Adult Nursing Exam 2
A nurse is working with a community group promoting healthy aging. What recommendation is best to help prevent osteoarthritis (OA)? a.Lose weight if needed. b.Get plenty of calcium. c.Avoid contact sports. d.Engage in weight-bearing exercise.
a. Lose weight if needed
The nurse knows that hematopoiesis occurs in what part of the musculoskeletal system? a.Yellow marrow b.Collagen matrix c.Cancellous tissue d.Red marrow
d. Red Marrow
A new nurse reads a client has a wound "healing by second intention" and asks what that means. Which description by the charge nurse is most accurate? a."The wound was stapled together after an infection was cleared up." b."The wound edges have been approximated and stitched together." c."The wound was contaminated by debris and can't be closed at all." d."The wound is an open cavity that will fill in with granulation tissue."
d."The wound is an open cavity that will fill in with granulation tissue."
A client has been brought to the emergency department after being covered in fertilizer after an explosion and fire at a warehouse. What action by the nurse is best? a. Assess the client's airway b. Irrigate the client's skin c. Brush any visible dust off the skin d. Call poison control for guidance
A. Assess the client's airway
A nurse assesses a client and identifies that the client has pale conjunctivae. Which focused assessment will the nurse complete next? a. Partial thromboplastin time b. Hemoglobin and hematocrit c. Liver enzymes d. Basic metabolic panel
b. Hemoglobin and hematocrit
A patient is having a temporary tracheostomy placed during surgery for oral cancer. What action by the nurse is best to relieve anxiety? a.Reassure the patient that you will take care of all of his or her needs. b.Give the patient a Magic Slate to write on postoperatively. c.Explain that staff will answer the call light promptly. d.Agree on a postoperative communication method.
d.Agree on a postoperative communication method
A patient is in the family practice clinic. Today, the patient weighs 186.4 lbs (84.7 kg). Six months ago, the patient weighed 211.8 lbs (96.2 kg). What action by the nurse is best? a.Perform a comprehensive nutritional assessment. b.Determine if there are food allergies or intolerances. c.Perform a rapid bedside blood glucose test. d.Ask the patient if the weight loss was intentional.
d.Ask the patient if the weight loss was intentional
The student nurse studying the gastrointestinal system understands that chyme refers to what? a.Nutrients after being absorbed b.Hormones that reduce gastric acidity c.Secretions that help digest food d.Liquefied food ready for digestion
d.Liquefied food ready for digestion
A nurse teaches a patient who is recovering from a contrast-enhanced CT. Which instruction should the nurse include in this patient's discharge teaching? a."Be sure to drink at least 3 L of fluids today to help eliminate the dye faster." b."You may have some dribbling of urine for several weeks after this procedure." c."Your skin may become slightly yellow from the dye used in this procedure." d."Avoid direct contact with your urine for 24 hours until the radioisotope clears."
a. "Be sure to drink at least 3 L of liquids today to help eliminate the dye faster."
A nurse is reviewing laboratory values for several patients. Which value causes the nurse to conduct nutritional assessments as a priority? a.Cholesterol: 142 mg/dL (3.7 mmol/L) b.Hemoglobin: 9.8 mg/dL (98 mmol/L) c.Prealbumin: 28 mg/dL d.Albumin: 3.5 g/dL
a.Cholesterol: 142 mg/dL
A patient had an endoscopic retrograde cholangiopancreatography (ERCP). The nurse instructs the patient and family about the signs of potential complications, which include what problems? (Select all that apply.) a.Pancreatitis b.Renal lithiasis c.Cholangitis d.Sepsis e.Perforation
a.Pancreatitis, c.Cholangitis, d.Sepsis, e.Perforation
What information does the nurse teach a women's group about osteoporosis? a."Women and men have an equal chance of getting osteoporosis." b."Men actually have higher rates of the disease but are underdiagnosed." c."Primary osteoporosis occurs in postmenopausal women due to lack of estrogen." d."There is no way to prevent or slow osteoporosis after menopause."
c. "Primary osteoporosis occurs in postmenopausal women due to lack of estrogen."
A Nurse assesses a client who has multiple areas of ecchymosis on both arms. Which question will he nurse ask first? a. "Are you using lotion on your skin?" b. "Do you have a family history of this?" c. "Do your arms itch?" d. "What medications are you taking?"
d. "What medications are you taking?"
A patient is receiving total parenteral nutrition (TPN). What action by the nurse is most important? a.Checking the TPN with another nurse b.Performing appropriate hand hygiene c.Assessing blood glucose as directed d.Changing the IV dressing each day
b.Performing appropriate hand hygiene
A nurse assesses a client who has had two epsidoes of bacterial cystitis in the last 6 months. Which questions would the nurse ask? (Select all that apply) a. "How much water do you drink every day?" b. "Do you take estrogen replacement therapy?" c. "Does anyone in your family have a history of cystitis?" d. "Are you on steroids or other immune suppressing drugs?" e. "Do you drink grapefruit juice ror orange juice daily?"
a. "How much water do you drink every day?" b. "Do you take estrogen replacement therapy?" d. "Are you on steroids or other immune suppressing drugs?"
After teaching a patient how to care for a furuncle in the axilla, a nurse assesses the patient's understanding. Which statement indicates the patient correctly understands the teaching? a."I'll cleanse the area prior to applying antibiotic cream." b."I'll keep my arm down at my side to prevent spread." c."I'll apply cortisone cream to reduce the inflammation." d."I'll apply a clean dressing after squeezing out the pus."
a. "I'll keep my arm down at my side to prevent spread."
A nurse cares for a postmenopausal patient who has had two episodes of bacterial urethritis in the last 6 months. The patient asks, "I never have urinary tract infections. Why is this happening now?" How will the nurse respond? a."Low estrogen levels can make the tissue more susceptible to infection." b."You should be more careful with your personal hygiene in this area." c."Your immune system becomes less effective as you age." d."It is likely that you have an untreated sexually transmitted disease."
a. "Low estrogen levels can make the tissue more susceptible to infection."
A patient is diagnosed with benign prostatic hyperplasia and seems sad and irritable. After assessing the patient's behavior, which statement by the nurse would be the most appropriate? a."Nocturia could cause interruption of your sleep and cause changes in mood." b."You seem depressed and should seek more pleasant things to do." c."The urine incontinence should not prevent you from socializing." d."It is common for men at your age to have changes in mood."
a. "Nocturia could cause interruption of your sleep and cause changes in mood."
A nurse teaches a young female patient who is prescribed amoxicillin (Amoxil) for a urinary tract infection. Which statement would the nurse include in this patient's teaching? a."Use a second form of birth control while on this medication." b."You will experience increased menstrual bleeding while on this drug." c."Watch for blood in your urine while taking this medication." d."You may experience an irregular heartbeat while on this drug."
a. "Use a second form of birth control while on this medication."
A nurse assesses patients on a medical-surgical unit. Which patient is at greatest risk for pressure ulcer development? a.A 65-year-old with hemi-paralysis and incontinence b.A 44-year-old prescribed IV antibiotics for pneumonia c.A 78-year-old requiring assistance to ambulate with a walker d.A 26-year-old who is bedridden with a fractured leg
a. A 65-year-old with hemi-paralysis and incontinence
A client asks the nurse why she has urinary incontinence. What risk factors would the nurse recall in preparing to respond to the client's question? (Select all that apply) a. Diuretic therapy b. Anorexia c. Stroke d. Dementia e. Arthritis f. Parkinsons
a. Diuretic therapy, c. Stroke, d. Dementia, e. Arthritis, f. Parkinsons
The nurse is caring for a client who is diagnosed with urinary tract infection (UTI). What common urinary signs and symptoms does the nurse expect? (Select all that apply) a. Dysuria b. Frequency c. Burning d. Fever e. Chills f. Hematuria
a. Dysuria, b. Frequency, c. Burning, f. Hematuria
A nurse plans care for a clinet who has a wound that is not healing. Which focused assessment will the nurse complete to develop the patient's plan of care? (Select all that apply). a. Height b. Allergies c. Alcohol use d. Pre-albumin laboratory results e. Liver enzyme laboratory results f. Weight
a. Height, c. Alcohol use, d. Pre-albumin lab results, e. Liver enzyme lab results
A nurse reviews the laboratory findings of a patient with a urinary tract infection. The laboratory report notes a "shift to the left" in a patient's white blood cell count. What action would the nurse take? a.Notify the provider and start an intravenous line for parenteral antibiotics. b.Assess the patient for a potential allergic reaction and anaphylactic shock. c.Collaborate with the unlicensed assistive personnel (UAP) to strain the patient's urine for renal calculi. d.Request that the laboratory perform a differential analysis on the white blood cells.
a. Notify the provider and start an intravenous line for parenteral antibiotics.
A patient had an arthroscopy 1 hour ago on the left knee. The nurse finds the left lower leg to be pale and cool, with 1+/4+ pedal pulses compared to the right leg. What action by the nurse is best? a.Notify the provider of the findings immediately. b.Document the findings in the patient's chart. c.Elevate the left leg on at least two pillows. d.Apply compression stockings.
a. Notify the provider of the findings immediately
A nurse has conducted a community screening event for oral cancer. What patient is the highest priority for referral to a dentist for cancer prevention? a.Patient who smokes and drinks daily b.Patient who tans for an upcoming vacation c.Patient who occasionally uses illicit drugs d.Patient who has poor oral hygiene practices
a. Patient who smokes and drinks daily
A nurse is caring for four patients receiving enteral tube feedings. Which patient should the nurse see first? a.Patient with a potassium level of 2.6 mEq/L (2.6 mmol/L) b.Patient with foul-smelling diarrhea c.Patient with a blood glucose level of 138 mg/dL (7.7 mmol/L) d.Patient with a sodium level of 138 mEq/L (138 mmol/L)
a. Patient with a potassium level of 2.6 mEq/L
A nurse is discharging a patient to a short-term rehabilitation center after a joint replacement. Which action by the nurse is most important? a.Providing a verbal hand-off report to the facility b.Administering pain medication before transport c.Answering any last-minute questions by the patient d.Ensuring the family has directions to the facility
a. Providing a verbal hand-off report to the facility
A nurse assesses a client who has open skin lesions. Which action by the nurse is most important? a. Put on gloves b. Ask the client about his or her occupation c. Assess the client's pain d. Obtain vital signs
a. Put on gloves
A nurse is assessing clients with pressure injuries. Which wound description is correctly matched to its description? a. Suspected deep tissue injury: nonblanchable deep purple or maroon b. Stage 2: may have visible adipose tissue and slough c. Stage 3: may have a pink or red wound bed d. Stage 4: wound bed is obscured with eschar or slough
a. Suspected deep tissue injury: nonblanchable deep purple or maroon
While assessing a patient, a nurse detects a bluish tinge to the patient's palms, soles, and mucous membranes. Which action will the nurse take next? a.Use pulse oximetry to assess the patient's oxygen saturation. b.Auscultate the patient's lung fields for adventitious sounds. c.Ask the patient about current medications he or she is taking. d.Palpate the patient's bilateral radial and pedal pulses.
a. Use pulse oximetry to assess the patient's oxygen saturation.
After treating several young women for urinary tract infections, the college nurse plans an educational offering on reducing the risk of getting a UTI. What information does the nurse include? (Select all that apply) a. Void before and after each act of intercourse b. Consider changing to spermicide from birth control pills c. Do not douche or use scented feminine products d. Wear loose fitting nylon panties e. Wipe or clean the perineum from front to back
a. Void before and after each act of intercourse, e. Wipe or clean the perineum from front to back
A nurse assesses patients on the medical-surgical unit. Which patient is at greatest risk for the development of bacterial cystitis? a.A 58-year-old female who is not taking estrogen replacement b.A 77-year-old male with mild congestive heart failure c.A 36-year-old female who has never been pregnant d.A 42-year-old male who is prescribed cyclophosphamide
a. a 58-year-old female who is not taking estrogen replacement
The nurse is preparing a client for a percutaneous kidney biopsy. Which lab tests results would the nurse review prior to the procedure? (Select all that apply) .a. Hemoglobin b. Hematocrit c. Sodium d. Potassium e. Platelet count f. Prothrombin time
a. hemoglobin, b. hematocrit, e. platelet count, f. prothrombin time
A nurse reviews a client's lab results. Which results from the client's urinalysis would the nurse identify as normal? (select all that apply) a. pH: 6 b. Specific gravity: 1.015 c. Protein: 1.2 mg/dL d. Glucose: negative e.. Nitrate: small f. Leukocyte esterase: positive
a. pH 6, b. specific gravity 1.015, d. glucose negative
A patient scheduled for a percutaneous transhepatic cholangiography (PTC) denies allergies to medication. What action by the nurse is best? a.Ask the patient about shellfish allergies. b.Instruct the patient on bowel preparation. c.Ensure that the patient has a ride home. d.Document this information on the chart.
a.Ask the patient about shellfish allergies
A nurse prepares to admit a patient who has herpes zoster. Which actions would the nurse take? (Select all that apply) a.Check the admission prescriptions for analgesia. b.Ensure that gloves are available in the room. c.Choose a roommate who also is immune suppressed. d.Assess staff for a history of or vaccination for chickenpox e.Prepare a room for reverse isolation.
a.Check the admission prescriptions for analgesia. b.Ensure that gloves are available in the room. d.Assess staff for a history of or vaccination for chickenpox
A nurse cares for patients with urinary incontinence. Which types of incontinence are correctly paired with their clinical manifestation? (Select all that apply.) a.Overflow incontinence—constant dribbling of urine b.Urge incontinence—loss of urine upon feeling the need to void c.Mixed incontinence--A combination of two or more different types of incontinence d.Stress incontinence—urine loss with physical exertion e.Functional incontinence—urine loss results from abnormal detrusor contractions
a.Overflow incontinence—constant dribbling of urine b.Urge incontinence—loss of urine upon feeling the need to void c.Mixed incontinence--A combination of two or more different types of incontinence d.Stress incontinence—urine loss with physical exertion
A patient is interested in learning about the risk factors for prostate cancer. Which factors does the nurse include in the teaching? (Select all that apply.) a.Race b.Eating too much red meat c.Advanced age d.Family history of prostate cancer e.Smoking f.Obesity
a.Race b.Eating too much red meat c.Advanced age d.Family history of prostate cancer
When working with older adults to promote good nutrition, what actions by the nurse are most appropriate? (Select all that apply.) a.Serve high-calorie, high-protein snacks. b.Assess dentures for appropriate fit. c.Allow uninterrupted time for eating. d.Ensure that the patient has glasses on when eating. e.Provide salty foods that the patient can taste.
a.Serve high-calorie, high-protein snacks. b.Assess dentures for appropriate fit. c.Allow uninterrupted time for eating. d.Ensure that the patient has glasses on when eating.
A student nurse learns about changes that occur to the musculoskeletal system due to aging. Which changes does this include? a.Some muscle tissue atrophy occurs with aging. b.Osteoarthritis occurs due to cartilage degeneration. c.Osteoporosis is a universal occurrence. d.Increased bone density leads to stiffness. e.Bone changes lead to potential safety risks.
a.Some muscle tissue atrophy occurs with aging. b.Osteoarthritis occurs due to cartilage degeneration. e.Bone changes lead to potential safety risks.
The nurse is teaching an uncircumcised 65-year-old patient about self-management of a urinary catheter in preparation for discharge to his home. What statement indicates a lack of understanding by the patient? a."The drainage bag needs to be changed at least once a week and as needed." b."I only have to wash the outside of the catheter once a week." c."I should take extra time to clean the catheter site by pushing the foreskin back." d."I should pour a solution of vinegar and water through the tubing and bag."
b. "I only have to wash the outside of the catheter once a week."
A confused patient with pneumonia is admitted with an indwelling catheter in place. During interdisciplinary rounds the following day, which question would the nurse ask the primary healthcare provider? a."Do you want daily weights on this patient?" b."Can we discontinue the indwelling catheter?" c."Should we get another chest x-ray today?" d."Will the patient be able to return home?"
b. "Can we discontinue the indwelling catheter?"
A patient is recovering from an esophagogastroduodenoscopy (EGD) and requests something to drink. What action by the nurse is best? a.Allow the patient cool liquids only. b.Assess the patient's gag reflex. c.Tell the patient to wait 4 hours. d.Remind the patient to remain NPO.
b.Assess the patinet's gag reflex
After educating a caregiver of a home care patient, a nurse assesses the caregiver's understanding. Which statement indicates that the caregiver needs additional education? a."I can help him shift his position every hour when he sits in the chair." b."If his tailbone is red and tender in the morning, I will massage it with baby oil." c."Drinking a nutritional supplement between meals will help maintain his weight." d."Applying lotion to his arms and legs every evening will decrease dryness."
b. "If his tailbone is red and tender in the morning, I will massage it with baby oil."
A patient has been prescribed denosumab (Prolia). What instruction about this drug is most appropriate? a."Sit upright for 30 to 60 minutes after taking it." b."Make appointments to come get your shot." c."Take the drug on an empty stomach." d."Drink at least 8 ounces (236 mL) of water with it."
b. "Make appointments to come get your shot."
A nurse cares for adult patients who experience urge incontinence. For which patient would the nurse plan a habit training program? a.A 52-year-old female with kidney failure b.A 78-year-old female who is confused c.A 65-year-old male with diabetes mellitus d.A 47-year-old male with arthritis
b. A 78-year-old female who is confused
A patient with osteoporosis is going home, where the patient lives alone. What action by the nurse is best? a.Refer the patient to Meals on Wheels. b.Arrange a home safety evaluation. c.Help the patient look into assisted living. d.Ensure that the patient has a walker at home.
b. Arrange a home safety evaluation.
A nurse assesses a patient's oral cavity and observes the condition depicted in the photo below: What action by the nurse is best? a.Refer the patient to an oncologist. b.Assess the patient for dysphagia. c.Ask about the patient's human immunodeficiency virus (HIV) status. d.Listen to the patient's lung sounds.
b. Assess the patient for dysphagia
After teaching a client who has a stage 2 pressure injury, a nurse assesses the client's understanding. Which dietary choice by the client indicates a good understanding of the teaching? a. Green salad, a banana, whole wheat dinner roll, coffee b. Chicken breast, broccoli, baked potato, ice water c. Vegetable lasagna and green salad, iced tea d. Hamburger, fruit cup, cookie, diet pop
b. Chicken breast, broccoli, baked potato, ice water
During skin inspection of a patient, a nurse observes lesions with wavy borders that are widespread across the patient's chest. Which descriptors will the nurse use to document these observations? a.Clustered and annular b.Diffuse and serpiginous c.Linear and circinate d.Coalesced and circumscribed
b. Diffuse and seripiginous
A nurse contacts the healthcare provider after reviewing a patient's laboratory results and noting a blood urea nitrogen (BUN) of 35 mg/dL (12.5 mmol/L) and a creatinine of 1.0 mg/dL (88.4 mcmol/L). What collaborative care measure does the nurse consult the provider about? a.Fluid restriction b.Intravenous fluids c.Hemodialysis d.Urine culture and sensitivity
b. Intravenous Fluids
A nurse review's a client's lab results. Which results from the client's urinalysis would the nurse recognize as abnormal? a. pH of 5.6 b. Ketone bodies present c. Specific gravity of 1.020 c. Clear and yellow color
b. Ketone bodies present
A nurse is caring for a clinet whose Braden Scale score is 9. What intervention demonstrates a lack of evidence-based knowledge? a. Requests a referral to a registered dietician nutrition. b. Raises the head of the bed no more than 45 degrees. c. Performs perineal cleansing every 2 hours. d. Assesses the client's entire skin surface daily
b. Raises the head of the bed no more than 45 degrees
A nurse evaluates the following data in a client's chart: Admission Note: A 66-year-old male with a health history of a cerebral vascular accident and left-sided paralysis. Lab Results: WBC Count 8000, Pre-albumin 15.2, Albumin 4.2, Lymphocyte count 2000 Wound Care Note: Sacral ulcer 4x2x1.5 Based on this information, which action would the nurse take? a. Perform a neuromuscular assessment b. Request a diety consult c. Initiate Contact Precaustions d. Assess the client's vital signs
b. Request a dietary consult
The nurse working in the orthopedic clinic knows that a patient with which factor has an absolute contraindication for having a total joint replacement? a.Needs multiple dental fillings b.Severe osteoporosis c.Over age 85 d.Urinary tract infection
b. Severe osteoporosis
A nurse assesses a patient who has psoriasis. Which action would the nurse take first? a.Don gloves and an isolation gown. b.Shake the patient's hand and introduce self. c.Assess for signs and symptoms of infections. d.Ask the patient if she might be pregnant.
b. Shake the patient's hand and introduce self
A nurse assesses a patient with renal insufficiency and a low red blood cell count. The patient asks, "Is my anemia related to the renal insufficiency?" How should the nurse respond? a."Kidney insufficiency inhibits active transportation of red blood cells throughout the blood." b."Erythropoietin is usually released from the kidneys and stimulates red blood cell production in the bone marrow." c."Red blood cells produce erythropoietin, which increases blood flow to the kidneys." d."Your anemia and renal insufficiency are related to inadequate vitamin D and a loss of bone density."
b."Erythropoietin is usually released from the kidneys and stimulates red blood cell production in the bone marrow."
A nurse assesses a client who presents with an increase in psoriatic lesions. Which questions would the nurse ask to identify a possible trigger for worsening of this client's psoriatic lesions? (Select all that apply.) a."Have you eaten a large amount of chocolate lately?" b."Have you changed any medications recently?" c."Have you been out of the country recently?" d."Have you recently used a public shower?" e."Have you recently had any other health problems?" f."Have you been under a lot of stress lately?"
b."Have you changed any medications recently?" e."Have you recently had any other health problems?" f."Have you been under a lot of stress lately?"
A patient is receiving total parenteral nutrition (TPN). On assessment, the nurse notes that the patient's pulse is 128 beats/min, blood pressure is 98/56 mm Hg, and skin turgor is dry. What action should the nurse perform next? a.Prepare to hang a normal saline bolus. b.Assess the 24-hour fluid balance. c.Turn up the infusion rate of the TPN. d.Assess the patient's oral cavity.
b.Assess the 24-hour fluid balance
A nurse sees patients in an osteoporosis clinic. Which patient would the nurse see first? a.Patient taking ibandronate (Boniva) who cannot remember when the last dose was b.Patient taking calcium with vitamin D (Os-Cal) who reports flank pain 2 weeks ago c.Patient taking raloxifene (Evista) who reports unilateral calf swelling d.Patient taking risedronate (Actonel) who reports occasional dyspepsia
c.Patient taking raloxifene (Evista) who reports unilateral calf swelling
After teaching a client with bacterial cystitis who is prescribed phenazopyridine, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? a. "I will not take this drug with food or milk." b. "I will have my partners tested for STIs" c. "An orange color in my urine should not alarm me" d. "I will drink two glasses of cranberry juice daily"
c. "An orange color in my urine should not alarm me"
A nurse teaches a patient with functional urinary incontinence. Which statement would the nurse include in this patient's teaching? a."Operations to repair your bladder are available, and you can consider these." b."You must clean around your catheter daily with soap and water." c."Buy slacks with elastic waistbands that are easy to pull down." d."Wash the vaginal weights with a 10% bleach solution after each use."
c. "Buy slacks with elastic waistbands tha are easy to pull down."
After teaching a client who expressed concern about a rash located beneath her breast, a nurse assesses the client's understanding. Which statement indicates the client has a good understanding of this condition? a. "This rash is probably due to fluid overload." b. "I need to wash this daily with antibacterial soap" c. "I can use power to keep this area dry" d. "I will schedule a mammogram as soon as I can."
c. "I can use powder to keep this area dry."
A nurse cares for an older adult client who has a chronic skin disorder. The client states, "I have not been to church in several weeks because of the discoloration of my skin." How will the nurse respond? a. "I will consult the chaplain to provide you with spiritual support." b. "You do not need to go to church. God is everywhere." c. "Tell me more about your concerns related to your skin." c. "Religious people are nonjudgmental and will accept you."
c. "Tell me more about your concerns related to your skin."
A nurse assesses a patient who is admitted with inflamed soft-tissue folds around the nail plates. Which question will the nurse ask to elicit useful information about the possible condition? a."Do you have diabetes mellitus?" b."Have you had a recent fungal infection?" c."What do you do for a living?" d."Are your nails professionally manicured?"
c. "What do you do for a living?"
A patient with bone cancer is hospitalized for a limb salvage procedure. How can the nurse best address the patient's psychosocial needs? a.Reinforce physical therapy to aid with ambulating normally. b.Explain that the surgery leads to a longer life expectancy. c.Assess the patient's coping skills and support systems. d.Refer the patient to the social worker or hospital chaplain.
c. Assess the patient's coping skills and support systems
A nurse evaluates the following data in a patient's chart: 78-year-old male with a past medical history of atrial fibrillation is admitted with a chronic leg wound. Prescriptions: Warfarin sodium (Coumadin). Sotalol (Betapace) Wound Care: Negative pressure wound therapy (NPWT) to leg wound Based on this information, which action would the nurse take first? a.Consult the wound care nurse to apply the VAC device. b.Obtain a prescription for a low-fat, high-protein diet with vitamin supplements. c.Contact the provider and express concerns related to the wound treatment prescribed. d. Assess the patient's vital signs and initiate continuous telemetry monitoring.
c. Contact the provider and express concerns to the wound treatment prescribed.
A patient is scheduled for a bone biopsy. What action by the nurse takes priority? a.Administering the preoperative medications b.Showing the patient's family where to wait c.Ensuring that informed consent is on the chart d.Answering any questions about the procedure
c. Ensuring that informed consent is on the chart
After teaching a patient who is at risk for the formation of pressure ulcers, a nurse assesses the patient's understanding. Which dietary choice by the patient indicates a good understanding of the teaching? a.Low-fat diet with whole grains and cereals and vitamin supplements b.Low-fat, low-cholesterol, high-fiber, low-carbohydrate diet c.High-protein diet with vitamins and mineral supplements d.Vegetarian diet with nutritional supplements and fish oil capsules
c. High protein diet with vitamins and mineral supplements
An older patient with diabetes is admitted with a heavily draining leg wound. The patient's white blood cell count is 38,000/mm3 (38 × 109/L) but the patient is afebrile. What action does the nurse take first? a.Refer the patient to the wound care nurse. b.Administer acetaminophen (Tylenol). c.Place the patient on contact isolation. d.Educate the patient on amputation.
c. Place the patient on contact isolation.
A nurse is caring for a patient after joint replacement surgery. What action by the nurse is most important to prevent wound infection? a.Culture any drainage from the wound. b.Assess the patient's white blood cell count. c.Use aseptic technique for dressing changes. d.Monitor the patient's temperature every 4 hours.
c. Use aseptic technique for dressing changes.
A patient has a large oral tumor. What assessment by the nurse takes priority? a.Circulation b.Breathing c.Airway d.Nutrition
c.Airway
A nurse is examining a patient reporting right upper quadrant (RUQ) abdominal pain. What technique would the nurse use to assess this patient's abdomen? a.Palpate the RUQ first. b.Auscultate after palpating. c.Palpate the RUQ last. d.Avoid any palpation
c.Palpate the RUQ last
A patient with bone cancer is hospitalized for an unrelated issue. The patient reports pain and it is not yet time for more medication. What comfort measures can the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a.Administering ibuprofen (Motrin) b.Referring the patient to a support group c.Providing soothing music d.Repositioning the patient e.Determine if pain is new or related to cancer diagnosis.
c.Providing soothing music d.Repositioning the patient
Which statement by a client to the nurse indicates that treatment for urge incontinence has been successful? a."I lose a little urine when I sneeze, but I wear a thin pad." b."I'm doing the exercises, but I think that surgery is my best choice." c."I have been using bladder compression and it works." d."I had a little trouble at first, but now I go to the toilet every 3 hours."
d. "I had a little trouble at first, but now I go to the toilet every 3 hours."
A nurse is discharging a patient after a total hip replacement. What statement by the patient indicates good potential for self-management? a."I can bend down to pick something up." b."I no longer need to do my exercises." c."I won't wash my incision to keep it dry." d."I will not sit with my legs crossed."
d. "I will not sit with m legs crossed"
A client contacts the clinic to report a life long mole has developed a crust with occasional bleeding. What instruction by the nurse is most appropriate? a. "Take monthly photographs of it so you can document any cahnges." b. "Wash daily with warm water and gentle soap to prevent infection." c. "Keep the lesion covered with a bandage and triple antibiotic ointment." d. "Please make an appointment to be seen here as soon as possible."
d. "Please make an appointment to be seen here as soon as possible"
A nurse teaches a client with functional urinary incontinence. Which statement would the nurse include in this client's teaching? a. "You must clean around your catheter daily with soap and water." b. "You will need to be on your drug therapy for life." c. "Operations to repair your bladder are available, and you can consider these." d. "You might want to get pants with elastic waistbands"
d. "You might want to get pants with elastic waistbands
A nurse cares for a patient who is recovering from a closed percutaneous kidney biopsy. The patient states, "My pain has suddenly increased from a 3 to a 10 on a scale of 0 to 10." Which action should the nurse take first? a.Administer the prescribed opioid analgesic. b.Examine the color of the patient's urine. c.Reposition the patient on the operative side. d.Assess the pulse rate and blood pressure.
d. Assess the pulse rate and blood pressure.
A nurse is caring for a client who has a non-healing pressure injury on the right ankle. Which action would the nurse take first? a. Draw blood for albumin, pre-albumin, and total protein b. Prepare for and assist with obtaining a wound culture c. Instruct the client to evaluate the foot d. Assess the right leg for pulses, skin color, and temp
d. Assess the right leg for pulses, skin color, and temp
A nurse obtains a sterile urine specimen from a patient's Foley catheter. After applying a clamp to the drainage tubing distal to the injection port, what action should the nurse take next? a.Clamp another section of the tube to create a fixed sample section for retrieval. b.Withdraw 10 mL of urine and discard it; then withdraw a fresh sample of urine. c.Insert a syringe into the injection port and aspirate the quantity of urine required. d.Clean the injection port cap of the drainage tubing with antiseptic solution.
d. Clean the injection port cap of the drainage tubing with antiseptic solution.
A patient has a metastatic bone tumor. What action by the nurse takes priority? a.Administer pain medication as prescribed. b.Elevate the extremity and apply moist heat. c.Place the patient on protective precautions. d.Handle the affected extremity with caution.
d. Handle the affected extremity with caution.
A nurse and an unlicensed assistive personnel (UAP) are caring for a patient with an open radical prostatectomy. Which comfort measure could the nurse delegate to the UAP? a.Evaluating swolling to scrotum and penis b.Managing pain through patient-controlled analgesia c.Administering an antispasmodic for bladder spasms d.Helping the patient transfer from the bed to the chair
d. Helping the patient transfer from the bed to the chair
A nurse performs a skin screening for a patient who has numerous skin lesions. Which lesion does the nurse evaluate first? a.Beige freckles on the backs of both hands b.Large cluster of pustules in the right axilla c.Thick, reddened papules covered by white scales d.Irregular blue mole with white specks on the lower leg
d. Irregular blue mole with white specks on the lower leg
A nurse assesses an older adult's skin. Which findings require immediate referral? (Select all that apply) a. Excessive moisture under axilla b. Increased hair thinning c. Presence of toenail fungus d. Lesion with various colors e. Spider veins on legs f. Asymmetric 6-mm dark lesion on forehead
d. Lesion with various colors, f. Asymmetric 6-mm dark lesion on forehead
A nurse cares for a patient admitted from a nursing home after several recent falls. What order would the nurse complete first? a.Encourage protein intake and additional fluids. b.Consult physical therapy for gait training. c.Administer intravenous antibiotics. d.Obtain urine sample for culture and sensitivity.
d. Obtain urine sample for culture and sensitivity.
A nurse reviews the urinalysis of a patient and notes the presence of glucose. What action should the nurse take? a.Contact the provider and recommend a 24-hour urine test. b.Document findings and continue to monitor the patient. c.Review the patient's recent dietary selections. d.Perform a bedside blood glucose assessment.
d. Perform a bedside glucose assessment
A nurse assesses an older adult patient with the skin disorder shown below: How will the nurse document this finding? a.Ecchymoses b.Senile angiomas c.Actinic lentigo d.Petechiae
d. Petechiae
A patient is awaiting bariatric surgery in the morning. What action by the nurse is most important? a.Teaching the patient about needed dietary changes b.Informing the patient that he or she will be out of bed tomorrow c.Answering questions the patient has about surgery d.Beginning venous thromboembolism prophylaxis
d.Beginning venous thromboembolism prophylaxis
A nurse is caring for a client with an electrical burn. The client has entrance wounds on the hands and exit wounds on the feet. What information is most important to include when planning care? a.The client may have memory and cognitive issues postburn. b.The respiratory system requires close monitoring for signs of swelling. c.Electrical burns increase the risk of developing future cancers. d.Everything between the entry and exit wounds can be damaged.
d.Everything between the entry and exit wounds can be damaged.
The nurse knows that a patient with prolonged prothrombin time (PT) values (not related to medication) probably has dysfunction in which organ? a.Kidneys b.Stomach c.Spleen d.Liver
d.Liver
A patient tells the nurse about losing weight and regaining it multiple times. Besides eating and exercising habits, for what additional data should the nurse assess as the priority? a.Food allergies and intolerances b.Reasons for wanting to lose weight c.Economic ability to join a gym d.Psychosocial influences on weight
d.Psychosocial influences on weight
