AAH prepost
B. Administer digoxin (Lanoxin) and furosemide (Lasix)
A patient diagnosed with alcoholism is admitted to a substance abuse unit complaining of decreased exercise tolerance, lower extremity edema, arrhythmias, and dyspnea. Which nursing intervention would be appropriate for this patient? A. Provide thiamine-rich foods B. Administer digoxin (Lanoxin) and furosemide (Lasix) C. Reorient client to person, place, and time D. Encourage high-sodium foods
2. Splitting.
A patient diagnosed with borderline personality disorder coyly requests diazepam (Valium). When the physician refuses, the client becomes angry and demands to see another physician. What defense mechanism is the patient using? 1. Undoing. 2. Splitting. 3. Altruism. 4. Reaction formation.
A) Perform a rapid physical assessment.
A patient has been brought to the emergency department with multiple trauma after a motor vehicle accident. After immediate threats to life have been corrected in a patient with multiple trauma, which action would the nurse perform? A) Perform a rapid physical assessment. B) Initiate health education. C) Perform diagnostic imaging. D) Establish the circumstances of the accident.
A) Blood/pressure 140/60, pulse 60, respirations 12
A patient is admitted to the hospital with a head injury resulting from an automobile accident. On admission the patient/client's vital signs are temperature 98.6'F (37'C), blood pressure 128/68, pulse 110, and respirations 26. One hour after admission, the nurse notes the presence of Cushing's triad when the patient/client's vital signs are: A) Blood/pressure 140/60, pulse 60, respirations 12 B) Blood/pressure 130/72, pulse 90, respirations 24 C) Blood/pressure 148/78, pulse 112, respirations 28 D) Blood/pressure 140/60, pulse 60, respirations 30
D. To detect and treat ventricular fibrillation and ventricular tachycardia
A patient who has undergone an implantable cardioverter Defibrillator (ICD) procedure asks the nurse about the purpose of this device. What would be the nurse's best response? A. To detect and treat bradycardia B. To detect and treat atrial fibrillation C. To shock your heart if you have a heart attack at home D. To detect and treat ventricular fibrillation and ventricular tachycardia
a. Check the tubing to ensure that the client is not lying on it or kinking it.
A patient who underwent a lobectomy and has a water-seal chest drainage system is breathing with a little more effort and at a faster rate than 1 hour ago. The client's pulse rate also increased. The nurse should: a. Check the tubing to ensure that the client is not lying on it or kinking it. b. Increase the suction. c. Lower the drainage bottles 2 to 3 feet below the level of the client's chest. d. Ensure that the chest tube has two clamps on it to prevent air leaks.
D) "Hypotension and cramping may occur."
A patient with end stage renal disease (ESRD) is scheduled for the first hemodialysis treatment. The patient/client asks the nurse what common complications may occur from the treatment. What would be the nurse's best reply? A) "High blood sugar levels and low protein levels may occur." B) "Excessive bleeding and double vision may occur." C) "Confusion and diarrhea may occur." D) "Hypotension and cramping may occur."
C. Show understanding of the client's needs by jointly setting up a two hour schedule to monitor pulse and heart rate.
A patient with high anxiety asks the nurse to take her pulse and listen to her heart several times each hour. What is the best way for the nurse to cope with this situation? A. Be solicitous of the clients needs and comply with her request B. Demonstrate firmness by denying the request C. Show understanding of the client's needs by jointly setting up a two hour schedule to monitor pulse and heart rate. D. Convey to the client that her distress is recognized, without meeting all of her requests
B. Commissurotomy
A patient with mitral valve stenosis is admitted to your unit. She is scheduled for surgery to repair her valve. What procedure is usually performed to open the mitral valve? A. Balloon Valvuloplasty B. Commissurotomy C. Chordoplasty D. Valve replacement
A. Absorption of oral or intramuscular drugs is diminished because of impaired circulation.
During the early emergent phase of burns, the nurse understands that analgesics should be given intravenously because A. Absorption of oral or intramuscular drugs is diminished because of impaired circulation. B. Analgesics do not need to be administered as frequently when they are given intravenously. C. Larger doses of narcotics can be given when administered intravenously than when given intramuscularly. D. Respiratory depression is easier to diagnose and treat when narcotics are administered intravenously.
B. Hypovolemic shock
Patient has been admitted to your unit with a gastrointestinal ulcer. The patient is NPO and has a nasogastric tube in place connected to low suction. What form of shock should you monitor this patient for? A. Cardiogenic shock B. Hypovolemic shock C. Distributive shock D. Obstructive shock
B. A 40-year-old patient who had a parathyroidectomy yesterday and has muscle twitching
The RN has just received change-of-shift report on the medical-surgical unit. Which patient/client will need to be assessed first? A. A 26-year-old patient with a parathyroid adenoma and they flank pain due to the kidney stone B. A 40-year-old patient who had a parathyroidectomy yesterday and has muscle twitching C. A 48-year-old patient with Hashimoto's thyroiditis and a large goiter D. A 62-year-old patient with hypothyroidism and an apical pulse rate of 71
C. Determine when the patient last urinated
The male patient with a C-6 spinal cord injury tells the home health nurse he has had a severe pounding headache for the last 2 hours. Which intervention should the home health nurse implement? A. Ask the patient if he has taken any medication for the headache B. Check the patient's respiratory rate C. Determine when the patient last urinated I think this is it! D. Inquire when the patient had his last meal
D. Full thickness
The newly admitted patient has burns on both legs. The burned areas appear white and leather-like. No blisters or bleeding are present, and the patient states that he has little pain. How should you categorize this injury? A. Superficial B. Partial-thickness superficial C. Partial-thickness deep D. Full thickness
B) The patient/client complains of extreme thirst and has an increased urine output.
The nurse is caring for a female patient who sustained a closed head injury 8 days ago due to a motor vehicle accident. Which signs and symptoms would alert the nurse to a complication of the head injury? A) The patient/client reports having trouble sleeping due to having nightmares about the wreck. B) The patient/client complains of extreme thirst and has an increased urine output. C) The patient/client tells the nurse she has a stuffy nose and green nasal discharge. D) The patient/client informs the nurse that she has started her menstrual period.
B. Versed and Nitroglycerin patch
The nurse is caring for a patient going to hemodialysis three times a week. The nurse expects to withhold which of the following medications until after hemodialysis? A. Versed and Vancomycin B. Versed and Nitroglycerin patch C. Nitroglycerin patch and allipurinol D. Vancomycin and allopurinol
A) Diminished or absent breath sounds on the affected side
The nurse is caring for a patient who is scheduled for a lobectomy for a diagnosis of lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes the patient/client's oxygen saturation rapidly dropping. The patient complains of shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Further assessment findings supporting the presence of a pneumothorax include? A) Diminished or absent breath sounds on the affected side B) Paradoxical chest wall movement with respirations C) Sudden loss of consciousness D) Muffled heart sounds
C. ST-segment elevation, T wave inversion, normal Q wave
The patient with a myocardial infarction has undergone electrocardiography (ECG). What changes in the ECG tracing would the nurse expect to see in this patient? A. ST-segment depression, flattened T wave, normal Q wave B. ST-segment depression, T wave inversion, normal Q wave C. ST-segment elevation, T wave inversion, normal Q wave D. ST-segment inversion, T wave inversion, abnormal Q wave
D. To cause fibrinolysis of the clot
What is the rationale for administering tissue plasminogen activator (t-PA) within 4.5 hours of a thrombotic stroke? A. To reduce the risk of vasospasms B. To decrease the risk of infection C. To increase platelet aggregation D. To cause fibrinolysis of the clot
A) A patient with a blunt chest trauma with some difficulty breathing
Which patient/client would the nurse prioritize as needing emergent treatment, assuming no other injuries are present except the ones outlined below? ✓ A) A patient with a blunt chest trauma with some difficulty breathing B) A patient with a sore neck who was immobilized in the field on a backboard with a cervical collar C) A patient with a possible fractured tibia with adequate pedal pulses D) A patient with an acute onset of confusion
