. d. QRS complex.

ANS: D The QRS complex represents ventricular depolarization. The P wave represents the depolarization of the atria. The PR interval represents depolarization of the atria, atrioventricular node, bundle of His, bundle branches, and the Purkinje fibers. The Q wave is the first negative deflection following the P wave and should be narrow and short.

The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, PR interval not measurable, ventricular rate of 162, R-R interval regular, and QRS complex wide and distorted, and QRS duration of 0.18 second. The nurse interprets the patient's cardiac rhythm as a. atrial flutter. b. sinus tachycardia. c. ventricular fibrillation. d. ventricular tachycardia.

ANS: D The absence of P waves, wide QRS, rate greater than 150 beats/min, and the regularity of the rhythm indicate ventricular tachycardia. Atrial flutter is usually regular, has a narrow QRS configuration, and has flutter waves present representing atrial activity. Sinus tachycardia has P waves. Ventricular fibrillation is irregular and does not have a consistent QRS duration.

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

ANS: D The low WBC count places the patient at risk for severe infection and is an indication that the chemotherapy dose may need to be lower or that WBC growth factors such as filgrastim (Neupogen) are needed. Although the other laboratory data indicate decreased levels, they do not indicate any immediate life-threatening adverse effects of the chemotherapy.

Which focused data will the nurse monitor in relation to the 4+ pitting edema assessed in a patient with cirrhosis? a. Hemoglobin b. Temperature c. Activity level d. Albumin level

ANS: D The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of edema. The other parameters are not directly associated with the patient's edema.

The nurse knows that discharge teaching about the management of a new permanent pacemaker has been most effective when the patient states a. "It will be several weeks before I can return to my usual activities." b. "I will avoid cooking with a microwave oven or being near one in use." c. "I will notify the airlines when I make a reservation that I have a pacemaker." d. "I won't lift the arm on the pacemaker side until I see the health care provider."

ANS: D The patient is instructed to avoid lifting the arm on the pacemaker side above the shoulder to avoid displacing the pacemaker leads. The patient should notify airport security about the presence of a pacemaker before going through the metal detector, but there is no need to notify the airlines when making a reservation. Microwave oven use does not affect the pacemaker. The insertion procedure involves minor surgery that will have a short recovery period.

A patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care? a. Restrict daily dietary protein intake. b. Reposition the patient every 4 hours. c. Perform passive range of motion twice daily. d. Place the patient on a pressure-relief mattress.

ANS: D The pressure-relieving mattress will decrease the risk for skin breakdown for this patient. Adequate dietary protein intake is necessary in patients with ascites to improve oncotic pressure. Repositioning the patient every 4 hours will not be adequate to maintain skin integrity. Passive range of motion will not take the pressure off areas such as the sacrum that are vulnerable to breakdown.

The nurse is reviewing the 12-lead electrocardiograph (ECG) for a healthy 74-yr-old patient who is having an annual physical examination. What finding is of most concern to the nurse? a. A right bundle-branch block. b. The PR interval is 0.21 seconds. c. The QRS duration is 0.13 seconds. d. The heart rate (HR) is 41 beats/min.

ANS: D The resting HR does not change with aging, so the decrease in HR requires further investigation. Bundle-branch block and slight increases in PR interval or QRS duration are common in older individuals because of increases in conduction time through the AV node, bundle of His, and bundle branches.

Which statement made by a patient with coronary artery disease after the nurse has completed teaching about the therapeutic lifestyle changes (TLC) diet indicates that further teaching is needed? a. "I will switch from whole milk to 1% milk." b. "I like salmon and I will plan to eat it more often." c. "I can have a glass of wine with dinner if I want one." d. "I will miss being able to eat peanut butter sandwiches."

ANS: D Although only 30% of the daily calories should come from fats, most of the fat in the TLC diet should come from monounsaturated fats such as are found in nuts, olive oil, and canola oil. The patient can include peanut butter sandwiches as part of the TLC diet. The other patient comments indicate a good understanding of the TLC diet.

A patient with late-stage cirrhosis develops portal hypertension. Which of the following options below are complications that can develop from this condition? Select all that apply. A. Increased albumin levels B. Ascites C. Splenomegaly D. Fluid volume deficit E. Esophageal varices

B. Ascites C. Splenomegaly E. Esophageal varices Portal hypertension is where the portal vein becomes narrow due to scar tissue in the liver, which is restricting the flow of blood to the liver. Therefore, pressure becomes increased in the portal vein and affects the organs connected via the vein to the liver. The patient may experience ascites, enlarged spleen (splenomagaly), and esophageal varices.

A patient is taking Digoxin. Apical pulse is 74, Digoxin level is 1.3 (0.5-2.0), K+ is 4.0. The nurse should: A. Hold the does and administer 2nd dose at 1800 B. Administer dose as ordered C. Hold dose and notify doctor of the Digoxin level D. Hold dose until the K+ level is normal

B. Administer dose as ordered

Which of the following interventions is appropriate for treating a child diagnosed with hemophilia with hemarthrosis? A. Administer Ibuprofen for back pain B. Administer the missing blood clotting factor C. Administer enoxaparin D. Administer a platelet transfusion

B. Administer the missing blood clotting factor

A 5 year old male is admitted with acute glomerulonephritis. On assessment, you note mild edema predominately in the face and tea-colored urine. The patient's blood pressure is 165/110, heart rate 95, oxygen saturation 98% on room air, and temperature 98.9F. In your nursing care plan, what nursing interventions will you include in this patient's plan of care? Select all that apply/ A. Initiate and maintain a high sodium diet daily B. Monitor intake and output hourly C. Encourage patient to ambulate every 2 hours while awake D. Assess color of urine after every void E. Weigh patient daily on a standing scale F. Encourage the patient to consume 4L of fluid per day

B. Monitor intake and output hourly D. Assess color of urine after every void E. Weigh patient daily on a standing scale Patients with acute glomerulonephritis experience proteinuria and hematuria. In addition, they may experience mild edema (mainly in the face/eyes), hypertension, and in severe case renal failure/oliguria/ Therefore, it is very important the nurse monitors intake and output every hour, assesses color of urine, and weighs the patient every day on a standing scale.

(Nurse Sarah) Which patient is experiencing partially compensated respiratory acidosis? A. PaCO2 30, pH 7.35, HCO3 26 B. PaCO2 53, pH 7.23, HCO3 28 C. PaCO2 45, pH 7.49, HCO3 21 D. PaCO2 50, pH 7.30, HCO3 23

B. PaCO2 53, pH 7.23, HCO3 28

The liver receives its blood supply from two sources. One of these sources is called the __________, which is a vessel network that delivers blood __________ in nutrients, but __________ in oxygen. A. hepatic artery, high, low B. hepatic portal vein, high, low C. hepatic lobule, high, low D. hepatic vein, low, high

B. hepatic portal vein, high, low Majority of the blood flow to the liver comes from the hepatic portal vein. This vessel network delivers blood HIGH in nutrients (lipids, proteins, carbs, etc.) from organs that aid in the digestion of food, but the blood is POOR in oxygen, The organs connected to the hepatic portal vein are: small/large intestine, pancreas, spleen, stomach. The hepatic artery delivers blood LOW in nutrients and HIGH in oxygen.

Which of the following interventions should the RN avoid with a child with hemophilia? A. Administering Tylenol rectal suppositories B. Administering Aspirin for pain C. Both A& B D. Administering carbonated beverages on diet

C. Both A& B

A client is diagnosed with gestational hypertension and is receivin magnesium sulfate. Which finding would the nurse interpret as indicating a therapeutic level of medication? A. Urinary output of 20 mL per hour B. respiratory rate of 10 breaths/minute C. Deep tendon reflexes 2+ D. Difficulty in arousing

C. Deep tendon reflexes 2+ With magnesium sulfate, deep tendon reflexes of 2+ would be considered normal and therefore a therapeutic level of the drug. Urinary output of less than 30 mL, a respiratory rate of less than 12 breaths/minute, and a diminished level of consciousness would indicate magnesium toxicity

What is the most appropriate pain management for a woman in labor at 8cm dilated? A. Nothing, its time to have the baby B. Narcotics (morphine, Stadol) C. Non-pharmacological methods D. Epidural

C. Non-pharmacological methods 8-10cm goes much faster than 0-7cm Epidurals are often not given because the woman is very close to delivery. Narcotics are not usually given because the short time to delivery can cause respiratory depression in the fetus. 8-10 cm can be very intense. Non-pharmacological methods should help her get through that Stage 1: 0-10cm fully dilated; consists of early (latent) and active labor Stage 2: fully dilated to birth of infant Stage 3: birth of infant to delivery of placenta; separation/expulsion

A patient with history of a-fib is on Warfarin. It is imperative that the nurse should check which lab prior to giving? Select all that apply. A. Platelet count B. aPTT C. Prothrombin D. INR

C. Prothrombin D. INR

The primary intervention for a premature neonate to assist in thermoregulation is: A. taking temperature B. Place the baby on the warmer C. Using a warm blanket to receive the newborn D. Dry off the newborn to prevent evaporation heat loss

C. Using a warm blanket to receive the newborn The initial contact with the newborn will be receiving them as they are being born. Drying the newborn, placing the baby on the radiant warmer, and taking a temperature will all come after the newborn is received and bundled.

Which of the following is the most accurate PE testing for a patient with contrast allergies? A. Doppler ultrasound B. Spiral CT C. V/Q scan D. D-dimer

C. V/Q scan

The nurse was assessing the patient who has bone pain, petechiae, and WBC 100,000. The RN suspects: A. Venous thromboembolism (VTE) B. Breast cancer C. Pt. reached the nadir from chemotherapy D. Leukemia

D. Leukemia

Which of the following antibiotics does not pose a high risk for developing clostridium difficile? A. Clindamycin (Cleocin) B. Cephlosporins (Cefazolin) C. Fluroquinolones (Levaquin) D. Metronidazole (Flagyl)

D. Metronidazole (Flagyl)