ADN FINALS test 1-6

A patient returns to the unit after a neck dissection. The surgeon placed a Jackson Pratt drain in the wound. When assessing the wound drainage over the first 24 postoperative hours the nurse would notify the physician immediately for what?

60 mL of milky or cloudy drainage

A nurse who provides care in an ambulatory clinic integrates basic cancer screening into admission assessments. What patient most likely faces the highest immediate risk of oral cancer?

A 65-year-old man with alcoholism who smokes

A case manager is responsible for ensuring that patients meet the criteria for diagnoses of chronic conditions in order to ensure their eligibility for federal programs. Which of these definitions may not apply for legal purposes?

A person who is temporarily disabled but later return to full functioning.

A patient who has recently been diagnosed with chronic heart failure is being taught by the nurse how to live successfully with her chronic condition. Her ability to meet this goal will primarily depend on her ability to do which of the following?

Adapt her lifestyle to accommodate her symptoms.

A patients health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohns disease, rather that ulcerative colitis, as the cause of the patients signs and symptoms?

An absence of blood in stool

You are admitting a patient into your rehabilitation unit after an industrial accident. The patients nursing diagnoses include disturbed sensory perception and you assess that he has decreased strength and dexterity. You know that this patient may need what to accomplish self-care?

Appropriate assistive devices

A patient who is legally blind is being admitted to the hospital. The patient informs the nurse that she needs to have her guide dog present during her hospitalization. What is the nurses best response to the patient?

Arrangements can be made for your guide dog to be at the hospital with you during your stay.

A patient has been experiencing progressive increases in knee pain and diagnostic imaging reveals a worsening effusion in the synovial capsule. The nurse should anticipate which of the following?

Arthrocentesis

A radial graft is planned in the treatment of a patients oropharyngeal cancer. In order to ensure that the surgery will be successful, the care team must perform what assessment prior to surgery?

Assessing the patency of the ulnar artery

The community nurse is caring for a patient who has paraplegia following a farm accident when he wasan adolescent. This patient is now 64 years old and has just been diagnosed with congestive heart failure.The patient states, Im so afraid about what is going to happen to me. What would be the best nursing intervention for this patient?

Assist the patient in making suitable plans for his care.

A clinic nurse is caring for a patient with a history of osteoporosis. Which of the following diagnostic tests best allows the care team to assess the patients risk of fracture?

Bone densitometry

An older adult patient has symptoms of osteoporosis and is being assessed during her annual physical examination. The assessment shows that the patient will require further testing related to a possible exacerbation of her osteoporosis. The nurse should anticipate what diagnostic test?

Bone densitometry

The nurse is assessing a patient for dietary factors that may influence her risk for osteoporosis. The nurse should question the patient about her intake of what nutrients? Select all that apply.

Calcium.Vitamin D

A nurse knows that patients with invisible disabilities like chronic pain often feel that their chronic conditions are more challenging to deal with than more visible disabilities. Why would they feel this way?

Despite appearances, invisible disabilities can be as disabling as visible disabilities.

The nurse is providing care for a patient with chronic obstructive pulmonary disease. When describing the process of respiration the nurse explains how oxygen and carbon dioxide are exchanged between the pulmonary capillaries and the alveoli. The nurse is describing what process?

Diffusion

A nurse is planning the care of a patient who has been diagnosed with renal failure, which the nurse recognizes as being a chronic condition. Which of the following descriptors apply to chronic conditions? Select all that apply.

Diseases where complete cures are rare. Diseases that do not resolve spontaneously. Diseases that have a prolonged course.

A nurse is addressing the prevention of esophageal cancer in response to a question posed by a participant in a health promotion workshop. What action has the greatest potential to prevent esophageal cancer?

Early diagnosis and treatment of gastroesophageal reflux disease

In your role as a school nurse, you are presenting at a high school health fair and are promoting the benefits of maintaining a healthy body weight. You should refer to reductions in the risks of what diseases? Select all that apply.

Heart disease.Stroke.Diabetes.Hypertension

A patient asks the nursing assistant for a bedpan. When the patient is finished, the nursing assistant notifies the nurse that the patient has bright red streaking of blood in the stool. What is this most likely a result of?

Hemorrhoids

blood testing (FOBT). What aspect of the patients current health status would contraindicate FOBT?

Hemorrhoids

You are caring for a young woman who has Down syndrome and who has just been diagnosed with type 2 diabetes. What consideration should you prioritize when planning this patients nursing care?

How her developmental disability influences her health management

You are caring for a patient who is being treated on the oncology unit with a diagnosis of lung cancer with bone metastases. During your assessment, you note the patient complains of a new onset of weakness with abdominal pain. Further assessment suggests that the patient likely has a fluid volume deficit. You should recognize that this patient may be experiencing what electrolyte imbalance?

Hypercalcemia

You are called to your patients room by a family member who voices concern about the patients status. On assessment, you find the patient tachypnic, lethargic, weak, and exhibiting a diminished cognitive ability. You also find 3+ pitting edema. What electrolyte imbalance is the most plausible cause of this patients signs and symptoms?

Hyperchloremia

The nurse is assessing the patient for the presence of a Chvosteks sign. What electrolyte imbalance would a positive Chvosteks sign indicate?

Hypocalcemia

An adult patient has been diagnosed with diverticular disease after ongoing challenges with constipation. The patient will be treated on an outpatient basis. What components of treatment should the nurseanticipate? Select all that apply.

Increased fiber intake. Fluid reduction

You are the nurse evaluating a newly admitted patients laboratory results, which include several values that are outside of reference ranges. Which of the following would cause the release of antidiuretic hormone (ADH)?

Increased serum sodium

A nurse is aware that the number of people in the United States who are living with disabilities is expected to continue increasing. What is considered to be one of the factors contributing to this increase?

Increased survival rates among people who experience trauma

The nurse is providing care for an older adult man whose diagnosis of dementia has recently led to urinary incontinence. When planning this patients care, what intervention should the nurse avoid?

Indwelling catheter

A nurse is assessing a patient who has peptic ulcer disease. The patient requests more information about the typical causes of Helicobacter pylori infection. What would it be appropriate for the nurse to instruct the patient?

Infection typically occurs due to ingestion of contaminated food and water.

A nurse is caring for a patient who is scheduled for a colonoscopy and whose bowel preparation will include polyethylene glycol electrolyte lavage prior to the procedure. The presence of what health problem would contraindicate the use of this form of bowel preparation?

Inflammatory bowel disease

The nurse is preparing to perform a patients abdominal assessment. What examination sequence should the nurse follow?

Inspection.auscultation.percussion. and palpation

A patient seeking care because of recurrent heartburn and regurgitation is subsequently diagnosed with a hiatal hernia. Which of the following should the nurse include in health education?

Instead of eating three meals a day, try eating smaller amounts more often.

A patient is undergoing diagnostic testing for a tumor of the small intestine. What are the most likely symptoms that prompted the patient to first seek care?

Intermittent pain and bloody stool

74-year-old woman experienced a cerebrovascular accident 6 weeks ago and is currently receiving inpatient rehabilitation. You are coaching the patient to contract and relax her muscles while keeping her extremity in a fixed position. Which type of exercise is the patient performing?

Isometric

The community health nurse is performing a home visit to an 84-year-old woman recovering from hip surgery. The nurse notes that the woman seems uncharacteristically confused and has dry mucous membranes. When asked about her fluid intake, the patient states, I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom. What would be the nurses best response?

Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of your fluids.

A patient has been diagnosed with a small bowel obstruction and has been admitted to the medical unit. The nurses care should prioritize which of the following outcomes?

Maintaining fluid and electrolyte balance

A patient has questioned the nurses administration of IV normal saline, asking whether sterile water would be a more appropriate choice than saltwater. Under what circumstances would the nurse administer electrolyte-free water intravenously?

Never, because it rapidly enters red blood cells, causing them to rupture.

An interdisciplinary team has been working collaboratively to improve the health outcomes of a young adult who suffered a spinal cord injury in a workplace accident. Which member of the rehabilitation team is the one who determines the final outcome of the process?

Patient

A female patient, 47 years old, visits the clinic because she has been experiencing stress incontinence when she sneezes or exercises vigorously. What is the best instruction the nurse can give the patient?

Perform Kegel exercises four to six times per day.

Diagnostic imaging and physical assessment have revealed that a patient with peptic ulcer disease has suffered a perforated ulcer. The nurse recognizes that emergency interventions must be performed as soon as possible in order to prevent the development of what complication?

Peritonitis

The nurses comprehensive assessment of a patient includes inspection for signs of oral cancer. What assessment finding is most characteristic of oral cancer in its early stages?

Presence of a painless sore with raised edges

A patient who has had a radical neck dissection is being prepared for discharge. The discharge plan includes referral to an outpatient rehabilitation center for physical therapy. What would the goals of physical therapy for this patient include?

Promoting maximum shoulder function

The nurse is caring for a patient diagnosed with cancer of the liver who has chosen to remain in his home as long as he is able. The nurse reviews the care plan for the patient and notes that it focuses on palliative measures. The nurse also notes that over the last 3 weeks, the patients condition has continued to deteriorate. What is the nurses best response to this clinical information?

Recognize that the patient is in the downward phase of chronic illness and should be reassessed

A patient who is receiving rehabilitation following a spinal cord injury has been diagnosed with reflex incontinence. The nurse caring for the patient should include which intervention in this patients plan of care?

Regular perineal care to prevent skin breakdown

A patient has been diagnosed with an esophageal diverticulum after undergoing diagnostic imaging.When taking the health history, the nurse should expect the patient to describe what sign or symptom?

Regurgitation of undigested food

A patient who is being treated for pneumonia starts complaining of sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect?

Respiratory acidosis

A 16-year-old presents at the emergency department complaining of right lower quadrant pain and is subsequently diagnosed with appendicitis. When planning this patients nursing care, the nurse should prioritize what nursing diagnosis?

Risk for Infection Related to Possible Rupture of Appendix

You are caring for a patient with a secondary diagnosis of hypermagnesemia. What assessment finding would be most consistent with this diagnosis?

Shallow respirations

You are caring for a patient with a history of chronic angina. The patient tells you that after breakfast he usually takes a shower and shaves. It is at this time, the patient says, that he tends to experience chest pain. What might you counsel the patient to do to decrease the likelihood of angina in the morning?

Shower in the evening and shave before breakfast.

A patient is scheduled for a bone scan to rule out osteosarcoma of the pelvic bones. What would be most important for the nurse to assess before the patients scan?

That the patient emptied the bladder

A patient has recently received a diagnosis of gastric cancer; the nurse is aware of the importance of assessing the patients level of anxiety. Which of the following actions is most likely to accomplish this?

The patient is encouraged to express fears openly.

You are caring for a 35-year-old man whose severe workplace injuries necessitate bilateral below-the knee amputations. How can you anticipate that the patient will respond to this news?

The patient will experience grief in an individualized manner.

An initiative has been launched in a large hospital to promote the use of people-first language in formal and informal communication. What is the significance to the patient when the nurse uses people-first language?

The person is of more importance to the nurse than the disability.

You are the nurse caring for a young mother who has a longstanding diagnosis of multiple sclerosis (MS). She was admitted to your unit with a postpartum infection 3 days ago. You are planning to discharge her home when she has finished 5 days of IV antibiotic therapy. With what information would it be most important for you to provide this patient?

The same information you would provide to a patient without a chronic condition

You are presenting patient teaching to a 48-year-old man who was just diagnosed with type 2 diabetes. The patient has a BMI of 35 and leads a sedentary lifestyle. You give the patient information on the risk factors for his diagnosis and begin talking with him about changing behaviors around diet and exercise. You know that further patient teaching is necessary when your patient tells you what?

There is nothing that can be done anyway, because chronic diseases like diabetes cannot be prevented.

A nurse is explaining a patients decreasing bone density in terms of the balance between bone resorption and formation. What dietary nutrients and hormones play a role in the resorption and formation of adult bones? Select all that apply.

Thyroid hormone. Growth hormone. Estrogen

A nurse is caring for a newly admitted patient with a suspected GI bleed. The nurse assesses the patients stool after a bowel movement and notes it to be a tarry-black color. This finding is suggestive of bleeding from what location?

Upper GI tract

A nurse is preparing to provide care for a patient whose exacerbation of ulcerative colitis has required hospital admission. During an exacerbation of this health problem, the nurse would anticipate that the patients stools will have what characteristics?

Watery with blood and mucus

A man and woman are in their early eighties and have provided constant care for their 44-year-old son who has Down syndrome. When planning this familys care, the nurse should be aware that the parents most likely have what concerns around what question?

Who will care for our son once were unable?

A patient has just had an arthroscopy performed to assess a knee injury. What nursing intervention should the nurse implement following this procedure?

Wrap the joint in a compression dressing.

A nurse is providing preprocedure education for a patient who will undergo a lower GI tract study the following week. What should the nurse teach the patient about bowel preparation?

You'll need to have enemas the day before the test.

A nurse is caring for a patient who has been scheduled for a bone scan. What should the nurse teach the patient about this diagnostic test?

Youll be encouraged to drink water after the administration of the radioisotope injection.

A 19-year-old patient with a diagnosis of Down syndrome is being admitted to your unit for the treatment of community-acquired pneumonia. When planning this patients care, the nurse recognizes that this patients disability is categorized as what?

A developmental disability

A patient has been diagnosed with peptic ulcer disease and the nurse is reviewing his prescribed medication regimen with him. What is currently the most commonly used drug regimen for peptic ulcers?

Antibiotics, proton pump inhibitors, and bismuth salts

A patient tells the nurse that her doctor just told her that her new diagnosis of rheumatoid arthritis is considered to be a chronic condition. She asks the nurse what chronic condition means. What would be the nurses best response?

Chronic conditions are defined as health problems that require management of several months or longer.

You are an emergency-room nurse caring for a trauma patient. Your patient has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would you interpret these results?

Metabolic acidosis with a compensatory respiratory alkalosis

A patient who underwent gastric banding 3 days ago is having her diet progressed on a daily basis. Following her latest meal, the patient complains of dizziness and palpitations. Inspection reveals that the patient is diaphoretic. What is the nurses best action?

Monitor the patient closely for further signs of dumping syndrome.

An older adult has a diagnosis of Alzheimers disease and has recently been experiencing fecal incontinence. However, the nurse has observed no recent change in the character of the patients stools. What is the nurses most appropriate intervention?

Toilet the patient on a frequent, scheduled basis

You are creating a nursing care plan for a patient who is hospitalized following right total hip replacement. What nursing action should you specify to prevent inward rotation of the patients hip when the patient is in a partial lateral position?

Use of an abduction pillow between the patients legs

A newly graduated nurse is admitting a patient with a long history of emphysema. The new nurses preceptor is going over the patients past lab reports with the new nurse. The nurse takes note that the patients PaCO2 has been between 56 and 64 mm Hg for several months. The preceptor asks the new nurse why they will be cautious administering oxygen. What is the new nurses best response?

Using oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia.