Adults 1 - Final
A patient with osteoporosis is going home, where the patient lives alone. What action by the nurse is best?
Arrange a home safety evaluation
A client's low hemoglobin level has necessitated transfusion of PRBCs. Prior to administration, what action should the nurse perform?
Assess the client's vital signs to establish baselines
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. What action by the nurse is best?
Assess the neurovascular status of the right leg.
A nurse cares for a patient who is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube. What action would the nurse take first?
Assess the patient for airway patency.
A nurse is monitoring a patient after moderate sedation. The provider has prewritten discharged orders and the patient's spouse is asking if they can leave. What action by the nurse is best?
Assess the patient using the modified Aldrete scale.
A patient is recovering from an esophagogastroduodenoscopy (EGD) and requests something to drink. What action by the nurse is best?
Assess the patient's gag reflex.
A client is receiving postoperative morphine through a patient-controlled analgesic (PCA) pump and the client's prescriptions specify an initial bolus dose. What is the nurse's priority assessment?
Assessment for respiratory depression
A postoperative patient vomited. After cleaning and comforting the patient, which action by the nurse is most important?
Auscultate lung sounds.
When teaching a client with sickle cell disease about strategies to prevent crises, what measures should the nurse recommend?
Avoiding cold temperatures and ensuring sufficient hydration
An adult client has been diagnosed with iron deficiency anemia. What nursing diagnosis is most likely to apply to this client's health status?
Fatigue related to decreased oxygen-carrying capacity
After teaching a patient who is prescribed a restricted sodium diet, a nurse assesses the patient's understanding. Which food choice for lunch indicates that the patient correctly understood the teaching?
Grilled chicken breast with glazed carrots
A patient having a tube feeding begins vomiting. What action by the nurse is most appropriate?
Hold the feeding until the nausea subsides.
A nurse assists with the insertion of a central vascular access device. Which actions will the nurse ensure are completed to prevent a catheter-related bloodstream infection? (Select all that apply.)
Include a review for the need of the device each day in the patient's plan of care. Remind the provider to perform hand hygiene prior to starting the procedure Ask everyone in the room to wear a surgical mask during the procedure.
A nurse assesses a patient with diabetes mellitus who is admitted with an acid-base imbalance. The patient's arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3- 18 mEq/L (18 mmol/L). Which manifestation does the nurse identify as an example of the patient's compensation mechanism?
Increased rate and depth of respirations
The circulating nurse is in the operating room and sees the surgeon don gown and gloves using appropriate sterile procedure. The surgeon then folds the hands together and places them down below the hips. What action by the nurse is most appropriate?
Inform the surgeon that the sterile field has been broken.
A medical-surgical nurse is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which intervention will the nurse suggest to the management team to make the biggest impact on decreasing complications?
Initiate a dedicated team to insert access devices.
A client comes to the clinic reporting fatigue and the health interview is suggestive of pica. Laboratory findings reveal a low serum iron level and a low ferritin level. With what would the nurse suspect that the client will be diagnosed?
Iron deficiency anemia
A nurse is providing education to a client with iron deficiency anemia who has been prescribed iron supplements. What should the nurse include in health education?
Iron will cause the stools to darken in color
A nurse assesses a patient who has cholecystitis. Which clinical manifestation indicates that the condition is chronic rather than acute?
Light-colored stools
A nurse plans care for a patient with acute pancreatitis. Which intervention would the nurse include in this patient's plan of care to reduce discomfort?
Maintain nothing by mouth (NPO) and administer intravenous fluids.
The nurse who is a member of the palliative care team is assessing a client. The client indicates that he has been saving his PRN analgesics until the pain is intense because his pain control has been inadequate. What teaching should the nurse do with this client?
Medication should be taken when pain levels are low so the pain is easier to reduce.
The nurse has been frequently assessing an older adult's pain after she suffered a humeral fracture in a fall. When applying the nursing process in pain management for a client of this age, what principle should the nurse best apply?
Monitor for signs of drug toxicity due to a decrease in metabolism.
The nurse caring for patients with gastrointestinal disorders would understand that which category best describes the mechanism of action of sucralfate (Carafate)?
Mucosal barrier fortifier
A client's intractable neuropathic pain is being treated using a multimodal approach to analgesia. After administering a recently increased dose of IV morphine to the client, the nurse has returned to assess the client and finds the client unresponsive to verbal and physical stimulation with a respiratory rate of five breaths per minute. The nurse has called a code blue and should anticipate the administration of what drug?
Naloxone
The nurse is caring for a patient with peptic ulcer disease who reports sudden onset of sharp abdominal pain. On palpation, the patient's abdomen is tense and rigid. What action takes priority?
Notify the health care provider immediately.
A patient has gastroesophageal reflux disease (GERD). The provider prescribes a proton pump inhibitor. About what medication would the nurse anticipate teaching the patient?
Omeprazole (Prilosec)
A nurse assesses a patient who is recovering from an ileostomy placement. Which clinical manifestation would alert the nurse to urgently contact the health care provider?
Pale and bluish stoma
A patient has arrived in the postoperative unit. What action by the circulating nurse takes priority?
Participating in hand-off report
A client's blood work reveals a platelet level of 17,000/mm3. When inspecting the client's integumentary system, what finding would be most consistent with this platelet level?
Petechiae
A patient has received intravenous anesthesia during an operation. What action by the postanesthesia care nurse is most important when the patient arrives in the PACU?
Place the patient on a cardiac monitor and pulse oximeter.
A preoperative nurse is reviewing morning laboratory values on four patients waiting for surgery. Which result warrants immediate communication with the surgical team?
Potassium: 2.9 mEq/L (2.9 mmol/l)
A student nurse is providing care to an older patient with stomatitis and dysphagia. What action by the student nurse requires the registered nurse to intervene?
Preparing to administer a viscous lidocaine gargle
A nurse cares for a patient who has cirrhosis of the liver. What action would the nurse take to decrease the presence of ascites?
Provide a low-sodium diet
A client's diagnosis of atrial fibrillation has prompted the primary provider to prescribe warfarin. When assessing the therapeutic response to this medication, what is the nurse's most appropriate action?
Review the client's international normalized ratio (INR)
A nurse plans care for a patient who is prescribed skeletal traction. Which intervention would the nurse include in this plan of care to decrease the patient's risk for infection?
Schedule for pin care to be provided every shift.
The nurse is assessing four patients with musculoskeletal disorders. The nurse would assess the patient with which laboratory result first?
Serum phosphorus: 2 mg/dL (0.65 mmol/L)
A nurse reviews the chart of a patient who has Crohn's disease and a draining fistula. Which documentation would alert the nurse to urgently contact the provider for additional prescriptions?
Serum potassium of 2.6 mEq/L (2.6 mmol/L)
A nurse assesses a patient who has appendicitis. Which clinical manifestation would the nurse expect to find?
Severe, steady right lower quadrant pain
A client suffers a leg wound which causes minor blood loss. As a result of bleeding, the process of primary hemostasis is activated. What will occur during this process?
Severed blood vessels constrict
A nurse assesses a patient's peripheral IV site, and notices edema and tenderness above the site. What action will the nurse take next?
Stop the infusion of intravenous fluids
The nurse caring for a client receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the client is having difficulty breathing and complains of severe chest tightness. What is the most appropriate initial action for the nurse to take?
Stop the transfusion immediately
A client is being treated for the effects of a longstanding vitamin B12 deficiency. What aspect of the client's health history would most likely predispose her to this deficiency?
The client is a vegan.
A client is being treated in the ICU after a medical error resulted in an acute hemolytic transfusion reaction. What was the etiology of this client's adverse reaction?
The donor blood was incompatible with that of the client.
The nurse is receiving an older adult client from the PACU. Part of the report had been passed on from the preoperative assessment where it was noted that the client has been agitated in the past following opioid administration. What principle should guide the nurse's management of the client's pain?
The elderly may require lower doses of medication and are easily confused with new medications.
A postoperative patient has an abdominal drain. What assessment by the nurse indicates that goals for the priority patient problems related to the drain are being met?
There is no redness, warmth, or drainage at the insertion site.
A patient is scheduled to have a fundoplication. What statement by the patient indicates a need to review preoperative teaching?
"After the operation I can eat anything I want.
A nurse cares for a patient who is recovering from laparoscopic cholecystectomy surgery. The patient reports pain in the shoulder blades. How would the nurse respond?
"Ambulating in the hallway twice a day will help."
A nurse teaches a patient who is being discharged home with a peripherally inserted central catheter (PICC). Which statement will the nurse include in this patient's teaching?
"Avoid carrying your grandchild with the arm that has the central catheter."
A nurse cares for a patient who has obstructive jaundice. The patient asks, "Why is my skin so itchy?" How would the nurse respond?
"Bile salts accumulate in the skin and cause the itching.
A nurse cares for a patient who is prescribed lactulose (Heptalac). The patient states, "I do not want to take this medication because it causes diarrhea." How would the nurse respond?
"Diarrhea is expected; that's how your body gets rid of ammonia."
A nurse is caring for a patient who is recovering from an above-the-knee amputation. The patient reports pain in the limb that was removed. How would the nurse respond?
"How would you describe the pain that you are feeling?"
After teaching a patient who is recovering from a vertebroplasty, the nurse assesses the patient's understanding. Which statement by the patient indicates a need for additional teaching?
"I can drive myself home after the procedure."
After teaching a patient who has been diagnosed with hepatitis A, the nurse assesses the patient's understanding. Which statement by the patient indicates a correct understanding of the teaching?
"I may have been exposed when we ate shrimp last weekend."
A nurse obtains a patient's health history at a community health clinic. Which statement alerts the nurse to provide health teaching to this patient?
"I take a lot of Tylenol for my arthritis pain."
After teaching a patient who is recovering from laparoscopic cholecystectomy surgery, the nurse assesses the patient's understanding. Which statement made by the patient indicates a correct understanding of the teaching?
"I will decrease the amount of fatty foods in my diet."
After teaching a patient who has diverticulitis, a nurse assesses the patient's understanding. Which statement made by the patient indicates a need for additional teaching?
"I will take a laxative nightly at bedtime to avoid becoming constipated."
After teaching a patient who is being treated for dehydration, a nurse assesses the patient's understanding. Which statement indicates that the patient correctly understood the teaching?
"I will weigh myself each morning before I eat or drink."
A nurse is giving a preoperative patient a dose of ranitidine (Zantac). The patient asks why the nurse is giving this drug when the patient has no history of ulcers. What response by the nurse is best?
"It helps prevent ulcers from the stress of the surgery."
A nurse cares for a patient with ulcerative colitis. The patient states, "I feel like I am tied to the toilet. This disease is controlling my life." How would the nurse respond?
"Let's discuss potential factors that increase your symptoms."
A nurse cares for a patient placed in skeletal traction. The patient asks, "What is the primary purpose of this type of traction?" How would the nurse respond?
"Skeletal traction will assist in realigning your fractured bone."
After teaching a patient who is prescribed pancreatic enzyme replacement therapy, the nurse assesses the patient's understanding. Which statement made by the patient indicates a need for additional teaching?
"The best time to take the enzymes is immediately after I have a meal or a snack."
A nurse cares for a patient who had a colostomy placed in the ascending colon 2 weeks ago. The patient states, "The stool in my pouch is still liquid." How would the nurse respond?
"The stool will always be liquid with this type of colostomy."
A nurse cares for an older adult patient who is recovering from a leg amputation surgery. The patient states, "I don't want to live with only one leg. I should have died during the surgery." How would the nurse respond?
"This is a big change for you. What support system do you have to help you cope?"
An unlicensed nursing assistant (NA) reports to the nurse that a postsurgical client rates her pain as 8 on a 0-to-10 point scale. The NA tells the nurse that he thinks the client is exaggerating and does not need pain medication. What is the nurse's best response?
"Unless there is strong evidence to the contrary, we should take the client's report at face value.'"
A nurse cares for a patient with hepatitis C. The patient's brother states, "I do not want to contract this infection, so I will not go into his hospital room." How would the nurse respond?
"Viral hepatitis is not spread through casual contact."
A nurse cares for a patient who has a family history of colon cancer. The patient states, "My father and my brother had colon cancer. What is the chance that I will get cancer?" How would the nurse respond?
"You should have a colonoscopy more frequently to identify abnormal polyps early."
A nurse assesses patients at a community health fair. Which patient is at greatest risk for the development of hepatitis B?
A 20-year-old college student who has had several sexual partners
A trauma nurse cares for several patients with fractures. Which patient would the nurse identify as at highest risk for developing deep vein thrombosis?
A 74-year-old man who smokes and has a fractured pelvis
A nurse teaches patients at a community center about risks for dehydration. Which patient is at greatest risk for dehydration?
A 76-year-old who is cognitively impaired
An intensive care nurse is aware of the need to identify clients who may be at risk of developing disseminated intravascular coagulation (DIC). Which of the following ICU clients most likely faces the highest risk of DIC?
A client who is being treated for septic shock
A client with kidney injury has decreased erythropoietin production. Upon analysis of the client's complete blood count, the nurse will expect which of the following results?
A decreased hemoglobin and hematocrit
The nurse is preparing to administer a unit of platelets to an adult client. When administering this blood product, which of the following actions should the nurse perform?
Administer the platelets as rapidly as the client can tolerate
A client has just returned from the postanesthetic care unit (PACU) following left tibia open reduction internal fixation (ORIF). The client is reporting pain, and the nurse is preparing to administer the client's first scheduled dose of hydromorphone. Prior to administering the drug, you would prioritize what assessment?
Allergy status
A nurse prepares to flush a peripherally inserted central catheter (PICC) line with 50 units of heparin. The pharmacy supplies a multidose vial of heparin with a concentration of 100 units/mL. Which of the syringes shown below will the nurse use to draw up and administer the heparin?
Always use a 10-mL syringe when flushing PICC lines because a smaller syringe creates higher pressure, which could rupture the lumen of the PICC.
A nurse evaluates the following arterial blood gas values in a patient: pH 7.48, PaO2 98 mm Hg, PaCO2 28 mm Hg, and HCO3- 22 mEq/L (22 mmol/L). Which patient condition does the nurse correlate with these results?
Anxiety-induced hyperventilation
The postoperative nurse is caring for a patient who reports feeling "something popped" after vomiting. What action by the nurse is a priority?
Apply a sterile nonadherent dressing
A woman who is in her third trimester of pregnancy has been experiencing an exacerbation of iron deficiency anemia in recent weeks. When providing the client with nutritional guidelines and meal suggestions, what foods would be most likely to increase the woman's iron stores?
Beef liver accompanied by orange juice
The postanesthesia care unit (PACU) nurse is caring for an older patient following a lengthy surgery. What assessment finding would indicate an effect of hypothermia?
Bradycardia
A nurse is caring for a patient who has the following arterial blood values: pH 7.12, PaO2 56 mm Hg, PaCO2 65 mm Hg, and HCO3- 22 mEq/L (22 mmol/L). Which clinical situation does the nurse correlate with these values?
Bronchial obstruction related to aspiration of a hot dog
A patient is receiving bolus feedings through a Dobhoff tube. What action by the nurse is most important?
Check tube placement before each feeding.
A client is being treated for DIC and the nurse has prioritized the nursing diagnosis of Risk for Deficient Fluid Volume Related to Bleeding. How can the nurse best determine if goals of care relating to this diagnosis are being met?
Closely monitor intake and output
The following data relate to an older patient who is 2 hours postoperative after an esophagogastrostomy: Physical AssessmentVital SignsPhysician OrdersSkin dryUrine output 20 mL/hrNG tube patent with 100 mL brown drainage/hrRestlessPulse: 128 beats/minBlood pressure: 88/50 mm HgRespiratory rate: 20 on ventilatorCardiac output: 2.1 L/minOxygen saturation: 99%Normal saline at 75 mL/hrMorphine sulfate 2 mg IV push every 1 hr PRN painIntake and output every hourVital signs every hourVancomycin (Vancocin) 1 g IV every 8 hr What action by the nurse is best?
Consult the surgeon about increased IV fluids
A client newly diagnosed with thrombocytopenia is admitted to the medical unit. After the admission assessment, the client asks the nurse to explain the disease. What potential etiology should the nurse explain to this client?
Decreased production of platelets
The nurse is caring for a client whose medical history includes chronic fatigue and poorly controlled back pain. These medical diagnoses should alert the nurse to the possibility of what consequent health problem?
Depression
A client on the medical unit is receiving a unit of PRBCs. Difficult IV access has necessitated a slow infusion rate and the nurse notes that the infusion began 4 hours ago. What is the nurse's most appropriate action?
Discontinue the remainder of the PRBC transfusion and inform the health care provider
An inpatient nurse brings an informed consent form to a patient for an operation scheduled for tomorrow. The patient asks about possible complications from the operation. What response by the nurse is best?
Do not have the patient sign the consent and call the surgeon.
The nurse caring for an older adult client with osteoarthritis is reviewing the client's chart. This client is on a variety of medications prescribed by different care providers in the community. In light of the QSEN competency of safety, what is the nurse most concerned about with this client?
Drug interactions
A nurse cares for a patient who has a new colostomy. Which action would the nurse take?
Empty the pouch frequently to remove excess gas collection.
A morbidly obese patient is admitted to a community hospital that does not typically care for bariatric-sized patients. What action by the nurse is most appropriate?
Ensure adequate staff when moving the patient.
A patient just returned to the surgical unit after a gastric bypass. What action by the nurse is the priority?
Ensure an adequate airway.
A nurse is caring for a patient who has just had a central venous access line inserted. What action will the nurse take next?
Ensure that an x-ray is completed to confirm placement.
A client with poorly controlled diabetes has developed end-stage kidney injury and consequent anemia. When reviewing this client's treatment plan, the nurse should anticipate the use of what drug?
Epoetin alfa
A client is asking for a breakthrough dose of analgesia. The pain-medication prescriptions are written as a combination of an opioid analgesic and a nonsteroidal anti-inflammatory drug (NSAID) given together. What is the primary rationale for administering pain medication in this manner?
To achieve better pain control than with one medication alone
A nurse assesses a patient with a fracture who is being treated with skeletal traction. Which assessment would alert the nurse to urgently contact the health provider?
Traction weights are resting on the floor
A nurse develops a plan of care for a patient who has a history of hypocalcemia. What interventions will the nurse include in this patient's care plan? (Select all that apply.)
Use a draw sheet to reposition the patient in bed Provide nonslip footwear for the patient to use when out of bed.
A preoperative nurse is assessing a patient prior to surgery. Which information would be most important for the nurse to relay to the surgical team?
Use of multiple herbs and supplements
A client is admitted to the hospital with pernicious anemia. The nurse should prepare to administer which of the following medications?
Vitamin B12
A patient is being taught about drug therapy for Helicobacter pylori infection. What assessment by the nurse is most important?
Willingness to adhere to drug therapy
