Adults 1 - Final, Final adult 1 .exm
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 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 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 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 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 assesses a patient who has appendicitis. Which clinical manifestation would the nurse expect to find?
Severe, steady right lower quadrant pain
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."
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 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 client comes to the clinic reporting pain in the epigastric region. What statement by the client suggests the presence of a duodenal ulcer?
"My pain resolves when I have something to eat."
One of the things a nurse has taught to a patient during preoperative teaching is to have nothing by mouth for the specified time before surgery. The patient asks the nurse why this is important. What is the most appropriate response for the patient?
"You will need to have food and fluid restricted before surgery so you are not at risk for choking."
A patient is being admitted with dehydration due to nausea and vomiting. Which fluid would you expect the patient to be started on?
0.9% Normal Saline
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 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 with 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
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 client: pH 7.48, PaO2 98 mm Hg, PaCO2 28 mm Hg, and HCO3 22 mEq/L. Which client condition should the nurse correlate with these results?
Anxiety-induced hyperventilation
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 patient with osteoporosis is going home, where the patient lives alone. What action by the nurse is best?
Arrange a home safety evaluation
The nurse is planning client teaching for a client who is scheduled for an open hemicolectomy. The nurse intends to address the topics of incision splinting and leg exercises during this teaching session. When is the best time for the nurse to provide teaching?
As soon as possible before the surgical procedure
A nurse evaluates a patient's arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm Hg, and HCO3-22 mEq/L. Which intervention does the nurse implement first?
Assess the airway
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 nurse is providing health promotion education to a patient diagnosed with an esophageal reflux disorder. What practice should the nurse encourage the patient to implement?
Avoid carbonated drinks.
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. Which clinical situation does the nurse correlate with these values?
Bronchial obstruction related to aspiration for a hot dog
A nurse assesses a client who is experiencing an acid-base imbalance. The client's arterial blood gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L. Which assessment should the nurse perform first?
Cardiac rate and rhythm
A patient has come to the outpatient radiology department for diagnostic testing. Which of the following diagnostic procedures will allow the care team to evaluate and remove polyps?
Colonoscopy
A nurse is evaluating a patient who is being treated for dehydration. Which assessment result does the nurse correlate a therapeutic response to the treatment plan?
Decreased orthostatic light-headedness and dizziness
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 patient 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 physician.
A patient is receiving the first of two ordered units of PRBCs. Shortly after the initiation of the transfusion, the patient complains of chills and experiences a sharp increase in temperature. What is the nurse's priority action?
Discontinue the transfusion.
A nurse is caring for a patient who just has been diagnosed with a peptic ulcer. When teaching the patient about his new diagnosis, how should the nurse best describe a peptic ulcer?
Erosion of the lining of the stomach or intestine
A patient with a sodium level of 178 is ordered to be stated on 0.45% Saline. What is the most important nursing intervention for this patient?
Give slowly and watch for signs and symptoms of cerebral edema
The nurse is preparing an elderly patient for a scheduled removal of orthopedic hardware, a procedure to be performed under general anesthetic. For which adverse effect should the nurse most closely monitor the patient?
Hypothermia
The intraoperative nurse is implementing a care plan that addresses the surgical patients risk for vomiting. Interventions that address the potential for vomiting reduce the risk of what subsequent surgical complication?
Hypoxia
A nurse is planning the care of a client with a diagnosis of sickle cell disease who has been admitted for the treatment of an acute vaso-occlusive crisis. What nursing diagnosis should the nurse prioritize in the client's plan of care?
Ineffective tissue perfusion related to thrombosis
A patient has been admitted to the hospital after diagnostic imaging revealed the presence of a gastric outlet obstruction (GOO). What is the nurse's priority intervention?
Insertion of an NG tube for decompression
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
A 21-year-old patient is positioned on the OR bed prior to knee surgery to correct a sports-related injury. The anesthesiologist administers the appropriate anesthetic. The OR nurse should anticipate which of the following events as the teams next step in the care of this patient?
Intubating
A patient has come to the OB/GYN clinic due to recent heavy menstrual flow. Because of the patient's consequent increase in RBC production, the nurse knows that the patient may need to increase her daily intake of what substance?
Iron
A nurse is providing education to 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 client who underwent a gastric resection 3 weeks ago is having her diet progressed on a daily basis. Following her latest meal, the client reports dizziness and palpations. Inspection reveals that the client is diaphoretic. What is the nurse's best action?
Monitor the client closely for further signs of dumping syndrome
During the care of a preoperative patient, the nurse has given the patient a preoperative benzodiazepine. The patient is now requesting to void. What action should the nurse take?
Offer the patient a bedpan or urinal.
A patient has arrived in the postoperative unit. What action by the circulating nurse takes priority?
Participating in hand-off report
The OR nurse acts in the circulating role during a patients scheduled cesarean section. For what task is this nurse solely responsible?
Performing documentation
The nurse is caring for a client who is postoperative day 2 following a colon resection. While turning him, wound dehiscence with evisceration occurs. What should be the nurse's first response?
Place saline-soaked sterile dressings on the wound.
The nurse is caring for an 88 year old client ho is recovering from an ileac-femoral bypass graft. The client is day 2 postoperative and has been mentally intact, as per baseline. When the assess the client, it is clear that he is confused and has been experiencing disturbed sleep patterns and impaired psychomotor skills. What complication should the nurse suspect?
Postoperative delirium
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
The nurse is caring for a patient with a duodenal ulcer and is relating the patient's symptoms to the physiologic functions of the small intestine. What do these functions include? Select all that apply.
Secretion of mucus Absorption of nutrients Movement of nutrients into the bloodstream
A nurse is completing a health history on a patient whose diagnosis is chronic gastritis. Which of the data should the nurse consider most significantly related to the etiology of the patient's health problem?
Smokes one pack of cigarettes daily.
An OR nurse is participating in an interdisciplinary audit of infection control practices in the surgical department. The nurse should know that a basic guideline for maintaining surgical asepsis is what?
Sterile surfaces or articles may touch other sterile surfaces.
Nurse caring for a patient receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the patient 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
A client who experienced an upper GI bleed due to gastritis has had the bleeding controlled and the client's condition is now stable. For the next several hours, the nurse caring for this client should assess for what signs and symptoms of recurrence?
Tachycardia, hypotension, and tachypnea
A nurse is admitting a patient diagnosed with late-stage gastric cancer. The patient's family is distraught and angry that she was not diagnosed earlier in the course of her disease. What factor contributes to the fact that gastric cancer is often detected at a later stage?
The early symptoms of gastric cancer are usually not alarming or highly unusual.
A patient with a history of peptic ulcer disease has presented to the emergency department (ED) in distress. What assessment finding would lead the ED nurse to suspect that the patient has a perforated ulcer?
The patient has a rigid, "boardlike" abdomen that is tender.
The nurse is providing preoperative teaching to a patient scheduled for surgery. The nurse is instructing the patient on the use of deep breathing, coughing, and the use of incentive spirometry when the patient states, "I don't know why you're focusing on my breathing. My surgery is on my hip, not my chest." What rationale for these instructions should the nurse provide?
To promote optimal lung expansion
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
The OR nurse is providing care for 25-year-old major trauma client who has been involved in motorcycle accident. What intraoperative change may suggest the presence of anesthesia awareness?
Vital signs changes and client movement
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
A patient is admitted to the ED complaining of severe abdominal pain, stating that he has been vomiting "coffee-ground" like emesis. The patient is diagnosed with a perforated gastric ulcer and is informed that he needs surgery. When can the patient most likely anticipate that the surgery will be scheduled?
Without delay because the bleed is emergent
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 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 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?"
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 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.
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 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
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 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.
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 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
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 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 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.
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 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."
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
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 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 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 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 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 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 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
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."
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
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.'"
The nurse is providing care for a client whose peptic ulcer disease will be treated with a Bilroth I procedure (gastroduodenostomy). The nurse should address which of the following topics when providing health education?
- The procedure carries a risk for dumping syndrome - The client's vagus nerve may be altered
A nurse is monitoring a client with peptic ulcer disease. Which assessment findings would most likely indicate perforation of the ulcer? Select all that apply.
-Tachycardia-Hypotension-A rigid, board-like abdomen
The nurse is providing care for a client whose peptic ulcer disease will be treated with a Billroth I procedure (gastroduodenostomy). The nurse should address which of the following topics when providing health education? Select all that apply.
-The procedure carries a risk for dumping syndrome-The client's vagus nerve may be altered
Maintaining an aseptic environment in the OR is essential to patient safety and infection control. When moving around surgical areas, what distance must the nurse maintain from the sterile field?
1 foot
The nurse is performing a preoperative assessment on a patient going to surgery. The patient informs the nurse that he drinks approximately two bottles of wine each day and has for the last several years. What postoperative difficulties can the nurse anticipate for this patient?
Alcohol withdrawal syndrome 2 to 4 days after his last alcohol drink
A patient is receiving education about his upcoming Billroth I procedure (gastroduodenostomy). This patient should be informed that he may experience which of the following adverse effects associated with this procedure?
Diarrhea and feelings of fullness
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
A patient who experienced an upper GI bleed due to gastritis has had the bleeding controlled and the patient's condition is now stable. For the next several hours, the nurse caring for this patient should assess for what signs and symptoms of recurrence?
Tachycardia, hypotension, and tachypnea
A patient is being treated in the ICU after a medical error resulted in an acute hemolytic transfusion reaction. What was the etiology of this patient's adverse reaction?
The donor blood was incompatible with that of the patient.
The nurse knows that elderly patients are at higher risk for complications and adverse outcomes during the intraoperative period. What is the best rationale for this phenomenon?
The elderly patient has reduced ability to adjust rapidly to emotional and physical stress.
A patient is being treated for the effects of a longstanding vitamin B12 deficiency. What aspect of the patient's health history would most likely predispose her to this deficiency?
The patient is a vegan.
The OR nurse is taking the patient into the OR when the patient informs the operating nurse that his grandmother spiked a 104F temperature in the OR and nearly died 15 years ago. What relevance does this information have regarding the patient?
The patient may be at risk for malignant hyperthermia.
A patient with gastroesophageal reflux disease (GERD) has a diagnosis of Barrett's esophagus with minor cell changes. Which of the following principles should be integrated into the patient's subsequent care?
The patient will require an upper endoscopy every 6 months to detect malignant changes.
The nurse is preparing a patient for surgery prior to her hysterectomy without oophorectomy. The nurse is witnessing the patient's signature on a consent form. Which comment by the patient would best indicate informed consent?
The physician is going to remove my uterus and told me about the risk of bleeding."
The nurse in the ED is caring for a man who has returned to the ED 4 days after receiving stitches for a knife wound on his hand. The wound is now infected, so the stitches were removed, and the wound is cleaned and packed with gauze. The ED doctor plans to have the man returned tomorrow to remove the packing and resuture the wound. This client's wound will now heal by what means?
Third intention
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
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
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 who had a hemiglossectomy earlier in the day is assessed postoperatively, revealing a patent airway, stable vital signs, and no bleeding or drainage from the operative site. The nurse notes the patient is alert. What is the patient's priority need at this time?
An effective means of communicating with the nurse
The client's surgery is nearly finished and the surgeon has opted to use tissue adhesives to close the surgical wound. This requires the nurse to prioritize assessments related to what complications?
Anaphylaxis
The OR nurse is providing care for a 25-year-old major trauma patient who has been involved in a motorcycle accident. The nurse should know that the patient is at increased risk for what complication of surgery?
Anesthesia awareness
The nurse is planning patient teaching for a patient who is scheduled for an open hemicolectomy. The nurse intends to address the topics of incision splinting and leg exercises during this teaching session. When is the best time for the nurse to provide teaching?
As soon as possible before the surgical procedure
A nurse assesses a client who is admitted with an acid-base imbalance. The client's arterial blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L. What action should the nurse take next?
Assess client's rate, rhythm, and depth of respiration.
A nurse evaluates a client's arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm Hg, and HCO3 22 mEq/L. Which intervention should the nurse implement first?
Assess the airway.
A nurse is caring for a client who has the following arterial blood values: pH 7.12, PaO2 56 mm Hg, PaCO2 65 mm Hg, and HCO3 22 mEq/L. Which clinical situation should the nurse correlate with these values?
Bronchial obstruction related to aspiration of a hot dog
A patient comes to the clinic complaining of pain in the epigastric region. What assessment question during the health interview would most help the nurse determine if the patient has a peptic ulcer?
Does your pain resolve when you have something to eat?"
The nurse is discharging a client home from an outpatient surgery center. The nurse has reviewed all of the discharge instructions with the client and her caregiver. What else should the nurse do before discharging the client from the facility? Select all that apply
Give prescriptions to the client Provide physician contact information for follow up Provide discharge instructions in writing
A patient presents to the walk-in clinic complaining of vomiting and burning in her mid-epigastria. The nurse knows that in the process of confirming peptic ulcer disease, the physician is likely to order a diagnostic test to detect the presence of what?
Infection with Helicobacter pylori
A client receiving tube feedings is experiencing diarrhea. The nurse and the health care provider suspects that the client is experiencing dumping syndrome. What intervention is most appropriate?
Keep the client in semi-fowlers position for 1 hour after feedings (STOP THE FEEDING)
A nurse is providing preoperative teaching to a patient who will soon undergo a cardiac bypass. The nurse's teaching plan includes exercises of the extremities. What is the purpose of teaching a patient leg exercises prior to surgery?
Leg exercises improve circulation and prevent venous thrombosis.
A client has just been diagnosed with acute gastritis after presenting in distress to the emergency department with abdominal symptoms. Which of the following actions should the nurse prioritize?
Providing the client with physical and emotional support
When administering a hypertonic solution the nurse should closely watch for?
Pulmonary Edema
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
The nurse is doing preoperative patient education with a 61-year-old male patient who has a 40-pack per year history of cigarette smoking. The patient will undergo an elective bunionectomy at a time that fits his work schedule in a few months. What would be the best instruction to give to this patient?
Stop smoking 4 to 8 weeks before the scheduled surgery to enhance pulmonary function and decrease infection.
A surgical client has been in the PACU for the past 3 hours. What are the determining factors for the client to be discharged from the PACU? SELECT ALL?
Sufficient oxygen saturation Stable blood pressure Adequate respiratory function
The perioperative nurse is constantly assessing the surgical patient for signs and symptoms of complications of surgery. Which symptom should first signal to the nurse the possibility that the patient is developing malignant hyperthermia?
Tachycardia
A nurse is caring for a patient following knee surgery that was performed under a spinal anesthetic. What intervention should the nurse implement to prevent a spinal headache?
Keep the patient positioned supine.
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.
