Study Guide for Final

A patients ideal body weight is 150 lbs. At which weight would the nurse patient be considered obese?

180 Rationale A weight that is 20% over ideal weight is considered obese. Calculate this by multiplying the current weight by 20% or 150 0.20 = 30. Then add this value of 30 to the current weight of 150 lbs. The patient would need to weigh 180 lbs. to be considered obese.

A patient is upset to learn that a recent hemoglobin A1c level is 10.3%. What should the nurse provide as the patients average blood glucose level based upon this percentage if the equation 28.7 HbA1c 46.7 is used? (Round to the nearest whole number.)

249 Rationale When using this equation, the patients average blood glucose level is calculated as being: 28.7 10.3 46.7 = 248.91. With rounding, it would be 249 mg/dL.

A patient is 5 feet 6 inches tall and weighs 225 pounds. What is this patients body mass index?

36.3 Rationale The nurse should use the equation weight (lb) / [height (in.)]2 703. The body mass index is 36.3.

A patient is prescribed to receive 20 mg of metoclopramide (Reglan) intramuscularly (IM). The medication available is 5 mg/ mL. How many mL of the medication should the nurse provide to the patient?

4 Rationale 20 mg 1 mL = 4 mL 5 mg

The nurse is caring for a patient with a history of asthma who is newly diagnosed with hyperthyroidism. What assessment finding should the licensed practical nurse (LPN) report immediately to the registered nurse (RN)? a. Heart rate 112 beats/min b. Temperature 97.2F (36.2C) c. Blood pressure 112/73 mm Hg d. Respiratory rate 20 breaths/min

A Rationale A heart rate of 112 beats per minute is abnormal. B. C. D. All the other vital signs are normal.

The spouse of a patient with an ascending ostomy asks if the patient will always have to wear a pouch. What response should the nurse make? a. A bag will be needed all of the time. b. A bag will be needed only during the night. c. A bag will be needed only to protect the stoma. d. No, a bag will not be needed after discharge from the hospital.

A Rationale A bag will be needed all of the time as the stool will be liquid to mushy. B. C. D. These responses are inappropriate for the patient with an ascending ostomy.

A patient with a new ileostomy asks if a bag needs to be worn on the abdomen. What is the most appropriate response by the nurse? a. Your stool will be liquid, so you will always need a bag. b. Your stool will be mushy, and you will need a bag most of the time. c. You will be taught to irrigate your stoma to eliminate the need for a bag. d. Your stool will be formed, and you may be able to regulate your bowel movements so that a bag will be optional.

A Rationale A conventional ileostomy is a small stoma in the right lower quadrant that requires a pouch at all times because of the continuous flow of liquid effluent. B. An ostomy device will always need to be worn by the patient. C. D. With an ileostomy, the stoma does not need to be irrigated and the stool will not be formed.

The nurse is caring for a patient with gastroesophageal reflux disease (GERD). Which patient statement indicates a need for nutritional instruction? a. I should drink milk, as it is the perfect food. b. Nutrition can affect health positively or negatively. c. Excessive intake of a nutrient can interfere with others. d. Classes of nutrients are carbohydrates, fats, proteins, vitamins, minerals, and water.

A Rationale A low-fat, high-protein diet is recommended because fat causes decreased functioning of the lower esophageal sphincter. Caffeine, milk products, and spicy foods should be avoided. B. C. D. These patient statements are appropriate for the patient with gastroesophageal reflux disease.

The nurse is reinforcing teaching about the most serious side effect of peritoneal dialysis with a patient scheduled for the first treatment. Which side effect should the patient state that indicates correct understanding? a. Peritonitis. b. Paralytic ileus. c. Respiratory distress. d. Cramps in the abdomen.

A Rationale A major complication of peritoneal dialysis is peritonitis, which can be life threatening. The major cause of peritonitis is poor technique when connecting the bag of dialyzing solution to the peritoneal catheter. B. Paralytic ileus and respiratory distress are not associated with peritoneal dialysis. D. Abdominal cramps can occur with this type of dialysis however they are not the most serious side effect of this treatment

The nurse is reinforcing teaching about the most serious side effect of peritoneal dialysis with a patient scheduled for the first treatment. Which side effect should the patient state that indicates correct understanding? a. Peritonitis. b. Paralytic ileus. c. Respiratory distress. d. Cramps in the abdomen.

A Rationale A major complication of peritoneal dialysis is peritonitis, which can be life threatening. The major cause of peritonitis is poor technique when connecting the bag of dialyzing solution to the peritoneal catheter. B. Paralytic ileus and respiratory distress are not associated with peritoneal dialysis. D. Abdominal cramps can occur with this type of dialysis however they are not the most serious side effect of this treatment.

The nurse is caring for a patient recovering from radical neck dissection for cancer and tracheostomy placement. What action by the nurse should take priority? a. Ensuring airway patency b. Ensuring adequate nutrition c. Teaching about smoking cessation d. Establishing ways of communication

A Rationale A tracheostomy is usually performed to protect the airway and prevent obstruction. The airway must be monitored and secretions controlled to prevent aspiration. B. C. D. These actions are important however do not take the priority over maintaining a patent airway.

A patient is diagnosed with hyperthyroidism. What should the nurse realize as being the most common cause of this disorder? a. Graves disease b. Multinodular goiter c. Radiation exposure d. Excess thyrotropin-releasing hormone (TRH) from the hypothalamus

A Rationale A variety of disorders can cause hyperthyroidism. Graves disease is the most common cause; it is thought to be an autoimmune disorder, because thyroid-stimulating antibodies are present in the blood of these patients. B. C. D. Multinodular goiter, radiation, and excess TRH are less commonly the cause.

A patient with acute abdominal pain has a serum potassium level of 2 mEq/L. What should the nurse do first? a. Call the physician STAT. b. Administer a Kayexalate enema. c. Document the result on the chart. d. Notify the physician during morning rounds.

A Rationale A. A serum potassium level of 2 mEq/L is dangerously low and places the patient at risk for cardiac complications. B. Kayexalate will lower the potassium level further and is inappropriate. C. The result can be documented after the physician is notified STAT. D. Waiting to notify the physician during morning rounds places the patient at risk for a cardiac event.

An older patient is admitted for treatment of fluid volume excess. For which serious respiratory complication of fluid volume excess should the nurse assess this patient? a. Pulmonary edema b. Pulmonary infarction c. Pulmonary fibrosis d. Pulmonary embolism

A Rationale A. Acute fluid excess typically results in congestive heart failure. As the fluid builds up in the heart, the heart is not able to properly function as a pump. The fluid then backs up into the lungs, causing a condition known as pulmonary edema. B, C, and D are not related to fluid volume.

The nurse learns that a patients serum pH is less than 6.35. The nurse should plan care for which of the following health problems? a. Acidosis b. Alkalosis c. Fluid volume excess d. Fluid volume deficit

A Rationale A. Any pH less than 7.35 is acidotic. Alkalosis occurs with a pH of more than 7.45. C. D. The blood pH is not used to determine fluid volume.

A patient is diagnosed with an abnormal potassium level. Which complication should the nurse assess for in this patient? a. Cardiac arrest b. Fluid overload c. Internal bleeding d. Tetany with laryngospasm

A Rationale A. Both hypokalemia and hyperkalemia can cause cardiac dysrhythmias and arrest. B. C. Fluid overload and internal bleeding are not associated with potassium abnormalities. D. Tetany is associated with hypocalcemia.

A patient with severe diarrhea has a potassium imbalance. Which symptoms should the nurse expect the patient to demonstration because of this imbalance? a. Shallow respirations, lethargy, nausea b. Pitting edema, confusion, bounding pulse c. Apathy, weakness, positive Chvosteks sign d. Kussmauls breathing, thirst, furrowed tongue

A Rationale A. Skeletal muscle activity diminishes with hypokalemia, resulting in shallow, ineffective respirations. The motility of the gastrointestinal (GI) system is slowed, causing nausea, vomiting, abdominal distention, and constipation. B. Edema and bounding pulse occur in fluid excess. C. A Positive Chvosteks sign is associated with hypocalcemia. D. Kussmaul breathing is a sign of acidosis.

An older patient with a colostomy was admitted for weakness, nausea, vomiting, and loose stools. Which action should the nurse take first to determine the effectiveness of this patients care? a. Weigh the patient. b. Measure urine specific gravity. c. Check a pulse oximetry reading. d. Determine the creatinine clearance.

A Rationale A. This patient is at risk for dehydration. Daily weight is the most reliable indicator of fluid loss or gain. B. Specific gravity is an indirect measure of fluid balance. C. Pulse oximetry reflects oxygenation status and is not related to hydration. D. Creatinine clearance is a measure of kidney function.

A patient recovering from radiological studies of the renal system has a nursing diagnosis of Impaired Urinary Elimination. Which outcome indicates that the nursing interventions have been effective? a. Patient voids 35 mL/hour of clear urine. b. Patient voids 30 mL/hour of cloudy urine. c. Patient voids 10 mL/hour of reddish urine. d. Patient voids an average of 15 mL/hour of dark-colored urine.

A Rationale An expected outcome would be for the patient to maintain a urine output greater than 30 mL per hour in the post-procedure period. B. Cloudy urine could indicate an infection. C. Only 10 mL of red urine could indicate renal failure. D. Urine output should be at least 30 mL/hr.

A patient scheduled for an ileostomy for Crohns disease asks the nurse to explain the procedure. What should the nurse respond? a. You will have a loop of colon brought out onto your abdomen. b. Your ileum will be anastomosed to your rectum, so your stools will be watery. c. Your ileum will be removed, and the end of your jejunum will be made into a stoma. d. Your colon will be removed, and the end of your small bowel will be brought out onto your abdomen.

A Rationale An ileostomy is an end stoma formed by bringing the terminal ileum out to the abdominal wall following a total proctocolectomy. A. B. C. These responses do not appropriately describe an ileostomy.

A patient hemorrhaging from an incision has a blood pressure of 70/0 mm Hg. What type of fluid replacement should the nurse anticipate will be ordered initially? a. 0.9 % normal saline b. Fresh frozen plasma c. Packed red blood cells d. Lactated Ringers with 50 mL albumin

A Rationale An isotonic solution such as 0.9% normal saline will be given immediately to restore fluid volume. B. B. Blood products will be considered based on the patients status and need to replace the lost blood. D. Lactated Ringers might be used to increase fluid volume however albumin will not be used.

A patient with pneumonia has a blood urea nitrogen (BUN) of 32 mg/dL and creatinine of 0.8 mg/dL. What should the nurse realize is the most probable explanation for this finding? a. The patient is dehydrated. b. The patient has septicemia. c. The patient is malnourished. d. The patient has kidney damage.

A Rationale BUN elevates with dehydration, because the loss of water makes the blood more concentrated. Creatinine levels are a very good indicator of kidney function. B. C. D. There is not enough information to determine if the patient is septic, malnourished, or has kidney damage.

The nurse is collecting data from a patient who has returned from a dialysis session. After dialysis, the nurse should anticipate which patient finding? a. Weight loss b. Hypertension c. Increased energy d. Distended neck veins

A Rationale Based upon the fluid pulled off during dialysis, weight will be lost. C. Following a treatment, the patient normally feels weak and fatigued. B. Hypotension may occur due to the fluid loss. D. Fluid and electrolyte levels drop rapidly, so there is no fluid overload.

The nurse is assisting with nutrition teaching for a patient who voices concern over coping with a diabetic diet. What response about medical nutrition therapy is correct? a. You will have a well-balanced, individualized meal plan that will be healthy for your whole family. b. You will need to avoid sugars and fats, but the dietitian will assist you in finding acceptable alternatives. c. Your diabetes will require special foods, but many stores now stock a variety of choices for people with diabetes. d. Medical nutrition therapy stresses high protein and low carbohydrate intake, but most people readily adapt to these restrictions.

A Rationale Because all diabetic nutrition recommendations emphasize low fat intake and balanced intake of other food groups, it is healthy for the whole family. B. Patients with diabetes do not have to avoid all sugars and fats. D. High protein is not recommended; low protein may be necessary if nephropathy occurs. C. Special foods are not necessary.

The nurse needs to obtain a urine specimen from a female patient. What action should the nurse take when obtaining this specimen? a. Obtain the first voided urine of the day. b. Direct the patient to wash her perineum before collecting the urine specimen. c. Have the patient urinate into a bedpan, then pour the urine into the specimen container. d. Have the patient void, throw that urine away, and then collect another specimen at least 1 hour later.

A Rationale Direct the patient to wash her perineum before collecting the urine specimen to reduce contamination. A. If the specimen is for a routine urinalysis, the first morning voided urine is best to obtain however the type of specimen is not known. C. Pouring urine from a bedpan could cause the specimen to be contaminated. D. There is no need for the patient to provide a double specimen

A patient who had surgery 3 days ago has a temperature of 98F (36.6C), blood pressure 82/72 mm Hg, pulse 120 beats/minute, and respirations 30/minute. Which type of shock should the nurse suspect is occurring in this patient? a. Septic b. Neurogenic c. Cardiogenic d. Hypovolemic

A Rationale During the early, or warm, phase of septic shock, blood pressure, urine output, and neck vein size may be normal, but the skin is warm and flushed. Fever is present in the majority of patients, although some may have a subnormal temperature. D. Septic shock progresses to a second phase with signs and symptoms similar to hypovolemic shock: hypotension; oliguria; tachycardia; tachypnea; flat jugular and peripheral veins; and cold, clammy skin. Body temperature may be normal or subnormal. B. C. There is no reason to suspect that this patient is experiencing neurogenic or cardiogenic shock.

The nurse teaching a patient with gastroesophageal reflux about the influence of body position on the disease process. Which patient statement indicates that teaching has been effective? a. I elevate the head of the bed 4 to 6 inches. b. I elevate the foot of the bed 12 to 16 inches. c. I sleep on my back without a pillow under my head. d. I sleep on my stomach with my head turned to the left.

A Rationale Elevating the head of the bed 4 to 6 inches helps prevent reflux of gastric contents into the esophagus. B. The head of the bed does not need to be elevated 12 to 16 inches. C. D. Sleeping flat or on the stomach could exacerbate symptoms of gastroesophageal reflux

The nurse is caring for a patient who reports feeling constipated, yet passes frequent small liquid stools. Which action should the nurse take? a. Check the patient for a fecal impaction. b. Administer an antidiarrheal medication. c. Explain that liquid stools indicate diarrhea. d. Check the abdomen for rebound tenderness.

A Rationale Fecal impaction results when the fecal mass is so dry it cannot be passed. Small amounts of liquid stool ooze around the fecal mass and cause incontinence of liquid stools. B. If the incontinence is treated with an antidiarrheal medication, it will worsen the constipation. C. The patient is not experiencing liquid stools. D. Rebound tenderness is not a manifestation of fecal impaction.

The nurse is caring for a patient who has a nephrostomy tube. What action should the nurse take to maintain the integrity of this device? a. Ensure tube is not kinked or clamped. b. Limit fluids to 1000 mL per 24 hours. c. Keep collection bag taped to abdomen. d. Remove and clean the tube once daily.

A Rationale For a nephrostomy tube, the nurse should ensure that it is draining adequately and is not kinked or clamped. B. Fluids do not need to be limited. C. The collection bag does not need to be taped to the abdomen. D. The tube is not to be removed and cleaned.

The nurse is caring for an 85-year-old patient with septic shock. What should the nurse keep in mind when repositioning this patient? a. Change positions slowly. b. Reduce flow rate of oxygen. c. Increase flow rate of IV fluids. d. Place in Trendelenburg position.

A Rationale For the geriatric patient, positions should be changed slowly. Age-related losses of cardiovascular reflexes can result in hypotension. B. C. The oxygen and IV flow rates cannot be changed without a health care providers order. D. Trendelenburg position is not indicated for this health problem.

The nurse is evaluating a patients ability to change an ostomy appliance. Which observation indicates that the patient can safely provide self-ostomy care? a. Stoma measured prior to applying new appliance b. Skin barrier applied tight to the base of the stoma c. Skin barrier cut to the same size as previous barrier d. Lotion applied to skin before application of skin barrier

A Rationale For the traditional skin barrier, the patient should measure the stoma with a stoma sizing guide initially with each appliance change, because the stoma will shrink for up to 6 months. B. The appliance should not be applied tightly to the base of the stoma. C. The stoma should be measured prior to each appliance application. D. The skin should be clean and dry prior to applying the skin barrier.

A patient with a nasogastric tube connected to suction is NPO (nothing by mouth) and reports a dry mouth and gagging feeling. What action should the nurse take? a. Provide oral care. b. Pull tube out 1 inch. c. Offer ice chips to swallow. d. Give lidocaine solution to coat the mouth.

A Rationale Frequent oral care is needed for comfort for patients who are NPO with NG tubes as dry mouth is a continual concern. B. The nurse should not reposition the patients nasogastric tube. C. The patient is NPO so ice chips would be contraindicated. D. There is no reason to provide lidocaine for the patients mouth.

The nurse is preparing to calculate a patients body mass index. What measurements does the nurse need to make this calculation? a. Height and weight b. Waist and hip measurements c. Weight and waist measurement d. Waist measurement and height

A Rationale Height and weight are used to calculate body mass index. B. Waist and hip measurements are used to calculate waist-to-hip ratio. C. D. There are no calculations that use weight and waist measurement or waist measurement and height.

A patient with possible viral hepatitis reports recent intake of raw shellfish. Which type of hepatitis should the nurse consider the patient is experiencing? a. Hepatitis A virus b. Hepatitis B virus c. Hepatitis C virus d. Hepatitis D virus

A Rationale Hepatitis A is spread by oralfecal contamination of water, shellfish, eating utensils, or equipment. B. C. D. These types of hepatitis are spread through blood and body fluids.

A patient is diagnosed with hypoglycemia. What glucose level should the nurse expect when monitoring the capillary blood glucose? a. 65 mg/dL b. 100 mg/dL c. 138 mg/dL d. 200 mg/dL

A Rationale Hypoglycemia is usually defined as a blood glucose level below 70 mg/dL, although patients may feel symptoms at higher or lower levels. B. This is a normal blood glucose level. C. D. These levels indicate hyperglycemia.

The nurse is making a visit to the home of a patient with functional incontinence. Which observation indicates that teaching about the disorder has been effective? a. Patient wearing sweat pants b. Patient drinking a cup of coffee c. Patient sitting with the legs elevated d. Patient restricting fluid intake after 6 pm

A Rationale If clothing is inhibiting timely voiding for the patient with functional incontinence, the patient should be instructed to wear clothing with Velcro fasteners or sweat pants. B. Coffee is a bladder irrigant and could precipitate voiding. C. Elevating the legs is not an action appropriate for functional incontinence. D. Restricting fluids after 6 pm is not an appropriate action for functional incontinence.

A patient receiving a tube feeding at 60 mL/hr has a residual of 10 mL. What action should the nurse take? a. Continue the feeding as ordered. b. Slow the feeding to 35 mL/hour. c. Decrease the feeding to 10 mL/hour. d. Hold the feeding, and notify the physician.

A Rationale If the residual amount is more than 100 mL or the amount specified by the agency or physician, the feeding should be stopped to prevent vomiting or aspiration and the physician notified. This feeding can be continued as ordered, as the residual amount is only 10 mL. B. C. D. The feeding does not need to be slowed, decreased, or held.

A patient who is unconscious begins to vomit blood. What action should the nurse take first? a. Turn patient onto side. b. Use water to rinse out mouth. c. Provide oral care to the patient. d. Administer antiemetic medication.

A Rationale If vomiting occurs, turn the patient onto his or her side to protect the airway and prevent aspiration. B. The patient is unconscious so water should not be placed into the patients mouth. C. Oral care can be done after the airway has been protected. D. Antiemetic medication requires a physicians order which may or may not be available at this time

A patient with chronic kidney disease is very weak due to low hemoglobin. What should the nurse understand as the best explanation for the anemia? a. Secretion of erythropoietin by the diseased kidney is reduced. b. There is loss of red blood cells in the urine with kidney disease. c. Chronic hypertension associated with chronic kidney disease suppresses the bone marrow. d. Metabolic acidosis associated with chronic kidney disease increases red blood cell fragility.

A Rationale In chronic kidney disease secretion of erythropoietin by the diseased kidney is reduced. B. C. D. This patient is not experiencing anemia because of a loss of red blood cells, chronic hypertension, or metabolic acidosis.

The nurse is caring for a patient who complains of nausea related to gastric cancer. Which supplement should the nurse suggest? a. Ginger b. Lemon c. Butterscotch d. Black licorice

A Rationale It has been believed that ginger can be an effective aid in relieving nausea in cancer patients receiving chemotherapy, pregnant patients, and postoperative patients. Research however did not find this to be so. Even so, patients might have some relief from using ginger for nausea. B. C. D. These supplements are not identified as helping with nausea

The nurse is visiting the home of a patient recovering from a sleeve gastrectomy. Which observation indicates that this surgery has been successful for the patient? a. Patient claims that she never feels hungry b. Patients skin is dry and hair is falling out c. Patient states that she is constantly hungry d. Patient has injected 100 mL of saline solution in the pouch

A Rationale Laparoscopic sleeve gastrectomy removes about 75% of the stomach to leave a slim gastric sleeve. This reduces the stomachs volume and limits food intake at one time. It also may decrease the hormone produced by the stomach that causes hunger. B. Dry skin and hair falling out indicates that the patient is not taking in an adequate amount of nutrients to support the skin and hair. C. Being constantly hungry indicates that the surgery was not successful since the hormone produced by the stomach that causes hunger should be reduced from this surgery. D. There is no saline solution injected into a pouch with this surgery.

The nurse is collecting data from a patient who reports right upper abdominal quadrant warmth and tenderness. When the nurse touches the area lightly to assess for warmth and tenderness, what data collection technique is being used? a. Palpation b. Inspection c. Percussion d. Auscultation

A Rationale Light palpation uses touch and depresses the abdomen 0.5 to 1 inch. B. Inspection is looking at or observing an area. C. Percussion is using the hands and fingers to produce a sound that identifies the density of the organs beneath the area being percussed. D. Auscultation is the use of a stethoscope to listen for sounds.

The nurse obtains vital signs on a patient with gastrointestinal bleeding who has a large, dark red, foul-smelling stool. Which vital sign changes should the nurse report as indicative of early shock? a. Normal blood pressure, tachycardia, and rapid respirations b. Rise in diastolic blood pressure, bradycardia, and slow respirations c. Decreasing systolic blood pressure, bradycardia, and slow respirations d. Drop in diastolic blood pressure, bradycardia, and shallow respirations

A Rationale Normal blood pressure, tachycardia, and rapid respirations occur in mild shock due to compensatory mechanisms. B. C. D. As shock progresses and compensatory mechanisms begin to fail, vital signs decrease.

The nurse is catheterizing a patient after voiding to determine the amount of residual urine in the bladder. What should the nurse consider as being the normal amount of urine within the bladder after urination? a. 50 mL b. 75 mL c. 100 mL d. 150 mL

A Rationale Normally, the bladder contains less than 50 mL after urination. B. C. D. These represent excessive amounts of residual urine after voiding.

The nurse teaches a patient to self-administer insulin. How can the nurse best evaluate whether the patient understands the instructions? a. Observe as the patient prepares and injects a dose of insulin. b. Have the patient list the steps of the procedure for insulin administration. c. Ask the patient an open-ended question about feelings related to the procedure. d. Ask the patient to repeat the information in the insulin pamphlet that was provided.

A Rationale Observing the patient as he or she demonstrates injection is the most objective measure. B. C. D. These are good additional steps, but they are not the best way to evaluate effectiveness of teaching.

A patient develops hyperparathyroidism related to a benign tumor. What laboratory result should the nurse expect to see? a. Elevated serum calcium b. Decreased serum calcium c. Elevated serum potassium d. Decreased serum potassium

A Rationale Over activity of one or more of the parathyroid glands causes an increase in parathyroid hormone (PTH), with a subsequent increase in the serum calcium level (hypercalcemia). This is achieved through movement of calcium out of the bones and into the blood, absorption in the small intestine, and reabsorption by the kidneys. C. D. Potassium level is not affected. B. The serum calcium level will not be decreased.

The nurse is caring for a patient with an exacerbation of Crohns disease. Which nursing action is most important to recommend for inclusion in the patients plan of care? a. Encourage oral fluids. b. Encourage frequent ambulation. c. Administer anti-gas agents as ordered. d. Apply protective ointment to perianal skin.

A Rationale Per Maslows hierarchy, preventing dehydration from diarrhea is important, so fluids are encouraged. B. C. D. Ambulation, anti-gas medications, and protective ointment to the perianal skin are not as important as ensuring the patients fluid and electrolyte status are maintained.

The nurse is caring for a patient with chronic liver failure. Which laboratory value should the nurse expect as a late sign of liver failure? a. Low serum albumin b. Low serum bilirubin c. Low serum ammonia d. Low serum aspartate aminotransferase (AST)

A Rationale Protein synthesis (albumin) is impaired in liver disease. B. C. D. Ammonia, bilirubin, and AST are all elevated in liver disease

A patient on an American Diabetes Association (ADA) exchange list diet receives a dinner meal tray and does not wish to eat the rice. Which food should the nurse substitute for the rice? a. A slice of bread b. A 4-oz glass of juice c. A half cup of custard d. A half cup of cottage cheese

A Rationale Rice and bread are both starches. C. D. Cottage cheese and custard are in the milk group. B. Juice is a fruit.

The nurse is contributing to a staff education program about complications associated with urinary catheters. Which type of shock should the nurse recommend be included in the presentation? a. Septic b. Cardiogenic c. Anaphylactic d. Hypovolemic

A Rationale Septic shock can develop from invasive procedures and devices. Indwelling urinary catheters can precipitate the development of septic shock. B. C. D. Cardiogenic, anaphylactic, and hypovolemic shock are not associated with the use of urinary catheters.

The LPN answers the call light of a patient with diabetes. The patient has a mild tremor, slight diaphoresis, and is fully oriented. What should the nurse do? a. Check the patients blood glucose level. b. Call the laboratory for a STAT glucose level. c. Call the RN to administer dextrose 50% intravenously. d. Administer 4 oz of orange juice with one packet of sugar.

A Rationale Since the patient is oriented, there is time to check the blood glucose. B. Calling the laboratory takes too long and is unnecessary. D. Giving orange juice or another CHO (carbohydrate) source will be the next step, but adding sugar increases the risk of hyperglycemia. C. 50% dextrose is used if the patient is unable to take oral CHO.

The nurse is contributing to the plan of care for patient with an ostomy. Why should the nurse recommend the use of a skin barrier product under the ostomy appliance? a. To keep stool from irritating the skin b. To ease removal of the pouch for changing c. To prevent the bag from sticking too tightly to the skin d. To prevent stool from coming in contact with the stoma

A Rationale Skin must be protected, as stool is irritating to the skin and will excoriate the skin if it is exposed to it. B. C. D. A skin barrier is not used to facilitate changing of the pouch, protect the bag from sticking to the skin, or to prevent stool from coming in contact with the stoma.

A patient with chronic obstructive pulmonary disease develops Cushings syndrome related to long-term steroid use. The physician writes an order to discontinue the steroids. Which action by the nurse is most appropriate? a. Question the order. b. Monitor the patients weight daily. c. Monitor the patients blood glucose level. d. Instruct the patient to report worsening respiratory symptoms.

A Rationale Steroids should always be tapered, never stopped abruptly, to prevent adrenal crisis. B. C. D. These actions are appropriate for patients on high-dose steroids, but abrupt cessation of the drug is life-threatening.

A female patient is prescribed glyburide (DiaBeta) for control of blood glucose. What precaution should the nurse teach the patient about this medication? a. Avoid drinking alcohol. b. Do not take it if you skip a meal. c. You will need to use two forms of birth control. d. Be sure it is discontinued before any tests involving contrast dye.

A Rationale Sulfonylureas interact with alcohol and can make the patient very ill. B. This action should be taken for meglitinides and alpha-glucosidase inhibitors. D. This action should be taken for metformin. C. Glitazones may interfere with birth control.

The nurse is caring for a patient following a thyroidectomy. Which postoperative assessment activity is most important to detect the development of thyrotoxic crisis? a. Monitor vital signs. b. Monitor the surgical dressing. c. Assess for confusion and delirium. d. Assess hand grips and foot presses.

A Rationale Symptoms of thyrotoxic crisis include tachycardia, high fever, hypertension (with eventual heart failure and hypotension), dehydration, restlessness, and delirium or coma; it is important to monitor vital signs to detect symptoms early. B. C. D. Monitoring the dressing and neurological status are good parts of routine care but do not help detect thyrotoxic crisis.

A patient who is taking atenolol (Tenormin) is experiencing shock. Which symptom of shock should the nurse expected to be absent in this patient? a. Pulse 115 beats per minute b. Respirations 28 per minute c. Blood pressure 88/48 mm Hg d. Capillary refill greater than 3 seconds

A Rationale Tachycardia will not be present as expected with sympathetic nervous system activation. Beta blockers block the response of the sympathetic nervous system, which is activated in shock. B. The sympathetic nervous system is activated in shock so respirations increase. C. Blood pressure drops in shock. D. Prolonged capillary refill is expected in shock due to decreased blood pressure and vasoconstriction from sympathetic nervous system response.

A patient with diabetes has peripheral neuropathy. What should the nurse do to prevent related complications? a. Wash, dry, and inspect feet daily. b. Use a lubricating lotion on feet daily. c. Avoid wearing shoes as much as possible. d. Soak feet in soap and water for 20 minutes daily.

A Rationale The feet must be washed, dried, and inspected daily to recognize pressure points or red areas before they turn into problems. D. Soaking feet can macerate skin. C. Well-fitting shoes protect the feet. B. Lubricating lotion is a good idea but is only one way to protect the feet and is not as essential as daily washing and inspection for the patient with neuropathy.

A patient hourly urine output is recorded. Which output rates should be brought to the attention of the registered nurse (RN) immediately? a. 15 mL/hr b. 40 mL/hr c. 60 mL/hr d. 80 mL/hr

A Rationale The minimum urine output should be 30 mL/hr, so 15 mL/hr should be reported. B. C. D. These rates are adequate and do not need to be reported.

A patient is recovering from a Billroth I procedure and has a nasogastric Levin tube set to low intermittent suction. As the patient turns in bed, the Levin tube is partially pulled out. Which action should the nurse take? a. Notify the registered nurse (RN). b. Irrigate the tube. c. Advance the tube. d. Place suction on continuous.

A Rationale The nurse needs to inform the RN or physician because the tube will need to be repositioned. The physician typically is the one that does the repositioning after gastric surgery so the suture line is not affected. B. C. D. The nurse should not irrigate the tube, advance the tube, or place the tube on continuous suction since these actions could injure the suture line

The nurse is caring for a patient who has renal calculi. Which action is essential for the nurse to take? a. Strain all urine. b. Limit fluids at night. c. Record blood pressure. d. Obtain a sterile urine specimen.

A Rationale The nurse should ensure that all urine is strained to detect passage of stones. B. This patient does not need to have fluids limited at night. C. Blood pressure does not need to be measured. D. A sterile urine specimen is not needed.

The nurse learns that a patient has a urine pH of 7.9. What question should the nurse ask the patient after learning of this laboratory value? a. Are you a vegetarian? b. Are you lactose intolerant? c. How much protein do you eat each day? d. How much acetaminophen do you take each day?

A Rationale The pH range of urine is 4.6 to 8.0, with an average of 6.0. Diet has the greatest influence on urine pH. A vegetarian diet results in more alkaline urine. B. Lactose does not influence urine pH. C. A high-protein diet results in more acidic urine. D. Acetaminophen use does not influence urine pH.

A patient is demonstrating manifestations of a pheochromocytoma. Which intervention is the most important for the nurse to implement? a. Provide a calm, quiet environment. b. Encourage frequent intake of fluids. c. Offer distraction such as television or music. d. Assist with ambulation at least three times a day.

A Rationale The patient with a pheochromocytoma is in a fight-or-flight state and needs a calm, quiet environment. C. D. Distraction and ambulation will stimulate the patient. B. Fluids do not address the problem.

The nurse is reinforcing teaching provided to a patient with esophageal varices. Which activity should the patient be taught to avoid? a. Lifting heavy objects b. Participating in aerobic activities c. Eating concentrated carbohydrates d. Rising suddenly from a reclining position

A Rationale The straining associated with lifting can cause the thin-walled varices to tear, causing severe bleeding. C. Eating carbohydrates may be recommended if the patient also has encephalopathy. B. D. Aerobic activities and rising from a reclining position will not increase pressure in the varices.

The nurse is reinforcing teaching provided to a patient about risk factors for the development of bladder cancer. What risk factor should the patient state that indicates understanding of this teaching? a. Smoking b. Hyperlipidemia c. Diet high in calcium d. Recurrent UTIs

A Rationale There is a strong correlation between cigarette smoking and bladder cancer. B. C. D. Hyperlipidemia, high calcium diet, and recurrent UTIs are not identified as risk factors for the development of bladder cancer.

A patient with chronic liver disease is prescribed dexlansoprazole (Kapidex). What should the nurse instruct the patient about this medication? a. Take the entire dose of medication whole. b. Crush the medication and sprinkle in water. c. Take this medication with a full glass of milk. d. Take half the medication with breakfast and the other half with dinner.

A Rationale This medication is a delayed-release proton pump inhibitor. The medication should be taken whole and not crushed. Milk does not need to be taken with this medication.

The nurse is contributing to a patients teaching plan on how to avoid dumping syndrome after a gastrectomy. What should be included in the teaching? a. Avoid fluids with meals. b. Increase activity after eating. c. Increase carbohydrate intake. d. Eat heavy meals to delay emptying.

A Rationale To avoid dumping syndrome, avoid fluids 1 hour before, with, or for 2 hours after meals to prevent rapid gastric emptying. B. The patient should rest after eating. C. Carbohydrates should be limited. D. The patient should eat small frequent meals.

The nurse is teaching a patient about gastric surgery and dumping syndrome. Which statement indicates that the patient understands dumping syndrome? a. I need to eat small frequent meals. b. I should drink lots of fluids with meals. c. I need to sit up for 2 hours after each meal. d. I can expect the symptoms to begin 2 hours after eating.

A Rationale Treatment for dumping syndrome includes teaching the patient to eat small, frequent meals that are high in protein and fat and low in carbohydrates, especially refined sugars. B. The patient should be taught to avoid fluids 1 hour before meals, with meals, or for 2 hours after meals to prevent rapid gastric emptying. C. It is best for the patient to lie down after meals to delay gastric emptying. D. The symptoms occur 5 to 30 minutes after eating.

A patient is newly diagnosed with type 1 diabetes mellitus. How should the nurse respond when the patient asks how long insulin injections will be necessary? a. You will need insulin injections for the rest of your life. b. Once your pancreas recovers, you may be able to discontinue the injections. c. If you follow your diet closely, your blood sugar may be controlled by just taking insulin pills. d. You may be able to stop the injections if you exercise regularly and adhere to the prescribed diet.

A Rationale Unless the patient receives a pancreas or islet cell transplant, insulin will be required for life. B. The pancreas will not recover. D. Patients with type 1 diabetes must have insulin to survive. C. Oral insulin is not available.

A female patient is embarrassed because of not being able to walk to the bathroom in time before become incontinent of urine. Which type of incontinence should the nurse plan care for this patient? a. Urge b. Total c. Stress d. Functional

A Rationale Urge incontinence is the involuntary loss of urine associated with an abrupt and strong desire to void. The patient typically reports being unable to make it to the bathroom in time. B. Total incontinence is a continuous and unpredictable loss of urine. It usually results from surgery, trauma, or a malformation of the ureter. C. Stress incontinence is the involuntary loss of less than 50 mL of urine associated with increasing abdominal pressure during coughing, sneezing, laughing, or other physical activities. D. Functional incontinence is the inability to reach the toilet because of environmental barriers, physical limitations, loss of memory, or disorientation.

The nurse is caring for patients in a primary care physician office. Which patient should the nurse recognize as being the highest risk for iodine deficiency? a. A 52-year-old vegan with dietary sodium restrictions b. A 49-year-old with celiac disease who takes digoxin (Lanoxin) c. A 44-year-old lacto-vegetarian with a 40 pack-year smoking history d. A 28-year-old with lactose intolerance and a history of Graves disease

A Rationale Vegetarians who consume sea salt, which contains virtually no iodine, are at higher risk of iodine deficiency. B. C. D. These patients are at a lesser risk for developing an iodine deficiency.

The nurse is reviewing a patients history and physical report. What term should the nurse recognize is being used to describe waste products building up in the blood? a. Uremia b. Septicemia c. Nitrosemia d. Proteinemia

A Rationale Waste products (blood urea nitrogen [BUN], creatinine, etc.) building up in the blood is called uremia. B. Septicemia is a bacterial infection in the blood. C. D. These terms do not describe waste products building up in the blood.

The nurse is providing discharge teaching to a patient with diarrhea. Which patient statement indicates that teaching has been effective? a. It is important that I increase fluid intake to prevent dehydration. b. I am at increased risk for a ruptured bowel, so I must remain on bedrest. c. I should tell future health-care workers that Ive been diagnosed with obstipation. d. My risk for a urinary tract infection is very high, so I should call the doctor if I have a pain.

A Rationale Weakness and dehydration from fluid loss may occur with diarrhea. B. A ruptured bowel is not an adverse effect of diarrhea. C. Obstipation is a term for chronic constipation. D. The patients risk for urinary tract infection is not high because of diarrhea.

A patient with gastrointestinal bleeding has hemoglobin of 8.5 g/dL. While receiving care the patient becomes anxious and irritable and bright red drainage appears through the nasogastric tube. The patients vital sign measurements are pulse 130 beats/minute, blood pressure 105/55 mm Hg, and respirations 28/minute. What should the nurse recognize as causing the changes in the patients vital signs? a. Early shock b. Patient anxiety c. Progressive shock d. Parasympathetic response

A Rationale When blood pressure falls, the body activates the sympathetic nervous system to increase cardiac output by causing the heart to beat faster and stronger. Compensatory responses produce the classic signs and symptoms of early shock: tachycardia; tachypnea; restlessness; anxiety; and cool, clammy skin with pallor. B. C. D. The patients change in vital signs is not caused by anxiety, progressive shock, or a parasympathetic response

The nurse is palpating the abdomen of a patient reporting mild abdominal pain in the upper right quadrant. How deep should the nurse depress this patients abdomen? a. 1 inch b. 2 inches c. 3 inches d. 4 inches

A Rationale When palpating the abdomen of a patient reporting mild abdominal pain in the upper right quadrant, the LPN should depress the abdomen no more than 1 inch. B. C. D. Deep palpation of the abdomen is done only by physicians and highly skilled nurses.

The nurse explains procedures and treatments while caring for a patient in shock. Why should the nurse provide these explanations to the patient? (Select all that apply.) a. Provide support b. Decrease anxiety c. Enhance learning d. Reduce the signs of shock e. Prevent future shock episodes

A, B Rationale A patient in shock is acutely ill and experiencing anxiety. Keeping the patient informed as able will help reduce anxiety and provide support as treatment plans are shared. C. The patient is acutely ill and most likely not able to learn anything at this time. D. E. Explaining procedures and treatments will not reduce the signs of shock or prevent future episodes of shock.

The nurse is collecting data from a patient with a vascular access graft in the right arm for dialysis. What should the nurse do when assessing this patient? (Select all that apply.) a. Auscultate for a bruit over the site. b. Palpate for a thrill in the right arm. c. Observe the tubing for bright red blood. d. Feel for a brachial pulse on the affected arm. e. Redress the arm daily, keeping the site sterile at all times.

A, B Rationale Arteriovenous grafts are checked for patency by palpating for a thrill (a tremor) and auscultating for a bruit (swishing sound) at the site of the graft or fistula. C. The graft is under the skin so there is no tubing. D. The distal radial pulse should be checked. E. There is no dressing over the site.

A patient diagnosed with prediabetes asks what can be done to prevent the development of the disease. What should the nurse recommend to this patient? (Select all that apply.) a. Exercise b. Lose weight c. Stop smoking d. Eliminate all starches from the diet e. Avoid red meat and root vegetables

A, B Rationale Those with prediabetes may be able to prevent the onset of diabetes with weight loss and exercise. C. Smoking does not influence the development of the disease. D. E. The patient should not be encouraged to eliminate a type or category of food.

A patient comes into the client after experiencing diarrhea with five liquid stools in the past 24 hours. Which additional patient symptoms should cause the nurse concern? (Select all that apply.) a. Fever b. Blood in the stool c. Severe abdominal cramping d. Blood pressure 138/72 mm Hg e. Oral intake of 3 L of fluid in 24 hours f. Weight loss of 1 pound in the past week

A, B, C Rationale Indications for medical intervention related to diarrhea include large volumes of stool; severe abdominal cramping; bloody stool; protracted duration of diarrhea; systemic symptoms such as fever; or history of a medical condition in which fasting, dehydration, or infection are hazardous. E. Oral intake of 3 L in 24 hours is sufficient to prevent dehydration. D. The listed blood pressure is stable. F. While weight loss is concerning, 1 pound in a week is not overly concerning.

A patient recovering from hepatitis is concerned about liver damage from the infection. What should the nurse instruct the patient to do to prevent long-term liver damage? (Select all that apply.) a. Get adequate rest. b. Ingest nutritious foods. c. Abstain from all alcohol. d. Restrict physical activity. e. Limit the intake of dairy products.

A, B, C Rationale Recovery varies and depends on the type of hepatitis. Full recovery is measured by the return to normal of all liver function tests and may take as long as 1 year. The effects of hepatitis can be considered reversible if the patient complies with a medical regimen of adequate rest, proper nutrition, and abstinence from alcohol or other liver-toxic agents for at least 1 year after liver function laboratory values return to normal. D. E. Physical activity and dairy products do not need to be restricted.

A patient with suspected hyperthyroidism is scheduled for a radioactive iodine uptake test. What symptoms of hyperthyroidism should the nurse note on the medical record? (Select all that apply.) a. Fatigue b. Tremor c. Weight loss d. Constipation e. Buffalo hump f. Cold intolerance

A, B, C Rationale Weight loss, fatigue, heat intolerance, tremor, increased pulse and blood pressure, and agitation or nervousness may be seen with hyperthyroidism. D. F. Cold intolerance and constipation are seen with hypothyroidism. E. Buffalo hump is seen in Cushings syndrome.

The nurse is collecting data for a patient who has suspected kidney disease. What health problems should the nurse consider as being associated with a high urine specific gravity? (Select all that apply.) a. Nephrosis b. Dehydration c. Heart failure d. Diabetes mellitus e. Diabetes insipidus f. Fluid volume excess

A, B, C, D Rationale A high specific gravity may occur from diabetes mellitus and high sugar concentrations in the urine, nephrosis, congestive heart failure, and dehydration. E. F. Specific gravity measurements are most likely lower in diabetes insipidus and fluid volume excess.

During an assessment, the nurse learns that an older patient has been taking twice the prescribed amount of calcium supplements. Which physical assessment findings should the nurse identify as being consistent with this patients intake of calcium? (Select all that apply.) a. Muscle weakness b. Faint bowel sounds c. Increased heart rate d. Elevated blood pressure e. Dry mucous membranes

A, B, C, D Rationale A. B. C. D. Acute hypercalcemia is associated with increased heart rate and blood pressure, skeletal muscle weakness, and decreased GI motility. E. Dry mucous membranes are associated with fluid volume deficit and not hypercalcemia.

The nurse is planning care for a patient with a fluid volume excess and a serum sodium level of 125 mg/dL. Which interventions should the nurse include in this patients plan of care? (Select all that apply.) a. Weigh daily. b. Monitor strict intake and output. c. Administer diuretics as prescribed. d. Implement fluid restriction as prescribed. e. Administer IV saline as prescribed.

A, B, C, D Rationale A. B. C. D. For patients who have a fluid excess and a low sodium level, a fluid restriction is often ordered. Diuretics that rid the body of fluid but do not cause sodium loss may also be used. Intake and output are strictly monitored, and the patient is weighed daily. E. IV saline is indicated if the patient does not have a fluid volume excess.

After collecting data the nurse suspects that an adolescent patient is at risk for developing anorexia nervosa. What data did the nurse use to come to this conclusion? (Select all that apply.) a. Age 17 years b. Phobia about weight gain c. Fearful of mother present during the interview d. Asked the nurse repeatedly why certain information was needed e. Texted with friends on the smartphone while interview in progress

A, B, C, D Rationale Anorexia nervosa is an eating disorder recognized by the American Psychiatric Association. This disease most commonly occurs in females between ages 12 and 18 who are from the middle and upper classes of Western culture. Young women with low self-esteem seem to be at highest risk. Anorexia nervosa is thought to be psychological in origin. Patients may have a phobia about weight gain, be afraid of a loss of control, and be mistrusting. E. Texting with friends does not suggest that the patient is at risk for developing anorexia nervosa.

Planning is underway to determine the best course of treatment for a patient with hyperparathyroidism. What should the nurse expect to observe when collecting data from this patient? (Select all that apply.) a. Fatigue b. Nausea c. Confusion d. Depression e. Hypertension

A, B, C, D Rationale Signs and symptoms of hyperparathyroidism are caused primarily by the increase in serum calcium level. Symptoms include fatigue, nausea, confusion, and depression. E. Hypertension is not a manifestation of hyperparathyroidism.

The nurse is participating in a local health fair. Which should the nurse include in a presentation on aging changes associated with the GI system? (Select all that apply.) a. Decreased peristalsis b. Increased constipation c. Decreased sense of taste d. Increased periodontal disease e. Decreased risk of colon cancer

A, B, C, D Rationale The sense of taste becomes less acute, and there is greater likelihood of periodontal disease and oral cancer. There may be difficulties with chewing if teeth have been lost. Secretions throughout the GI tract are reduced, and the effectiveness of peristalsis diminishes because of loss of muscle elasticity and slowed motility. Indigestion may become more common, especially if the lower esophageal sphincter (LES) loses its tone, and there is greater chance of peptic ulcer. In the colon, diverticula may form. Constipation may be a problem, as may hemorrhoids. E. The risk of colon cancer also increases with age.

A patient in shock is being transported to the nearest emergency department. Upon arrival in which order should the nurse provide care? Place the actions in the order that they should be performed. a. Ensure breathing. b. Secure an airway. c. Assess level of consciousness. d. Prepare for x-rays and other tests. e. Apply pressure to bleeding wounds. f. Monitor heart rate and blood pressure.

A, B, C, D, E, F Rationale The order of interventions and testing is guided by the stability of the patient. The order for interventions should be securing an airway, ensure breathing, monitor heart rate and blood pressure, apply pressure to bleeding wounds, assess level of consciousness, and prepare for x-rays and other diagnostic tests.

The nurse is assisting in the care of a patient with early signs and symptoms of shock. Which diagnostic tests should the nurse expect to be prescribed for this patient? (Select all that apply.) a. Urinalysis b. Chest x-ray c. Arterial blood gas d. Complete blood count e. Electroencephalogram (EEG) f. Blood type and crossmatch

A, B, C, D, F Rationale Complete blood count, chest x-ray, blood typing and crossmatch, arterial blood gases, and urinalysis are diagnostic tests done in the assessment of shock. E. EEG would not be done.

A patient with a UTI is concerned about the expectation to void every three hours. What should the nurse explain to the patient about voiding this frequently? (Select all that apply.) a. Empties the bladder b. Reduces urine stasis c. Prevents reinfection d. Cleanses the perineum e. Lowers bacterial counts

A, B, C, E Encourage voiding every 3 hours to empty the bladder, lower bacterial counts, reduce stasis, and prevent reinfection. D. Voiding every 3 hours for a UTI is not done to cleanse the perineum.

The nurse is contributing to the plan of care for a patient who has chronic kidney disease. What possible effects of this condition should the nurse consider? (Select all that apply.) a. Anemia b. Cardiac dysrhythmias c. Peripheral neuropathy d. Increased bone density e. Anorexia, nausea, vomiting f. Increase in function of oil and sweat glands

A, B, C, E Rationale Chronic kidney disease can lead to anemia, cardiac dysrhythmias, peripheral neuropathy, and anorexia, nausea, and vomiting. D. F. Chronic kidney disease does not cause increases in bone density or in the function of oil and sweat glands.

A patient with a UTI is concerned about the expectation to void every three hours. What should the nurse explain to the patient about voiding this frequently? (Select all that apply.) a. Empties the bladder b. Reduces urine stasis c. Prevents reinfection d. Cleanses the perineum e. Lowers bacterial counts

A, B, C, E Rationale Encourage voiding every 3 hours to empty the bladder, lower bacterial counts, reduce stasis, and prevent reinfection. D. Voiding every 3 hours for a UTI is not done to cleanse the perineum.

A patient with irritable bowel syndrome is being started on the FODMAP diet. What foods should the nurse instruct the patient to avoid when following this diet? (Select all that apply.) a. Milk b. Pears c. Apples d. Broccoli e. Brussels sprouts

A, B, C, E Rationale FODMAP stands for Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols. Foods that should be avoided on this diet include milk, pears, apples, and Brussels sprouts. D. Broccoli does not need to be avoided on this diet.

The nurse is participating in care planning for a patient with urge incontinence. What should the nurse recommend be included in this patients plan of care? (Select all that apply.) a. Void every 2 hours. b. Practice relaxation breathing. c. Use urge inhibition techniques. d. Reduce fluid intake for several hours before sleep. e. Gradually increase length of time between voidings.

A, B, C, E Rationale For urge incontinence, the nurse should teach the patient to void at frequent intervals (every 2 hours) and then gradually increase the length of time between voidings. The nurse also should teach urge inhibition techniques (distraction), such as relaxation breathing. D. Reducing fluid intake is not an appropriate action to help treat urge incontinence.

The nurse is caring for a patient with an indwelling catheter. What should the nurse include in this patients routine care? (Select all that apply.) a. Encourage fluid intake. b. Maintain a closed system. c. Secure the catheter to the patients leg. d. Clamp the catheter for 1 hour each shift. e. Remove the catheter as soon as possible. f. Use sterile technique when emptying the drainage bag.

A, B, C, E Rationale Routine care should include encourage fluid intake, maintain a closed system, secure the catheter to the patients leg, and remove the catheter as soon as possible. F. Aseptic technique should be used when emptying the drainage bag. D. The catheter should not routinely be clamped.

A patient being discharged is prescribed treatment for long-term hypoparathyroidism. What should the nurse include in discharge teaching? (Select all that apply.) a. Eat a diet high in calcium. b. Eat a diet high in phosphates. c. Have regular eye examinations. d. Add iron-rich foods to your diet. e. Follow up with regular laboratory tests. f. Take oral calcium and vitamin D supplements as prescribed.

A, B, C, E, F Rationale A high calcium diet with calcium supplements is necessary to maintain serum calcium levels. Eye examinations are important because calcifications can occur in the eyes, and cataracts can develop. A high-phosphate diet may lower serum calcium. Follow-up laboratory tests are important to be sure the calcium level is normal. D. Hypoparathyroidism will not alter iron stores; increased intake of iron-rich foods is not necessary.

The nurse is reinforcing teaching provided to a patient with chronic kidney disease who is receiving hemodialysis three times a week at a hemodialysis center. Which statements should be included? (Select all that apply.) a. You may feel weak and fatigued after the treatment. b. You may not be able to eat before the treatment session. c. You will need to be weighed before and after the session. d. Your medication schedule will be the same on dialysis days. e. Report any numbness, swelling, redness, or drainage from the dialysis access site. f. You may experience some bleeding from the puncture site or a nosebleed. Report it if it doesnt stop within a few minutes.

A, B, C, E, F Rationale Sessions cause fatigue and the need to rest. Eating may not be possible for some patients as digestion of food causes blood diversion to the gastrointestinal (GI) tract which can drop blood pressure as fluid is removed during dialysis. Weight must be monitored to determine effect of treatment. Side effects must be reported at the access site and if bleeding from the heparin occurs. D. Medications such as hypertensives may need to be held before dialysis.

The nurse is reviewing the goals and recommendations of the American Diabetes Association (ADA) prior to planning a patients care. What should the nurse keep in mind for this patient? (Select all that apply.) a. Aspirin therapy b. Yearly flu vaccine c. Hemoglobin A1c less than 7% d. Blood pressure less than 150/90 mm Hg e. Statin therapy for patients over 40 years old f. Peak postprandial capillary glucose less than 180 mg/dL

A, B, C, E, F Rationale The ADA recommends all of the goals. D. Blood pressure should be less than 140/80 mm Hg.

The nurse is teaching a patient about the HbA1c laboratory test. Which patient statements indicates teaching has been effective? (Select all that apply.) a. The test shows long-term blood sugar control. b. This test can be used to help diagnose diabetes. c. The test can be done in the physicians office while Im waiting. d. The test looks back at blood sugar averages over the past 6 months. e. If I eat anything with sugar in it the day before the test, it will show up on the test. f. This test can help determine if my treatment plan is managing my diabetes effectively.

A, B, C, F Rationale The hemoglobin A1c is used to gather baseline data and to monitor progress of diabetes control. In 2009, the American Diabetes Association (ADA) also changed its guidelines to include the HbA1c as a diagnostic test for diabetes. It also assists in determining the degree of effectiveness of a patients treatment plan. Newer methods allow this test to be done in a physicians office while the patient waits. D. E. It reflects the average blood glucose level for the previous 2 to 3 months.

A patient has the nursing diagnosis of Deficient Fluid Volume related to anorexia, nausea, vomiting, and excessive T-tube drainage related to cholecystitis. Which interventions should the nurse recommend be included in the plan of care? (Select all that apply.) a. Monitor skin turgor. b. Administer antiemetics as ordered. c. Clamp T-tube for 2 hours each shift. d. Monitor daily weight and intake and output. e. Encourage use of incentive spirometer every hour while awake. f. Contact the physician if T-tube drainage is greater than 150 mL within 24 hours of surgery

A, B, D Rationale Daily weights, intake and output, and skin turgor are good measures of fluid balance. Antiemetics will help reduce vomiting and contribute to fluid balance. F. About 500 to 1000 mL of yellowish-green bile is common within the first 24 hours after surgery. C. Clamping the T-tube is inappropriate and may put pressure on the surgical site. E. Use of incentive spirometer contributes to oxygenation status and not deficient fluid volume.

The nurse is monitoring a patient with chronic kidney disease. Which findings should the nurse realize indicates fluid overload? (Select all that apply.) a. Periorbital edema b. Crackles in the lungs c. Postural hypotension d. Increased blood pressure e. Decreased pulse pressure f. Auditory wheezes on inspiration

A, B, D Rationale Neck vein distention, periorbital edema, hypertension and crackles in the lungs are symptoms of fluid overload. C. E. F. Postural hypotension, decreased pulse pressure, and auditory wheezes on inspiration are not manifestations of fluid overload.

The nurse is caring for a patient who has a nursing diagnosis of acute postoperative pain after a gastrectomy. The patient has a nasogastric (NG) tube. What interventions should the nurse implement? (Select all that apply.) a. Encourage total bedrest. b. Monitor NG tube functioning. c. Reposition NG tube once a shift. d. Provide pain medication as ordered. e. Start a regular diet once bowel sounds are detected. f. Evaluate pain regularly and report changes to the RN.

A, B, D Rationale Pain should be monitored and evaluated hourly while awake. Maintaining NG tube function prevents distention and pain due to pressure on the suture line. Giving pain medication as needed is essential. C. The nurse does not reposition the NG tube after gastric surgery, and it would not be repositioned once a shift. A. The patient should be up and ambulating as soon as ordered to prevent complications. E. After removal of the NG tube, clear fluids may be ordered with progression to full liquids, soft food, and then a regular diet as the patient tolerates.

The nurse determines that a patient with severely bleeding wounds does not have an adequate airway. What should the nurse do to help this patient? (Select all that apply.) a. Insert an oral airway. b. Insert a nasal airway. c. Apply 100% oxygen via face mask. d. Prepare for endotracheal intubation. e. Attempt the head tilt/chin lift method.

A, B, D, E Rationale A compromised airway must be treated immediately with the head-tilt/chin-lift method, an oral or nasal airway, or endotracheal intubation. C. Applying 100% oxygen via face mask will not be effective if the patient does not have an airway.

The nurse is caring for a patient recovering from an endoscopic retrograde cholangiopancreatography (ERCP). Which findings should the nurse report to the charge nurse immediately? (Select all that apply.) a. Nausea and vomiting b. Onset of a fever and chills c. Urine output 100 mL the last hour d. Heart rate of 110 beats per minute e. Increased right upper quadrant pain

A, B, D, E Rationale After an ERCP the nurse should report nausea and vomiting, onset of fever and chills, rapid heart rate, and increased right upper quadrant pain which could indicate an infection or perforation of the pancreas. C. Urine output of 100 mL the last hour would not need to be reported to the charge nurse.

The nurse is assisting to prepare dietary teaching for a patient with diverticulosis. Which food items should the nurse suggest be added to this patients teaching plan? (Select all that apply.) a. Peas b. Salad c. Cheese d. Prunes e. Raisins

A, B, D, E Rationale Dietary considerations for a patient with diverticulosis (without evidence of inflammation) include foods that are soft but high in fiber, such as prunes, raisins, and peas. Unprocessed bran can be added to soups, cereals, and salads to give added bulk to the diet. Fiber should be in-creased in the diet slowly to prevent excess gas and cramping. C. Cheese can cause constipation and should be avoided.

The nurse is teaching a patient newly diagnosed with ulcerative colitis about triggers for exacerbation of the disease. What should the nurse urge the patient to do to prevent a future exacerbation? (Select all that apply.) a. Do not use tobacco b. Reduce exposure to stress c. Restrict fluids to 2 liters per day d. Read food labels to avoid food additives e. Avoid ingesting foods sprayed with pesticides

A, B, D, E Rationale Environmental agents such as pesticides, tobacco, radiation, and food additives may precipitate an exacerbation. Diet or psychological stress may trigger or worsen an attack of symptoms. C, There is no need for the patient to restrict fluids.

A patient is upset to learn that an occult blood test of a stool specimen was positive for blood. What should the nurse assess in this patient to determine if the results were falsely positive? (Select all that apply.) a. Ingestion of fish b. Use of aspirin or NSAIDs c. Recent intake of whole milk and cheese d. Ingestion of red meat three days before the test e. Recent dental procedure causing bleeding gums

A, B, D, E Rationale False-positive occult blood results can occur with bleeding gums following a dental procedure; ingestion of red meat within 3 days before testing; ingestion of fish, and use of drugs, including aspirin and NSAIDs. C. Whole milk and cheese are not identified as causing a false positive occult blood test of a stool specimen.

The nurse is contributing to a patients plan of care. Which foods should the nurse recommend to be avoided or used with caution to reduce the possibility of ileostomy blockage? (Select all that apply.) a. Celery b. Apples c. Potatoes d. Dried fruits e. Mushrooms f. Broiled chicken

A, B, D, E Rationale Foods that can cause ileostomy blockage include celery, apples, dried fruits, and mushrooms. C. F. Potatoes and chicken are not identified as causing ostomy blockages.

While collecting data, the nurse suspects that a patient is experiencing renal calculi. What did the nurse assess to come to this conclusion? (Select all that apply.) a. Nausea b. Flank pain c. Fever and chills d. Costovertebral tenderness e. Pain radiating to the genitalia

A, B, D, E Rationale Symptoms of renal calculi include excruciating flank pain and renal colic. When a stone is lodged in the ureter, it is common to have pain radiate down to the genitalia. The pain results when the stone prevents urine from draining. The patient also may have costovertebral tenderness. Some people develop nausea because of the proximity of the gastrointestinal structures. C. Fever and chills are not manifestations of renal calculi

While collecting data, the nurse suspects that a patient is experiencing renal calculi. What did the nurse assess to come to this conclusion? (Select all that apply.) a. Nausea b. Flank pain c. Fever and chills d. Costovertebral tenderness e. Pain radiating to the genitalia

A, B, D, E Rationale Symptoms of renal calculi include excruciating flank pain and renal colic. When a stone is lodged in the ureter, it is common to have pain radiate down to the genitalia. The pain results when the stone prevents urine from draining. The patient also may have costovertebral tenderness. Some people develop nausea because of the proximity of the gastrointestinal structures. C. Fever and chills are not manifestations of renal calculi.

The nurse is participating in planning care for a patient who is experiencing nausea. Which interventions should be included in this patients plan of care? (Select all that apply.) a. Provide antiemetics as prescribed b. Ensure the environment is odor-free c. Monitor intake, output, and vital signs d. Provide oral care every 2 hours as needed e. Instruct to avoid odors or foods that precipitate nausea

A, B, D, E Rationale To provide comfort for the patient with nausea the nurse should provide antiemetics as prescribed to relieve nausea, ensure the environment is odor-free to avoid triggering stimuli, provide oral care to remove taste of emesis and enhance patient comfort, and instruct to avoid odors or foods that precipitate nausea. C. Monitoring intake, output, and vital signs would be appropriate if the patient were at risk for fluid volume deficit.

A patient with Crohns disease is scheduled for an ileoanal pouch. What should the nurse include when teaching the patient about this surgery? (Select all that apply.) a. Stool will pass through the anus. b. A temporary ileostomy is needed. c. The stool is hard and brown in color. d. An ostomy pouch will need to be worn. e. Several bowel movements occur per day.

A, B, E Rationale Because the anus and sphincter are saved, stool still passes through the anus. A temporary ileostomy is created to allow the pouch to heal. . Several bowel movements per day occur. C. The stool is of soft consistency. D. An ileoanal pouch does not require an ostomy pouch to be worn.

The nurse is reinforcing teaching provided to a patient who is being discharged with a new colostomy. Which comments by the patient indicate understanding of the discharge teaching? (Select all that apply.) a. I will empty the pouch when it is less than half full. b. I can spray deodorant into the pouch after I clean it. c. I will not be concerned if there is no stool for several days. d. Im so glad I can eat all the foods I like now, including hot dogs. e. I always check the seal and tape around the stoma after I shower. f. I should change the pouch each morning and evening to prevent infection.

A, B, E Rationale The patient should empty the pouch before it is less than half full, use a deodorant spray in the pouch, and check the stoma seal after showering. D. Ostomy patients receive a soft diet initially, progressing to a general diet as the surgeon prescribes. Stringy, high-fiber foods are avoided initially. C. Lack of stool could indicate a blockage and should be reported. F. Pouches are changed as needed, from every 3 days to every 14 days.

A patient in shock has a falling blood pressure. What should the nurse realize occurs as the sympathetic nervous system responds to falling blood pressure? (Select all that apply.) a. Blood glucose levels increase. b. Sodium and water are retained. c. Less oxygen is delivered to tissues. d. Vasodilation leads to increased fluid loss. e. Epinephrine is released from the adrenal medulla. f. Blood is shunted away from the skin, kidneys, and intestines.

A, B, E, F Rationale F. As a compensatory mechanism (fight or flight), blood is shunted away from the skin, kidneys, and intestines to supply the major organs. A. Blood glucose levels increase for energy. B. Sodium and water are retained to ensure adequate fluid volume. E. Epinephrine is released from the adrenal medulla to stimulate increased cardiac output. C. D. Vasoconstriction occurs, and the goal is to increase oxygen delivered to the tissues.

A patient is suspected of having dilutional hyponatremia. What manifestations of this disorder should the nurse expect to observe in this patient? (Select all that apply.) a. Nausea b. Headache c. Constipation d. Weak, slow pulse e. Muscle weakness f. Elevated blood pressure

A, B, E, F Rationale Manifestations of dilutional hyponatremia include bounding pulse, elevated blood pressure, muscle weakness, headache, personality changes, nausea, diarrhea, convulsions, and coma. C. D. Constipation and slow weak pulse are not manifestations of this disorder.

A patient has a history of low calcium levels. Which foods should the nurse include when teaching a patient how to increase dietary calcium? (Select all that apply.) a. Milk b. Carrots c. Spinach d. Oatmeal e. Peaches f. Cauliflower

A, C, D Rationale A. C. D. Spinach, oatmeal, and dairy products are good sources of calcium. B. E. F. Carrots, peaches, and cauliflower are not identified as foods high in calcium.

The nurse is providing teaching to a patient with reactive hypoglycemia. Which instructions related to glucose monitoring should the nurse provide? (Select all that apply.) a. It is important to check your blood sugar at bedtime. b. It is important to check blood sugar 1 hour before meals. c. You will need to check your blood sugar 2 hours after meals. d. You should check your blood sugar when you get up in the morning. e. Two hours before each meal is the best time to check your blood sugar. f. Checking your blood sugar once a day, at the same time each day, is sufficient.

A, C, D Rationale Low blood glucose may occur as an overreaction of the pancreas to eating. The pancreas senses a rising blood glucose and produces more insulin than is necessary for the use of that glucose. As a result, the blood glucose drops to below normal. Readings should be taken in the morning on arising, 2 hours after each meal, at bedtime, and during symptoms of hypoglycemia. These results may then be taken to the physician for interpretation. B. E. F. Checking blood glucose levels at these times will not help the patient control reactive hypoglycemia.

A patient is diagnosed with diabetic ketoacidosis (DKA). Which manifestations should the nurse expect to observe in this patient? (Select all that apply.) a. Dehydration b. Hypertension c. Flulike symptoms d. Kussmauls respirations e. Cheyne-Stokes respirations f. Edema associated with fluid overload

A, C, D Rationale The body attempts to compensate for acidosis by deepening respirations, thereby blowing off excess carbon dioxide. The deep, sighing respiratory pattern is called Kussmauls respirations. F. With such high blood glucose and the accompanying polyuria, the body becomes dehydrated very quickly. B. Tachycardia, hypotension, and shock can result. Acidosis also causes potassium to leave the cells and accumulate in the blood (hyperkalemia). Potassium is then lost in large amounts in the urine. The combination of dehydration, potassium imbalance, and acidosis causes the patient to develop flulike symptoms, including abdominal pain and vomiting. The patient loses consciousness and death occurs if DKA is not treated. E. Cheyne-Stokes respirations are not associated with diabetes.

The nurse is caring for a patient with an elevated uric acid level. Which health problems should the nurse consider as potentially causing this patients elevation? (Select all that apply.) a. Leukemia b. Steroid use c. Malnutrition d. Kidney disease e. Use of thiazide diuretics f. Gastrointestinal bleeding

A, C, D, E Rationale An elevated uric acid level can be caused by kidney disease, malnutrition, leukemia, and use of thiazide diuretics. B. F. Elevated uric acid levels are not associated with steroid use or gastrointestinal bleeding.

The nurse is reinforcing teaching for a patient who is on a clear liquid diet. Which patient statement(s) indicates correct understanding of the foods that would be appropriate on this diet? (Select all that apply.) a. Beef broth b. Grape juice c. Apple juice d. Orange gelatin e. Tea with sugar f. Vanilla ice cream

A, C, D, E Rationale Clear liquids are liquid items that you can see through. B. F. Ice cream and grape juice are not on a clear liquid diet.

After completing a health interview the nurse is concerned that a patient is at risk for developing type 2 diabetes mellitus. What information did the nurse use to make this determination? (Select all that apply.) a. BMI 33 b. Belongs to a book club c. Mother has type 2 diabetes mellitus d. Recently was downsized from employment e. First cousin killed in an automobile crash

A, C, D, E Rationale Heredity is responsible for up to 90% of cases of type 2 diabetes. Obesity is also a major contributing factor. Often the patient with a new diagnosis of type 2 diabetes is obese, relates a family history of diabetes, and has had a recent life stressor such as the death of a family member, illness, or loss of a job. B. Belonging to a book club would not increase this patients risk of developing type 2 diabetes mellitus.

The nurse is caring for a patient recovering from a bleeding gastric ulcer. Which patient statements indicate correct understanding of beverages to avoid after treatment of a bleeding gastric ulcer? (Select all that apply.) a. Beer b. Milk c. Coffee d. Iced tea e. Lemonade f. Diet soda pop

A, C, D, F Rationale Foods known to cause discomfort such as spicy foods, carbonated drinks, caffeinated products, and alcohol, should be avoided during the healing period. B. E. There is no reason for the patient to abstain from milk or lemonade.

A patient is considering surgery to treat obesity. Which factors meet established criteria for the use of surgery in the treatment of obesity? (Select all that apply.) a. Hypertension b. Presence of gallstones c. Gross obesity for 5 years d. Psychiatric and social stability e. Body weight 50% above ideal weight f. Failure to reduce weight with other forms of therapy

A, C, D, F Rationale Patients who do not respond to medical methods of weight loss, who weigh 100 pounds over ideal body weight, or have a BMI over 40, or BMI over 35 with severe health effects as a result, might be candidates for surgical weight loss. Additional screening for psychiatric and social stability is required. B. E. Gallstones and percentage of body weight are not criteria for Bariatric surgery.

The nurse is caring for a patient recovering from an incisional cholecystectomy. Which activities should the nurse identify as having the highest priority for this patient? (Select all that apply.) a. Managing pain b. Performing leg exercises c. Coughing and deep breathing d. Ambulating early and frequently e. Choosing low-fat foods from the menu f. Encouraging use of an incentive spirometer

A, C, D, F Rationale Preventing respiratory complications is the priority as the high incision can be painful with respiration and may make the patient reluctant to cough and clear secretions. Controlling pain so the patient will be willing to deep breathe and cough and use an incentive spirometer are important. Ambulation as soon as ordered promotes lung expansion to prevent respiratory complications. B. E. These actions are important but not the highest priority.

The nurse is monitoring a patient being for septic shock. Which findings indicate that the patient is improving? (Select all that apply.) a. SpO2 94% b. pH is 7.33 c. Pulse 75 beats/minute d. Temperature 101F (38.3C) e. Blood pressure 110/90 mm Hg f. Urine output less than 25 mL/hr

A, C, E Rationale Oxygen saturation of 94%, pulse of 75 beats/minute, and blood pressure of 110/90 mm Hg all indicate that the patient is improving. F. Urine output should be 30 mL/hr to be normal. D. Normal temperature is 98.6F (37C). B. pH below 7.35 is abnormal and indicates ongoing acidosis related to shock.

A patient with fecal incontinence has an excoriated perianal region. Which interventions should be discussed with the RN? (Select all that apply.) a. Stool culture b. Antibiotic therapy c. Protective barrier cream d. Baby powder to peri area e. A low-pressure rectal tube f. Nasogastric (NG) tube to suction

A, C, E Rationale Research supports the use of the Flexi-Seal Management Systema soft silicone tube with a low-pressure balloon at the end inserted into the rectum. Stool cultures are appropriate to identify the presence of an infectious agent. Protective barrier cream is recommended to protect the skin from digestive enzymes. F. NG tube to suction is not necessary, although bowel rest with NPO status may be ordered. D. Baby powder will not promote healing or protect the skin. B. Antibiotics will not be ordered until stool specimen results indicate an infectious agent.

The nurse reinforces teaching provided to a patient with constipation and straining who is experiencing abdominal distention and intestinal rumbling. What should be included in the teaching? (Select all that apply.) a. Set a time for defecation every day. b. Increase the intake of foods containing vitamin K. c. Increase intake of fiber, especially bran, in the diet. d. Sit on the toilet with feet planted firmly on the floor. e. Drink water each morning and about 2 to 3 L throughout the day. f. Use enemas and rectal suppositories if constipation persists after 2 days.

A, C, E Rationale The patient should be encouraged to establish a time for defecation each day. The patient should increase the intake of fiber and drink water in the morning and throughout the day. D. Placing feet on a footstool to promote flexion of the hips aids defecation. F. Enemas and rectal suppositories are used only in extreme cases and are discontinued when an acute episode is resolved. B. Vitamin K does not help with constipation.

The nurse is reinforcing teaching for a patient who has hepatitis. Which functions of the liver should the nurse include in the teaching? (Select all that apply.) a. Form bilirubin b. Produce white blood cells c. Synthesize clotting factors d. Store sodium and potassium e. Synthesize essential amino acids f. Phagocytize worn red blood cells

A, C, F Rationale The liver forms bilirubin, synthesizes clotting factors, and phagocytizes worn out red blood cells. B. D. E. These actions are performed by other body organs or functions.

The nurse is contributing to the teaching plan for another nurses team of patients. Which patients should the nurse expect to be scheduled for an upper GI series? (Select all that apply.) a. A 45-year-old with a suspected hiatal hernia b. A 19-year-old with symptoms of appendicitis c. A 52-year-old with a family history of polyps d. A 78-year-old who has frank blood in his stool e. A 65-year-old who is receiving treatment for hemorrhoids f. A 33-year-old who is experiencing symptoms of pyloric stricture

A, C, F Rationale Upper GIs are used to detect such things as strictures, ulcers, tumors, polyps, hiatal hernias, and motility problems in the upper GI tract. E. Hemorrhoids are not detected or treated with an upper GI series. B. Appendicitis is not detected with an upper GI series. D. Frank blood in the stool is indicative of a lower GI problem.

A patient is admitted to the hospital with new-onset diabetes insipidus. Which nursing diagnoses should the nurse include in the plan of care? (Select all that apply.) a. Risk for Deficient Fluid Volume b. Risk for Injury related to fractures c. Risk for Injury related to hypertension d. Knowledge Deficit related to disease process e. Impaired Gas Exchange related to decreased oxygenation

A, D Rationale Diabetes insipidus causes excessive urination and fluid loss. C. Hypotension, not hypertension, would more likely be related to fluid loss. B. E. Bone fracture and impaired gas exchange are not related to diabetes insipidus.

The nurse notes it is time to administer prescribed gentamicin (Garamycin) for a patient with acute kidney injury and suspected streptococcal pneumonia. Which action should the nurse take at this time? (Select all that apply.) a. Hold medication. b. Administer drug as ordered. c. Administer half of the prescribed dose. d. Consult physician about medication order. e. Flush the tubing with heparin before infusing.

A, D Rationale The medication should be held until the physician can be consulted about the medication order, as this is a nephrotoxic agent and the patient already has renal damage. Another agent will likely be ordered. B. The medication should not be provided as ordered. C. The nurse cannot alter the prescribed dose of the medication. E. The tubing does not need to be flushed with heparin before administering this medication.

The nurse is caring for a patient of Mexican American descent who is experiencing diarrhea. Which foods should the nurse expect the patient to select for the next days meals? (Select all that apply.) a. Fish b. Beef c. Cheese d. Chicken e. Fresh Fruit

A, D, E Rationale Diarrhea is considered a hot disease and would be treated by eating cold foods such as fish, chicken, and fresh fruit. B. C. These food items are considered hot substances, used to treat cold health problems

A patient with morbid obesity is admitted to the hospital for leg wounds. Which observations should the nurse expect when collecting data from this patient? (Select all that apply.) a. BMI 41 b. Hyper-excitable c. Lethargy and malaise d. Shortness of breath with walking e. Body weight 120 lbs over ideal weight

A, D, E Rationale Obesity that interferes with activities of daily living such as breathing or walking is considered as being morbid obesity. Morbid obesity refers to people whose BMI is above 40, which is about 100 lb overweight for men and about 80 lb overweight for women. B. Hyper-excitable is not a manifestation of morbid obesity. C. Lethargy and malaise are not identified as manifestations of morbid obesity.

The nurse is reinforcing teaching provided to a patient with polycystic kidney disease. Which patient statements indicate a correct understanding of the teaching? (Select all that apply.) a. It is a hereditary disease. b. It affects women more than men. c. Symptoms appear in early childhood. d. Genetic counseling is appropriate for individuals with this diagnosis. e. There is no effective treatment to stop the progression of the disease. f. It is characterized by the formation of multiple grapelike cysts in the kidney.

A, D, E, F Rationale Polycystic kidney disease is a hereditary disorder that can result in kidney disease. Because this is a hereditary disorder, genetic counseling is appropriate. There is no treatment to stop the progression of polycystic kidney disease. Polycystic kidney disease is characterized by formation of multiple cysts in the kidney that can eventually replace normal kidney structures. B. The disease affects men and women equally. C. The patient generally first shows signs of the disease in adulthood.

The nurse is caring for a patient with type 2 diabetes mellitus. Which symptoms should the nurse recognize as indicating the patient is experiencing a Somogyi effect? (Select all that apply.) a. Patient reports night sweats. b. Bedtime glucose is 110 mg/dL. c. Fasting morning glucose is 80 mg/dL. d. Fasting morning glucose is 264 mg/dL. e. Patient complains of headaches in the morning. f. Blood glucose is rising despite increased doses of insulin.

A, D, E, F Rationale The Somogyi effect may be at fault when the patients blood glucose seems to be rising in spite of increasing insulin doses. If insulin levels are too high, the blood glucose may drop too low, stimulating release of counterregulatory hormones (epinephrine, glucagon, corticosteroids, growth hormone) that then elevate the blood glucose. The low glucose levels often occur during the night, and the patient may report night sweats or morning headaches. The high morning glucose is then interpreted as hyperglycemia, and the insulin dose may be further increased, compounding the problem. B. C. These are not manifestations of the Somogyi effect.

The nurse is reinforcing teaching provided to a patient about caring for a new fistula in the left arm for dialysis. Which patient statements indicates correct understanding? (Select all that apply.) a. Do not sleep on my arm. b. Keep my arm elevated at all times. c. Keep a firm bandage on my arm. d. Wear loose clothing on my left arm. e. Avoid carrying heavy things with my left arm. f. Do not allow blood pressures to be taken on my left arm.

A, D, E, F Rationale The fistula must be protected from clotting. This would be done by not sleeping on the arm, wearing loose clothing, avoiding carrying heavy items with the arm, and not permitting blood pressure to be assessed on the arm. B. C. The arm does not need to be elevated or have a firm bandage applied.

The nurse is reinforcing teaching provided to a patient about appropriate diet modifications to help prevent exacerbations of inflammatory bowel disease. Which patient statements indicate that teaching has been effective? (Select all that apply.) a. I should avoid caffeine and spicy fiber foods. b. I should avoid concentrated sweets and starches. c. It is important to eat more whole grains and bran. d. High-fiber foods should not be included in my diet. e. I should increase my intake of fresh fruits and vegetables. f. Milk and other dairy products should be limited in my diet.

A, D, F Rationale High-fiber foods, caffeine, spicy foods, and milk products are avoided with inflammatory bowel disease. B. C. E. These items can be safely consumed by the patient with inflammatory bowel disease.

The nurse is reviewing structures within the hepatobiliary system with a patient with liver disease. Which structures should the nurse identify as being a part of this system? (Select all that apply.) a. Liver b. Colon c. Jejunum d. Bile duct e. Esophagus f. Gallbladder

A, D, F Rationale The liver, bile duct, and gallbladder make up the hepatobiliary system. B. C. E. These organs are a part of the GI system.

The nurse is contributing to a patients plan of care. Which patients should the nurse recommend as benefiting from PN? (Select all that apply.) a. A patient who has esophageal cancer b. A patient scheduled for toe amputation c. A patient who has just had an appendectomy d. A patient who has been admitted with chest pain e. A patient with severe burns across the face and chest f. A patient who has respiratory distress from emphysema

A, E Rationale Patients with conditions such as burns, trauma, cancer, AIDS, malnutrition, anorexia nervosa, or fever, or those undergoing major surgery may need PN. The patient with esophageal cancer or burns across the face and chest may have difficulty swallowing and need nutritional support via PN. B. C. D. F. These patients may not necessarily benefit from PN.

The nurse is caring for a patient with kidney disease. How should the nurse end a 24-hour urine test at the end of the 24 hours? a. The final voiding before 24 hours is discarded. b. The patient voids at the end of 24 hours, adding it to the collection container. c. One hundred milliliters of collected urine is placed into a specimen cup and sent to the laboratory. d. The patient voids, and the first and last specimens from 24 hours are sent to the laboratory.

B

The nurse is caring for a patient who has a nasogastric tube in place following gastric surgery. Why should the nurse use normal saline to irrigate the nasogastric tube? a. It decreases electrolytes. b. It maintains electrolytes. c. It maintains fluid volume. d. It increases fluid volume.

B Normal saline is used for irrigation to prevent electrolyte loss and imbalance. A. C. D. Irrigating a nasogastric tube with normal saline is not done to decrease electrolytes, maintain fluid volume, or increase fluid volume.

A patient asks what can be done to prevent long-term complications of diabetes. What should the nurse respond to this patients question? a. Regularly inspect feet. b. Carefully control blood glucose. c. Limit fluids to prevent stress to kidneys. d. Keep orange juice with sugar available at all times.

B Rational Over time, chronic hyperglycemia causes a variety of serious complications in persons with diabetes. The Diabetes Control and Complications Trial showed that individuals with type 1 diabetes who maintain tight control of blood glucose experience fewer long-term complications than individuals who take traditional care of their diabetes. A. Feet should be inspected daily, but this is not the most important strategy to prevent complications. C. Fluids are only limited in patients who already have end-stage nephropathy. D. Orange juice (without sugar) is good to have on hand but will not prevent long-term complications.

After a thyroid scan, a patient is diagnosed with a hot nodule. What should this finding suggest to the nurse? a. The nodule is malignant and a thyroidectomy is necessary. b. The nodule is benign and may need a biopsy to confirm the diagnosis. c. The nodule is malignant and chemotherapy must be started immediately. d. The nodule is benign but will be treated with chemotherapy and radiation.

B Rationale A hot nodule indicates a benign tumor. A fine-needle aspiration biopsy confirms the diagnosis. A. C. If the thyroid scan shows a cold nodule, the tumor is malignant. D. Chemotherapy and radiation are not used to treat a hot benign tumor.

A patient is being evaluated for renal dialysis. What creatinine clearance value should the nurse realize this patient must have to live without needing dialysis treatments? a. 5 mL b. 10 mL c. 20 mL d. 50 mL

B Rationale A minimum creatinine clearance of 10 mL per minute is needed to live without dialysis. A. The patient would need dialysis for this value. C. D. The patient can live without dialysis with these values however they are not the minimum value to live without dialysis.

A patient being seen for diabetes at an outpatient clinic has a hemoglobin A1c level of 14%. On what conclusion should the nurse base further assessment? a. The patient has not been following the treatment regimen at home. b. The patients blood glucose levels have been elevated for the last 2 to 3 months. c. The patient may have had numerous hypoglycemic episodes during the last month. d. The patient generally adheres to the treatment regimen but has had increased carbohydrate intake in the last 3 months.

B Rationale A normal HbA1c is 4% to 6%. Glucose in the blood attaches to hemoglobin in the red blood cells, which live about 3 months. When the glucose that is attached to the hemoglobin is measured, it reflects the average blood glucose level for the previous 2 to 3 months. A. C. D. The result simply shows that glucose has been high, not the reason behind it.

The nurse is caring for a patient who has not been diagnosed with diabetes. Which serum glucose result should the nurse expect on routine laboratory work? a. 45 mg/dL b. 88 mg/dL c. 115 mg/dL d. 270 mg/dL

B Rationale According to the American Diabetes Association a normal plasma glucose level is less than 100 mg/dL. A. This is considered hypoglycemia. C. If the fasting plasma glucose is between 100 and 125 mg/dL, the patient has prediabetes. D. A value over 126 mg/dL is diabetes.

A patient is admitted with suspected septic shock. Which action should the nurse take first? a. Obtain patient temperature. b. Insert an IV access device. c. Determine if the patient has any medication allergies. d. Reassure the patient that everything possible will be done.

B Rationale After ensuring a patent airway, the priority treatment interventions are providing cardiovascular support to maintain systolic blood pressure at least at 90 mm Hg. IV access is critical to provide fluids first and then antibiotics. D. Reassuring the patient is not the first priority. A. C. Septic shock is related to infection, so obtaining a temperature and determining medication allergies, as antibiotics will be given, will take place after the IV is started

A patient is prescribed furosemide (Lasix). Which electrolyte should the nurse monitor carefully because of this medication? a. Calcium b. Potassium c. Phosphate d. Magnesium

B Rationale All the listed electrolytes may be lost with furosemide therapy, but the one of most concern is potassium, as it can cause cardiac complications when out of balance.

A patient in shock is diagnosed with metabolic acidosis. What should the nurse realize as being the mechanism behind the development of this acid-base imbalance? a. Excessive aerobic metabolism b. Excessive anaerobic metabolism c. Decreased anaerobic metabolism d. Release of cortisol and glucagon

B Rationale Anaerobic metabolism results in the production of lactic acid as an unwanted by-product. Unless the lactic acid can be circulated to the liver and removed from the bloodstream, the blood will become increasingly acidic. A. Metabolic acidosis will not develop in the presence of aerobic metabolism. C. Decreased anaerobic metabolism will not cause metabolic acidosis to develop. D. The release of cortisol and glucagon ensures the body tissues receive fuel because of the shock.

The nurse is caring for a patient admitted with a possible bowel obstruction. Which patient symptom should cause the nurse the most concern? a. Flank pain b. Fecal vomiting c. Watery diarrhea d. Occult blood in the stool

B Rationale As a bowel obstruction becomes more extreme, peristaltic waves reverse, propelling the intestinal contents toward the mouth, eventually leading to fecal vomiting. A. Flank pain is not associated with a bowel obstruction. C. Watery diarrhea would not be present with a bowel obstruction. D. Occult blood in the stool is not present with a bowel obstruction.

A patient receiving tube feedings at 50 mL/hour has a residual volume of 250 mL of undigested tube feeding. What action should the nurse take? a. Discard aspirated tube feeding, and run tube feeding as ordered by the physician. b. Report amount of aspirated tube feeding to the RN for consultation with the physician. c. Return aspirated tube feeding to the patient, and run feeding at a slower rate of 20 mL/hour. d. Return aspirated tube feeding to the patient, and wait 2 hours before restarting tube feeding at 50 mL/hr

B Rationale As the residual amount is more than 100 mL or the amount specified by the agency or physician, the RN and the physician are notified, and the feeding will likely be stopped to prevent vomiting or aspiration. A. C. D. The nurse should not continue this tube feeding because of the risk of vomiting or aspiration.

The nurse is collecting data from a patient with kidney disease. Which adventitious lung sound should the nurse recognize as being caused by fluid overload? a. Stridor b. Crackles c. Wheezes d. Pleural friction rub

B Rationale Assessment of vital signs, lung sounds, edema, daily weights, and intake and output can provide valuable data related to urinary function. Fluid retention in the lungs is manifested as crackles, which are popping sounds heard on inspiration and sometimes on expiration. C. Wheezes might be heard however do not necessarily indicate fluid overload. A. D. Stridor and pleural friction rub are not heard in fluid overload.

A patient with a history of renal failure is admitted to the hospital because of decreasing urine output and a potassium level of 5.9 mEq/L. Which food should the nurse teach the patient to avoid? a. Gelatin b. Potatoes c. Zucchini d. White bread

B Rationale B. A potassium level of 5.9 is high (nl 3.5 to 5 mEq/L). Since potatoes are high in potassium, this is the food that the nurse should instruct the patient to avoid. A. C. D. These food items are not high in potassium.

The nurse is preparing to provide a patient with an IV fluid that has a lower osmolarity than blood. Which type of fluid should the nurse document that the patient is going to receive? a. Isotonic b. Hypotonic c. Hypertonic d. Hydrophobic

B Rationale B. A solution that has a lower osmolarity than blood is called hypotonic. A. A fluid that has the same osmolarity as the blood is called isotonic. C. Hypertonic solutions exert greater osmotic pressure than blood. D. A substance that is hydrophobic does not dissolve in water.

The nurse is reviewing the composition of the body cells with a young adult patient admitted for treatment of type 1 diabetes mellitus. The nurse should teach the patient that which of the following is an approximate percentage of water in the young adult body? a. 50% b. 60% c. 70% d. 80%

B Rationale B. Approximately 60% of a young adults body weight is water. A. Older adults are less than 50% water. C. D. Infants body composition is between 70% and 80% water

A patient is prescribed an electrolyte replacement. How should the nurse explain the purpose of an electrolyte to the patient? a. Any substance that enhances a chemical reaction b. A chemical that can conduct electricity when dissolved in water c. A substance that uses electrical current to attach to receptor sites d. A substance secreted by a gland and carries messages to target tissues

B Rationale B. Electrolytes are chemicals that can conduct electricity when dissolved in water. Examples of electrolytes are sodium, potassium, calcium, magnesium, acids, and bases. A. A substance that enhances a chemical reaction is a catalyst. C. A substance that uses electrical current to attach to receptor sites does not define any substance having to do with an electrolyte. D. A substance secreted by a gland that carries messages to target tissues is a hormone

A patient has been prescribed furosemide (Lasix). Which foods should the nurse recommend the patient consume while taking this medication? a. Eggs and broths b. Potatoes and fruits c. Breads and cereals d. Pasta and cream soups

B Rationale B. Lasix is a potassium-wasting diuretic, so the patient is at risk for hypokalemia. Potatoes and fruits are high in potassium. A, C, and D are not high-potassium foods.

The nurse instructs a patient on how to safely take 20 mEq of an oral potassium supplement. Which patient statement indicates that teaching has been successful? a. I should crush the potassium tablets. b. I should mix this medication in 4 ounces of juice. c. I should use a salt substitute while taking this medication. d. I should expect to be nauseated and vomit when taking this medication.

B Rationale B. The medication should be diluted in the recommended liquid. The amount of fluid to use for dilution is most commonly 4 ounces of fluid to 20 mEq of potassium. A. Potassium tablets should not be crushed. C. Salt substitutes should not be used while taking this medication. D. Nausea and vomiting should be reported to the health care provider.

A patient develops an irregular heart rate, abdominal cramping, and diarrhea after a thyroidectomy. Which emergency medication should the nurse anticipate being prescribed for this patient? a. Furosemide (Lasix) b. Calcium gluconate c. Potassium chloride d. Diazepam (Valium)

B Rationale B. These are initial signs of hypocalcemia, which can occur with accidental removal of the parathyroid glands during thyroidectomy. A, C, and D will not raise serum calcium levels

While assessing an older adult patient with fluid excess, the nurse notes the following: T = 98.6F, P = 92, R = 18, BP = 166/88 mm Hg, bilateral crackles, oxygen saturation = 95%. Which action should the nurse take first? a. Provide oxygen at 2 L per nasal cannula. b. Place the patient in a high Fowlers position. c. Provide a urinal and encourage the patient to void. d. Lay the patient flat in bed to listen to bowel sounds.

B Rationale B. To facilitate ease in breathing, the head of the patients bed should be in semi-Fowlers or high Fowlers position. These positions allow greater lung expansion and thus aid respiratory effort. A. Oxygen is not necessary at this time, as the pulse oximeter reading is within normal limits. C. Voiding will not relieve fluid overload in the absence of diuretic therapy. D. Laying the patient flat in bed may cause dyspnea.

A patient is newly diagnosed with acromegaly. Which nursing diagnosis should the nurse identify as being appropriate for this patient? a. Imbalanced Nutrition b. Body Image Disturbance c. Ineffective Airway Clearance d. Risk for Complications related to fluid imbalance

B Rationale Body image disturbance is likely due to changes in physical appearance. A. C. D. Airway clearance, nutrition, and fluid balance are not directly affected.

While providing care for a patient who has recently completed chemotherapy for colorectal cancer, the nurse notes the patient has an elevated carcinoembryonic antigen (CEA) level. How should the nurse interpret this test result? a. The patient is cured. b. The patient has a residual or recurrent tumor. c. The liver has been damaged by chemotherapy. d. The patient should be placed in protective isolation.

B Rationale CEA and carbohydrate antigen 19-9 are markers used to monitor gastrointestinal (GI) cancer treatment effectiveness and detect recurrence. A. An elevated level does not indicate that the patient is cured. C. An elevated CEA level would not be seen in the absence of disease and does not indicate liver function. D. Extremely low white blood cell counts would be used to determine if the patient needed to be placed in protective isolation.

The nurse is collecting data from a patient with suspected cancer of the bladder. What finding should the nurse recognize as the most common symptom of cancer of the bladder? a. Pain b. Hematuria c. Urine retention d. Burning on urination

B Rationale Cancer of the bladder usually causes painless hematuria. A. C. D. Pain, urine retention, and burning on urination are not the most common symptoms of bladder cancer.

The nurse is caring for a patient who is scheduled for a cystoscopy (C&P) with basket extraction of a stone. What is the most important postoperative care for the nurse to provide? a. Limiting fluid intake b. Measuring urine output c. Monitoring daily weights d. Observing for acute kidney injury

B Rationale Care following a C&P includes measuring urine to make sure the patient has not developed urinary retention from swelling of the urinary meatus. A. Fluids should be encouraged. C. Daily weights is not necessary for this procedure. D. The patient is not at risk for developing an acute kidney injury.

The nurse is collecting data from a newly admitted patient. Which finding should the nurse identify as a risk factor for constipation? a. The patient does not like milk or milk products. b. The patient has had hemorrhoids for the past 5 years. c. The patient had part of the stomach removed 10 years ago because of ulcers. d. The patient has a history of breast cancer treated with chemotherapy 3 years ago.

B Rationale Causes for constipation include rectal or anal conditions such as hemorrhoids. A. Absence of milk products in the diet is not a known cause for constipation. C. Stomach surgery is not a cause for constipation. D. History of breast cancer treatment does not cause constipation.

The nurse is caring for a patient with acute pancreatitis who is vomiting. What should the nurse frequently assess in this patient? a. Skin color and pain b. Vital signs and urinary output c. Bowel sounds and body weight d. Ability to move lower extremities

B Rationale Complications of pancreatitis include cardiovascular, pulmonary, and renal failure. Monitoring vital signs and urinary output helps identify for the onset of these life-threatening complications. D. Lower extremity movement is not affected. A. Pain is expected and should be monitored, but it is not life threatening. C. Bowel sounds and body weight are also important, but changes are not as immediately life threatening as cardiovascular, pulmonary, and renal failure.

The nurse is checks the gastric pH and provides antacids as prescribed to a patient recovering from a motor vehicle crash. What is the nurse attempting to prevent by these interventions? a. Shock b. Stress ulcers c. Malnutrition d. Metabolic acidosis

B Rationale Critically ill patients may develop gastric or small intestinal stress ulcers from ischemia. The stress response to the illness causes reduced blood flow to the stomach and small intestine. A. C. D. These interventions are not done to prevent the development of shock, malnutrition, or metabolic acidosis.

The nurse is caring for a patient in mild shock. Which medication should the nurse question before providing if ordered for a patient experiencing shock? a. Benadryl b. Morphine c. Dopamine d. Solu-Medrol

B Rationale Decreased afterload occurs from vasodilation that occurs from morphine. Shock is characterized by hypotension, so any drug such as morphine that decreases blood pressure should be avoided or used cautiously. A. C. D. Benadryl, Solu-Medrol, and Dopamine are all medications used to treat shock.

A patients urinalysis results are: white blood cells (WBC) 100+/hpf; red blood cells (RBC) 4/hpf; bacteria, moderate amount; nitrite, positive; specific gravity, 1.025; urine, cloudy. What should the nurse recognize these findings indicate? a. Dehydration b. Urinary tract infection c. Contamination from menstruation d. Contamination of the specimen from bacteria on the perineum

B Rationale Elevated WBCs, bacteria, nitrites, and cloudy urine indicate an infection. A. C. D. These findings do not indicate dehydration, contamination from menstruation, or bacterial contamination of the specimen.

A standard care plan for impaired skin integrity has been implemented for a patient with a small sore on the sole of the left foot. What action should the nurse use to evaluate the effectiveness of the plan? a. Monitor and record blood glucose levels daily. b. Assess and document the wound condition daily. c. Observe the patients ability to change the dressing. d. Assess the patients understanding of preventive foot care.

B Rationale Evaluation must address skin integrityassessing and documenting wound condition is the only response that does this. A. Monitoring glucose levels evaluates diabetes control, not skin integrity. C. D. Assessing the patients understanding or observing a dressing change evaluates the patients knowledge, not skin integrity.

A patient whose blood glucose level ranges between 150 to 200 mg/dL has an episode of hypoglycemia. Which patient activity most likely caused the hypoglycemia? a. Took a nap b. Took a bicycle ride c. Went to a birthday party d. Received news of a pay raise

B Rationale Exercise can lower blood glucose. C. D. Eating at a party or stress (such as a pay raise) can raise glucose. A. Taking a nap should not affect it.

A patient with an adrenal disorder is prescribed fludrocortisone. What is important for the nurse to monitor in this patient? a. Serum calcium levels b. Serum potassium levels c. Thyroid hormone levels d. Serum magnesium levels

B Rationale Fludrocortisone is a mineral corticoid replacement, so it will cause sodium and water retention and potassium loss. Potassium should be monitored. A. C. D. It will not directly affect calcium, magnesium, or thyroid hormone levels.

The nurse is planning care for a patient with diabetes insipidus. What data should the nurse to monitor this patient? a. Pupil responses and hand grasps b. Intake and output and daily weight c. Bowel sounds and abdominal girth d. Blood glucose before meals and at bedtime

B Rationale Fluid balance is best monitored with daily weights; intake and output may also be helpful. C. D. Bowel sounds, abdominal girth, and blood glucose are not affected. A. Neurological symptoms would occur only late in the disorder if the patient does not receive care.

The nurse is caring for a male patient with functional incontinence. What action should the nurse take to help prevent incontinence? a. Teach the patient how to do Kegel exercises. b. Ensure that the patient has ready access to the urinal. c. Teach the patient to increase the time between voiding. d. Give the patient cranberry juice to keep the urine acidic.

B Rationale Functional incontinence is the inability to reach the toilet because of environmental barriers, physical limitations, loss of memory, or disorientation, so ensuring access to a urinal is important. A. Kegel exercises are helpful with stress or urge incontinence. C. Prolonging the time between voiding is helpful for urge incontinence. D. Cranberry juice does not affect continence.

A patient with glomerulonephritis asks, How could I have gotten this? How should the nurse respond? a. Has anyone in your family had glomerulonephritis? b. Have you had a sore throat or skin infection recently? c. Glomerulonephritis almost always follows a bladder infection. d. Glomerulonephritis often results from having unprotected sex.

B Rationale Glomerulonephritis can be caused by a variety of factors but is most commonly associated with a group A beta-hemolytic streptococcus infection following a streptococcal infection of the throat or skin. A. Glomerulonephritis is not contracted from another person. C. D. Glomerulonephritis is not caused by a bladder infection or having unprotected sex.

The nurse is caring for a patient recovering from a renal biopsy. For which complication should the nurse monitor the patient during the 24 hours after the procedure? a. Polyuria b. Bleeding c. Infection d. Urinary obstruction

B Rationale Grossly bloody urine, falling blood pressure, and rising pulse are signs of bleeding and are reported immediately. A. C. D. Polyuria, infection, and urinary obstruction are not complications typically associated with a renal biopsy.

The LPN admits a well-known patient to the clinic and notes that the patients face and features seem broader and coarser. Which laboratory test should the nurse expect to be prescribed for this patient? a. Cortisol b. Growth hormone c. Glucose tolerance test d. Vanillylmandelic acid (VMA)

B Rationale Growth hormone is elevated in individuals with acromegaly (gigantism). A. C. D. The patients manifestations do not indicate the need for these laboratory tests to be prescribed.

The nurse is caring for a patient after surgery to drain a pancreatic abscess. Which action should the nurse take to monitor for complications? a. Document output. b. Monitor blood glucose. c. Monitor for hyperproteinemia. d. Review serum potassium levels.

B Rationale Hyperglycemia will occur if the insulin-producing islets of Langerhans are affected by the surgery. A. Intake and output may be recorded, but they do not directly relate to complications from surgery. C. D. Hyperkalemia and hyperproteinemia are not directly related to pancreatic surgery, although electrolyte imbalances may occur with many surgeries. Low protein level is more likely than high

A patient is admitted to the hospital with hyperosmolar hyperglycemia. The patient is 40% overweight and has a blood glucose value of 987 mg/dL. What is the priority nursing diagnosis for this patient? a. Ineffective Self Health Management b. Deficient Fluid Volume related to osmotic diuresis c. Noncompliance related to diabetes self-care regimen d. Imbalanced Nutrition: More Than Body Requirements

B Rationale Hyperosmolar hyperglycemia causes diuresis and dehydration. A. C. D. Dehydration and diuresis is more immediately life threatening than noncompliance, ineffective health management, or imbalanced nutrition.

The nurse is caring for a patient with diabetes insipidus. What type of IV fluid should the nurse expect to be ordered for fluid replacement? a. Isotonic b. Hypotonic c. Hypertonic d. Parenteral nutrition

B Rationale Hypotonic IV fluids, such as 0.45% saline, may be ordered to replace intravascular volume without adding excessive sodium. IV fluids are especially important if the patient is unable to take oral fluids. A. C. Isotonic and hypertonic fluids will add sodium. D. There is no reason for this patient to be prescribed parenteral nutrition

The nurse is evaluating care provided to a patient with bulimia nervosa. Which observation indicates that addition care is required? a. Patient sits and talks with others after eating a meal b. Patient states that looking in a mirror makes her nauseated c. Patient states importance of continuing with therapy sessions d. Patient plans meals and appropriate snacks at the beginning of the day

B Rationale If looking in the mirror makes the patient nauseated, the patient is not developing a positive self-image and would need additional interventions for this area. A. Talking with others after a meal indicates that the patient is not purging after eating. C. Stating the importance of continuing with therapy sessions indicates that the patient sees the value of meeting with someone to talk about feelings and behaviors. D. Planning meals and snacks indicates the patient is not binging.

A patient 6 hours after a thyroidectomy has a temperature of 104F, pulse 144 beats per minute, respirations 24 per minute, and blood pressure 184/108 mm Hg. Which orders should the nurse anticipate being prescribed for this patient? a. Aspirin and bedrest b. Beta blockers and a cooling blanket c. Epinephrine and compression dressings d. Diphenhydramine (Benadryl) and Fowlers position

B Rationale If thyrotoxic crisis occurs, treatment is first directed toward relieving the life-threatening symptoms. Acetaminophen is given for the fever. IV fluids and a cooling blanket may be ordered to cool the patient. A beta-adrenergic blocker, such as propranolol, is given for tachycardia. A. Aspirin is avoided because it binds with the same serum protein as T4, freeing additional T4 into the circulation. C. Epinephrine will make symptoms worse. Compression dressing on the thyroid could impair the airway. D. Benadryl and Fowlers position do not address the problem.

The nurse is collecting data for a patient with acute pancreatitis. Which laboratory test result should the nurse expect? a. Decreased serum lipase b. Elevated serum amylase c. Elevated serum albumin d. Decreased serum ammonia

B Rationale In acute pancreatitis, serum amylase (normal: 80 to 180 U/dL) rises quickly and then returns to normal in 3- 5 days. A. In acute pancreatitis. serum lipase (normal: 0 to 160 U/L) may be elevated 5 to 40 times normal. C. Albumin will be low. D. Ammonia is monitored in liver disease.

While receiving report from the previous shift, the nurse is informed that a nasogastric tube was placed in a patient who has a bowel obstruction. For which reason should the nurse realize the tube was inserted? a. To feed the patient b. To relieve distention c. To administer medications d. To prevent another obstruction

B Rationale In most cases, the bowel is decompressed using a nasogastric tube, which relieves symptoms and may resolve the obstruction. A. C. D. The nasogastric tube is not inserted to feed the patient, administer medications, or prevent another obstruction.

A patient who is one day postoperative thyroidectomy reports feeling numb around the mouth and is experiencing random muscle twitches. Which intravenous (IV) medication should the nurse anticipate that the physician will prescribe? a. Iodine b. Calcium gluconate c. Potassium chloride d. Sodium bicarbonate

B Rationale In the absence of parathyroid hormone, serum calcium levels drop, and tetany results. IV calcium gluconate is given to treat acute tetany. A. C. D. Sodium, potassium, and iodine will not help restore calcium level.

The nurse is collecting data from a patient who is scheduled for an ileostomy. Which technique should the nurse use to help identify optimal stoma placement? a. Palpation b. Inspection c. Percussion d. Auscultation

B Rationale Inspection is observation. The abdomen is visually inspected to note the condition of the skin, the contour, belt line, and other factors that would affect optimal stoma placement. A. C. D. These techniques of data collection would not be appropriate when determining optimal placement for a stoma.

A patient being treated with rosiglitazone (Avandia) for type 2 diabetes mellitus is receiving a routine follow-up assessment. In addition to hemoglobin A1c and a fasting plasma glucose test, which other laboratory test should the nurse expect to be monitored in this patient? a. Blood lipids b. Liver function tests c. Urine for microalbumin d. Complete blood count (CBC)

B Rationale Liver function must be monitored in patients taking glitazones. A. C. Lipids and microalbumin are important to monitor in any diabetic patient but are not unique to glitazones. D. CBC is nonspecific.

The nurse is contributing to a patients plan of care. For which patient would the nursing diagnosis of Risk for Constipation be most appropriate? a. A 37-year-old taking NSAIDs for bursitis b. A 59-year-old taking narcotics for chronic pain control c. A 74-year-old taking antibiotics for a urinary tract infection d. A 67-year-old taking anticoagulant therapy for a history of deep vein thrombosis

B Rationale Medications, such as narcotics, tranquilizers, and antacids with aluminum, decrease motility of the large intestine and may contribute to constipation. A. C. D. NSAIDs, antibiotics, and anticoagulants are not identified as causing constipation.

The nurse is preparing a patient for a thyroidectomy to treat hyperthyroidism. What patient statement indicates to the nurse that the patient understands the preoperative instructions? a. I know that I should avoid turning my head after surgery. b. I will probably need thyroid replacement medication after surgery. c. I will avoid taking any thyroid or antithyroid drugs before surgery. d. I will need to increase my calorie intake after surgery to avoid weight loss.

B Rationale Most patients require thyroid replacement therapy after thyroidectomy. A. Patients should be taught range-of-motion exercises, not to avoid turning the head. D. Calories will need to be reduced, not increased. C. Antithyroid drugs may be ordered to stabilize thyroid function prior to surgery.

The nurse is collecting data from a patient with liver failure to detect encephalopathy. What instructions should the nurse give to the patient to collect this data? a. Stand with your eyes closed. b. Hold out your arms and hands. c. Kneel on your hands and knees. d. Bear down as though you were having a bowel movement.

B Rationale Neuromuscular function is monitored by asking the patient to hold his or her arms out straight in front and steady. If asterixis, or liver flap, is present, the patients hands will unwillingly dip and return to the horizontal position in a flapping motion. A. C. D. These actions do not check for encephalopathy.

The nurse is preparing to initiate a tube feeding through a patients nasogastric (NG) tube. Prior to initiating this feeding what should the nurse use to irrigate the tube? a. Sterile water b. Normal saline c. Cranberry juice d. Carbonated water

B Rationale Normal saline is used for NG tube irrigation to prevent loss of electrolytes. A. Sterile water could cause an electrolyte imbalance in the patient. C. D. Cranberry juice and carbonated water are not appropriate fluids to flush a nasogastric tube.

A patient is demonstrating signs of anaphylactic shock. What action should the nurse take first? a. Provide pain relief. b. Ensure a patent airway. c. Provide patient teaching. d. Obtain a detailed patient history.

B Rationale Patients may have symptoms including wheezing, laryngeal edema, angioedema, and severe bronchospasm, which make it essential for the nurse to ensure a patent airway first. A. C. D. The other actions may be done but are a lower priority than a patent airway.

The nurse is reinforcing teaching provided to a patient with chronic liver failure. What should the patient be instructed to help prevent injury? a. Drink plenty of clear fluids. b. Brush your teeth with a soft-bristled brush. c. Be sure to get 20 minutes of exercise daily. d. Take an aspirin a day to prevent heart complications.

B Rationale Patients with chronic liver failure often have deficient clotting factors, and a firm toothbrush can cause bleeding gums. A. C. Fluids and exercise will not prevent injury and may be contraindicated. D. Aspirin has antiplatelet properties and can increase bleeding risk.

The nurse is ready to begin a tube feeding via an NG feeding tube for a patient who is comatose. What action should the nurse take before starting the feeding? a. Listen to bowel sounds. b. Check the pH of gastric aspirate. c. Secure the NG tube with additional tape. d. Irrigate the tube with 10 mL of sterile water.

B Rationale Prior to instilling anything into the NG tube, it is essential to verify placement of the NG tube; after x-ray is performed, the preferred method of verification is to check the pH of the gastric aspirate. A. Bowel sounds can be auscultated at any time. C. The NG tube should have been secured after insertion. D. The tube is irrigated with normal saline and not sterile water.

The nurse is reinforcing teaching for a patient who is on four injections of regular insulin daily. About how many hours after each injection of insulin should the nurse teach the patient to be alert for symptoms of hypoglycemia? a. 1/2 hour b. 3 hours c. 8 hours d. 12 hours

B Rationale Regular insulin peaks in 2 to 5 hours, so blood sugar will be lowest at this time. A. C. D. Onset is a half hour, and duration is 5 to 8 hours.

A patient is experiencing respiratory distress and mild shock. In which position should the nurse place the patient? a. Prone b. Head elevated c. Trendelenburg position d. Flat with elevated foot of bed

B Rationale Respiratory distress is most life threatening and so must be addressed first. It is easier to breathe in an upright position so elevating the head of the bed should be done. A. The prone position will not facilitate oxygenation. C. D. The Trendelenburg or elevating the foot of the bed will not aid with oxygenation.

A 30-year-old patient with ulcerative colitis is scheduled for a proctosigmoidoscopy. Which finding should cause the nurse to clarify routine preparation orders with the physician? a. The patients age b. Presence of severe diarrhea c. Complaints of abdominal cramping d. Patients weight is 10% below ideal body weight

B Rationale Routine preparation with severe diarrhea can result in electrolyte imbalance. Bowel preparation may not be ordered for patients with bleeding or severe diarrhea. A. C. D. The patients age, complaints of abdominal cramping, or current weight are not contraindications for the routine preparation for this diagnostic test.

The nurse is caring for a patient with an absorption disorder. What term should the nurse use to document fat in the patients stool? a. Oleorrhea b. Steatorrhea c. Lactorrhea d. Lipidorrhea

B Rationale Steatorrhea is fat in the stool. A. C. D. These words are not used to describe fat in the stool.

A patient with hypovolemic shock is experiencing oliguria due to hemorrhage. Which should the nurse recognize as the most likely cause of the patients oliguria? a. End-stage renal failure b. Secretion of aldosterone c. Inadequate oral fluid intake d. Obstructed urinary catheter

B Rationale Stimulation of the renin-angiotensin-aldosterone system from decreased cardiac output causes vasoconstriction and retention of sodium and water to decrease further fluid loss, resulting in oliguria. A. There is no evidence to support that the patient is in end-stage renal failure. C. Since the patient is in hypovolemic shock, it is unlikely that oral fluids are being provided. D. There is not enough information to support that a urinary catheter is kinked in this patient.

The nurse notes that a patient with a history of a myocardial infarction is straining during defecation. Which response by the nurse is best? a. Be careful, you might get a headache when you push so hard. b. It is important that you not strain because it could cause damage to your heart. c. Your blood pressure gets very low when you strain like that and you could faint. d. Chronic constipation often causes a dilated colon, so it is good that you are staying empty.

B Rationale Straining to have a bowel movement (Valsalvas maneuver) can result in cardiac, neurological, and respiratory complications. If the patient has a history of heart failure, hypertension, or recent myocardial infarction, straining can lead to cardiac rupture and death. A. C. D. These responses are not appropriate for the patient with a history of myocardial infarction who is straining with a bowel movement.

A patient enters the emergency department in adrenal crisis. The patient is lethargic and vital signs are blood pressure 85/52 mm Hg and pulse 88 beats/min. Which event in the patients week most likely precipitated this crisis? a. Eating a high-fat diet b. Being laid off from a job c. Taking Tylenol for a headache d. Maintaining usual exercise of walking each night

B Rationale Stress causes a need for an increase in cortisol, the bodys stress hormone. Being laid off is a stressor. A. C. D. Tylenol, walking, and a high-fat diet are not unusually stressful.

The nurse is assisting with a group class on complications of diabetes. Which information should the nurse include as factors that can precipitate hyperglycemia? a. Skipping meals b. Stress or illness c. Frequent urination d. Drinking too much water

B Rationale Stress or illness causes release of stress hormones, which are associated with hyperglycemia. A. Skipping meals causes hypoglycemia. C. D. Thirst and urination are symptoms of hyperglycemia, not causes.

Patients are being treated in the intensive care unit for anaphylactic, septic, and neurogenic shock. For which type of shock should the nurse plan to provide care? a. Obstructive b. Distributive c. Cardiogenic d. Hypovolemic

B Rationale Subcategories of distributive shock include anaphylactic, septic, and neurogenic shock. A. Obstructive shock is caused by a blockage of blood flow in the cardiovascular circuit outside the heart. C. Cardiogenic shock is caused by heart pump failure. D. Hypovolemic shock is caused by a decrease in the circulating blood volume.

The nurse is reinforcing discharge teaching about recurrence of pancreatitis to a patient with chronic pancreatitis. What information should the nurse include? a. Periodic epigastric pain is a normal occurrence. b. Report anorexia, hyperglycemia, or weight loss. c. Recurrence of pancreatitis is unlikely to happen. d. Report jaundice, flatulence, or amber-colored urine.

B Rationale Symptoms of chronic pancreatitis include epigastric or left upper quadrant (LUQ) pain, weight loss, and anorexia. Malabsorption, fat intolerance, and diabetes mellitus occur late in the disease. D. Jaundice is a sign of liver and gallbladder disease. C. Recurrence is likely. A. Pain is not normalit is a warning sign.

As part of ongoing data collection and care of a patient in shock, the nurse notes a slowing heart rate, systolic blood pressure less than 60 mm Hg, a decreasing temperature, decreasing respiration rate, and scant urine output. These signs and symptoms should indicate to the nurse that the patient is in which stage of shock? a. Mild b. Severe c. Moderate d. Compensated

B Rationale Symptoms of decompensated shock include slowing heart rate, systolic blood pressure less than 60 mm Hg, decreasing temperature, decreasing respiration rate, and almost no urine output as compensation mechanisms have failed and death is imminent. A. C. D. These manifestations do not indicate that the patient is in mild, moderate, or compensated shock

A patient with a history of a myocardial infarction has chest pain. The patients skin color is grayish, blood pressure is 88/70 mm Hg, pulse is 116 beats/minute and irregular, and respirations are 30/minute. Which action should the nurse take? a. Place the patient supine. b. Notify the charge nurse. c. Check the urine specific gravity. d. Infuse 0.9% normal saline wide open

B Rationale The charge nurse can notify the physician so orders can be received to aid the critically ill patient. A. The supine position would hinder breathing. D. Increased fluids could overwhelm the heart. C. Urine specific gravity is used to determine fluid volume status and is not needed for this patient.

The nurse is caring for a patient with a kidney infection. When providing prescribed medications, the nurse should recall that which structure is the capillary network in each nephron? a. Corpuscles b. Glomerulus c. Renal tubules d. Bowmans capsule

B Rationale The glomerulus is a capillary network that arises from an afferent arteriole and empties into an efferent arteriole. A. C. D. These structures are not the capillary network with a nephron.

After an episode of shock, a patients laboratory results reveal elevated serum levels of ammonia and bilirubin and decreased plasma proteins and clotting factors. Which organ should the nurse recognize as being damaged from the shock? a. Heart b. Liver c. Kidneys d. Intestines

B Rationale The liver may be injured both by ischemia and by toxins created by the shock state as blood is circulated through it for cleansing. Signs and symptoms of liver injury include decreased production of plasma proteins; abnormal clotting, because clotting factor production by the liver is impaired; and elevated serum levels of ammonia, bilirubin, and liver enzymes. A. C. D. Changes in ammonia, bilirubin, plasma proteins, and clotting factors are not associated with damage to the heart, kidneys, or intestines.

The nurse is reinforcing teaching provided to a patient with a history of acute pancreatitis. Which item should the patient be instructed to avoid? a. High-sodium foods b. Alcoholic beverages c. Carbonated beverages d. Foods with preservatives

B Rationale The major cause of chronic pancreatitis in men is excessive alcohol ingestion, which causes repeated attacks of acute pancreatitis. Advise patients with acute pancreatitis from excessive alcohol ingestion that abstinence could prevent recurrence of the pancreatitis and prevent the possibility of chronic pancreatitis. A. C. D. Carbonated beverages, sodium, and preservatives do not trigger pancreatitis.

The nurse is caring for a patient on a gastrointestinal unit. Which patient statement should cause the nurse the most concern? a. My stool has been dark green and hard to pass lately. b. Lately, Ive had two or three loose, sticky black stools every day. c. Usually I move my bowels every day and the stool is light brown. d. My stool is soft and dark brown; I usually move my bowels twice a day.

B Rationale The nurse should be most concerned if there were evidence of blood loss causing black tarry stools (melena). A. Stool that is dark green and hard to pass could indicate constipation caused by an iron preparation. C. D. More information is needed before becoming concerned about these descriptions.

The nurse is contributing to the plan of care for a patient who is having an intravenous pyelogram (IVP) done to diagnose possible bladder cancer. Which intervention should the nurse recommend be included for the patient after the procedure? a. Document heart rhythm. b. Monitor creatinine level. c. Monitor arterial blood gases (ABGs). d. Review thyroid-stimulating hormone (TSH) and T4 levels.

B Rationale The nurse should monitor creatinine levels to observe for renal damage after the IVP due to the dye that is used. A. C. D. Heart rhythm, arterial blood gases, and thyroid hormone levels do not need to be monitored after an IVP.

Data collection findings for a patient include shortness of breath with crackles in the lung bases, jugular vein distention, daily weight increased by 3 pounds from yesterday, report of chest pain, blood pressure 86/40 mm Hg, pulse 132 beats/minute, and respirations 30/minute. Which order should the nurse question? a. Electrocardiogram (ECG) STAT b. 500 mL 0.9% NS over 30 minutes c. Oxygen 2 L/min via nasal cannula d. Arterial blood gases (ABGs) STAT and repeat in 1 hour

B Rationale The patient data indicates possible cardiogenic shock. This means that any fluid given may overwhelm the heart, which could lead to death. The nurse should question IV orders for a cardiogenic shock patient. A. C. D. An ECG, ABGs, or oxygen would be appropriate orders.

The nurse is helping to prepare a patient for a renal biopsy. In which position should the nurse help the patient assume? a. Sims b. Prone c. Supine d. Fowlers

B Rationale The patient is in a prone position, usually with a sandbag under the abdomen, and the biopsy is taken through the flank area. A. C. D. These positions are not appropriate when obtaining a renal biopsy.

A patient with a colostomy says, My pouch blows up like a balloon when I pass gas. What is an appropriate response by the nurse? a. Make a tiny pinhole in the top of the pouch to let air out. b. Empty the gas like you would if the pouch was full of stool. c. Peel back a tiny corner of the skin barrier to allow gas to escape. d. Remove the pouch and put on a new one when it gets too full of gas.

B Rationale The pouch should be emptied the same as emptying for stool. A. A pinhole will allow odor to escape so that should never be done. D. A new pouch is not necessary and would cost too much. C. Disrupting the skin barrier often could irritate the skin.

During an assessment, the nurse notes that a patient has crystals deposited on the skin. What should this finding indicate to the nurse? a. Gout b. Uremic frost c. Poor hygiene d. Metabolic alkalosis

B Rationale The presence of crystals on the skin is called uremic frost and is a late sign of waste products building up in the blood (uremia). When the waste products are not filtered by the kidneys or with treatment, they can come out through the skin and look like a coating of frost in the winter. A. C. D. Crystal deposits on the skin do not indicate gout, poor hygiene, or metabolic alkalosis.

On arrival in the emergency department, a patient who was in a motor vehicle accident is apprehensive, confused, and hypotensive. The patient has tachycardia, oliguria, and cool clammy skin. What should the nurse do first? a. Cover patient with warm blankets. b. Perform a rapid head-to-toe assessment. c. Obtain patients medical history from family. d. Reorient the patient to person, place, and time.

B Rationale The priority is to assess the patient in shock quickly, starting with the Cs: airway, breathing, circulation, and disability. A. Covering with blankets can occur after the initial rapid assessment is completed. C. The patients medical history can be obtained at a later time. D. The patient can be reoriented at a later time.

The nurse is collecting data for a patient with kidney disease. When reviewing a urinalysis report, which range should the nurse recognize as normal specific gravity of urine? a. 0.080 to 0.100 b. 1.002 to 1.035 c. 2.600 to 3.000 d. 4.612 to 5.030

B Rationale The usual range of specific gravity of urine is 1.002 to 1.035. A. C. D. These are not normal ranges for the urine specific gravity.

A patient with a hiatal hernia is experiencing heartburn. Which should the nurse suggest to this patient? a. Eat large meals. b. Avoid bedtime snacks. c. Sleep flat without a pillow. d. Recline 1 hour before meals.

B Rationale Treatment for hiatal hernia includes avoiding bedtime snacks. A. Small meals that pass easily through the esophagus should be eaten. C. The head of the bed should be elevated 6 to 12 inches to prevent reflux. D. Reclining for 1 hour after eating should be avoided.

The nurse is caring for a patient who is newly diagnosed with acromegaly. Which treatment does the nurse anticipate? a. Adrenalectomy b. Irradiation of the thyroid gland c. Irradiation or removal of the pituitary gland d. Administration of IV beta blockers

B Rationale Treatment of acromegaly includes irradiation or removal of the pituitary to reduce growth hormone levels. A. B. D. Adrenalectomy, beta blockers, and thyroid irradiation do not address the problem, which is in the pituitary.

The nurse is caring for a patient with cultural dietary needs. Which question should the nurse include in a cultural dietary assessment? a. What restaurants do you go to? b. Which foods do you most commonly eat? c. Which unavailable cultural foods do you prefer to eat? d. What foods are available in the country where you lived?

B Rationale Understanding cultural influences, respecting them, and assisting the patient to maintain desired cultural practices are important for nutritional maintenance. Finding out which foods the patient likes will allow for planning to include those foods in meals. A. C. D. These questions do not necessarily assess the patients cultural dietary preferences.

The nurse is identifying care to delegate to unlicensed assistive personnel. Which actions could be safely delegated in the care of a patient with fulminant liver failure? a. Evaluating the patients mental status b. Assisting with bathing and positioning c. Assessing the stool and urine for blood d. Monitoring laboratory studies for abnormal values

B Rationale Unlicensed assistive personnel can safely bathe and position a patient in liver failure. A. C. D. Assessment, monitoring, and evaluating are nursing functions and are beyond the scope of practice for unlicensed assistive personnel.

The nurse is reinforcing teaching with a patient who had a large portion of the stomach removed. Which patient statement indicates understanding of why the patient will need to receive vitamin B12 for life? a. Sickle cell anemia b. Pernicious anemia c. Iron-deficiency anemia d. Acquired hemolytic anemia

B Rationale Vitamin B12 deficiency can occur after some or all of the stomach is removed because intrinsic factor secretion is reduced or gone. Normally, vitamin B12 combines with intrinsic factor to prevent its digestion in the stomach and promote its absorption in the intestines. Lifelong administration of vitamin B12 is required to prevent the development of pernicious anemia. A. C. D. Removal of part of the stomach will not lead to the development of sickle cell anemia, iron-deficiency anemia, or acquired hemolytic anemia.

A patient is experiencing melena. What does this observation indicate to the nurse? a. The patient has a ruptured diverticulum b. The patient has ingested a large volume of red meat c. Blood has begun to seep into the stomach over the last 3 hours from esophageal varices d. Blood has been in the gastrointestinal tract for more than 8 hours after being in contact with hydrochloric acid

B Rationale When blood has been in the GI tract for more than 8 hours and has come in contact with hydrochloric acid, it causes melena, or black and tarry stools. A. B. C. These are not identified causes for the development of melena.

A patient with a duodenal peptic ulcer vomits old blood. What description should the nurse use to document the appearance of the vomitus? a. Duodenal fecal matter b. Coffee-ground particles c. Undigested particles of food d. Chyme streaked with a black syrupy material

B Rationale When blood mixes with hydrochloric acid and enzymes in the stomach, a dark, granular material resembling coffee grounds is produced. This indicates old bleeding, as fresh bleeding would be red in color. A.C. D. The nurse should not document the appearance of the patients emesis as being duodenal fecal matter, undigested food particles or a chyme mixture

A patient with gastrointestinal bleeding is awake, alert, and oriented and has vital sign measurements of: blood pressure 130/90 mm Hg, pulse 118 beats/minute, respirations 18/minute, and temperature 98.6F (37C). Which finding should the nurse consider as a possible sign of early shock? a. Respirations 18/min b. Heart rate 118 beats/min c. Temperature 98.6F (37C) d. Blood pressure 130/90 mm Hg

B Rationale When blood pressure falls, the body activates the sympathetic nervous system to increase cardiac output by causing the heart to beat faster and stronger. Compensatory responses produce the classic signs and symptoms of the initial stage of shock: tachycardia; tachypnea; restlessness; anxiety; and cool, clammy skin with pallor. A. C. D. These findings are all within normal limits and do not necessarily indicate manifestations of early shock.

A patient who is hemorrhaging has pale mucous membranes, blood pressure 92/52 mm Hg, pulse 160 beats/minute, and respirations 30/minute. The patient is receiving IV fluids at 150 mL/hour, has a blood transfusion infusing, and is being provided oxygen via a mask. What should the nurse recognize as the most likely cause of the patients respiratory rate? a. Electrolyte imbalances b. Inadequate tissue perfusion c. Rapid rate of fluid replacement d. Reaction to the blood transfusion

B Rationale When blood pressure falls, the body activates the sympathetic nervous system to increase cardiac output to deliver adequate oxygen to the tissues by causing the heart to beat faster and stronger. Compensatory responses produce the classic signs and symptoms of the initial stage of shock: tachycardia; tachypnea; restlessness; anxiety; and cool, clammy skin with pallor. A. An electrolyte imbalance will not affect the patients respiratory rate. C. The fluids should provide the body with needed volume and reduce the rapid respiratory rate. D. A blood transfusion reaction would have manifestations other than a rapid respiratory rate.

A patient asks what causes diverticulitis. How should the nurse respond? a. The lining of your colon is irritated and inflamed. b. You have little pouches in your colon that are inflamed. c. You have little outpouchings that occur in weak areas of the colon. d. The visceral and parietal membranes in your abdomen are inflamed.

B Rationale When food and bacteria are trapped in a diverticulum, inflammation and infection develop. This is called diverticulitis. A. C. D. These responses do not appropriate explain diverticulitis.

The nurse is collecting data for a patient who is taking Prevacid for peptic ulcer disease. Which data collection finding requires immediate intervention? a. A rash b. Tarry stools c. Constipation d. Changes in mental status

B Rationale With Prevacid administration, the nurse should assess for epigastric or abdominal pain and for blood in stool (tarry stools), emesis, or gastric aspirate. Notify the physician if any evidence of bleeding has occurred. A. C. D. Rash, constipation, and mental status changes are not identified adverse effects of Prevacid.

While assessing a patients abdomen, the nurse notes a yellow-tinge to the skin. How should the nurse document this finding? a. Striae b. Jaundice c. Caput medusae d. Spider angioma Multiple Response

B Rationale Yellowing of the skin is termed jaundice. A. Striae are light silver-colored or thin red lines on the skin. C. Caput medusae are bluish purple swollen vein patterns extending out from the navel. D. Spider angiomas are thin reddish purple vein lines close to the skin surface.

The nurse is reinforcing teaching provided to a patient recovering from an acute attack of cholecystitis. Which foods should the nurse caution the patient to avoid? (Select all that apply.) a. Rice b. Eggs c. Cheese d. Lean meats e. Fresh fruits

B, C Rationale Eggs and cheese are high in fat content and will stimulate gallbladder contraction. A, D, E, Fruits, lean meats, and rice are low in fat content and therefore safer for the patient to consume.

While collecting data, the nurse becomes concerned that a patient is at risk for developing liver cancer. What information did the nurse use to come to this conclusion? (Select all that apply.) a. Lives in an urban community b. Ingests four six-packs of beer each day c. Smokes two packs of cigarettes each day d. Has a history of chronic hepatitis B infection e. Employed as a remote computer operator

B, C, D Rationale Patients with a history of chronic hepatitis B infection, and heavy alcohol use or smoking have an increased risk for cancer of the liver. A. E. Home setting and employment do not increase the patients risk for developing liver cancer.

The nurse is instructing the mother of an adolescent with hepatitis on ways to prevent the spread of infection in the home. What should the nurse include in this mothers teaching? (Select all that apply.) a. Use bar soap. b. Wear rubber gloves when handling the patients used laundry. c. Wash contaminated linens separately from other family linens. d. Identify a separate bedroom and bathroom for the patient to use. e. Wash gloves with 10% bleach solution after use for cleaning the bathroom.

B, C, D, E Rationale At home and if possible, the patient with hepatitis should have a separate bedroom and bathroom. The person cleaning the bathroom should wear disposable gloves or rubber gloves and then clean the gloves with a 10% bleach solution. Contaminated linens used by a patient with hepatitis should be washed separately from household laundry and in hot water. One cup of bleach should be added with the detergent to each load. Rubber gloves should be worn to wash the patients laundry. A. The family should be advised to use liquid soap instead of bar soap.

The nurse suspects a patient is experiencing fluid volume excess. What did the nurse most likely assess in this patient? (Select all that apply.) a. Thirst b. Bounding pulse c. Shallow respirations d. Distended neck veins e. Pitting edema of the feet

B, C, D, E Rationale B. C. D. E. Manifestations of fluid volume excess include a bounding pulse and shallow respirations, distended neck veins, and pitting edema in the feet. A. Thirst is a manifestation of fluid volume deficit.

The nurse is reviewing normal kidney function with a patient experiencing an acute kidney injury. Which hormones should the nurse include that affect kidney function? (Select all that apply.) a. Estrogen b. Aldosterone c. Parathyroid hormone d. Antidiuretic hormone (ADH) e. Atrial natriuretic hormone (ANH) f. Thyroid-stimulating hormone (TSH)

B, C, D, E Rationale Hormones that affect kidney function include aldosterone, which promotes reabsorption of sodium ions from the filtrate to the blood and excretion of potassium ions into the filtrate; ADH, which promotes reabsorption of water from the filtrate to the blood; ANH, which decreases reabsorption of sodium ions, which remain in the filtrate; and parathyroid hormone, which promotes reabsorption of calcium ions from the filtrate to the blood and excretion of phosphate ions into the filtrate. A. F. Estrogen and TSH do not affect renal function.

The nursing home administrator for a skilled nursing facility is concerned because a large number of older residents are developing UTIs. What should the staff nurse explain about the development of UTIs in this population? (Select all that apply.) a. Overuse of antibiotics b. Diminished immune function c. Enlarged prostate in older men d. Presence of neurogenic bladder e. Decline in estrogen in older women

B, C, D, E Rationale Older adults have an increased incidence of UTIs due to diminished immune function and neurogenic bladder which fails to completely empty. Older men are predisposed to infection because an enlarged prostate obstructs urine flow. In older women, the decline in estrogen can also contribute to the risk of UTI. A. Overuse of antibiotics is not identified as a reason for UTI development in older patients.

A patient diagnosed with syndrome of inappropriate antidiuretic hormone is scheduled for surgery in a few days. What should the nurse expect to be prescribed for this patient to help manage the symptoms until surgery? (Select all that apply.) a. Salt restriction b. Fluid restriction c. Furosemide (Lasix) d. Conivaptan (Vaprisol) e. Hypertonic saline infusion

B, C, D, E Rationale Symptoms of SIADH can be alleviated by restricting fluids to 800 to 1000 mL per 24 hours. Hypertonic saline fluids may be administered intravenously. A loop diuretic such as furosemide (Lasix) increases water excretion. A vasopressin receptor antagonist such as conivaptan (Vaprisol) may be used to block the action of ADH in the kidney. A. Oral salt may be encouraged to maintain the serum sodium level.

A patient with type 2 diabetes mellitus is prescribed metformin (Glucophage). What should the nurse assess and monitor in this patient? (Select all that apply.) a. Weight gain b. Fluid retention c. Family history of glaucoma d. Presence of renal or hepatic disease e. Presence of congestive heart failure (CHF) f. Need for diagnostic tests involving use of contrast dyes

B, C, D, E, F Rationale Withhold if the patient is having tests involving contrast dye. It is contraindicated in renal and hepatic disease and CHF. Notify physician of early symptoms of lactic acidosis: hyperventilation, myalgia, and malaise. A. Glucophage may enhance weight loss, not gain. C. A family history of glaucoma is not a contraindication for this medication.

The nurse is contributing to the plan of care for a patient with chronic kidney disease. The nurse has recognized a growing body of evidence related to restricting protein intake. Which evidence should the nurse use to develop the plan of care? (Select all that apply.) a. Protein requirements should be based on ideal body weight. b. Increased protein is recommended for patients on hemodialysis. c. Protein calorie malnutrition should be avoided for patients on hemodialysis. d. Optimum nutritional status should be maintained for all patients with kidney disease. e. All patients with renal compromise should limit protein intake to less than 0.5 g/kg/day. f. Protein energy malnutrition is a predictor of mortality and morbidity for patients on dialysis.

B, C, D, F Rationale Protein energy malnutrition is a predictor for morbidity and mortality in patients on dialysis. For patients receiving hemodialysis, increased protein is recommended. It is advisable to avoid protein calorie malnutrition with patients on hemodialysis. Optimum nutritional status should be maintained for all patients with kidney disease. E. A protein-controlled diet is recommended or patients with kidney disease. A. Protein requirements are based on actual weight of the patient and not ideal body weight.

The nurse is preparing to administer insulin to a patient with type 1 diabetes mellitus. Which sites should the nurse consider for this injection? (Select all that apply.) a. Forearm b. Buttocks c. Abdomen d. Anterior thigh e. Ventrogluteus f. Posterior aspect of the arm

B, C, D, F Rationale The abdomen, back of the arm, buttocks, and thigh have adequate subcutaneous tissue for injection. E. The ventrogluteus is a muscle. A. The forearm does not have adequate subcutaneous tissue.

A patient is developing anaphylactic shock. What should the nurse expect to observe in this patient? (Select all that apply.) a. Polyuria b. Urticaria c. Bronchospasm d. Muscle cramps e. Laryngeal edema

B, C, E Rationale Anaphylactic shock symptoms include urticaria, pruritus, wheezing, laryngeal edema, angioedema, and severe bronchospasm. A. Decreased urine rather than increased urination would be seen in a patient in shock. D. Muscle cramps are not associated with anaphylactic shock.

While collecting data the nurse suspects a patient is experiencing manifestations of Addisons disease. What observations did the nurse make to come to this conclusion? (Select all that apply.) a. Ankle edema b. Bronzing of the skin c. Blood pressure 90/55 mm Hg d. Bruises over the upper chest and arms e. Weight loss 10 lbs from last examination

B, C, E Rationale In primary AI, increased ACTH may produce hyperpigmentation of the skin, causing the patient to have a tanned or bronze appearance. The most significant sign of Addisons disease is hypotension. Low cortisol levels cause weight loss. A. D. Ankle edema and bruising are not manifestations of Addisons disease.

The nurse is contributing to a staff education program about the risks of smoking and conditions related to smoking. Which statements by a staff member indicate correct understanding of the teaching? (Select all that apply.) a. Kidney stones b. Kidney cancer c. Bladder cancer d. Hydronephrosis e. Diabetic nephropathy f. UTI

B, C, E Rationale Smoking is a risk factor for kidney cancer. There is a strong correlation between cigarette smoking and bladder cancer. Risk factors for the development of diabetic nephropathy include hypertension, genetic predisposition, smoking, and chronic hyperglycemia. A. D. F. No correlation between UTIs, kidney stones, or hydronephrosis and cigarette smoking has been established.

A patient is diagnosed with liver failure. Which vitamin supplements should the nurse expect to be prescribed for this patient? (Select all that apply.) a. Vitamin C b. Vitamin D c. Vitamin K d. Vitamin B6 e. Vitamin B12

B, C, E Rationale The liver stores the fat-soluble vitamins A, D, E, and K and the water-soluble vitamin B12. A. Vitamin C is a water-soluble vitamin that is not stored in the liver. D. The liver does not store Vitamin B6.

The nurse is assisting in the preparation of a patient for a hypophysectomy. What should the nurse emphasize when teaching this patient? (Select all that apply.) a. Blow the nose twice a day b. Use an incentive spirometer. c. Avoid bending from the waist. d. Cough using the huff technique. e. Perform deep breathing exercises

B, C, E Rationale The nurse should emphasize that it will be important after surgery to avoid any actions that increase pressure on the surgical site, such as coughing, sneezing, nose blowing, straining to move bowels, or bending from the waist. Instruct the patient in deep-breathing exercises or use of an incentive spirometer. A. Nose blowing should be avoided. D. Because coughing can raise intracranial pressure it is contraindicated.

The nurse is caring for a patient with an indwelling urinary catheter. Which instructions should the nurse provide to help prevent development of a urinary tract infection? (Select all that apply.) a. Limit fluid intake to decrease the flow of urine. b. Position the tubing to allow free flow of the urine. c. Use aseptic technique when emptying the drainage bag. d. Wash the perineum with an antibacterial soap every 8 hours. e. Keep the catheter securely taped to prevent catheter movement. f. Empty the urinary bag every 4 hours to prevent stagnation of urine.

B, C, E Rationale The nurse should instruct to position the tubing to allow free flow of urine, use aseptic technique when emptying the drainage bag, and keep the catheter securely taped or fastened to the leg. A. Fluids should be encouraged. D. The perineum should be washed daily and prn. F. The drainage bag does not need to be emptied every 4 hours.

The nurse is collecting data for a patient with acute liver failure. Which laboratory test findings should the nurse recognize as supporting this diagnosis? (Select all that apply.) a. Elevated platelet count b. Elevated prothrombin time c. Elevated serum bilirubin level d. Elevated serum potassium level e. Elevated alanine aminotransferase level (ALT) f. Elevated aspartate aminotransferase level (AST)

B, C, E, F Rationale AST and ALT are found in high concentrations in liver cells and are released with death of liver cells. Serum bilirubin and urobilinogen may be elevated. In patients with severe hepatitis, prothrombin time may be elevated because the liver can no longer make prothrombin. A. D. Potassium and platelet counts are not directly affected.

The nurse is preparing to assess an older patient for fluid balance. Which areas of the body should the nurse use to assess for skin turgor? (Select all that apply.) a. Hand b. Sternum c. Forearm d. Forehead e. Upper thigh

B, D Rationale B. D. When assessing an older patient for skin turgor, skin over the forehead or sternum should be used. The skin over these areas usually retains elasticity and is therefore a more reliable indicator of skin turgor. A. C. E. The hand, forearm, or upper thigh are not reliable areas to assess for skin turgor.

During a health history, the nurse learns that a patient uses laxatives every day to ensure a bowel movement. What should the nurse expect to be prescribed for this patient? (Select all that apply.) a. Daily enema b. Psyllium (Metamucil) c. Daily rectal suppository d. Docusate sodium (Colace) e. Methylnaltrexone (Relistor)

B, D Rationale Chronic laxative use should be discontinued. Bulk-forming agents such as psyllium (Metamucil) or stool softeners such as docusate sodium (Colace) should be used instead of laxatives. Enemas and rectal suppositories are used only in extreme cases and are discontinued when an acute episode is resolved. Methylnaltrexone (Relistor) given subcutaneously treats opioid-induced constipation for patients receiving palliative care when other laxatives have not been effective. It does not treat other forms of constipation.

The nurse is participating in a community health fair program focusing on risk factors for cancer. Which should be included as increasing the risk for colon cancer? (Select all that apply.) a. Low-fat diet b. Low-fiber diet c. Low-sodium diet d. History of rectal polyps e. History of ulcerative colitis f. Family history of breast cancer

B, D, E Rationale A major causative agent of colon cancer is lack of fiber in the diet, which prolongs fecal transit time and in turn prolongs exposure to possible carcinogens. Additional risk factors include a family history of colon cancer, ulcerative colitis, or polyps of the rectum or large intestine. A. C. F. These factors do not increase the risk for colon cancer.

The nurse provides teaching to a patient prescribed budesonide (Entocort EC) for Crohns disease inflammation. Which patient statements indicate that more teaching is necessary? (Select all that apply.) a. I should avoid grapefruit juice. b. I must avoid the sun while taking this drug. c. I should swallow the pill whole, not crushed. d. I will take the pill each evening before going to bed. e. I can just stop taking the medication once I feel better. f. I might experience mood swings or weight gain on this medication.

B, D, E Rationale This medication does not cause photosensitivity. The medication should be taken as prescribed in the morning and not stopped when the patient feels better. A. Grapefruit juice should be avoided. C. The medication should be swallowed whole. F. Mood swings or weight gain may be noted with the medication.

The nurse is reinforcing teaching provided to a patient with a history of calcium oxalate kidney stones. The nurse recognizes that teaching has been effective if the patient avoids which foods? (Select all that apply.) a. Bread b. Cocoa c. Lettuce d. Spinach e. Chicken f. Instant coffee

B, D, F Rationale A low oxalate diet restricts foods such as beets, rhubarb, spinach, cocoa, and instant coffee. A. C. E. Bread, lettuce, and chicken do not need to be restricted on this diet.

The nurse is providing care to a patient anticipating radiation therapy for head and neck cancer. What should the nurse include in pre-therapy education? (Select all that apply.) a. Water is an appropriate substitute for saliva. b. Good oral hygiene habits are important to prevent decay. c. Tooth decay occurs less frequently when oral tissues are dry. d. It is important that you visit the dentist before radiation therapy begins. e. All of your teeth will need to be pulled before you start radiation therapy. f. Artificial saliva can be used if the radiation therapy causes drying of the mouth.

B, D, F Rationale The importance of daily and ongoing oral care should be considered for all patients. Prior to any radiation therapy of the head or neck area, a thorough oral examination and any needed restorative dental procedures should be completed. An artificial saliva substitute should be considered for patients with xerostomia (dry mouth). C. Xerostomia can lead to rampant tooth decay in older adults, putting their dentition at risk. A. Water does not contain the necessary compounds such as lubricants to protect the teeth. E. Teeth do not need to be pulled prior to radiation therapy.

A patient with hypertension is advised to follow a low-sodium diet. If chosen by the patient, which foods indicate further teaching is necessary? (Select all that apply.) a. Coffee b. Pretzels c. Lemonade d. Applesauce e. Tomato juice f. Dried black beans

B, E Rationale B. E. Low-sodium foods are those with less than 140 mg sodium per serving. Tomato juice and pretzels have more than 200 mg per serving which indicates that further teaching is needed. A, C, D, F. These foods are not as high in sodium as tomato juice and pretzels.

The nurse is collecting data for a patient with kidney disease. Which information should the nurse identify as being normal urinalysis findings? (Select all that apply.) a. pH 3.5 b. Amber color c. Small amount of nitrite d. Red blood cells of 8/hpf e. Specific gravity of 1.010 f. Small quantities of enzymes

B, E, F Rationale Straw to amber color, specific gravity 1.002 to 1.028, small quantities of enzymes, and hormones would all indicate a normal analysis finding. A. Normal pH is 4.6 to 8. D. Red blood cells should be 0 to 4/hpf. C. Nitrite is negative.

A patient is to be started on clear liquids after an appendectomy. Which food should the nurse identify as being a clear liquid? a. Oatmeal. b. Ice cream. c. Cranberry juice. d. Graham crackers.

C Rationale A clear liquid is one that can you can see through and has no pulp such as cranberry juice, apple juice, soda, or black coffee. A. Oatmeal would be permitted on a soft diet. B. Ice cream would be permitted on a full liquid diet. D. Graham crackers would be permitted on a regular diet.

The nurse is to obtain orthostatic blood pressure measurements for a patient on dialysis for end-stage renal disease. What should the nurse do when measuring this patients blood pressure? a. Take blood pressure before and after dialysis treatments. b. Check blood pressure every minute three times for four readings. c. Obtain blood pressure while the patient is lying, sitting, and standing. d. Monitor blood pressure before and after an antihypertensive medication is given.

C Rationale A drop in blood pressure accompanied by a rise in pulse rate as the patient rises to sitting or standing positions is called orthostatic or postural hypotension and may indicate fluid deficit. The nurse will check blood pressure while the patient is lying, sitting, and standing. A. B. D. These do not describe the correct approach to measure orthostatic blood pressure measurements.

The nurse is caring for a patient on a full liquid diet. The nurse recognizes that the patient understands teaching if the patient requests which food item? a. Salad b. Cheese c. Milkshake d. Hamburger

C Rationale A full liquid diet is any item that is liquid at room temperature as a milkshake would be. A. B. D. These food items are appropriate for a regular diet.

The nurse is caring for a patient following a thyroidectomy. What item is most important to have at the bedside? a. Hemostats b. Gauze dressings c. Tracheostomy set d. Suture removal kit

C Rationale A tracheostomy set is most essential in case swelling impedes the airway. A. Hemostats are not necessary. B. D. Dressings and a suture removal kit may be needed at some point, but they are not as important as airway maintenance

A patient with liver failure takes acetaminophen (Tylenol) 650 mg tablets by mouth for severe arthritis pain. How many tablets should the nurse instruct that the patient can safely take in one 24 hour period? a. 2 b. 3 c. 4 d. 5

C Rationale Acetaminophen (Tylenol) overdose is the most common cause of ALF. Acetaminophen should not exceed 3000 mg in a 24 hour period. If each tablet contains 650 mg, then divide 3000 mg/650 mg = 4.6 tablets. The patient can safely take 4 tablets of the medication in one day.

The nurse is monitoring a patient and finds a bulging area in the patients groin. Which additional finding should cause the nurse the most concern? a. The bulging disappears at times. b. The white blood cell count is 10,000/mm3. c. The patient develops pain at the site and vomiting. d. The bulging occurs when the patient coughs or strains.

C Rationale An incarcerated hernia may become strangulated if the blood and intestinal flow are completely cut off. Symptoms are pain at the site of the strangulation, nausea and vomiting and colicky abdominal pain. A. The disappearance of the bulge means the hernia can be reduced. B. An elevated white blood cell count means an infection is present. D. Bulging with coughing or straining is an indication that a hernia is present.

Despite aggressive treatment, the condition of a patient in shock continues to worsen. Surgical intervention stops the bleeding, and the shock stabilizes. Which finding should the nurse act upon immediately? a. The blood pH is 7.36. b. Bowel sounds are hypoactive. c. Urinary output is 15 mL/hour. d. Pupils are equally reactive to light.

C Rationale Because blood is shunted away from the kidneys early in shock to save fluid and provide oxygen to vital organs, the kidneys commonly are injured first. The kidneys can tolerate reduced blood flow for about 1 hour before sustaining permanent damage. Urine output should be monitored for reduction to detect injury. D. Pupils that are equally reactive to light are normal. B. Bowel sounds typically remain hypoactive after surgery. A. Acidosis is expected with shock, and a pH within normal limits is normal.

A patient recovering from GI surgery 4 hours ago is alert and oriented and complains of feeling thirsty. Diet orders read, clear liquids, advance as tolerated. Which action should the nurse take? a. Notify the RN. b. Ask the patient if she has passed any flatus. c. Allow the patient to take small sips of water. d. Inform the patient she must remain NPO (nothing by mouth) until she has bowel sounds.

C Rationale Because there is an order for liquids and the patient is stable, the nurse can provide the patient with sips of fluid. A. RN does not need to be informed prior to giving the fluids. B. D. There does not appear to be an advantage to maintaining patients NPO postoperatively until bowel function returns. If ordered, nutrition can be provided to patients undergoing GI surgery early postoperatively which may improve their recovery with fewer complications.

A student nurse is reviewing the use of intravenous (IV) fluids for a school paper. Which definition should the student use to explain the process of diffusion? a. The expenditure of energy to transport a solute b. The movement of solute and water caused by hydrostatic pressure differences c. Movement of a solute from an area of higher concentration to an area of lesser concentration d. Movement of water from an area of lesser concentration to an area of higher concentration

C Rationale C. Diffusion is a process in which a substance moves from an area of higher concentration to an area of lower concentration. D. Movement of water refers to osmosis. A. Active transport involves expenditure of energy. B. Filtration is promoted by hydrostatic pressure differences between areas.

An older adult with gastroenteritis is disoriented and weak and has the following laboratory test results: Hct 56% (normal 40% to 51%) BUN 32 mg/dL (normal 6 mg/dL to 20 mg/dL) Which nursing diagnosis should the nurse select for this patient? a. Risk for injury b. Excess fluid volume c. Deficient fluid volume d. Impaired skin integrity

C Rationale C. Elevated blood urea nitrogen (BUN) and hematocrit (Hct) show concentration due to Deficient fluid volume. B. Excess fluid volume would be associated with low BUN and Hct. A. D. Impaired skin integrity and Risk for injury are possible, but they are not indicated by the data provided.

A patient is hypoventilating and retaining carbon dioxide. On which acid-base imbalance should the nurse focus when caring for this patient? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

C Rationale C. Patients who are hypoventilating retain carbon dioxide, which combines with water in the body to form carbonic acid. Because the cause is respiratory, it is a respiratory acidosis, not a metabolic problem. A, B, and D are not associated with hypoventilation and carbon dioxide retention.

A patient with hypertension is placed on a low-sodium diet. The nurse recognizes that further teaching is necessary if the patient chooses which menu? a. Pork chop, steamed brown rice, and fruit cocktail b. Broiled salmon, mashed sweet potato, broccoli, and pumpkin pie c. Tomato soup, grilled cheese sandwich, salad, and chocolate chip cookie d. Grilled chicken, boiled potatoes, frozen green beans, and gelatin dessert

C Rationale C. Processed cheeses and canned soups are high in sodium. A. B. D. Poultry, fish, fruits, and fresh vegetables have small amounts of sodium.

The nurse is concerned that an older patient is at risk for dehydration. What reduced function did the nurse assess in this patient? a. Filtration b. Kidney function c. Sensation of thirst d. Cardiac contractility

C Rationale C. Reduced sensation of thirst causes patients to take in less water, which can be dangerous in an older patient who has reduced body water. A, B, and D can potentially increase water retention.

The nurse is testing a patient for the presence of Trousseaus sign. Which patient response should the nurse recognize as a positive result? a. Weakness of the arm b. Pain in the arm and hand c. Spasticity of the arm and fingers d. Redness of the arm below the cuff

C Rationale C. Spasticity indicates impending tetany. A. B. D. Weakness, redness, or pain may be signs of circulatory impairment but not tetany.

The nurse is reinforcing teaching provided to a patient with gallstones. What substance should the nurse instruct that makes up most gallstones? a. Sodium b. Calcium c. Cholesterol d. Phosphorus

C Rationale Cholelithiasis is the presence of stones in the gallbladder. These stones are most often composed primarily of cholesterol. B. Pigment stones appear to be composed of calcium bilirubinate, which occurs when free bilirubin combines with calcium; however, this is not the most frequent substance. A. D. Sodium and phosphorus are not primary components of gallstones.

The nurse is caring for a patient who is being screened for diverticulosis. Which patient statement indicates understanding of conditions that predispose to diverticulosis? a. Colon cancer. b. Chronic diarrhea. c. Chronic constipation. d. Diet high in red meats.

C Rationale Chronic constipation usually precedes the development of diverticulosis by many years. When the patient is chronically constipated, pressure within the bowel is increased, leading to development of diverticula. A. D. A diet high in red meat is believed to contribute to the development of colon cancer. B. Chronic diarrhea does not cause diverticulosis.

The nurse is caring for a patient who has developed esophagitis from gastroesophageal reflux disease (GERD). For which additional complication should the nurse anticipate providing care to this patient? a. Laryngospasm b. Bronchospasm c. Barretts esophagus d. Aspiration pneumonia

C Rationale Complications of GERD can result in esophagitis. Over time, this can lead to changes in the epithelium of the esophagus and lead to Barretts esophagus, a precancerous lesion. A. B. D. Laryngospasm, bronchospasm, and aspiration pneumonia are not complications typically associated with gastroesophageal reflux disease.

The nurse contributes to the plan of care for a patient with edema. Which action should the nurse take as the best indicator of this patients fluid volume status? a. Vital signs b. Skin turgor c. Daily weight d. Intake and output

C Rationale Daily weight is the single best indicator of fluid balance in the body. A. B. D. Vital signs, skin turgor, and intake and output are not the best indicators of fluid balance in the body.

The nurse is providing a patient with cholelithiasis the medication ursodiol (Actigall). What should the nurse instruct the patient about this medication? a. This medication is used prior to having surgery. b. This medication works best with a high-fat diet. c. This medication may take a few months to work. d. This medication makes sure the stones never return.

C Rationale Dissolution of small non-calcified stones (less than 2 centimeters) with the bile acid drugs ursodiol (Actigall) is used for those who are not surgical candidates. Treatment with the dissolution drugs may take months and stones may return.

The nurse is teaching a patient with diverticulosis how to avoid complications. Which patient statement indicates that teaching has been effective? a. I will avoid milk and milk products. b. I should avoid very hot and spicy foods. c. I will increase fluids and fiber in my diet. d. I should cook vegetables thoroughly before eating.

C Rationale Diverticulosis is managed by preventing constipation. Diverticulitis can be prevented by increasing dietary fiber to prevent constipation and onset of diverticulosis. A. B. D. Avoiding milk products, hot and spicy foods, and cooking vegetables will not prevent the development of complications from diverticulosis.

A patient is receiving a dopamine infusion for shock. What should the nurse expect to assess in the patient because of this medication? a. Pain relief b. Decreased heart rate c. Increased blood pressure d. Increased respiratory rate

C Rationale Dopamine strengthens myocardial contraction, increases systolic blood pressure, and increases cardiac output. A. Dopamine is not an analgesic. B. Dopamine increases the heart rate. D. Dopamine does not affect respiratory rate.

The nurse is caring for a patient with lung cancer who develops syndrome of inappropriate antidiuretic hormone (SIADH) secretion. Which assessment findings should the nurse expect? a. Fatigue and weakness b. Poor skin turgor and polyuria c. Weight gain and concentrated urine d. Truncal obesity and thin extremities

C Rationale Excess antidiuretic hormone (ADH) causes water retention, with weight gain and concentrated urine. B. Poor skin turgor and polyuria are associated with diabetes insipidus, not SIADH. D. Truncal obesity and thin extremities are signs of Cushings syndrome. A. Fatigue and weakness are nonspecific.

The nurse is preparing a patient for an NG tube insertion. To decrease the patients anxiety about insertion of a nasogastric tube, what should the nurse do? a. Administer a narcotic. b. Administer a sedative. c. Explain the procedure. d. Assess the patients gag reflex.

C Rationale Explaining what is to be done reduces patient anxiety because the patient knows what to expect and can prepare to cope with it. A. B. A narcotic or sedative is not helpful when inserting an NG tube into a patient. D. The patients gag reflex will be assessed during tube insertion.

A patient is scheduled for an intravenous pyelogram (IVP). What care should the nurse provide before the patient has this procedure? a. IV antibiotics b. Opioid pain medication c. Enema evening before the test d. Bedrest for 16 hours before the test

C Rationale For an IVP, enemas may be given the evening before the test to empty the colon. A. B. D. The patient does not need antibiotics, opioid medication, or bedrest before the procedure.

The nurse is reinforcing teaching provided to a patient with a peptic ulcer. Which patient statement indicates understanding about the function of hydrochloric acid in gastric juice? a. Digestion of starch b. Inactivation of pepsin c. Destruction of pathogens d. Maintenance of a pH of 7 to 8

C Rationale Hydrochloric acid creates the pH of 1 to 2 that is necessary for pepsin to function and to kill most microorganisms that enter the stomach. A. B. D. These responses do not explain the function of hydrochloric acid in gastric juice.

The nurse is auscultating bowel sounds and hears two bowel sounds over 5 minutes. How should the nurse document this finding? a. Absent bowel sounds b. Normal bowel sounds c. Hypoactive bowel sounds d. Hyperactive bowel sounds

C Rationale Hypoactive bowel sounds are bowel sounds that are infrequent (normal is 5 to 30) over a 5-minute period and can occur in patients with a paralytic ileus or following abdominal surgery. A. Since the nurse heard sounds, absent bowel sounds would be incorrect to document. B. Normal bowel sounds occur 5 to 30 times over a 5 minute period. D. Hyperactive bowel sounds would be more than 30 sounds over a 5 minute period.

The nurse is caring for a patient who has a non-vented nasogastric tube. Which suction setting should the nurse select? a. Low continuous suction b. High continuous suction c. Low intermittent suction d. High intermittent suction

C Rationale If suction is ordered, low intermittent suction is used with non-vented nasogastric tubes (Levin). A. B. D. These settings are inappropriate for this type of nasogastric tube.

A patient in shock is found unresponsive. The nurse knows that immediate cardiopulmonary resuscitation is required because brain cells begin to die if deprived of oxygen for how many minutes? a. 1 b. 2 c. 4 d. 8

C Rationale If the brain is deprived of circulation for more than 4 minutes, brain cells die from a lack of oxygen and glucose. As a result, prolonged shock can result in brain death. A. B. Brain cells do not begin to die until 4 minutes have passed without oxygen and glucose. D. Brain cells are dying if deprived of oxygen and glucose for 8 minutes

The nurse is caring for a patient in the critical care unit. What should the nurse identify as a goal for this patients blood glucose levels? a. 50 to 100 mg/dL b. 100 to 150 mg/dL c. 140 to 180 mg/dL d. 180 to 240 mg/dL

C Rationale In 2009, the American Diabetes Association (ADA) and American Association of Clinical Endocrinologists determined that glucose levels in critically ill hospitalized patients should be maintained between 140 and 180 mg/dL, preferably with the use of IV insulin. A. B. D. These are not recognized blood glucose level goals for a patient who is critically ill.

The nurse is caring for a patient with a sliding hiatal hernia. In which position should the nurse expect the patient to report that the symptoms are more acute? a. Sitting b. Standing c. Lying down d. Semi-Fowlers

C Rationale In a sliding hiatal hernia, the stomach slides up into the thoracic cavity when a patient is supine and then goes back into the abdominal cavity when upright. Sliding hiatal hernia symptoms are worse when lying down. A. B. D. The symptoms of a hiatal hernia are not worse when sitting, standing, or in the semi-Fowlers position

A patient is newly diagnosed with diabetes insipidus. Which medications should the nurse anticipate being prescribed for long-term patient management? a. Mithramycin b. Inderal (propranolol) c. Desmopressin acetate d. Calcium and vitamin D

C Rationale In patients who require long-term therapy, synthetic antidiuretic hormone (ADH) (desmopressin, or DDAVP) in the form of a nasal spray is used, usually twice a day. A. B. D. Inderal, calcium, and mithramycin will not affect fluid balance.

A patient has a glomerular filtration rate of 20 mL/min. For which stage of renal failure should the nurse plan care for this patient? a. Mild b. Slight c. Severe d. Moderate

C Rationale In severe renal failure the glomerular filtration rate is between 15 to 29 mL/min. A. In mild failure the rate is 60 to 89 mL/min. B. In slight failure the rate is greater than or equal to 90 mL/min. D. In moderate failure, the rate is 30 to 59 mL/min.

The nurse is reviewing the causes for the development of type 1 diabetes mellitus with a patient who is newly diagnosed with the disorder. What major factor in the development of this disease should the nurse include? a. Obesity b. A high-fat diet c. An autoimmune response d. A diet high in concentrated carbohydrates

C Rationale In type 1 diabetes, it is believed that the pancreas may attack itself following certain viral infections or administration of certain drugs; this is called an autoimmune response. Almost 90% of patients newly diagnosed with type 1 diabetes have islet cell antibodies in their blood. B. D. Diet can be a risk factor in many disorders but does not directly cause diabetes. A. Obesity is a risk factor for type 2 diabetes.

A patient with glomerulonephritis develops acute kidney injury. Which form of kidney injury should the nurse realize has occurred with this patient? a. Prerenal b. Postrenal c. Intrarenal d. Suprabladder

C Rationale Intrarenal kidney injury occurs when there is damage to the nephrons inside the kidney. Causes are ischemia, reduced blood flow, toxins, infectious processes leading to glomerulonephritis, trauma to the kidney, allergic reactions to radiograph dyes, and severe muscle injury. A. B. This patients kidney injury is not caused by a pre- or postrenal injury. D. Suprabladder is not a type of kidney injury.

The nurse is reinforcing teaching provided to a patient with a hiatal hernia. Which patient statement indicates a correct understanding of lifestyle modification to reduce symptoms? a. Avoid high-stress situations. b. Perform daily aerobic exercise. c. Avoid nicotine and alcohol use. d. Carefully space activity periods with rest.

C Rationale Lifestyle changes for symptomatic hiatal hernia include losing weight, antacids, eating small meals that pass easily through the esophagus, not reclining for 3-4 hours after eating, elevating the head of the bed 6 to 12 inches to prevent reflux, and avoiding bedtime snacks, spicy foods, alcohol, caffeine, and smoking. A. B. D. Stress, exercise, and rest periods are not recommendations for the patient with a hiatal hernia.

The nurse is inspecting a patients oral cavity. What is the most important safety reason for the nurse to inspect for loose teeth when collecting data on the oral cavity of a patient? a. Loose teeth are unsightly to the patient. b. Loose teeth can cause dental abscesses. c. Loose teeth can be aspirated into the airway. d. Loose teeth can prevent the patient from eating.

C Rationale Loose teeth can be aspirated into the airway and become a choking risk. A. The nurse is not inspecting for loose teeth because it is unsightly to the patient. B. The nurse is not inspecting for loose teeth because of the risk for dental abscesses. D. Missing teeth is more likely to prevent a patient from eating.

The LPN is caring for a patient with diabetes insipidus and obtains a urine specific gravity reading of 1.002. Which response by the LPN is most important? a. Document the results. b. Advise the patient to drink less water. c. Report the reading to the RN because therapy is ineffective. d. Report the reading to the RN because the patient may be receiving too much medication.

C Rationale Normal urine specific gravity is 1.010 to 1.025. 1.002 is too low, meaning therapy is not effective. A. Results should be documented, but it is most important to assure the patient is treated. D. It is unlikely the patient is receiving too much medication. B. The patient needs to drink to replace water lost in urine.

A patient with hepatic encephalopathy is required to consume 50 grams of protein each day. Which item should be provided to the patient for a mid-afternoon snack? a. Apple b. Crackers c. Peanut butter d. Whole grain bread

C Rationale Only in cases of severe protein intolerance should protein be restricted and then for as short a time as possible with supplemental branched-chain amino acids administered until normal protein intake is resumed. Of the food choices, peanut butter has the most protein. A. B. D. An apple is protein free. Crackers and whole grain bread are carbohydrates.

The nurse is contributing to the teaching plan for a patient recovering from a cholecystectomy. Which dietary modification should the nurse recommend for the first few weeks after surgery? a. Decrease intake of fresh fruits and vegetables to minimize pressure on the small intestine. b. Consume at least four servings of meat, cheese, and peanut butter daily to boost protein intake and aid healing. c. Distribute fat intake in small portions throughout the day to prevent excessive fat in the intestine at any one time. d. Take pancreatic enzymes with meals to replace enzymes that would normally have been secreted before the cholecystectomy.

C Rationale Patients are put on high-protein, low-fat diets. Fat should be slowly reintroduced into the diet. Once the duodenum becomes accustomed to constant infusion of bile, the patients individual tolerance for fat becomes the only restriction for diet. A. Fruits and vegetables are not contraindicated. B. Meat, cheese, and peanut butter are high in fat. D. Pancreatic enzymes are not necessarythe pancreas has not been removed.

The nursing assistant is delivering patient meals. Which meal should the nurse expect to be delivered to a patient who had gastric bypass surgery the day before? a. Soft diet b. Full liquids c. Clear liquids d. General diet

C Rationale Patients are started on a clear liquid diet because of the small stomach pouch that has been created. A. B. The patient will progress to these diets over the next days. D. This patient will not be provided with a general diet for quite a while.

A patient recovering from a cholecystectomy earlier in the day is reluctant to deep breathe and cough. What intervention should the nurse use to assist the patient to cough and breathe? a. Remind the patient to deep breathe and cough every hour. b. Teach the patient to use relaxation and distraction techniques. c. Medicate the patient for pain, and assist to splint the abdomen. d. Reinforce the importance of the deep breathing and coughing activities.

C Rationale Patients are usually reluctant to cough and deep breathe after cholecystectomy because the high incision makes coughing painful. Medicating for pain and splinting the incision allow the patient to cough without excessive pain. A. D. Simply reminding and teaching do not solve the problem. B. Relaxation is helpful but should be in addition to, not instead of, analgesia

A patient at home with type 1 diabetes has a glucose level of 324 mg/dL. It is usually less than 150 mg/dL. What should the patient do first? a. Call the physician. b. Have a glass of orange juice. c. Check the urine for ketones and drink water. d. Exercise and recheck glucose level in 2 hours.

C Rationale Patients with type 1 diabetes are at risk of ketoacidosis when blood glucose is out of control. Hydration is important. Checking the urine for ketones can help determine if ketoacidosis is developing. B. Orange juice will further increase blood glucose. A. The physician should be contacted if it remains high or if ketones are present. D. Exercise is not recommended when glucose is high.

The nurse is caring for a patient who is placed on a modified bland diet. Which should be removed before serving the patients dinner tray? a. Salt b. Sugar c. Pepper d. Mayonnaise

C Rationale Pepper, which is spicy, would not be included in a bland diet. A. B. D. These food items are bland.

The nurse is providing care for a marathon runner who is newly diagnosed with diabetes mellitus. What explanation about exercise is best for the nurse to provide? a. You will need to avoid regular exercise since it will lower your blood sugar. b. You can still exercise, but running is too strenuous for someone with diabetes. c. You should always take some emergency glucose with you when you are running. d. Exercise is best done when insulin is peaking, so it is important to know the onset and peak of your type of insulin.

C Rationale Persons with diabetes should always carry a quick source of sugar when exercising in case the blood glucose drops too low. D. Individuals on intermediate-acting insulin are taught to avoid exercising at the time of day when their blood glucose is at its lowest point (i.e., when insulin or medication is peaking) and to have a carbohydrate snack before exercising if blood glucose is less than 100 mg/dL. A. Exercising at similar times each day also helps prevent blood glucose fluctuations. B. Running is not too strenuous for someone who is used to doing it, but patients with neuropathy or foot problems should consult with a physician first.

The nurse is reviewing goals for blood glucose monitoring with a patient newly diagnosed with type 2 diabetes mellitus. What pre-prandial blood glucose goal should the nurse instruct the patient to achieve? a. 50 to 100 mg/dL b. 60 to 100 mg/dL c. 70 to 130 mg/dL d. 80 to 150 mg/dL

C Rationale Preprandial glucose should be 70 to 130 mg/dL to maintain control and reduce risk of complications. A. B. D. These are not recognized pre-prandial blood glucose goals.

The nurse is reinforcing teaching provided to a patient with chronic kidney disease. Which patient statement indicates the need for further teaching? a. I do not use salt substitute. b. My fluid intake is restricted. c. As long as I dont eat protein, Ill be okay. d. Since Im on dialysis, I cannot eat just anything I want.

C Rationale Protein may be restricted when the patients kidneys are failing but increased if dialysis is started. A. B. D. These statements indicate that teaching has been effective.

The nurse is caring for a patient who has diarrhea. Which nursing action is the highest priority? a. Provide perineal skin care. b. Auscultate the abdomen daily. c. Encourage oral fluid replacement. d. Provide analgesics for abdominal pain.

C Rationale Replacing fluids and electrolytes is the first priority which is accomplished by increasing oral fluid intake or using solutions with glucose and electrolytes if ordered by the physician. A. Perineal skin care may or may not need to be done. B. There is no reason to auscultate the abdomen every day. D. There is no indication that the patient is experiencing abdominal pain.

A patient scheduled for diagnostic tests for hypothyroidism. Which symptoms should the nurse expect to observe in a patient with this disorder? a. Tremor and oily skin b. Anxiety and tachycardia c. Dry skin and slowed heart rate d. Increase in appetite and diarrhea

C Rationale Symptoms of hypothyroidism are related to the reduced metabolic rate and include fatigue, weight gain, bradycardia, constipation, mental dullness, feeling cold, shortness of breath, decreased sweating, and dry skin and hair. A. B. D. These symptoms are associated with hyperthyroidism.

The nurse is assisting with the care of a patient who has PN infusing. Which data should be the most concerning to the nurse? a. Heart rate 92 beats/min b. Respiratory rate 16/min c. Blood glucose 260 mg/dL d. Urine output 60 mL in the past hour

C Rationale The glucose level is elevated. It is important to monitor glucose levels as ordered and to look for signs of hyperglycemia due to the high dextrose in PN. A. B. D. This data is all within normal limits

The nurse is reinforcing teaching provided to a patient with acute diarrhea. Which statement indicates the patient understands the most common cause for this health problem? a. Excessive fluid intake. b. Excessive fiber in the diet. c. Viral or bacterial infection. d. Inflammatory bowel disease.

C Rationale The most common cause of acute diarrhea is a bacterial or viral infection. A. B. Excessive food and fiber are not causes for diarrhea. D. Inflammatory bowel disease can cause chronic diarrhea.

The nurse is caring for a patient who suddenly begins having large amounts of bright red hematemesis. After the patient is turned onto the side, what should the nurse do? a. Encourage iced oral fluids. b. Lower the head of the bed. c. Obtain the patients vital signs. d. Place a cool cloth on the patients forehead.

C Rationale The nurse should collect data, including vital signs, to report to the RN and physician for treatment orders. A. The nurse should not give the patient anything by mouth. B. Lowering the head of the bed could lead to aspiration. D. Placing a cool cloth on the patients forehead might be offered after the physician and RN have been notified.

The nurse is caring for a patient with hepatic encephalopathy. Which prescribed medication should the nurse question before providing to this patient? a. Vitamin K b. Neomycin sulfate c. Diazepam (Valium) d. Lactulose (Cephulac)

C Rationale The nurse should question medications such as sedatives, opioids, and tranquilizers because these can precipitate hepatic encephalopathy. Valium is a sedative. A. B. D. These medications are all used in the treatment of liver disorders

The nurse is reviewing a urinalysis report. What should the nurse recognize as the normal average pH of urine? a. 2 b. 4.2 c. 6 d. 7.4

C Rationale The pH range of urine is 4.6 to 8, with an average of 6. A. B. D. These values are not considered the normal average pH of urine.

The nurse is receiving report on patients assigned for the next shift. Which patient should the nurse observe first? a. A patient who has a pressure ulcer who is due for a dressing change b. A patient with diabetes who has a blood sugar of 85 and is eating lunch c. A patient with cellulitis who is receiving the first dose of IV antibiotics and who is reporting a feeling of tightness in the throat d. A patient with sickle cell anemia who is receiving a monthly transfusion of a unit of packed red blood cells who is reporting left knee pain

C Rationale The patient may be having an allergic reaction and requires immediate attention to intervene as anaphylactic shock may occur. A. B. D. There are no abnormalities occurring that require immediate intervention.

The nurse is instructing a patient on the use of Kegel exercises. How many times a day should the nurse recommend that these exercises be performed? a. 10 to 20 b. 15 to 30 c. 30 to 80 d. 85 to 100

C Rationale The patient should be advised to perform these exercises 30 to 80 times per day. A. B. D. The exercises need to be done more than 30 times a day however not as much as 85 to 100 times a day.

The nurse is caring for a patient with chronic kidney disease. Which data collection technique is the best one for the nurse to use to determine this patients fluid volume status? a. Vital signs b. Skin turgor c. Daily weight d. Intake and output

C Rationale The patient should have daily weights monitored, at the same time every day. Weight change is the best estimation of fluid balance. A. B. D. Vital signs, skin turgor, and intake and output are not the best measurements to indicate fluid balance.

The nurse is reinforcing teaching provided to a patient about antibiotics prescribed for a UTI. Which patient statement indicates teaching has been effective? a. I will take the antibiotics until my urine is no longer cloudy. b. I will take the antibiotics whenever I feel discomfort from urinating. c. I will take the antibiotics until they are gone regardless of symptoms. d. I will take the antibiotics until my temperature has been normal for 3 days.

C Rationale The patient should take the prescribed medication for a UTI until all medication has been taken. A. B. D. These statements indicate that teaching has not been effective.

The nurse is caring for a patient recovering from ileostomy surgery. What should have the highest priority when caring for the patient after surgery? a. Food intake b. Participation in stoma care c. Stoma condition every 8 hours d. Bowel sounds every 4 hours for 24 hours

C Rationale The patient with a new ostomy has many nursing care needs. In addition to routine postoperative assessment, a stoma should be inspected at least every 8 hours to detect complications, such as color changes, that may require immediate surgery. A. Postoperatively food intake may be limited. B. It is too soon to expect the patient to participate in stoma care. D. Bowel sounds will most likely be absent or sluggish after surgery.

The nurse is reviewing GI function with a patient. Which body structure should the nurse emphasize as accomplishing mechanical digestion in the stomach? a. Mucosa b. Gastric glands c. Smooth muscle layers d. Striated muscle layers

C Rationale The stomach wall has three layers of smooth muscle that provide very efficient mechanical digestion to change food to a thick liquid called chyme. A. B. D. These structures do not perform mechanical digestion in the stomach.

The nurse is reinforcing 24-hour fluid intake teaching for a patient to prevent further UTIs. Which amount should the patient state that indicates that teaching has been effective? a. 1000 mL. b. 1500 mL. c. 3000 mL. d. 5000 mL.

C Rationale To prevent UTIs, the patient should be encouraged to drink up to 3000 mL of fluid a day if there are no fluid restrictions from the physician. A. B. Less than 2 liters of fluid per day is not sufficient to prevent the onset of a UTI. D. There is no need for the patient to ingest 5 liters of fluid per day.

The nurse is caring for a patient who has a permanent gastric feeding tube. What nursing action would be most helpful to prevent aspiration during feedings? a. Administer careful oral care daily. b. Check placement of the tube hourly. c. Elevate head of bed at least 30 degrees. d. Ask the physician to order daily x-rays.

C Rationale To prevent aspiration during tube feedings the nurse should elevate the head of the patients bed more than or equal to 30 degrees at all times for feeding. A. B. D. These actions would not prevent the patient from developing aspiration with tube feedings.

The nurse is caring for a patient with diabetes. For which symptom should the nurse be the most concerned? a. Fatigue b. Heartburn c. Diaphoresis d. Muscle cramps

C Rationale Tremor and sweating are sympathetic symptoms of hypoglycemia. Treatment of hypoglycemia is more urgent than treatment of hyperglycemia. A. Thirst, fatigue, and glycosuria are symptoms of hyperglycemia. B. Heartburn is more commonly related to gastric acid secretion. D. Muscle cramps are more commonly related to electrolyte imbalances.

The LPN is assisting in the care of a 51-year-old patient recovering from a hypophysectomy. Which observation should the nurse identify as needing immediate intervention? a. Urine specific gravity of 1.19 b. Hemoglobin level of 13.2 g/dL c. Urinary output of 800 mL in 4 hours d. Complaints of pain at a 5 on a scale of 0 to 10

C Rationale Tumors, trauma, or other problems in the hypothalamus or pituitary gland can lead to decreased production or release of antidiuretic hormone (ADH), causing diabetes insipidus and resulting in excess urinary output. A. B. The listed hemoglobin and urine specific gravity are within normal limits for the patient. D. Pain is not the highest priority in this scenario.

A patient hospitalized for orthopedic surgery had a urinary catheter inserted. The patient later develops a urinary tract infection (UTI) and asks the nurse what caused it. What is the appropriate response by the nurse? a. There was a change in the pH of your urine. b. You probably did not void frequently enough. c. Bacteria probably ascended the catheter, causing the infection. d. There are always bacteria on your perineum that enter your urine.

C Rationale UTIs are almost always caused by an ascending infection, starting at the external urinary meatus and progressing toward the bladder and kidneys. Instrumentation, or having instruments or tubes inserted into the urinary meatus, is a predisposing cause. A. B. D. Change in urinary pH, infrequent voiding, and presence of bacteria are not predisposing causes for UTIs

A patient hospitalized for orthopedic surgery had a urinary catheter inserted. The patient later develops a urinary tract infection (UTI) and asks the nurse what caused it. What is the appropriate response by the nurse? a. There was a change in the pH of your urine. b. You probably did not void frequently enough. c. Bacteria probably ascended the catheter, causing the infection. d. There are always bacteria on your perineum that enter your urine.

C Rationale UTIs are almost always caused by an ascending infection, starting at the external urinary meatus and progressing toward the bladder and kidneys. Instrumentation, or having instruments or tubes inserted into the urinary meatus, is a predisposing cause. A. B. D. Change in urinary pH, infrequent voiding, and presence of bacteria are not predisposing causes for UTIs.

A patient with liver failure and esophageal varices is prescribed to receive vasopressin. What should the nurse realize is the purpose for this medication? a. To promote portal circulation b. To reduce ammonia buildup and encephalopathy c. To constrict vessels causing bleeding in esophageal varices d. To maintain blood pressure in a patient with hypotension related to bleeding varices

C Rationale Vasopressin is a vasoconstrictor and will reduce bleeding in varices. A. It reduces, and does not promote, circulation. D. It can maintain blood pressure, but that is not the primary reason it is given to patients with varices. B. It does not affect ammonia levels.

A patient with hyperparathyroidism asks why ambulation three times per day is necessary because it is so difficult to do so. Which response by the nurse is best? a. Walking is good for you; I walk three times a day. b. Walking is important for preventing cardiovascular disease. c. Walking will keep the calcium where it belongsin your bones. d. Walking is important to maintaining adequate serum calcium levels.

C Rationale Walking and weight-bearing exercises help keep calcium in the bones. B. Exercise helps prevent cardiovascular disease, but this is not the reason it is recommended. A. The nurse should not give advice based on his or her own habits. D. Walking keeps calcium in the bones, not the blood.

The nurse is ready to begin a tube feeding via a nasogastric feeding tube for a patient who is comatose. Which action should the nurse take? a. Lay the patient supine. b. Elevate the head of the bed 10 degrees. c. Place the patient in high Fowlers position. d. Place the patient onto the left side with knees flexed.

C Rationale When feedings are administered, patients must be positioned in a sitting or high Fowlers position to reduce the risk of aspiration. A. B. D. These positions increase the patients risk of aspiration.

The nurse is caring for a patient with a vented nasogastric tube ordered to suction after a gastrectomy. What type of suction should the nurse use to decrease the development of complications? a. Continuous low suction b. Continuous high suction c. Intermittent low suction d. Intermittent high suction

C Rationale With a physicians order, the nasogastric tube is connected to suction equipment, usually set on low intermittent suction if the secretions are not too thick, to prevent injury to the gastric mucosa. The vent also helps prevent this injury. A. B. D. These settings for suction might cause injury to the gastric mucosa.

The nurse is monitoring a patient recovering from an emergency appendectomy. Which finding should be reported to the physician immediately? a. Pain at the operative site b. Absence of bowel sounds c. Abdomen rigid on palpation d. 3-centimeter spot of bloody drainage on dressing

C Rationale With peritonitis, a life-threatening complication, abdominal rigidity is present. The physician should be notified promptly for treatment orders. A. The patient will be experiencing post-operative pain. B. Absence of bowel sounds is expected after anesthesia. D. Bleeding is expected after surgery.

The nurse determines that a patient with hypovolemic shock is improving. What did the nurse observe to come to this conclusion? (Select all that apply.) a. Heart rate increasing b. Respiratory rate increasing c. Present of peripheral pulses d. Systolic blood pressure increasing e. Urine output 20 mL over the last hour

C, D Rationale Perfusion is first evident in peripheral pulses. An increase in blood pressure occurs because of an improvement in circulating blood volume. A. B. Increasing heart and respiratory rates indicate that the patient is not improving. E. A urine output of less than 30 mL per hour indicates insufficient perfusion of the kidneys caused by the shock.

The nurse is caring for a patient diagnosed with chronic hepatitis B. Which medications should the nurse anticipate being prescribed for this patient? (Select all that apply.) a. Interferon alpha-2a b. Ribavirin (Rebetol) c. Adefovir (Hepsera) d. Lamivudine (Epivir) e. Peginterferon alpha-2b

C, D Rationale To manage chronic hepatitis B infection, the antivirals adefovir (Hepsera) or lamivudine (Epivir) may be used. A. B. Interferon therapy (peginterferon alpha-2b [Peg-Intron] or interferon alpha-2a [Pegasys]) along with an antiviral medication (oral ribavirin [Rebetol]) is considered to prevent chronic hepatitis C infection.

The nurse is contributes to the plan of care for an older patient. What should the nurse recognize as normal signs of aging within the renal system? (Select all that apply.) a. Bladder size increases b. Urethral changes position c. Number of nephrons decreases d. Detrusor muscle tone decreases e. Glomerular filtration rate increases

C, D Rationale With age, the number of nephrons in the kidneys decreases, often to half the original number by age 70 or 80. E. The GFR also decreases; this is in part a consequence of arteriosclerosis and diminished renal blood flow. A. The urinary bladder decreases in size. D. The tone of the detrusor muscle decreases. B. The urethra does not change position with aging.

The nurse is caring for a patient who has aphthous stomatitis. What care should the nurse provide? (Select all that apply.) a. Make patient NPO. b. Place on fluid restriction. c. Apply a topical anesthetic. d. Teach to avoid irritating foods. e. Suggest stress management techniques.

C, D, E Rationale Aphthous stomatitis appears as small, white, painful ulcers on the inner cheeks, lips, tongue, gums, palate, or pharynx and typically lasts for several days to 2 weeks. Self-induced trauma such as biting the lips and cheeks can cause these ulcers to develop, as well as stress or exposure to irritating foods. Application of topical tetracycline several times a day usually shortens the healing time. A topical anesthetic such as benzocaine or lidocaine provides pain relief and makes it possible to eat with minimal pain. A. The patient does not need to be NPO. B. A fluid restriction is not necessary.

While participating in the creation of a teaching plan, the nurse suggests that a patient ingest cranberry juice every day to reduce the risk of developing a UTI. What information did the nurse use to make this suggestion? (Select all that apply.) a. The fiber in cranberries reduces the amount of sediment in the urine. b. Cranberries facilitate the removal of fluid from the interstitial spaces. c. Compounds in cranberries inhibit the adherence of E. coli to the urogenital mucosa. d. Cranberries reduce the incidence of UTIs in patients after renal transplants. e. Cranberries contain a substance that prevents bacteria from sticking on the walls of the bladder.

C, D, E Rationale In a systematic review of studies that compared the use of cranberries containing products to prevent UTI with placebo or nonplacebo controls, it was found that cranberry containing products are associated with a protective effect against UTIs. Cranberries contain a substance that can prevent bacteria from sticking on the walls of the bladder. Other compounds found in cranberries inhibit the adherence of E coli to the urogenital mucosa. It was also found that cranberries are effective in reducing the annual number of UTI episodes by 63.9% in clients after renal transplantation. A. Cranberries do not reduce the amount of sediment in urine. B. It is not known if cranberries facilitate the removal of fluid from the interstitial spaces.

A patient with type 1 diabetes mellitus is prescribed insulin glargine (Lantus). What should the nurse instruct the patient about this medication? (Select all that apply.) a. It can be inhaled. b. It is not injectable. c. It has no peak action time. d. It has a duration of 24 hours. e. It cannot be mixed with other insulin.

C, D, E Rationale This insulin has not peak action time, lasts 24 hours, and cannot be mixed with any other insulins. B. Lantus is injected subcutaneously. A. It cannot be inhaled.

The nurse is providing education to a patient recovering from a recent cholecystectomy. What should the nurse include in the teaching? (Select all that apply.) a. Fat should be less than 20% of total diet. b. Raw fruits and vegetables should be avoided. c. It is important to increase the protein intake in your diet. d. If you are overweight, it is suggested that you lose weight. e. There are no dietary restrictions once you leave the hospital. f. Fat is introduced slowly and adjusted according to individual tolerance.

C, D, F Rationale Patients are put on high-protein, low-fat diets. Encourage obese patients to lose weight. After a cholecystectomy, fat should be slowly reintroduced into the diet. A. B. E. Once the duodenum becomes accustomed to constant infusion of bile, the patients individual tolerance for fat becomes the only restriction for diet.

The nurse is reviewing data for a patient with acute kidney injury. Which diagnostic test results should the nurse recognize that indicate kidney injury? (Select all that apply.) a. Hematocrit 20% b. Uric acid 8 ng/dL c. Serum creatinine 4.2 mg/dL d. Blood urea nitrogen 40 mg/100 mL e. Urine output of 100 mL in 24 hours f. Fixed urine specific gravity of 1.010

C, E, F Rationale A serum creatinine level above 1.5 mg/dL means there is kidney dysfunction. The higher the creatinine level, the more impaired the kidney function. A fixed urine specific gravity is also indicative of renal compromise and impending failure. Normal urinary output is 1000 to 2000 mL per 24 hours. Individuals with acute kidney injury experience oliguria (reduced output). A. B. D. These test results are not consistent with a renal injury.

A patient is recovering from a renal arteriogram. What actions should the nurse take when caring for this patient? (Select all that apply.) a. Check vital signs twice daily. b. Raise the head of the bed to 90 degrees. c. Check distal pulses in leg every 30 to 60 minutes. d. Encourage the patient to ambulate as soon as possible. e. A pressure dressing and sandbag used to apply pressure. f. Implement bedrest for 12 hours, and instruct the patient not to bend leg.

C, E, F Rationale Patient care following angiography includes bedrest for up to 12 hours to prevent bleeding at the injection site. Pressure dressing is applied, and a sandbag is used to apply pressure. Distal pulses in the leg are checked every 30 to 60 minutes. B. D. The patient is instructed not to bend the leg, and the head of the bed is not raised more than 45 degrees. A. Vital signs, dressing, and pulses in the affected extremity are monitored frequently.

The nurse has instructed a patient prescribed omeprazole (Prilosec) for peptic ulcer disease on use of the medication. What patient statements indicate understanding of the instructions? (Select all that apply.) a. I should not take antacids while Im on this medication. b. If I wish, I can open the capsule and sprinkle it on food. c. I will take the capsule before eating a meal in the morning. d. I will need to take this drug for 3 weeks for my ulcer to heal. e. I will report any abdominal pain, diarrhea, or bleeding that occurs. f. Ill have to have regular blood counts and tests of my liver enzymes.

C, E, F Rationale The patient should be instructed to take before meal in morning and notify the physician if bleeding, diarrhea, headache, or abdominal pain develops. The patient will need to have complete blood counts and liver enzymes routinely assessed when taking this medication. A. This medication may be taken with antacids. B. The capsule should be swallowed whole. D. This medication must be taken 4 to 8 weeks for ulcer healing.

A patient with pancreatitis is receiving care to address the nursing diagnosis Imbalanced Nutrition: Less than required related to pain, NPO, and nasogastric suction. After 10 days of treatment, which findings should indicate to the nurse that the treatment plan has been effective? (Select all that apply.) a. The patient reports pain relief. b. The serum sodium is 130 mEq/L. c. The patients albumin level is 3.8 g/L. d. The serum potassium level is 3.7 mEq/L. e. The patient has mild diarrhea and steatorrhea. f. The patient has returned to baseline body weight.

C, F Rationale An albumin level greater than 3.5 mg/dL and return to baseline weight are evidence of improving nutrition. A. D. These are good results but are not directly related to nutrition goals. E. Mild diarrhea and steatorrhea are not desirable outcomes. B. The sodium value is lower than normal and indicates continued electrolyte imbalance.

A patient with chronic kidney disease has a serum potassium level of 6 mEq/L. Which action should the nurse take? (Select all that apply.) a. Obtain consent for hemodialysis. b. Administer the patient an antacid. c. Place the patient on a cardiac monitor. d. Give the patient a glass of orange juice. e. Repeat laboratory test of electrolyte levels. f. Inform RN to notify physician.

C, F Rationale As the kidneys lose their ability to excrete electrolytes, such as sodium, potassium, and magnesium, these substances accumulate at high levels in the blood and may cause life-threatening dysrhythmias. Notify the RN and physician for treatment orders, and place the patient on a cardiac monitor to detect dysrhythmias. A. The patient may or may not need dialyzed at this time. B. An antacid will not help reduce the potassium level. D. Orange juice has potassium and would be contraindicated for the patient at this time. E. The physician needs to prescribe repeat laboratory tests for the patient.

The nurse is reviewing the results of a patients urinalysis. Which components should the nurse identify as being abnormal in urine? (Select all that apply.) a. Urea b. Water c. Protein d. Ammonia e. Hormones f. Red blood cells

C, F Rationale Persistent proteinuria is seen with renal disease from damage to the glomerulus. Intermittent protein in the urine can result from strenuous exercise, dehydration, or fever. Protein in the urine is a significant sign of renal problems. Blood in the urine may be caused by infection, stones, cancer, renal disease, or trauma. A. B. D. E. These components are considered normal within urine.

The nurse is caring for a patient after a liver transplant. Which symptom should the nurse report immediately as a possible indication of rejection of the liver? a. Pulse rate of 80 beats per minute b. Prothrombin time (PT) of 14 seconds c. Decreased alanine aminotransferase (ALT) d. A temperature greater than 101F (38.3C)

D Rationale A fever is associated with immune system activity and possible rejection. C. Decreased ALT is desirable in liver disease. B. Normal PT is 8.8 to 11.6 seconds, so 14 seconds is near normal. A. Pulse of 80 beats/min is normal.

The nurse is caring for a patient with chronic liver failure. Which medication order should the nurse question? a. Lactulose b. Neomycin c. Multivitamins d. Acetaminophen

D Rationale Acetaminophen (Tylenol) overdose is the most common cause of ALF. Acetaminophen should not exceed 3000 mg in a 24 hour period. A. B. C. Multivitamins, Lactulose, and Neomycin are all used to treat symptoms of liver disease.

A patient is being prepared for an upper GI series. Which statement indicates that the patient understands the preparation for this test? a. I should eat a soft diet the night before the procedure. b. I must not eat or drink for 4 hours after the procedure. c. Ill be given a clear liquid diet the night after the procedure. d. I cant have anything to eat or drink for 6 to 8 hours before the procedure.

D Rationale An appropriate patient diet preparation for an upper GI series is placing the patient on NPO restriction 6 to 8 hours before the procedure for best visualization. A. B. C. These statements indicate that the patient does not understand the correct way to prepare for this diagnostic test

The nurse is reinforcing teaching for a patient who is scheduled for an upper GI series. Which patient statement indicates teaching has been effective? a. It is an estimated rectal cholangiopancreatophonography. b. It is a scope inserted into the duodenum with dye injection. c. It is a sigmoidoscopy with radiography after injection of dye. d. It is an x-ray of the esophagus, stomach, and duodenum using barium.

D Rationale An upper GI is an x-ray of the esophagus, stomach, and duodenum using barium. A. B. C. These statements do not correctly explain an upper GI series.

A patient with acute pancreatitis is experiencing severe pain. What position should the nurse encourage the patient to assume? a. Semi-Fowlers position b. Prone with a pillow under the abdomen c. Supine with legs elevated and head on a small pillow d. Sitting in a chair leaning forward with a pillow for back support

D Rationale An upright position keeps abdominal organs from pressing against the inflamed pancreas. A. B. C. These positions increase the risk of organs pressing against the pancreas.

A patient with biliary colic is prescribed an anticholinergic medication to help treat biliary colic. For which medical diagnosis should the nurse question the administration of this medication? a. Asthma b. Psoriasis c. Diabetes mellitus d. Prostatic hypertrophy

D Rationale Anticholinergic medications are contraindicated in patients with prostatic hypertrophy. A. B. C. Anticholinergic medications are not contraindicated in diabetes, asthma, or psoriasis.

A patient who has diabetic nephropathy asks the nurse, Why am I using smaller doses of insulin than I used to? What would be the best explanation by the nurse? a. Insulin is now more potent than it used to be. b. It would be best if you spoke with your physician about this. c. You have probably decreased the amount of food you are eating. d. Your kidneys are no longer breaking down the insulin as much as before.

D Rationale As renal function decreases, the patient needs smaller doses of insulin because the kidney normally degrades insulin. A. Insulin is not more potent than it used to be. B. The nurse can explain why the dosage of insulin has changed. C. There is no evidence that the patient has changed the amount of food being ingested.

The nurse is caring for a patient with esophageal varices. Which symptom should alert the nurse to possible bleeding? a. Asterixis b. Dark amber urine c. Hard formed stool d. Blood-streaked emesis

D Rationale Blood from varices may streak emesis or may be more frank. B. C. Constipation and dark urine may accompany liver disease but are not signs of bleeding. A. Asterixis is a sign of encephalopathy.

On admission, a patient with gastrointestinal bleeding had vital signs of a blood pressure of 140/80 mm Hg, pulse 72 beats/minute, respirations 14 breaths/minute, and temperature 98.8F (37.1C). What finding should be reported to the registered nurse (RN) or physician immediately? a. Pulse 78 beats/minute b. Crampy abdominal pain c. Occult blood in the stool d. Blood pressure 104/68 mm Hg

D Rationale Blood pressure 104/68 mm Hg is a significant drop from the patients prior pressure and may indicate that the patient is going into shock. Prompt treatment is needed. A. This is a normal pulse. B. Crampy abdominal pain does not indicate acute distress. C. Occult blood in the stool would be expected in the patient with gastrointestinal bleeding.

A patient with progressive shock is diaphoretic and confused. The most recent blood pressure measurement was 82/40 mm Hg and a urinary catheter output was 10 mL for 1 hour. Intravenous (IV) fluids are infusing at 150 mL/hr. Which action should the nurse take related to the urine output? a. Encourage oral fluids. b. Irrigate urinary catheter. c. Increase IV fluid infusion rate. d. Check urinary catheter for kinking.

D Rationale Collecting data is the first step in critically thinking about a situation. In this case, the urine output is lower than normal, which could be due to several reasons. The initial action of the nurse should be to inspect the urinary catheter system for proper functioning. If the catheter system is inhibiting urine output, then that issue must be addressed to correct the situation. Other interventions will not help if the system is the cause. B. Catheter irrigation is invasive and breaks the sterile system. A. Oral fluids will not help if the system is kinked; also the patient is confused and so may not be able to take oral fluids safely, and an IV is infusing to hydrate the patient. C. An order is needed to increase the IV rate.

The nurse is caring for an unstable patient with acute kidney injury. What therapy should the nurse expect to be ordered? a. Hemodialysis b. Urinary catheter c. Peritoneal dialysis d. Continuous renal replacement therapy (CRRT)

D Rationale Continuous renal replacement therapy (CRRT) is used to remove fluid and solutes in a con-trolled, continuous manner in unstable patients with AKI. Unstable patients may not be able to tolerate the rapid fluid shifts that occur in hemodialysis, so CRRT provides an alternative therapy that results in less dramatic fluid shifting. A. C. The patient is not stable enough for hemodialysis or peritoneal dialysis. B. A urinary catheter may or may not be indicated for this patient.

A patient with chronic obstructive pulmonary disease prescribed corticosteroid therapy asks what the medication does. What should the nurse respond to the patient? a. It is an anti-infective and helps kill bacteria. b. The medication causes your airways to dilate. c. The medication is an expectorant that helps you cough up secretions. d. It is an anti-inflammatory agent that reduces the swelling in your airways.

D Rationale Corticosteroids are potent anti-inflammatory agents. A. B. C. Corticosteroids are not antibiotics, bronchial dilators, or expectorants.

The nurse is caring for a patient on a clear liquid diet. The nurse should recognize that the patient requires further teaching if the patient requests which food? a. Gelatin b. Beef broth c. Cranberry juice d. Coffee with cream

D Rationale Cream is not on a clear liquid diet. A. B. C. Clear liquids are liquid items that you can see through.

A 22-year-old patient with inflammatory bowel disease has been having 16 or more stools per day. Which symptom should the nurse expect to find during the assessment? a. Dyspnea and crackles in the lungs b. Decreased hemoglobin and hematocrit c. Bounding pulse and increased blood pressure d. Furrows of the tongue and sticky mucous membranes

D Rationale D. A patient having 16 stools a day is at risk for dehydration; furrowed tongue and sticky mucous membranes are signs of dehydration. A, B, and C are signs of fluid excess.

After an assessment, the nurse determines that a patient is at risk for respiratory acidosis. Which health problem did the nurse assess to come to this conclusion? a. Anxiety b. Diabetes c. Kidney failure d. Chronic lung disease

D Rationale D. Chronic lung disease is associated with hypoventilation, which causes carbon dioxide retention and acidosis. A. Anxiety is associated with respiratory alkalosis. B. C. Diabetes and kidney failure are associated with metabolic acidosis.

A patient with uncontrolled diabetes mellitus develops metabolic acidosis. Which assessment finding indicates that the patients compensatory mechanisms are working? a. Vomiting b. Excessive thirst c. Watery diarrhea d. Deep rapid breathing

D Rationale D. Deep rapid breathing gets rid of carbon dioxide, which leaves less carbon dioxide to combine with water to make carbonic acid in the body. A. Vomiting causes acid loss and can result in alkalosis. B. Thirst corrects dehydration, not acidosis. C. Watery diarrhea can worsen metabolic acidosis.

The nurse is concerned that a patient has a high volume of insensible water loss. What is the patient experiencing that is causing the nurse this concern? a. Diarrhea b. Vomiting c. Urination d. Perspiration

D Rationale D. Insensible losses may occur without the person recognizing the loss. Perspiration and water lost through respiration and feces are examples of insensible losses. A. B. C. Sensible losses are those of which the person is aware such as urination, vomiting, and diarrhea.

A patient having a severe anxiety attack has an arterial blood gas result showing respiratory alkalosis. Which nursing action should the nurse take first? a. Administer nasal oxygen at 6 L/min. b. Give the patient a glass of orange juice. c. Place the patient in high Fowlers position. d. Have the patient rebreathe air from a paper bag.

D Rationale D. Rebreathing from a paper bag reduces carbon dioxide loss, which increases carbonic acid in the body, correcting alkalosis. A. B. Oxygen and orange juice will not help. C. The Fowlers position will increase ventilation and could worsen alkalosis.

The nurse is preparing diet teaching for a female patient who is postmenopausal, weighs 100 lbs. and is 5 feet 1 inch tall. Which food should the nurse encourage the patient consume? a. Red meat b. Fresh fruits c. Whole grains d. Dairy products

D Rationale D. The patient is at risk for osteoporosis. Dairy products should be encouraged. A. B. C. Red meat, fresh fruits, and whole grains do not help prevent the development of osteoporosis

An older adult patient has an IV infusion of 0.45% normal saline infusing at 150 mL/hr. Which assessment finding should cause the nurse to be most concerned? a. Tenderness at the IV site b. Capillary refill is <3 seconds c. Urine specific gravity is 1.018 d. Newly noted crackles in the lungs

D Rationale D. This patient is at risk for fluid volume overload; newly noted crackles are indicative of fluid volume overload. A. Tenderness at the IV site is concerning, but is not the highest priority listed. B. C. The values listed for urine specific gravity and capillary refill are normal.

The nurse is caring for a patient who is being treating for fluid volume excess. Which assessment finding indicates that treatment has been effective? a. Respiratory rate 24/min b. Output 1500 mL in 24 hours c. Blood pressure 132/80 mm Hg d. Weight loss of 5 lb in 24 hours

D Rationale D. Weight is the most reliable measure of fluid volume. A. The respiratory rate is slightly elevated, which can be a sign of fluid excess. B. Output of 1500 mL may be normal and does not necessarily indicate resolution of fluid excess. C. The blood pressure may be within the patients normal limits.

A patient comes into the clinic with complaints of extreme thirst, extreme urination, and ongoing hunger. Which blood glucose level should the nurse use to determine if the patient has diabetes? a. 110 mg/dL b. 126 mg/dL c. 185 mg/dL d. 210 mg/dL

D Rationale Diabetes is diagnosed if the random plasma glucose is 200 mg/dL or greater, with symptoms of diabetes. A. B. C. These levels will not be used to determine if the patient has diabetes.

The nurse is providing care to a patient 3 days after a Billroth I procedure. About which observation should the nurse be most concerned? a. Pulse 58 beats per minute b. Incisional pain score 4 on a 1 to 10 scale c. Patient becomes tearful while viewing the incision d. Reports of abdominal cramping shortly after eating

D Rationale Dumping syndrome is a complication of Billroth I procedure and occurs 5 to 30 minutes after eating. Symptoms include dizziness, tachycardia, fainting, sweating, nausea, diarrhea, a feeling of fullness, and abdominal cramping. A. A pulse of 58 beats per minute could be within the patients normal pulse range. B. C. Pain and the emotional reaction to the incision are psychosocial concerns and are not the highest priority at this time.

The nurse is reinforcing teaching provided to a patient with dumping syndrome. Which patient statement indicates a correct understanding of this condition? a. It is delayed gastric emptying. b. Glucose is dumped into the bloodstream. c. Digestive secretions enter the esophagus. d. There is rapid entry of food into the jejunum.

D Rationale Dumping syndrome occurs with the rapid entry of food into the jejunum without proper mixing of the food with digestive juices. On entering the jejunum, the food draws extracellular fluid into the bowel from the circulating blood volume to dilute the high concentration of electrolytes and sugars. A. Delayed gastric emptying does not described dumping syndrome. B. With dumping syndrome glucose is not dumped into the blood stream. C. Digestive secretions entering the esophagus describe gastroesophageal reflux disease.

A patient is diagnosed with end-stage kidney disease. The nurse realizes that what percentage of functioning nephrons have been lost in this patient? a. 25% b. 50% c. 75% d. 90%

D Rationale End-stage renal disease (ESRD) occurs when 90% of the nephrons are lost. A. Renal disease is not diagnosed when 25% of functioning nephrons are lost. B. In the early, or silent stage (decreased renal reserve), the patient is usually without symptoms, even though up to 50% of nephron function may have been lost. C. The renal insufficiency stage occurs when the patient has lost 75% of nephron function and some signs of mild kidney disease are present

A patient is diagnosed with end-stage kidney disease. The nurse realizes that what percentage of functioning nephrons have been lost in this patient? a. 25% b. 50% c. 75% d. 90%

D Rationale End-stage renal disease (ESRD) occurs when 90% of the nephrons are lost. A. Renal disease is not diagnosed when 25% of functioning nephrons are lost. B. In the early, or silent stage (decreased renal reserve), the patient is usually without symptoms, even though up to 50% of nephron function may have been lost. C. The renal insufficiency stage occurs when the patient has lost 75% of nephron function and some signs of mild kidney disease are present.

The nurse is reinforcing patient teaching on the best way to prevent transmission of infectious diarrhea. Which patient statement indicates correct understanding of the teaching? a. Wear a mask and gown. b. Avoid sharing eating utensils. c. Keep the perineal area clean and dry. d. Wash hands frequently and after toileting.

D Rationale Ensure hand washing by patient, family, and health care staff to prevent the spread of infection. A. A mask and gown do not need to be worn. B. Avoid sharing eating utensils will not prevent the spread of infectious diarrhea. C. Keeping the perineal area clean and dry will promote comfort and prevent skin breakdown.

The nurse is caring for a patient who has an ileostomy and feels crampy. The nurse notes that the stoma has become edematous and pale and suspects a blockage. What action should the nurse take? a. Administer a laxative such as milk of magnesia. b. Have the patient drink 2 to 3 L of water or other liquid. c. Administer a 1000-mL warm tap water enema through the stoma. d. Have the patient get into a tub full of warm water and drink warm liquids.

D Rationale For an ileostomy blockage, have the patient get into a tub of warm water, get into a knee-to-chest position, and sip on warm liquid such as coffee, tea, bouillon, broth, or hot chocolate. A. B. C. These interventions are not appropriate for the patient with an ileostomy blockage.

A patient is experiencing rapid deep breathing, fruity odor, lethargy, and weight loss. Laboratory results include a blood glucose of 720 mg/dL. Which symptom should indicate to the nurse that the patient has type 1 diabetes mellitus? a. Thirst b. Hunger c. Lethargy d. Fruity odor

D Rationale Fruity odor occurs with ketoacidosis in type 1 diabetes, which is very rare in type 2. A. B. C. The symptoms can occur in either type 1 or type 2 diabetes mellitus.

A nurse is approached by a neighbor who has a neck growth that appears to be a goiter. What should the nurse do? a. Advise the neighbor to switch to iodized salt when cooking. b. Palpate the neighbors thyroid gland for enlargement or nodules. c. Ask if the neighbor has numbness or tingling in the hands or lips. d. Question the neighbor about symptoms of hypothyroidism or hyperthyroidism.

D Rationale Further assessment is the first step in deciding what to do. B. Palpating the gland is inappropriate because the patient might be experiencing hyperthyroidism. A. Instructing about iodized salt is not appropriate without a definitive diagnosis. C. Numbness and tingling signify a parathyroid, not a thyroid, problem.

A patients Levin NG tube inserted for decompression of the bowel, which is connected to low intermittent suction, is not draining. The patient reports feeling full, uncomfortable, and nauseous. After verifying tube placement, what action should the nurse take next? a. Provide an antiemetic. b. Remove the nasogastric tube. c. Notify the physician immediately. d. Gently irrigate tube with normal saline.

D Rationale Gently irrigate the tube with normal saline to ensure patency and that the tube does not adhere to the stomach wall. A. An antiemetic would not help the tube drain. B. The NG tube cannot be removed without a health care providers (HCPs) order. C. The physician may need to be notified but after an attempt at irrigation is made.

The nurse is contributing to the plan of care for a patient with gluten enteropathy (celiac disease). What should the nurse recommend be eliminated from the diet of the patient? a. Red meats b. Milk and milk products c. Fresh fruits and vegetables d. Wheat, rye, oats, and barley

D Rationale Gluten is a protein found in wheat, barley, oats, and rye. In celiac disease, a high-calorie, high-protein, gluten-free diet is ordered to relieve symptoms and improve nutritional status. A. B. C. Gluten is not found in red meat, milk, milk products, or fresh fruits and vegetables.

The nurse develops a nursing diagnosis of fluid volume excess related to sodium retention secondary to steroid therapy as evidenced by weight gain of 12 pounds in 2 weeks and edema of lower extremities. Which goal is most appropriate? a. Patient will verbalize importance of low-sodium diet. b. Ankle circumference will be measured for edema daily. c. Patients fluid volume will decrease as evidenced by discontinuing steroids. d. Patient will have improved fluid balance as evidenced by weight returning to baseline.

D Rationale Having improved fluid balance as evidenced by weight returning to baseline addresses the problem. A. B. Verbalizing the importance of a low-sodium diet and measuring ankle circumference daily are actions. C. Discontinuing steroids is not evidence of improved fluid volume.

A patient is admitted for care because of heat stroke. Why should the nurse include interventions to prevent the onset of shock? a. The heat causes excessive dilation of veins and arteries. b. Inability to tolerate oral fluids could lead to more water lost. c. Parasympathetic stimulation causes blood to pool in the extremities. d. Excessive water lost through sweating can lead to hypovolemic shock.

D Rationale Heat exhaustion or heatstroke can also cause hypovolemic shock by excessive water loss through sweating. A. Excessive dilation of veins and arteries can lead to distributive shock. B. There is no evidence to support that the patient is unable to tolerate oral fluids. C. Parasympathetic stimulation causing blood to pool in the extremities is associated with neurogenic shock.

After collecting data the nurse determines that a patient is at risk for compression fractures. What health problem caused the nurse to come to this conclusion? a. Hypothyroidism b. Hyperthyroidism c. Hypoparathyroidism d. Hyperparathyroidism

D Rationale Hyperparathyroidism causes calcium to move from bone to blood, increasing risk of fracture. C. Hypoparathyroidism does not pull calcium from bone. A. B. Thyroid problems do not affect calcium movement.

A patient who is on hemodialysis for chronic kidney disease is prescribed sevelamer hydrochloride (Renagel) with meals. What explanation should be provided to the patient as the primary reason the medication is being given? a. To prevent metabolic acidosis b. To prevent gastrointestinal ulcer formation c. To relieve gastric irritation from excess acid production d. To prevent damage to bones from high phosphorus levels

D Rationale Hyperphosphatemia, a phosphorous level above 5 mg/dL, is associated with a low calcium level. These imbalances cause the bones to release calcium, causing patients to be prone to fractures. Sevelamer hydrochloride (Renagel) is a medication that binds with the phosphates in the stool and be eliminated. A. B. C. This medication does not prevent metabolic acidosis, gastrointestinal ulcer formation, or relieve gastric irritation.

A patient is prescribed levothyroxine (Synthroid) for hypothyroidism. Which statement should the nurse include when teaching the patient about this medication? a. If you do not take your medication, you will retain water and begin to see swelling in your feet and legs. b. Cushings syndrome is a complication of severe hypothyroidism, so you need to take this medication regularly. c. Thyrotoxicosis results from too little thyroid hormone, so you should monitor your temperature every day. d. Worsening hypothyroidism can result in a condition called myxedema coma, so it is important to take this medication.

D Rationale If a patient does not take medication to correct hypothyroidism, worsening hypothyroidism will occur, which can lead to myxedema coma. A. Fluid excess is not directly related to hypothyroidism. C. Thyrotoxicosis occurs with too much, not too little, thyroid hormone. B. Cushings syndrome is caused by deficient cortisol, not thyroid hormone.

The nurse is reviewing discharge instructions with a patient recovering from a hypophysectomy. What should the nurse emphasize with this teaching? a. Be sure to take your prescribed bromocriptine (Parlodel) every day. b. You must learn to accept the enlargement of soft tissues that occurred before surgery. c. Visual changes you experienced before surgery will begin to reverse within 6 months. d. Be sure to take the thyroid hormone, corticosteroids, and sex hormones that have been prescribed for you.

D Rationale If the pituitary is removed, lifelong replacement of thyroid hormone, corticosteroids, and sex hormones is important to maintain homeostasis. A. Bromocriptine reduces growth hormone release. B. Soft tissue will reduce in size some; telling the patient to learn to accept it is not therapeutic. C. Visual changes may not reverse.

A patient receiving 70 mL of tube feeding per hour has a residual amount of 120 mL. What action should the nurse take? a. Slow the feeding to 35 mL/hr. b. Continue the feeding as ordered. c. Increase the feeding to 100 mL/hr. d. Hold the feeding, and notify the physician.

D Rationale If the residual amount is more than 100 mL or the amount specified by the agency or physician, the feeding should be stopped to prevent vomiting or aspiration and the physician notified. A. Slowing the feeding is not going to reduce the amount of residual. B. Continuing the feeding as ordered increases the patients risk for aspiration or vomiting. C. Increasing the feeding will increase the patients risk for aspiration or vomiting

The nurse is reviewing the process of digestion with a patient diagnosed with malabsorption syndrome. How many mL of fluid should the nurse instruct that is absorbed through the intestinal mucosa into the portal bloodstream? a. 1000 b. 2000 c. 4000 d. 8000

D Rationale In the normal process of digestion, the intestinal mucosa absorbs more than 8000 mL of liquid with nutrients and electrolytes into the portal bloodstream. A. B. C. These volumes are significantly lower than the estimated amount of liquid absorbed into the portal bloodstream.

A patient with a bowel obstruction asks for the term that describes telescoping of the bowel. Which should the nurse respond to this patient? a. Ileus. b. Volvulus. c. Adhesions. d. Intussusception

D Rationale Intussusception occurs when peristalsis causes the intestine to telescope into itself, which can cause a mechanical obstruction. A. B. C. These terms do not describe telescoping of the bowel.

A patient with gallstones asks why jaundice has developed. What should the nurse explain as the most likely cause for the patients jaundice? a. Hepatitis b. Cirrhosis c. Hemolysis d. Bile duct obstruction

D Rationale Jaundice occurs when the bile duct is obstructed and free flow of bile into the intestine is interrupted. A. B. C. Hemolysis, cirrhosis, and hepatitis can all cause jaundice but are not the most common cause in patients with gallbladder disease.

The nurse suspects appendicitis in a patient complaining of abdominal pain. Which assessment finding should cause the nurse to notify the physician? a. The patient burps after drinking a glass of water. b. Tympanic, hollow sounds are heard on percussion. c. Bowel sounds are hyperactive in the upper quadrants. d. Palpation of the abdomen is positive for rebound tenderness.

D Rationale Local rebound tenderness (intensification of pain when pressure is released after palpation) in the right lower quadrant of the abdomen is a classic sign of appendicitis. A. B. C. Burping, tympanic bowel sounds, and hyperactive bowel sounds are not associated with appendicitis.

The nurse is caring for a patient with exophthalmos secondary to Graves disease. What nursing interventions are appropriate for this patient? a. Myotic eyedrops and privacy b. Television and other diversionary activities c. An accepting attitude and lubricating eyedrops d. Reassurance that the symptoms will resolve when the Graves disease is under control

D Rationale Lubricating eyedrops will help keep the eyes moist if the patient is unable to close them. An accepting attitude is important if the patients body image is disturbed. A. B. Diversion and myotic eyedrops do not address the problem. D. Symptoms will not resolve with treatment.

The nurse is preparing to discuss long-term complications of diabetes with a patient newly diagnosed with the disorder. Which structure should the nurse identify as causing complications because of underlying damage? a. Heart b. Liver c. Brain d. Blood vessels

D Rationale Most of the complications of diabetes involve either the large blood vessels in the body (macrovascular complications) or the tiny blood vessels, such as those in the eyes or kidneys (microvascular complications). A. C. Damage to the blood vessels can affect the brain or heart. B. Liver complications are not common in diabetes.

The spouse of a patient in neurogenic shock asks what is happening to the patient. How should the nurse response to the spouse? a. This is because of an allergic reaction. b. There is a drop in circulating blood volume. c. The heart has failed to pump blood throughout the body. d. The blood vessels have dilated and lowered the blood pressure.

D Rationale Neurogenic shock is a form of distributive shock in which massive vasodilation of the peripheral circulation occurs, causing hypotension. A. B. C. Neurogenic shock is not caused by an allergic reaction, drop in circulating blood volume, or heart failure.

The nurse determines that a patients urine output is normal. How many mL of urine did the patient void within the last 24 hours? a. 150 to 400 mL b. 250 to 500 mL c. 750 to 1000 mL d. 1000 to 2000 mL

D Rationale Normal urinary output is 1000 to 2000 mL per 24 hours. A. B. C. These volumes represent inadequate amounts of urine output for 24 hours.

A patient with cholelithiasis is having clay-colored stools. What should the nurse realize as the most common cause of clay-colored stools? a. Retrograde bile flow into the liver b. Accumulation of bile salts in the skin c. Cirrhosis from chronic liver irritation d. A gallstone lodged in the common bile duct

D Rationale Obstruction of bile flow (e.g., from a stone in the duct) may result in stools that are clay-colored, because bile is not present in the stool to give it color. A. B. C. Other liver and gallbladder disorders can also cause clay-colored stools, but in a patient with cholelithiasis, a stone lodged in the duct would be the most common.

The nurse is caring for a patient who has an acute kidney injury. Which diagnostic test result should the nurse identify as most supporting this diagnosis? a. Hematocrit 20% (normal 38% to 47%) b. Uric acid 8 ng/dL (normal 2.5 to 5.5 ng/dL) c. 24-hour creatinine clearance 5 mL/min (normal 100 mL/min) d. Blood urea nitrogen 20 mg/100 mL (normal 8 to 25 mg/100 mL)

D Rationale Of the tests listed a normal 24-hour creatinine clearance of 100 mL/min is the most accurate test for renal function. A value less than 100 mL/min indicates kidney disease. A. B. Hematocrit and uric acid levels are not used to diagnose kidney disease. D. Blood urea nitrogen test is also used to detect kidney disease however the value is within normal limits.

A patient is prescribed PN. For which percentage of dextrose should the nurse prepare the patient to have a central venous catheter placed for this infusion? a. 5% b. 8% c. 10% d. 12%

D Rationale PN dextrose greater than 12% should be administered through a central venous catheter into a large vein to prevent vein irritation and thrombophlebitis. A. B. C. These dextrose percentages can be safely administered through a peripheral site.

The nurse is assisting with the care of a patient who has PN containing dextrose 50% infusing. The patient asks why the rate keeps being increased. How should the nurse respond to this patient? a. It is important to increase the PN whenever your blood sugar is low. b. It is important to do this to help reduce bile secretion and prevent heartburn. c. By changing the rate, it helps your body increase absorption of the electrolytes. d. It is started slowly and increased slowly to allow your pancreas to adjust insulin levels.

D Rationale PN is started slowly to give the pancreas time to adjust to increasing insulin production for the high amounts of glucose in the PN. A. The rate is not changed because the patients blood sugar is low. B. The rate is not changed because of bile secretion or heartburn. C. The rate is not changed to encourage the body to absorb electrolytes.

The nurse provides comfort measures to maintain normal body temperature and reduce pain and anxiety for a patient who is experiencing shock. What is the purpose of the nurse performing these actions? a. Increases fluid volume b. Decreases fluid volume c. Increases oxygen demand d. Decreases oxygen demand

D Rationale Pain, anxiety, and cold all increase body tissue demands for blood and oxygen. This places an increased workload on the heart. Maintaining normal body temperature and reducing pain and anxiety will reduce oxygen demand. A. B. C. Maintaining normal body temperature and reducing pain and anxiety will not impact fluid balance or increase oxygen demand.

The nurse is collecting data from a patient with acute pancreatitis. Which symptoms should the nurse anticipate? a. Low abdominal pain, bradycardia, and confusion b. Shortness of breath, hypotension, and restlessness c. Fever, tachycardia, right upper quadrant pain, and jaundice d. Abdominal distention, respiratory distress, and mid-epigastric pain

D Rationale Patients with acute pancreatitis are very ill, with dull abdominal pain, guarding, a rigid abdomen, hypotension or shock, and respiratory distress from accumulation of fluid in the retroperitoneal space. The abdominal pain is generally located in the midline just below the sternum, with radiation to the spine, back, and flank. A. B. C. These manifestations are not associated with pancreatitis.

The nurse is caring for a patient with an inflamed appendix. Which complication is most likely to occur if the appendix ruptures? a. Colitis b. Enteritis c. Hepatitis d. Peritonitis

D Rationale Perforation, abscess of the appendix, and peritonitis are major complications of appendicitis. A. B. C. Colitis, enteritis, and hepatitis are not complications of a ruptured appendix.

The nurse is reinforcing teaching provided to a patient about risk factors for prerenal injury. Which risk factor should the patient state that indicates understanding of this teaching? a. Kidney stones. b. Enlarged prostate. c. Exposure to nephrotoxins agents. d. Use of nonsteroidal anti-inflammatory drugs.

D Rationale Prerenal injury causes include decreased blood pressure from dehydration, blood loss, shock, trauma to or blockage in the arteries to the kidneys, and NSAIDs and cyclooxygenase-2 inhibitors, which impair the autoregulatory responses of the kidney by blocking prostaglandin, which is necessary for renal perfusion. A. B. Kidney stones and enlarged prostate are risk factors for a postrenal injury. C. Nephrotoxic agents are risk factors for an intrarenal injury.

A patient with a nasogastric tube to low intermittent suction after surgery begins to vomit bright red blood. Which action should the nurse take first? a. Administer oxygen. b. Irrigate the nasogastric tube. c. Increase the intravenous rate. d. Turn the patient onto his or her side.

D Rationale Protection of the airway during vomiting is a priority to prevent aspiration. Those at risk of aspiration are persons who are unconscious, older, and experiencing gag reflex impairments. Place these types of persons on their side when they begin to vomit. This allows the gastric contents to be expelled from the mouth rather than pooling at the back of the throat and being aspirated. A. The patient does not necessarily need oxygen at this time. B. The patient could aspirate while the nurse is irrigating the nasogastric tube. C. There is no reason to increase the patients intravenous infusion at this time.

The nurse is reviewing the history and physical of a patient who has an infection. What term should the nurse realize describes an infection of the kidneys? a. Cystitis b. Hepatitis c. Urethritis d. Pyelonephritis

D Rationale Pyelonephritis is infection of the renal pelvis, tubules, and interstitial tissue of one or both kidneys. A. Cystitis is inflammation and infection of the bladder wall. B. Hepatitis is inflammation and infection of the liver. C. Urethritis is inflammation of the urethra.

The nurse is reinforcing teaching provided to a patient scheduled for pyloroplasty. Which patient statement indicates a correct understanding of the procedure? a. The doctor will stitch the top of my stomach to help me lose weight. b. The doctor will cut the nerve that goes to my stomach so less acid is released. c. The pylorus will be narrowed to prevent gastric reflux and help my ulcers heal. d. The surgery will improve the movement of food from my stomach to my small intestine.

D Rationale Pyloroplasty widens the exit of the pylorus to improve emptying of the stomach. A. Suturing part of the stomach is part of Bariatric surgery. B. Cutting the nerve to the stomach is a vagotomy. C. There is no surgery to narrow the pylorus.

A patient has a glomerular filtration rate of 55%. What should this value indicate to the nurse? a. This is a normal value. b. The patient is in renal failure. c. The patient needs to be on a fluid restriction. d. The patients other tests will be in the normal range.

D Rationale Renal function test values may be within the normal range until the glomerular filtration rate is less than 50% of normal. A. This value is not normal. B. This value does not indicate that the patient is in renal failure. C. There is no reason to place this patient on fluid restriction.

The nurse is assisting in the planning of care for a patient in shock. Which nursing diagnoses should the nurse recommend be included in the patients plan of care? a. Hopelessness b. Risk for aspiration c. Excess fluid volume d. Inadequate tissue perfusion

D Rationale Shock is defined as inadequate tissue perfusion so the nursing diagnosis of inadequate tissue perfusion is appropriate for the nurse to recommend. A. Shock does not necessarily lead to hopelessness. B. The patient in shock is not necessarily at risk for aspiration. C. Excess fluid volume would be appropriate for the patient experiencing cardiogenic shock.

The family of a patient in shock asks the nurse to explain the condition. How should the nurse respond to this family? a. It is caused by massive blood loss. b. It is a profound circulatory collapse. c. It is the result of overwhelming emotion. d. There is inadequate oxygen delivered to the tissues.

D Rationale Shock is defined as inadequate tissue perfusion, in which there is insufficient delivery of oxygen and nutrients to the bodys tissues and inadequate removal of waste products from these tissues. A. Shock can occur from a massive blood loss but the mechanism is more involved. B. Shock can cause profound circulatory collapse however the mechanism also includes an inadequate amount of oxygen reaching body tissues. C. The term shock is not being used because an overwhelming emotion.

The nurse is collecting data from a patient who is reporting abdominal pain. Which symptom suggests that the patient is experiencing appendicitis? a. Suprapubic pain b. Midepigastric pain c. Substernal pain that radiates to the back d. Pain in the right lower abdominal quadrant

D Rationale Signs and symptoms of appendicitis include fever, increased white blood cells, and generalized pain in the upper abdomen. Within hours of onset, the pain usually becomes localized to the right lower quadrant at McBurneys point. A. B. C. Appendicitis pain is not located in the suprapubic, mid-epigastric, or substernal regions.

After an episode of shock, a patients laboratory results reveal decreased clotting factors. Based on these laboratory results, the nurse should monitor for which complication of shock? a. Brain attack b. Multisystem organ failure c. Adult respiratory distress syndrome d. Disseminated intravascular coagulation

D Rationale Signs and symptoms of liver injury include abnormal clotting because clotting factor production by the liver is impaired, so the nurse monitors for coagulation disorders such as disseminated intravascular coagulation. A. B. C. Alterations in clotting factors will not predispose the patient to develop a brain attack, multisystem organ failure, or adult respiratory distress syndrome.

The nurse is assisting with discharge of a patient with Addisons disease following an adrenal crisis. Which instruction is most important for the nurse to reinforce? a. The need for a well-balanced diet b. How to monitor blood glucose levels c. The importance of 30 minutes of exercise each day d. The importance of taking steroid replacements as prescribed

D Rationale Steroid replacements are essential because the patient with Addisons disease does not have adequate steroid hormones. B. Blood glucose levels are monitored if a patient is on high-dose steroids, not for replacement steroids. A. C. Diet and exercise are important but are not immediately life-threatening if not carried out.

The nurse is collecting data from a patient with stress incontinence. Which finding should the nurse document? a. The patient is unable to tell when there is the need to urinate. b. The patient is unable to hold urine when under emotional stress. c. The patient is unable to reach the bathroom and urinates in underwear. d. The patient loses small amounts of urine when he or she coughs or sneezes.

D Rationale Stress incontinence is the involuntary loss of less than 50 mL of urine associated with increasing abdominal pressure during coughing, sneezing, laughing, or other physical activities. A. B. C. These statements do not describe stress incontinence.

A patient recovering from a thyroidectomy is being assessed for tetany. What is the most likely cause of tetany after this surgery? a. Swelling of the incisional area b. Overdose of preoperative antithyroid medication c. Accidental removal of the parathyroid glands during surgery d. Excess circulating thyroid hormone released during manipulation of the gland during surgery

D Rationale Tetany can occur if the parathyroid glands are accidentally removed during thyroid surgery. Because of the proximity of the parathyroid glands to the thyroid, it is sometimes difficult for the surgeon to avoid them. In the absence of parathyroid hormone, serum calcium levels drop, and tetany results. D. Excess thyroid hormone causes a thyrotoxic crisis. A. B. Swelling and antithyroid medication do not cause tetany.

A patient with type 1 diabetes mellitus asks what caused the fruity odor that was present at diagnosis. How should the nurse respond? a. Excess sugar is excreted in the urine, which causes the fruity odor. b. The proteins in the blood are metabolized to a substance that has a fruity odor. c. The excess sugar in the blood is metabolized to fructose and excreted via the lungs. d. In the absence of available sugar, the body breaks down fat into ketones, which have a fruity odor.

D Rationale The expired air has a fruity odor caused by the ketones which occurs when fat is broken down and may be mistaken for alcohol. Some nurses have likened the odor to Juicy Fruit gum. A. B. C These responses do not correctly describe the process for the fruity odor.

The nurse discovers that a patient recovering from surgery is hemorrhaging from the incisional site. What action should the nurse take? a. Offer oral fluids. b. Warm the patient. c. Relieve the patients apprehension. d. Apply pressure to the bleeding site.

D Rationale The first priority is to control the bleeding with direct pressure. A. B. C. The other options may be considered but are not the first priority.

A patient recovering from vascular leg surgery is found standing in a large pool of blood flowing from the surgical site. After assisted into bed, the patient is pale with a palpable pulse. What action should the nurse take? a. Notify the charge nurse. b. Start an infusion of 0.9% NaCl. c. Apply oxygen at 2 L/min via nasal cannula. d. Elevate legs and apply pressure over the bleeding site.

D Rationale The first priority is to control the bleeding with direct pressure. Elevating the legs will also help. A. The charge should be notified while the bleeding is being controlled by calling for assistance. B. C. Oxygen and IV fluids may be needed but require a physicians order.

The nurse is monitoring hourly urine output from an indwelling catheter for a patient experiencing hypovolemic shock. What should the nurse do if the patients urine output drops to 15 mL for one hour of monitoring? a. Document the finding. b. Flush the urinary catheter c. Clamp the catheter for 30 minutes. d. Immediately report the drop in urine output.

D Rationale The kidneys can tolerate reduced blood flow for about 1 hour before sustaining permanent damage. Cells in the kidneys die when there is a lack of oxygen and nutrients. If there is widespread damage to the kidneys, complete renal failure is likely. A. The nurse needs to do more than document the findings. B. The urinary catheter does not need to be flushed. C. Clamping the catheter for 30 minutes is not going to improve the patients urine output.

The nurse is caring for a patient with an acidbase imbalance from kidney disease. How should the nurse explain the role of the kidneys to maintain acidbase balance in the body to the patient? a. Promoting retention of proteins b. Promoting excretion of carbon dioxide c. Conserving or excreting potassium ions d. Conserving or excreting bicarbonate ions

D Rationale The kidneys regulate the acidbase balance of the blood by the excretion or conservation of ions such as hydrogen or bicarbonate. A. Promoting retention of proteins will not maintain acidbase balance. B. C. Excretion of carbon dioxide or conserving or excreting potassium does not contribute to maintaining acidbase balance in the body.

The nurse is caring for a patient with bulimia. Which complication should the nurse recognize that this patient is at risk for developing? a. Weight gain b. Fluid overload c. Ischemic stroke d. Metabolic alkalosis

D Rationale The loss of hydrochloric acid from the stomach due to vomiting can result in metabolic alkalosis. A. B. C. This patient is not at any particular risk for developing weight gain, fluid overload, or ischemic stroke.

The nurse is reviewing the anatomy of the kidney with a patient scheduled for renal surgery. What should the nurse explain as being the structural and functional unit of the kidney? a. Cortex b. Medulla c. Pyramid d. Nephron

D Rationale The nephron is the structural and functional unit of the kidney. Urine is formed in the approximately 1 million nephrons in each kidney. A. B. C. Cortex, medulla, and pyramid are different parts of the kidney.

The nurse is caring for a patient whose NG tube, attached to low intermittent suction to decompress a bowel obstruction, is not draining. After checking placement, which action should the nurse take? a. Advance the NG tube 2 inches. b. Change the suction setting to high. c. Reinsert the NG tube in the other nare. d. Irrigate the NG tube with 30 milliliters of normal saline.

D Rationale The nurse should irrigate the NG tube with 30 mL of normal saline to see if it is obstructed or on the stomach wall. B. Suction should remain on a low setting to prevent damage to the lining of the stomach. A. The tube should not be advanced without an HCPs order. C. The NG tube should not be pulled and reinserted without an HCPs order.

A 19-year-old patient reports flank pain and scanty urination. The nurse notices periorbital edema, and the urinalysis reveals white blood cells, red blood cells, albumin, and casts. What question would be most important for the nurse to include in data collection? a. Is your vision blurred? b. Are you sexually active? c. Have you had any gastrointestinal problems lately? d. Have you had a strep infection of the throat or skin recently?

D Rationale The patient has symptoms of glomerulonephritis, which can be caused by a variety of factors but is most commonly associated with a group. A beta-hemolytic streptococcus infection following a streptococcal infection of the throat or skin. A. B. C. Asking about blurred vision, sexual activity, and gastrointestinal problems would not be appropriate for this patients health problem.

While doing volunteer health screenings at a local mall a patient with a large growth on the neck approaches the nurse. What finding should alert the nurse to send the patient to the physician immediately? a. The patient seems depressed. b. The growth is difficult to conceal with clothing. c. The patient complains of being very tired lately. d. The patient makes a funny high-pitched sound with each breath.

D Rationale The patient is exhibiting stridor, which indicates poor airway clearance. Airway problems always take priority. A. B. C. These findings are concerning however airway takes the priority.

The nurse is reinforcing teaching for a patient who is scheduled for an esophagogastroduodenoscopy. Which patient statement indicates understanding of pre-procedure diet instructions? a. I may have a full liquid breakfast. b. I will not eat or drink 12 hours before the procedure. c. I can drink only clear liquids 2 hours before the procedure. d. I will have nothing to eat or drink 8 to 12 hours before the procedure.

D Rationale The patient will have nothing to eat or drink 8 to 12 hours typically before the procedure. A. B. C. These statements indicate the patient does not understand the pre-procedure diet instructions.

After collecting data, the nurse suspects that a patient is experiencing cardiogenic shock. Which finding supports this nurses suspicion? a. Oliguria b. Tachypnea c. Bronchospasm d. Pulmonary edema

D Rationale The presence of pulmonary edema is what differentiates cardiogenic shock from other forms of shock. A. B. C. Oliguria, tachypnea, and bronchospasm are manifestations associated with other forms of shock.

The nurse is collecting data from a patient with a stoma. What should the nurse document for a health stoma? a. Gray and dry b. Black and dry c. Bluish and wet d. Pink and moist

D Rationale The stoma should be pink to red, moist, and well attached to the surrounding skin. A. C. A bluish or gray stoma indicates inadequate blood supply. B. A black stoma indicates necrosis.

The nurse notes that the urine from a patient with an ileal conduit has mucus strands. What action should the nurse take? a. Notify the physician. b. Send a urine sample to the laboratory for culture. c. Ask the patient about a history of UTIs. d. Nothing, as the nurse understands that this is a normal finding.

D Rationale The urine from an ileal conduit contains mucus because it comes through the ileum, which normally secretes mucus. A. B. C. There is no need to notify the physician, send a specimen for culture, or ask the patient about a history of UTIs

The nurse notes that the urine from a patient with an ileal conduit has mucus strands. What action should the nurse take? a. Notify the physician. b. Send a urine sample to the laboratory for culture. c. Ask the patient about a history of UTIs. d. Nothing, as the nurse understands that this is a normal finding.

D Rationale The urine from an ileal conduit contains mucus because it comes through the ileum, which normally secretes mucus. A. B. C. There is no need to notify the physician, send a specimen for culture, or ask the patient about a history of UTIs.

The nurse is reinforcing teaching provided to a patient being tested for type B gastritis. Which patient statement indicates a correct understanding of the test that is used to diagnose this condition? a. Colonoscopy. b. Barium enema. c. Abdominal x-ray. d. Esophagogastroduodenoscopy.

D Rationale Type B gastritis can also be diagnosed by endoscopy, upper gastrointestinal x-ray examination, and gastric aspirate analysis. A. B. C. Colonoscopy, barium enema, and abdominal x-ray are not used to diagnose type B gastritis

A patient with cholecystitis is prescribed promethazine (Phenergan) for nausea. Which adverse effect of the medication should the nurse instruct the patient to report? a. Diarrhea b. Insomnia c. Dry mouth d. Urine retention

D Rationale Urine retention can be life threatening and should be reported immediately. B. C. Dry mouth and insomnia are not emergencies. A. Constipation, not diarrhea, is more likely to occur.

The nurse determines that treatment has been effective for a patient with diabetes insipidus. Which laboratory value did the nurse use to come to this conclusion? a. Urine ketones b. Serum potassium c. Fasting blood glucose d. Urine specific gravity

D Rationale Urine specific gravity is a good measure of urine concentration and antidiuretic hormone (ADH) function. B. Diabetes insipidus does not directly affect potassium level. A. C. Blood glucose and urine ketones are monitored in diabetes mellitus, not diabetes insipidus.

A licensed practical nurse (LPN) who typically works on a medical unit has been assigned to cover staffing deficits on a surgical unit. After obtaining report, the nurse realizes that one of the assigned patients is currently receiving parenteral nutrition (PN). Which action should the nurse take? a. Provide patient care as assigned. b. Ask another nurse to trade patients for the shift. c. Notify the supervisor that another nurse will need to be pulled. d. Notify the charge nurse that an adjustment in the patient assignment is necessary.

D Rationale Usually, registered nurses (RNs) are responsible for administering PN. Therefore, the LPN should discuss the assignment with the charge nurse and seek a possible adjustment. A. Providing patient care as assigned would be beyond the LPNs scope of practice. B. The LPN cannot make a patient care assignment change. C. The LPN needs to work through the charge nurse.

The employee health nurse is preparing vaccines to administer to patient care staff to permanently protect them from hepatitis. For which types of hepatitis does the nurse have vaccines? a. HAV b. HBV c. HCV d. Both HAV and HBV

D Rationale Vaccines against HBV are available and provide permanent, active immunity to HBV. A vaccine for HAV has also been developed. C. A vaccine for hepatitis C does not exist.

A patient involved in a motor vehicle accident has pale mucous membranes, diaphoresis, confusion, blood pressure 88/48 mm Hg, irregular heart rhythm, and metabolic acidosis. Which finding should the nurse recognize as the likely cause of acidosis? a. Hyperventilation b. Aerobic metabolism c. Inadequate ventilation d. Anaerobic metabolism

D Rationale When cells are deprived of oxygen, they shift to anaerobic metabolism, resulting in the production of lactic acid. Unless the lactic acid is removed from the bloodstream, the blood will become increasingly acidic, resulting in metabolic acidosis. C. Inadequate ventilation leads to respiratory acidosis as CO2 levels rise. A. Hyperventilation leads to respiratory alkalosis as CO2 levels decrease. B. Aerobic metabolism is normal.

he nurse is reinforcing teaching provided to a patient with a peptic ulcer. Which patient statement indicates understanding of the medication ranitidine (Zantac)? a. It clings to the ulcer. b. It coats your stomach. c. It neutralizes stomach acid. d. It reduces production of gastric acid.

D Rationale Zantac reduces production of gastric acid, which aids in healing the ulcer. A. B. C. These statements do not explain the purpose or mechanism of Zantac.

Place the following individuals in order (14) related to their risk for dehydration, ranking from highest to lowest. A. A 28-year-old patient who is nothing by mouth (NPO) prior to an endoscopy B. An 8-year-old patient who has had diarrhea for 16 hours C. A 64-year-old patient who is taking potassium supplements D. A 72-year-old patient who has had a fever and anorexia for 48 hours

D, B, A, C Rationale D. Those at highest risk for dehydration are older patients, infants, children, and any patient with a condition that may cause fluid loss. Fever causes fluid loss, and anorexia will reduce oral intake. B. The patient with diarrhea is at risk for dehydration due to fluid loss, but has not had the condition for as long as the patient in option D, and there is no evidence that the 8-year-old is not taking fluids. A. Patients who are NPO have restricted fluid intake. C. Potassium supplements do not cause water loss.

The nurse is reinforcing teaching on diet therapy provided to a patient with type 2 diabetes mellitus. Which patient explanations about create your plate indicate that teaching has been effective? (Select all that apply.) a. Half the plate is protein b. Divide the plate into 4 quarters c. One quarter of the plate is fruit d. One 8 ounce glass of low-fat milk e. Half the plate is non-starchy vegetables

D, E Rationale Half the plate is filled with non-starchy vegetables. An 8 ounce glass of nonfat or low-fat milk completes the meal. B. When creating the plate, the place should be divided into one half and two quarters. C. One quarter is filled with starchy foods, such as whole grains and starchy vegetables. Fruit should be one serving A. The last quarter is used for meats and meat substitutes.

A patient is prescribed to ingest a high-calcium diet. What foods should the nurse instruct the patient to ingest? (Select all that apply.) a. Chicken b. Potatoes c. Beef and pork d. Sardines, salmon e. Milk, cheese, and yogurt f. Whole grain breads and cereals

D, E Rationale Milk products and canned fish are high in calcium. A. B. C. F. Meats, chicken, potatoes, and grains are not as high in calcium.

A 32-year-old female patient is diagnosed with uncomplicated cystitis. Which medications should the nurse expect to be prescribed for this patient? (Select all that apply.) a. Ciprofloxacin (Cipro) b. Aztreonam (Azactam) c. Decadron (Solu-Medrol) d. Nitrofurantoin (Macrodantin) e. Sulfamethoxazole and trimethoprim (Bactrim, Septra)

D, E Rationale Treatment of uncomplicated cystitis is most often a combination of sulfa medication, such as sulfamethoxazole and trimethoprim (Bactrim, Septra), or nitrofurantoin (Macrodantin). A. Complicated cystitis is often treated with ciprofloxacin (Cipro). B. Aztreonam (Azactam) may be used to treat UTIs. C. Decadron (Solu-Medrol) is a steroid and is not used to treat cystitis

A 32-year-old female patient is diagnosed with uncomplicated cystitis. Which medications should the nurse expect to be prescribed for this patient? (Select all that apply.) a. Ciprofloxacin (Cipro) b. Aztreonam (Azactam) c. Decadron (Solu-Medrol) d. Nitrofurantoin (Macrodantin) e. Sulfamethoxazole and trimethoprim (Bactrim, Septra)

D, E Rationale Treatment of uncomplicated cystitis is most often a combination of sulfa medication, such as sulfamethoxazole and trimethoprim (Bactrim, Septra), or nitrofurantoin (Macrodantin). A. Complicated cystitis is often treated with ciprofloxacin (Cipro). B. Aztreonam (Azactam) may be used to treat UTIs. C. Decadron (Solu-Medrol) is a steroid and is not used to treat cystitis.

The nurse reviews the process to obtain a midstream urine specimen for culture and sensitivity with a female patient. Which patient statements indicate understanding of this process? (Select all that apply.) a. A 24-hour urine specimen is needed. b. A second-voided specimen is preferred. c. I should wash from the back to the front. d. The labia should be kept separated while voiding. e. When urine starts to flow, collect it in the clean container provided. f. The genitalia should be thoroughly cleaned with the towelettes provided.

D, F Rationale Female patients should be told to separate the labia with one hand and keep it separated while washing with provided towelettes and collecting the specimen to decrease the risk of contamination of the specimen. B. The first morning specimen is best, but collection can occur at any time. E. The container must be sterile for a culture. A. A 24-hour specimen is not needed. C. Women should wash from the front to the back.

The nurse is monitoring a patient who has been in a shock state for several days. For which serious complications should the nurse observe in the patient and then report? (Select all that apply.) a. Sepsis b. Malnutrition c. Diabetes mellitus d. Cerebrovascular accident e. Adult respiratory distress syndrome f. Multiple organ dysfunction syndrome

E, F Rationale Acute respiratory distress syndrome, disseminated intravascular coagulation, and multiple organ dysfunction syndrome are three serious conditions that may follow a prolonged episode of shock. A. B. C. D. Sepsis, malnutrition, diabetes mellitus, and cerebrovascular accident are not considered complications of shock.

The nurse is reinforcing teaching provided to a patient who has a small bowel obstruction. Which processes occur in the small intestine that should be included in this teaching? (Select all that apply.) a. Production of bile b. Absorption of water c. Production of insulin d. Mechanical digestion of food to chyme e. Production of enzymes to complete carbohydrate metabolism f. Production of peptides to complete the digestion of proteins to amino acids

E, F Rationale Enzymes to complete carbohydrate metabolism and production of peptides to digest proteins occur in the small intestines. A. B. C. D. These processes occur in other body organs.