EXAM 3 med surge

The healthcare provider is preparing a patient for a total colectomy and the placement of an ileostomy. The patient asks where the stoma will be located. The healthcare provider identifies which of the following areas as the correct stoma site? 1. RUQ 2. RLQ 3. LUQ 4. LLQ

2. Right lower quadrant

The most common finding in individuals at risk for sudden cardiac death is a. aortic valve disease b. mitral valve disease c. left ventricular dysfunction d. atherosclerotic heart disease

c. left ventricular dysfunction Rationale: Left ventricular dysfunction (ejection fraction less than 30%) and ventricular dysrhythmias after myocardial infarction are the strongest predictors of sudden cardiac death (SCD).

A client has just undergone arterial revascularization. Which statement by the client indicates a need for further teaching related to postoperative care? A. "My leg might turn very white after the surgery." B. "I should be concerned if my foot turns blue." C. "I should report a fever or any drainage." D. "Warmness, redness, and swelling are expected."

A Pallor is one of the signs of decreased perfusion along with increased pain, poikilothermia, paresthesia, pulselessness, and paralysis

3.Which patient would be at highest risk for hypothermia after surgery? A 42-year-old patient who had a laparoscopic appendectomy A 38-year-old patient who had a lumpectomy for breast cancer A 20-year-old patient with an open reduction of a fractured radius A 75-year-old patient with repair of a femoral neck fracture after a fall

A 75-year-old patient with repair of a femoral neck fracture after a fall Patients at highest risk for hypothermia are those who are older, debilitated, or intoxicated. Also, long surgical procedures and prolonged anesthetic administration place the patient at increased risk for hypothermia.

The nurse in the cardiology clinic is reviewing teaching about hypertension, provided at the client's last appointment. Which actions by the client indicate that teaching has been effective? (Select all that apply.) A. Has maintained a low-sodium, no-added-salt diet B. Has lost 3 pounds since last seen in the clinic C. Cooks food in palm oil to save money D. Exercises once weekly E. Has cut down on caffeine

A, B, E Clients with hypertension should consume low-sodium foods and should avoid adding salt. Weight loss can result in lower blood pressure. Caffeine promotes vasoconstriction, thereby elevating blood pressure.

Which patient is most at risk for respiratory depression related to opioid administration for pain relief? A. 82-year-old patient who had abdominal surgery 4 hours ago B. 24-year-old patient who had a vaginal delivery 12 hours ago C. 32-year-old patient with chronic neuropathic pain for 6 months D. 20-year-old patient with a closed reduction of a fractured right arm

A. 82-year-old patient who had abdominal surgery 4 hours ago Patients most at risk for respiratory depression include those who are older, have underlying lung disease, have a history of sleep apnea, or are receiving other central nervous system depressants. For postoperative patients the greatest risk is in the first 24 hours after surgery. Respiratory depression related to opioid administration is higher in hospitalized patients who are opioid naïve.

The nurse is caring for a client diagnosed with aortic stenosis. What assessment finding does the nurse expect in this client? a. Bounding arterial pulse b. Slow, faint arterial pulse c. Narrowed pulse pressure d. Elevated systolic pressure

ANS: C In aortic stenosis, the client presents with narrowed pulse pressure when blood pressure (BP) is assessed.

33. Which assessment finding in a patient who had a total gastrectomy 12 hours previously is most important to report to the health care provider? a. Absent bowel sounds b. Scant nasogastric (NG) tube drainage c. Complaints of incisional pain d. Temperature 102.1° F (38.9° C)

ANS: D An elevation in temperature may indicate leakage at the anastomosis, which may require return to surgery or keeping the patient NPO. The other findings are expected in the immediate postoperative period for patients who have this surgery.

10. A patient who recently has been experiencing frequent heartburn is seen in the clinic. The nurse will anticipate teaching the patient about a. barium swallow. b. radionuclide tests. c. endoscopy procedures. d. proton pump inhibitors.

ANS: D Because diagnostic testing for heartburn that is probably caused by gastroesophageal reflux disease (GERD) is expensive and uncomfortable, proton pump inhibitors are frequently used for a short period as the first step in the diagnosis of GERD. The other tests may be used but are not usually the first step in diagnosis.

A client with a history of heart failure is being discharged. Which priority instruction will assist the client in the prevention of complications associated with heart failure? a. "Avoid drinking more than 3 quarts of liquids each day." b. "Eat six small meals daily instead of three larger meals." c. "When you feel short of breath, take an additional diuretic." d. "Weigh yourself daily while wearing the same amount of clothing."

ANS: D Clients with heart failure are instructed to weigh themselves daily to detect worsening heart failure early, and thus avoid complications. Other signs of worsening heart failure include increasing dyspnea, exercise intolerance, cold symptoms, and nocturia.

The client who just started taking isosorbide dinitrate (Isordil) reports a headache. What is the nurse's best action? a. Titrate oxygen to relieve headache. b. Hold the next dose of Isordil. c. Instruct the client to drink water. d. Administer PRN acetaminophen.

ANS: D The vasodilating effects of this drug frequently cause clients to have headaches during the initial period of therapy. Clients should be told about this side effect and encouraged to take the medication with food. Some clients obtain relief with mild analgesics, such as acetaminophen.

When completing the health history of a pt w/ a suspected cardiac disorder, which of the following childhood illnesses should the nurse ask about? 1. rheumatic fever & strep throat infections 2. rubella & chicken pox 3. asthma & bronchitis 4. otitis media & respiratory syncytial virus (RSV)

Answer: 1 Rationale 1: Rheumatic fever & streptococcal throat infections are caused by beta- hemolytic streptococci, which have a propensity to form growths & calcium deposits on the leaflets of heart valves. This sets the individual up for valvular stenosis. Rationale 2,3,4: The other childhood illnesses are not directly related to cardiac disorders.

The nurse should recognize that the liver performs which functions (select all that apply)? A Bile storage B Detoxification C Protein metabolism D Steroid metabolism E Red blood cell (RBC) destruction

B Detoxification C Protein metabolism D Steroid metabolism The liver performs multiple major functions that aid in the maintenance of homeostasis. These include metabolism of proteins and steroids as well as detoxification of drugs and metabolic waste products. The Kupffer cells of the liver participate in the breakdown of old RBCs. The liver produces bile, but storage occurs in the gall bladder.

The nurse is watching the cardiac monitor, and a patient's rhythm suddenly changes. There are no P waves. Instead there are fine, wavy lines between the QRS complexes. The QRS complexes measure 0.08 sec (narrow), but they occur irregularly with a rate of 120 beats/min. The nurse correctly interprets this rhythm as what? A. Sinus tachycardia B. Atrial fibrillation C. Ventricular fibrillation D. Ventricular tachycardia

B. Atrial fibrillation Atrial fibrillation is represented on the cardiac monitor by irregular R-R intervals and small fibrillatory (f) waves. There are no normal P waves because the atria are not truly contracting, just fibrillating. Sinus tachycardia is a sinus rate above 100 beats/minute with normal P waves. Ventricular fibrillation is seen on the ECG without a visible P wave; an unmeasurable heart rate, PR or QRS; and the rhythm is irregular and chaotic. Ventricular tachycardia is seen as three or more premature ventricular contractions (PVCs) that have distorted QRS complexes with regular or irregular rhythm, and the P wave is usually buried in the QRS complex without a measurable PR interval.

When caring for the client with a left forearm arteriovenous (AV) fistula created for hemodialysis, the nurse must do which of these? Select all that apply. A. Check brachial pulses daily B. Auscultate for a bruit each shift C. Teach the client to palpate for a thrill over the site D. Elevate the arm above heart level E. Ensure that no blood pressures are taken in that arm

B. Auscultate for a bruit each shift, C. Teach the client to palpate for a thrill over the site, and E. Ensure that no blood pressures are taken in that arm

The nurse recognizes that which medication when given in heart failure may improve morbidity and mortality? a. Dobutamine (Dobutrex) b. Carvedilol (Coreg) c. Digoxin (Lanoxin) d. Bumetamide (Bumex)

B: Beta-adrenergic blockers reverse consequences of sympathetic stimulation and catecholamine release that worsen heart failure; they improve morbidity, mortality, and quality of life. Dobutamine and digoxin are inotropic agents used in acute heart failure; they do not improve mortality. Bumetamide is a high-ceiling diuretic that promotes fluid excretion; it does not improve morbidity and mortality.

After administration of a dose of metoclopramide, which patient assessment finding would show the medication was effective? a. Decreased blood pressure b. Absence of muscle tremors c. Relief of nausea and vomiting d. No further episodes of diarrhea

Correct answer: C Metoclopramide is classified as a prokinetic and antiemetic medication. If it is effective, the patient's nausea and vomiting should resolve. Metoclopramide does not affect blood pressure, muscle tremors, or diarrhea.

A significant cause of venous thrombosis is: a. Altered blood coagulation b. Stasis of blood c. Vessel wall injury d. All of the above

D. All

The patient is receiving fentanyl (Duragesic) patch for control of chronic cancer pain. What should the nurse observe for in the patient as a potential adverse effect of this medication? A. Hypertension B. Pupillary dilation C. Urinary incontinence D. Decreased respiratory rate

D. Decreased respiratory rate Respiratory depression is a potentially life-threatening adverse effect of fentanyl (Duragesic), which is an opioid analgesic, via any route.

The nurse is preparing to administer a dose of bisacodyl (Dulcolax). In explaining the medication to the patient, the nurse would explain that it acts in what way? A. Increases bulk in the stool B. Lubricates the intestinal tract to soften feces C. Increases fluid retention in the intestinal tract D. Increases peristalsis by stimulating nerves in the colon wall

D. Increases peristalsis by stimulating nerves in the colon wall Bisacodyl is a stimulant laxative that aids in producing a bowel movement by irritating the colon wall and stimulating enteric nerves. It is available in oral and suppository forms. Fiber and bulk forming drugs increase bulk in the stool; water and stool softeners soften feces, and saline and osmotic solutions cause fluid retention in the intestinal tract.

Which of the following represents a positive response to administration of erythropoietin (Epogen, Procrit)? A. Hematocrit of 26.7% B. Potassium within normal range C. Free from spontaneous fractures D. Less fatigue

D. Less fatigue: Treatment of anemia with erythropoietin will result in increased (H&H) and decreased shortness of breath (SOB) and fatigue.

The nurse would question the use of which cathartic agent in a patient with renal insufficiency? A. Bisacodyl (Dulcolax) B. Lubiprostone (Amitiza) C. Cascara sagrada (Senekot) D. Magnesium hydroxide (Milk of Magnesia)

D. Magnesium hydroxide (Milk of Magnesia) Milk of Magnesia may cause hypermagnesemia in patients with renal insufficiency. The nurse should question this order with the health care provider. Bisacodyl, lubiprostone, and cascara sagrada are safe to use in patients with renal insufficiency as long as the patient is not currently dehydrated.

Which foods should the nurse encourage a client with diverticulosis to incorporate into the diet? Select all that apply. 1. Bran cereal. 2. Broccoli. 3. Tomato juice. 4. Navy beans. 5. Cheese.

1, 2, 4. Clients with diverticulosis are encouraged to follow a high-fiber diet. Bran, broccoli, and navy beans are foods high in fiber. Tomato juice and cheese are low-residue foods.

A patient presenting to the ER with a hypertensive crisis (BP greater than 180/120), may have damage to which of the following? A. Brain B. Kidney C. Liver D. Heart E. Stomach F. Eyes

A, B. D. F CVA retinopathy heart failure renal failure IV beta blocker will be ordered immediately for a pt in a hypertensive crisis

Sinus bradycardia (rate 56 bpm) is identified in a sleeping pt on telemetry. Which is the priority nursing action? 1. Awaken the pt & see how the heart rate responds. 2. Call the physician & report this dysrhythmia. 3. Check the medication administration record & see if there is a PRN medication that will improve this rhythm. 4. Call for an immediate 12-lead electrocardiogram (ECG).

Answer: 1 Rationale 1: The priority is to awaken the pt to determine how the heart rate is affected with activity as it normally should increase. The pt should be evaluated to determine how the dysrhythmia is affecting heart function. Many pts who are asymptomatic while in sinus bradycardia can be observed & require no further intervention. Common reasons for sinus bradycardia for the nurse to consider include athletic conditioning, sleep, or a conduction disorder. Rationale 2: Notifying the physician without first assessing the pt's response would not be appropriate. Rationale 3: The priority is to awaken the pt to determine how the heart rate is affected with activity as it normally should increase. The pt should be evaluated to determine how the dysrhythmia is affecting heart function. Many pts who are asymptomatic while in sinus bradycardia can be observed & require no further intervention. Rationale 4: Ordering an ECG requires a physician's prescription.

our patient is being discharged home on an around-the-clock opioid for chronic rheumatoid arthritis pain. You would expect an order for which of the following classes of medications to accompany this order? a. Laxative b. Antibiotic c. Stool softener d. Proton pump inhibitor

laxative

our patient is recovering from knee surgery and states that her pain level is 7 on a 0-10 pain scale. She received a dose of medication 15 minutes ago. Which interventions may be beneficial for this patient at this time? (Select all that apply.) a. Massage her back. b. Help her to reposition on her side. c. Tell her that she cannot have any more pain medication at this time as she may become addicted d. Take a few minutes and talk to her about the pictures of her family that she brought with her from home.

massage her back Help her to reposition on her side

What should be included in the physical assessment? What would you be looking for?

• Assess vital signs, looking for fever, hypotension, and/or tachycardia that might indicate inflammatory condition and possible sepsis • Inspect abdomen for distention, peristaltic waves • Auscultate for presence of bowel sounds, bruits • Palpate abdomen for masses, rebound tenderness

What diagnostic studies might you expect to be ordered?

• CBC • Electrolytes • Hepatic panel • Serum amylase • Urinalysis • CT scan of the abdomen

The nurse is providing discharge education to a client with hypertrophic cardiomyopathy (HCM). What priority instruction will the nurse include? a. "Take your digoxin at the same time every day." b. "You should begin an aerobic exercise program." c. "You should report episodes of dizziness or fainting." d. "You may have only two alcoholic drinks daily."

ANS: C The client with HCM is instructed to notify the health care provider if episodes of fainting, dizziness, or palpitations occur because these may signal the onset of deadly dysrhythmias. Clients with HCM are instructed to avoid strenuous exercise and alcohol. Cardiac glycosides are contraindicated in obstructive HCM.

6. The nurse is assessing a patient with gastroesophageal reflux disease (GERD) who is experiencing increasing discomfort. Which patient statement indicates that additional patient education about GERD is needed? a. "I take antacids between meals and at bedtime each night." b. "I sleep with the head of the bed elevated on 4-inch blocks." c. "I quit smoking several years ago, but I still chew a lot of gum." d. "I eat small meals throughout the day and have a bedtime snack."

ANS: D GERD is exacerbated by eating late at night, and the nurse should plan to teach the patient to avoid eating at bedtime. The other patient actions are appropriate to control symptoms of GERD.

The nurse is starting a client on digoxin (Lanoxin) therapy. What intervention is essential to teach this client? a. "Avoid taking aspirin or aspirin-containing products." b. "Increase your intake of foods high in potassium." c. "Hold this medication if your pulse rate is below 80 beats/min." d. "Do not take this medication within 1 hour of taking an antacid."

ANS: D Gastrointestinal absorption of digoxin is erratic. Many medications, especially antacids, interfere with its absorption. Clients are taught to hold their digoxin for bradycardia; a heart rate of 80 is too high for this cutoff.

When following up in the clinic with a client with heart failure, how does the nurse recognize that the client has been compliant with fluid restrictions? a. Auscultation of crackles b. Pedal edema c. Weight loss of 6 pounds since the last visit d. Reports sucking on ice chips all day for dry mouth

C: Weight loss in this client indicates effective fluid restriction and diuretic drug therapy. Lung crackles indicate intra-alveolar edema and fluid excess. Pedal edema indicates fluid excess. This indicates noncompliance with fluid restrictions; alternative methods of treating dry mouth should be explored.

The nurse is admitting a 68-year-old preoperative patient with a suspected abdominal aortic aneurysm (AAA). The medication history reveals that the patient has been taking warfarin (Coumadin) on a daily basis. Based on this history and the patient's admission diagnosis, the nurse should prepare to administer which medication? a. Vitamin K b. Cobalamin c. Heparin sodium d. Protamine sulfate

Correct Answer: A Coumadin is a Vitamin K antagonist anticoagulant that could cause excessive bleeding during surgery if clotting times are not corrected before surgery. For this reason, vitamin K is given as the antidote for warfarin (Coumadin).

The first priority of collaborative care of a patient with a suspected acute aortic dissection is to a. reduce anxiety. b. control blood pressure. c. monitor for chest pain. d. increase myocardial contractility.

Correct answer: b Rationale: The initial goals of therapy for acute aortic dissection without complications are blood pressure (BP) control and pain management. BP control reduces stress on the aortic wall by reducing systolic BP and myocardial contractility.

The nurse teaches the client recovering from acute kidney disease to avoid which of these? A. Nonsteroidal anti-inflammatory drugs B. Angiotensin-converting enzyme (ACE) inhibitors C. Opiates D. Acetaminophen

A. Non-steroidal anti-inflammatory drugs (NSAIDs): Nonsteroidal anti-inflammatory drugs may be nephrotoxic. ACE inhibitors are used for treatment of hypertension and to protect the kidneys, especially in the diabetic client, from progression of kidney disease. Opiates may be used by clients with kidney disease if severe pain is present; however, excretion may be delayed. Acetaminophen is hepatotoxic, not generally nephrotoxic.

The nurse should question an order written for Percocet for a patient exhibiting which clinical manifestation? A. Severe jaundice B. Oral candidiasis C. Increased urine output D. Elevated blood glucose

A. Severe jaundice Acetaminophen and oxycodone are the ingredients in Percocet. Because acetaminophen is metabolized in the liver, the patient could develop acetaminophen toxicity in the presence of severe liver disease (evidenced by jaundice). The prudent nurse would question the order before administration.

A client who has had a prosthetic valve replacement asks the nurse why he must take anticoagulants for the rest of his life. What is the nurse's best response? a. "The prosthetic valve places you at greater risk for a heart attack." b. "Blood clots form more easily in artificial replacement valves." c. "The vein taken from your leg reduces circulation in the leg." d. "The surgery left a lot of small clots in your heart and lungs."

ANS: B Synthetic valve prostheses and scar tissue provide surfaces on which platelets can aggregate easily and initiate the formation of blood clots.

The nurse is reviewing a new prescription for propranolol (Inderal) for a pt with coronary heart disease (CHD). The nurse would call the physician & question this prescription if the pt has which history? 1. has a history of asthma & chronic obstructive pulmonary disease (COPD) 2. is also taking antioxidants 3. is also taking simvastatin (Zocor) 4. has a history of bleeding disorders

Answer: 1 Rationale 1: Class II beta-blockers such as propranolol are used to reduce heart rate & myocardial contractility & in the treatment of supraventricular tachycardia. These drugs may cause bronchospasm & are contraindicated for pts with asthma, chronic obstructive pulmonary disease (COPD), or other restrictive or obstructive lung diseases. Rationale 2: Antioxidants may be taken concurrently. Rationale 3: Simvastatin may be taken concurrently. Rationale 4: Bleeding disorders are not associated with propranolol use

1. What is the most appropriate way to assess the pain of a patient who is oriented and has recently had surgery? • Assess the patient's body language. • Observe cardiac monitor for increased heart rate. • Ask the patient to rate the level of pain. • Ask the patient to describe the effect of pain on the ability to cope.

Ask the patient to rate the level of pain. Correct

A patient with a history of stroke 4 years ago resulting in aphasia (inability to verbally express thoughts) returns to the surgical unit after a cholecystectomy. The surgeon ordered an intravenous pain medication every 4 hours as needed (PRN) for postoperative pain. The best nursing intervention related to pain control after surgery would be to: a. Administer the pain medication when the patient becomes restless b. Wait until the patient verbalizes that hse is experiencing pain to administer the pain medication. c. Assess the patient's level of pain using a Faces Pain Scale and administer pain medication as ordered d. Administer the pain medication every 4 hours as the client can't express pain.

Assess the patients level of pain using a Faces pain scale and administer pain medication as orderd

Which priority problems may be considered for the client with heart failure? Select all that apply. a. Decreased fluid volume related to compromised regulatory mechanism b. Impaired Physical Mobility related to limited cardiovascular endurance c. Impaired Gas Exchange related to ventilation-perfusion imbalance d. Potential for pulmonary edema e. Risk for Ineffective renal Perfusion related to hypervolemia

B, C, D, E: Owing to intra-alveolar edema and poor cardiac output, the client is fatigued, has limited endurance, and may develop hypoxemia. Owing to limited cardiac reserve, the client is at risk for pulmonary edema. The client with heart failure has poor cardiac output, reduced blood flow to the kidney, and accumulation of pulmonary and peripheral fluid.

After administering acetaminophen and oxycodone (Percocet) for pain, which intervention would be of highest priority for the nurse to complete before leaving the patient's room? A. Leave the overbed light on at low setting. B. Ensure that the upper two side rails are raised. C. Offer to turn on the television to provide distraction. D. Ensure that documentation of intake and output is accurate.

B. Ensure that the upper two side rails are raised. Percocet has acetaminophen and oxycodone as ingredients. Since the medication contains an opioid analgesic with sedative properties, the nurse must ensure patient safety before leaving the room, such as leaving the top two bedrails raised. This will help prevent the patient from falling from bed, while not restraining the patient (as four side rails would do). Leaving the light or television on will not provide a positive environment for healing sleep.

The patient is admitted with acute coronary syndrome (ACS). The ECG shows ST-segment depression and T-wave inversion. What should the nurse know that this indicates? A. Myocardia injury B. Myocardial ischemia C. Myocardial infarction D. A pacemaker is present.

B. Myocardial ischemia The ST depression and T wave inversion on the ECG of a patient diagnosed with ACS indicate myocardial ischemia from inadequate supply of blood and oxygen to the heart. Myocardial injury is identified with ST-segment elevation. Myocardial infarction is identified with ST-segment elevation and a widened and deep Q wave. A pacemaker's presence is evident on the ECG by a spike leading to depolarization and contraction.

Which of the following does the nurse recognize as a contributing factor to high BP? A. decreased CO B. pulse rate of 100 C. increased afterload D. decreased stroke volume

C Increased afterload=increased PVR and BP = CO x PVR so if PVR increases then BP increases

After attempting lifestyle changes with no improvement in the HTN, the nurse should expect the physician to prescribe which medication first? A. Calcium Channel Blocker B. ARB C. Thiazide diuretic D. Renin inhibitor

C. Thiazide diuretic is the first med to give, sometimes will be combined with a beta blocker. This combo is done so a lower dose of each med can be given.

The nurse is caring for a postoperative patient with a colostomy. The nurse is preparing to administer a dose of famotidine (Pepcid) when the patient asks why the medication was ordered since the patient does not have a history of heartburn or gastroesophageal reflux disease (GERD). What response by the nurse would be the most appropriate? A. "This will prevent air from accumulating in the stomach, causing gas pains." B. "This will prevent the heartburn that occurs as a side effect of general anesthesia." C. "The stress of surgery is likely to cause stomach bleeding if you do not receive it." D. "This will reduce the amount of HCl in the stomach until the nasogastric tube is removed and you can eat a regular diet again."

D. "This will reduce the amount of HCl in the stomach until the nasogastric tube is removed and you can eat a regular diet again." Famotidine is an H2-receptor antagonist that inhibits gastric HCl secretion and thus minimizes damage to gastric mucosa while the patient is not eating a regular diet after surgery. Famotidine does not prevent air from accumulating in the stomach or stop the stomach from bleeding. Heartburn is not a side effect of general anesthesia.

What should the nurse instruct the patient to do to best enhance the effectiveness of a daily dose of docusate sodium (Colace)? A. Take a dose of mineral oil at the same time. B. Add extra salt to food on at least one meal tray. C. Ensure dietary intake of 10 g of fiber each day. D. Take each dose with a full glass of water or other liquid.

D. Take each dose with a full glass of water or other liquid. Docusate lowers the surface tension of stool, permitting water and fats to penetrate and soften the stool for easier passage. The patient should take the dose with a full glass of water and should increase overall fluid intake, if able, to enhance effectiveness of the medication. Dietary fiber intake should be a minimum of 20 g daily to prevent constipation. Mineral oil and extra salt are not recommended.

Although the client with cardiac failure is asymptomatic, the nurse suspects noncompliance with prescribed home therapy. Which laboratory test confirms the nurse's suspicions? a. B-type natriuretic peptide (BNP) 90 pg/mL b. Serum electrolytes c. Hemoglobin and hematocrit d. Digoxin level of 0.2 ng/dL

D: A therapeutic digoxin level is 0.8 to 2.0 ng/dL. A level of 0.2 ng/dL indicates that the client has not been taking his digoxin as prescribed. A BNP test is a cardiac failure diagnostic tool but is not the best indicator of decreased compliance. Electrolytes are not an early indicator of decreased cardiac compliance. Hemoglobin and hematocrit are not early indicators of decreased cardiac compliance.

After administering a dose of promethazine to a patient with nausea and vomiting, what medication side effect does the nurse explain is common and expected? a Tinnitus b Drowsiness c Reduced hearing d Sensation of falling

correct: b Although being given to this patient as an antiemetic, promethazine also has sedative and amnesic properties. For this reason, the patient is likely to experience drowsiness as an adverse effect of the medication. Tinnitus, reduced hearing, and loss of balance are not side effects of promethazine.

8.The patient donated a kidney, and early ambulation is included in her plan of care. But the patient refuses to get up and walk. What rationale should the nurse explain to the patient for early ambulation? "Early walking keeps your legs limber and strong." "Early ambulation will help you be ready to go home." "Early ambulation will help you get rid of your syncope and pain." "Early walking is the best way to prevent postoperative complications."

"Early walking is the best way to prevent postoperative complications."

31. The nurse is caring for a patient who recently had surgery to repair a hernia. The patient's pain was 7 out of 10 before receiving pain medication. One hour after receiving an oral opioid, the patient ranks his pain at 3 out of 10. The patient asks the nurse why he isn't receiving more pain medication. Which is the nurse's best response? • "This medication can be given only every 4 hours. It is not time for you to have any other pain medication right now." • "I will notify the health care provider to come perform an assessment if your pain doesn't improve in 30 minutes." • "If the pain becomes severe, we may need to transfer you to an intensive care unit." • "It can take 2 hours for oral pain medication to work, and your pain is going down. Let's try boosting you up in bed and putting an ice pack on the incision to see if that helps."

"It can take 2 hours for oral pain medication to work, and your pain is going down. Let's try boosting you up in bed and putting an ice pack on the incision to see if that helps."

The healthcare provider is teaching a patient diagnosed with Crohn's disease who is recovering from a bowel resection. Which of the following statements made by the patient indicates the teaching has been effective? 1. "Now that the bowel has been removed, the disease is cured." 2. "The disease might reappear in another part of the bowel." 3. "Now I can discontinue taking my multivitamin supplements." 4. "I might develop ulcerative colitis because some of my bowel is missing."

2. "The disease might reappear in another part of the bowel."

The client who had an abdominal surgery has a Jackson Pratt drainage tube. Which assessment data warrant immediate intervention by the nurse? 1. The bulb is round and has 40 mL of fluid 2. The drainage tube is taped to the dressing. 3. The insertion site is pink and has not drainage. 4. The bulb has suction and is sunken in.

1. The JP bulb should be depressed, which indicates suction is being applied. A round bulb indicates the bulb is full and needs to be emptied and suction reapplied. (2. The tube should be taped to the dressing to prevent accidentally pulling the drain out of the insertion site) (3. The insertion site should be pink and without any sign of infection, which include drainage, warmth, and redness.) (4. the bulb should be sunken in or depressed, indicating suction is being applied)

A client who is receiving epidural analgesia complains of nausea and loss of motor function in his legs. The nurse obtains his blood pressure and notes a drop in his blood pressure from the previous reading. Which complication is the patient most likely experiencing? a. Infection at the catheter insertion site b. Side effect of the epidural analgesic c. Epidural catheter migration d. Spinal cord damage

Epidural catheter mgration

19. Which question is least useful in the assessment of a client with AIDS? a. Are you a drug user? b. Do you have many sex partners? c. What is your method of birth control? d. How old were you when you became sexually active?

19. Answer D. Drug use is a risk factor for AIDS. Multiple sex partners is a risk factor for AIDS. Birth control methods are important to prevent a baby from being born with the AIDS virus. The age at which sexual activity began it not relevant as it does not usually provide information that identifies the presence of risk factors for AIDS.

A nurse is administering a dopamine infusion at a moderate dose to a client who has severe HF. Which of the following is an expected effect? 1. Lowered heart rate 2. Increased myocardial contractility 3. Decreased conduction through the AV node D. Vasoconstriction of the renal blood vessels

2. Increased myocardial contractility -- thus increasing CO

After instructing a client with diverticulosis about appropriate self-care activities, which of the following client comments indicate effective teaching? Select all that apply. 1. "With careful attention to my diet, my diverticulosis can be cured." 2. "Using a cathartic laxative weekly is okay to control bowel movements." 3. "I should follow a diet that's high in fiber." 4. "It is important for me to drink at least 2,000 mL of fluid every day." 5. "I should exercise regularly."

3, 4, 5. Clients who have diverticulosis should be instructed to maintain a diet high in fiber and, unless contraindicated, should increase their fluid intake to a minimum of 2,000 mL/ day. Participating in a regular exercise program is also strongly encouraged. Diverticulosis can be controlled with treatment but cannot be cured. Clients should be instructed to avoid the regular use of cathartic laxatives. Bulk laxatives and stool softeners may be helpful to maintain regularity and decrease straining.

A male client had abdominal surgery and the nurse suspects he has peritonitis. Which assessment data support the diagnosis of peritonitis? 1. Absent bowel sounds & potassium level of 3.9 mEq/L 2. Abdominal cramping & hemoglobin of 14 g/dL 3. Profuse diarrhea & stool specimen shows Campylobacter. 4. Hard, rigid abdomen & white blood cell count 22,000/mm^3

4. A hard, rigid abdomen indicates an inflamed peritoneum (abdominal wall cavity) resulting from an infection, which results in an elevated WBC level. (1. absent bowel sounds indicate paralytic ileus, not peritonitis. K level is normal) (2. abdominal cramping is not peritonitis. hgb is normal) (3. this bug does cause acute diarrhea - not peritonitis) from MedSurg Success pg 268

4. Which of the following is the FIRST priority in preventing infections when providing care for a client? a. Handwashing b. Wearing gloves c. Using a barrier between client's furniture and nurse's bag d. Wearing gowns and goggles

4. Answer A. Handwashing remains the most effective way to avoid spreading infection. However, too often nurses do not practice good handwashing techniques and do not teach families to do so. Nurses need to wash their hands before and after touching the client and before entering the nursing bag.

A patient has been admitted to the medical unit after several days of watery diarrhea related to Crohn's disease. The healthcare provider recognizes which of the following symptoms as most concerning? 1. Right upper quadrant pain 2. Elevated hematocrit 3. Elevated leukocytes 4. Palpitations

4. Pappitations

The nurse is caring for a client with mitral valve stenosis. What clinical manifestation alerts the nurse to the possibility that the client's stenosis has progressed? a. Oxygen saturation of 92% b. Dyspnea on exertion c. Muted systolic murmur d. Upper extremity weakness

ANS: B Dyspnea on exertion develops as the mitral valvular orifice narrows and pressure in the lungs increases.

14. The nurse will plan to teach the patient with newly diagnosed achalasia that a. a liquid or blenderized diet will be necessary. b. drinking fluids with meals should be avoided. c. endoscopic procedures may be used for treatment. d. lying down and resting after meals is recommended.

ANS: C Endoscopic and laparoscopic procedures are the most effective therapy for improving symptoms caused by achalasia. Patients are advised to drink fluid with meals. Keeping the head elevated after eating will improve esophageal emptying. A semisoft diet is recommended to improve esophageal emptying.

6. In caring for the postoperative patient on the clinical unit after transfer from the PACU, which care can be delegated to the unlicensed assistive personnel (UAP)? Monitor the patient's pain. Do the admission vital signs. Assist the patient to take deep breaths and cough. Change the dressing when there is excess drainage.

Assist the patient to take deep breaths and cough.

5. Bronchial obstruction by retained secretions has contributed to a postoperative patient's recent pulse oximetry reading of 87%. Which health problem is the patient probably experiencing? Atelectasis Bronchospasm Hypoventilation Pulmonary embolism

Atelectasis The most common cause of postoperative hypoxemia is atelectasis, which may be the result of bronchial obstruction caused by retained secretions or decreased respiratory excursion. Bronchospasm involves the closure of small airways by increased muscle tone, whereas hypoventilation is marked by an inadequate respiratory rate or depth. Pulmonary emboli do not involve blockage by retained secretions.

An 85-year-old woman seen in the primary care provider's office for a well check complains of difficulty swallowing. What common effect of aging should the nurse assess for as a possible cause? A Anosmia B Xerostomia C Hypochlorhydria D Salivary gland tumor

B Xerostomia Xerostomia (decreased saliva production), or dry mouth, affects many older adults and may be associated with difficulty swallowing (dysphagia). Anosmia is loss of sense of smell. Hypochlorhydria, a decrease in stomach acid, does not affect swallowing. Salivary gland tumors are not common.

Which of the following control systems play a major role in maintaining blood pressure? Select All That Apply A. Renovascular system B. Arterial baroreceptor system C. Regulation of body fluid volume D. Respiratory System E. Renin-angiotensin-aldosterone system F. Vascular autoregulation G. Pulmonary system

B, C, E, F

A patient reports a history of severe mitral valve disorder. What sign or symptom does the nurse expect to find?

Exertional dyspnea

32. Which of the following is the best way for the nurse to manage pain for a patient with chronic pain from arthritis? • Administer pain medication before any activity. • Provide intravascular bolus as needed for breakthrough pain. • Give medications around-the-clock. • Administer pain medication only when nonpharmacological measures have failed.

Give medications around-the-clock. Correct

The patient is being discharged following a mitral valve replacement and will be prescribed the anticoagulant warfarin. Which food should the nurse instruct him to avoid?

Green leafy vegetables

The nurse is caring for a patient with cardiomyopathy. Which assessment finding should alert the nurse to worsening of the condition?

Increasing dyspnea

The nurse is caring for a patient who was diagnosed with aortic valve stenosis. What would indicate that the patient's stenosis is worsening?

Peripheral cyanosis

A compensatory mechanism involved in HF that leads to inappropriate fluid retention and additional workload of the heart is a. ventricular dilation b. ventricular hypertrophy c. neurohormonal response d. sympathetic nervous system activation

c. neurohormonal response Rationale: The following mechanisms in heart failure lead to inappropriate fluid retention and additional workload of the heart: activation of the renin-angiotensin-aldosterone system (RAAS) cascade and release of antidiuretic hormone from the posterior pituitary gland in response to low cerebral perfusion pressure that results from low cardiac output.

A nurse is developing a plan of care for a client scheduled for surgery. Then nurse should include which activity in the nursing care plan for the client on the day of surgery? 1. Have the client void immediately before surgery. 2. Avoid oral hygiene and rinsing with mouthwash. 3. Verify that the client has not eaten for the last 24 hours. 4. Report immediately any slight increase in blood pressure or pulse.

1. Have the client void immediately before surgery. Rationale: The nurse would assist the client to void immediately before surgery so that the bladder will be empty. Oral hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of food and fluids for 6 to 8 hours before surgery instead of 24 hours. A slight increase in blood pressure and pulse is common during the preoperative period and is usually the result of anxiety. Test-Taking Strategy: Read each option carefully. Eliminate option 4 because of the words "immediately" and "slight". Eliminate option 3, knowing that the client should be NPO for 6 to 8 hours before surgery. There is no useful reason for option 2; in fact, oral hygiene may make the client feel more comfortable. Review general preoperative care if you had difficulty with this question.

A patient in asystole is likely to receive which drug treatment? A. Epinephrine and atropine B. Lidocaine and amiodarone C. Digoxin and procainamide D. β-adrenergic blockers and dopamine

A. Epinephrine and atropine Normally the patient in asystole cannot be successfully resuscitated. However, administration of epinephrine and atropine may prompt the return of depolarization and ventricular contraction. Lidocaine and amiodarone are used for PVCs. Digoxin and procainamide are used for ventricular rate control. β-adrenergic blockers are used to slow heart rate, and dopamine is used to increase heart rate.

The S1 heart sound corresponds to which of the following physiological events? 1. closure of the AV valves 2. closure of the semilunar valves 3. ejection of blood from the atria 4. the onset of relaxation

Answer: 1 Rationale 1: S1 corresponds to the closure of the AV valves. Rationale 2: Closure of the semilunar valves corresponds to S2. Rationale 3: These valves are not associated w/ ejection of blood from just the atria or relaxation of the muscle. Rationale 4: These valves are not associated w/ ejection of blood from just the atria or relaxation of the muscle

2. The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the postanesthesia care unit (PACU). What should the nurse's initial action be upon the patient's arrival? Assess the patient's pain. Assess the patient's vital signs. Check the rate of the IV infusion. Check the physician's postoperative orders.

Assess the patient's vital signs. The highest priority action by the nurse is to assess the physiologic stability of the patient. This is accomplished in part by taking the patient's vital signs. The other actions can then take place in rapid sequence.

The client begins therapy with lisinopril (Prinivil, Zestril). What should the nurse consider at the start of therapy with this medication? a. The client's ability to understand medication teaching b. The risk for hypotension c. The potential for bradycardia d. Liver function tests (LFTs)

B: Angiotensin-converting enzyme (ACE) inhibitors are associated with first-dose hypotension and orthostatic hypotension, which are more likely in those older than 75 years. Although desirable, understanding of medication teaching is not essential. ACE inhibitors are vasodilators; they do not affect heart rate. Renal function, not liver function, may be altered by ACE inhibitors.

What would be your priority assessment?

Because abdominal pain could be caused by an inflammatory or infectious process, the patient is at risk for septic shock. Therefore it is imperative to assess the patient's vital signs and his GI status.

A 74-yr-old female patient with osteoporosis is diagnosed with gastroesophageal reflux disease (GERD). Which over-the-counter medication to treat GERD should be used with caution? a. Sucralfate b. Cimetidine c. Omeprazole d. Metoclopramide

Correct answer: C There is a potential link between proton pump inhibitors (PPIs) (e.g., omeprazole) use and bone metabolism. Long-term use or high doses of PPIs may increase the risk of fractures of the hip, wrist, and spine

The nurse suspects that a client has developed an acute arterial occlusion of the right lower extremity based on which signs/symptoms? (Select all that apply.) A. Hypertension B. Tachycardia C. Bounding right pedal pulses D. Cold right foot E. Numbness and tingling of right foot F. Mottling of right foot and lower leg

D, E, F Pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia (cool limb), and mottled color are characteristics of acute arterial occlusion.

Which teaching by the nurse will help the client prevent renal osteodystrophy? A. Low-calcium diet B. Avoiding peas, nuts, and legumes C. Drinking cola beverages only once daily D. Avoiding dairy enriched with vitamin D

Kidney failure causes hyperphosphatemia. Client must restrict phosphorus-containing foods such as beans, peas, nuts (peanut butter), and legumes. Kidney failure decreases serum calcium, resulting in demineralization of the bone; do not restrict calcium in the diet. Cola beverages are high in phosphorus and are to be avoided. Dairy products are high in phosphorus, contributing to hypocalcemia and bone breakdown.

1.Unless contraindicated by the surgical procedure, which position is preferred for the unconscious patient immediately postoperative? Supine Lateral Semi-Fowler's High-Fowler's

Lateral

33. A nurse is caring for a patient who fell on the ice and has connective tissue damage in the wrist and hand. What does type of pain does the nurse document that the patient has? • Visceral pain • Somatic pain • Peripherally generated pain • Centrally generated pain

Somatic pain

The nurse determines a patient has experienced the beneficial effects of therapy with famotidine when which symptom is relieved? Nausea Belching Epigastric pain Difficulty swallowing

correct answer c Famotidine is an H2-receptor antagonist that inhibits parietal cell output of HCl acid and minimizes damage to gastric mucosa related to hyperacidity, thus relieving epigastric pain. It is not indicated for nausea, belching, and dysphagia.

The nurse is evaluating the effectiveness of imipramine (Tofranil), a tricyclic antidepressant, for a patient who is receiving the medication to help relieve chronic cancer pain. Which information is the best indicator that the imipramine is effective? a. The patient states, "I feel much less depressed since I've been taking the imipramine." b. The patient sleeps 8 hours every night. c. The patient says that the pain is manageable and that he or she can accomplish desired activities. d. The patient has no symptoms of anxiety.

The patient says that the pain is manageable and that he or she can accomplish desired activities

18. The nurse is evaluating the effectiveness of guided imagery for pain management as used for a patient who has second- and third-degree burns and needs extensive dressing changes. Which statement best describes that guided imagery is effectively controlling the patient's pain during dressing changes? • The patient's need for analgesic medication decreases during the dressing changes. • The patient rates pain during the dressing change as a 6 on a scale of 0 to 10. • The patient's facial expressions are stoic during the procedure. • The patient can tolerate more pain, so dressing changes can be performed more frequently.

The patient's need for analgesic medication decreases during the dressing changes. Correct

15. A nurse is assessing a patient who started to have severe pain 3 days ago. When the nurse asks the patient to describe the pain, the patient states, "The pain feels like it is in my stomach. It is a burning pain, and it spreads out in a circle around the spot where it hurts the most." What type of pain does the nurse document that the patient is having at this time? • Superficial pain • Idiopathic pain • Chronic pain • Visceral pain

Visceral pain Correct

When asked about pain, a client complains of having severe discomfort from arthritis. Vital signs are unchanged, and the client is calmly watching television. Which of the following nursing diagnoses is most appropriate? a. Acute pain b. Altered sensory perception c. Impaired mobility d. Chronic pain

chronic pain

The patient understand that which of the following are factors that he can change to decrease his risk of HTN? Select All That Apply A. smoking B. family history C. Alcohol consumption D. increased LDL E. Sedentary lifestyle

A, C. D, E Pt can change all but his family history

The silent killer, essential HTN, sometimes doesn't have obvious s/s, but some that may be reported by the patient include: Select All That Apply A. Dizziness B. Kidney disease C. Headache D. Syncope (fainting) E. Hot/flushed F. Nose bleed (epistaxis) G. Diabetes

A, C. D, E, F Kidney disease and diabetes are not s/s and are a factor in secondary HTN, not primary

A patient complains of nausea. When administering a dose of metoclopramide (Reglan), the nurse should teach the patient to report which potential adverse effect? A. Tremors B. Constipation C. Double vision D. Numbness in fingers and toes

A. Tremors Extrapyramidal side effects, including tremors and tardive dyskinesias, may occur as a result of metoclopramide (Reglan) administration. Constipation, double vision, and numbness in fingers and toes are not adverse effects of metoclopramide.

When assessing a patient receiving morphine sulfate 2 mg every 10 minutes via PCA pump, the nurse should take action as soon as the patient's respiratory rate drops down to or below which parameter? A. 16 breaths/min B. 14 breaths/min C. 12 breaths/min D. 10 breaths/min

C. 12 breaths/min To protect the patient from adverse effects of respiratory depression from this medication, the nurse should alert the physician as soon as the respiratory rate drops down to or below 12 breaths/min.

A patient with a history of chronic cancer pain is admitted to the hospital. When reviewing the patient's home medications, which of these will be of most concern to the admitting nurse? a. Oxycodone (OxyContin) 80 mg twice daily b. Ibuprofen (Advil) 800 mg three times daily c. Amitriptyline (Elavil) 50 mg at bedtime d. Meperidine (Demerol) 25 mg every 4 hours

Meperidine. Response Feedback: Rationale: Meperidine is contraindicated for chronic pain because it forms a metabolite that is neurotoxic and can cause seizures when used for prolonged periods. The ibuprofen, amitriptyline, and oxycodone are all appropriate medications for long-term pain management

To obtain the most complete assessment data about a patient's chronic pain pattern, the nurse asks the patient a. "Can you describe where your pain is the worst?" b. "What is the intensity of your pain on a scale of 0 to 10?" c. "Would you describe your pain as aching, throbbing, or sharp?" d. "Can you describe your daily activities in relation to your pain?"

can you describe your daily activities in relation to your pain? Response Feedback: Rationale: The assessment of chronic pain should focus on the impact of the pain on patient function and daily activities. The other questions are also appropriate to ask, but will not give as complete information.

A patient with extensive second-degree burns on the legs and trunk is using patient-controlled analgesia (PCA) with IV morphine to be delivered at 1 mg every 10 minutes to control the pain. Several times during the night, the patient awakens in severe pain, and it takes more than an hour to regain pain relief. The most appropriate action by the nurse is to a. request that the health care provider order a bolus dose of morphine to be given when the patient awakens with pain. b. consult with the patient's health care provider about adding a continuous morphine infusion to the PCA regimen at night. c. teach the patient to push the button every 10 minutes for an hour before going to sleep even if the pain is minimal. d. administer a dose of morphine every 1 to 2 hours from the PCA machine while the patient is sleeping.

consult with there patient's health care provider about adding a continuous morphine infusion to the PCA regimen at night. Response Feedback: Rationale: Adding a continuous dose of the morphine at night will allow the patient to sleep without being awakened by the pain. Administering a dose of morphine when the patient awakens would not address the problem. Teaching the patient to administer unneeded medication before going to sleep might result in oversedation and respiratory depression. It is inappropriate for the nurse to administer the morphine while the patient sleeps because the nurse could not assess the pain level.

A patient is receiving morphine sulfate intravenously (IV) for right flank pain associated with a kidney stone in the right ureter. The patient also complains of right inner thigh pain and asks the nurse whether something is wrong with the right leg. In responding to the question, the nurse understands that the patient a. is experiencing referred pain from the kidney stone. b. has neuropathic pain from nerve damage caused by inflammation. c. has acute pain that may be progressing into chronic pain. d. is experiencing pain perception that has been affected by the morphine received earlier.

experiencing referred pain from the kidney stone

A patient with chronic cancer pain experiences breakthrough pain (level 9 of 10) and anxiety while receiving sustained-release morphine sulfate (MS Contin) 160 mg every 12 hours. All these medications are ordered for the patient. Which one will be most appropriate for the nurse to administer first? a. Ibuprofen (Motrin) 400-800 mg orally b. Immediate-release morphine 30 mg orally c. Amitriptyline (Elavil) 10 mg orally. d. Lorazepam (Ativan) 1 mg orally

immediate release morphine 30 mg orally

A patient with chronic abdominal pain has learned to control the pain with the use of imagery and hypnosis. A family member asks the nurse how these techniques work. The nurse's reply will be based on the information that these strategies. a. impact the cognitive and affective components of pain. b. prevent transmission of nociceptive stimuli to the cortex. c. increase the modulating effect of the efferent pathways. d. slow the release of transmitter chemicals in the dorsal horn.

impact the cognitive and affective components of pain

Patient-controlled analgesia (PCA) effectiveness is evaluated by: a. The number of minutes on the lockout interval b. How large a loading dose is required to relieve pain c. The client's indicating that pain is a 1 on a scale of 1 to 10 d. When the client is sleeping

the clients indicating that the pain is a 1 on a scale of 1 to 10

What questions would you ask L.C?

• What medical problems do you currently have or have recently had? • Are you taking any medications, including over-the-counter medications? • Can you describe your pain? What makes it worse? What makes it better? How long ago did it start? Is it always present? Does it radiate anywhere? Can you rate it on a scale of 1 to 10? • Have you been exposed to any toxic chemicals? • Have you recently traveled outside of the United States? • Do you smoke? • Do you drink alcohol? • What do you weigh? How tall are you? Have you lost weight recently? • How is your appetite? Do you have any food allergies? • Have you had any changes in your stools? • Have you noticed any blood in your stool?

While waiting to perform x-rays on an injured right hand according to non-pharmacological pain management practice, pain can be modulated or reduced if the nurse: a. Performs frequent pain assessment b. Administers a placebo c. Applies ice to the right elbow d. Turns off the light and shuts the door

applies ice to the right elbow

Severe cancer pain is most effectively treated with analgesics given: a. Around the clock, with extra doses available as needed b. Around the clock, in titrated doses c. As needed by the client d. Sparingly, to avoid side effects

around the clock, with an extra dose available as needed

15. A patient who is nauseated and vomiting up blood-streaked fluid is admitted to the hospital with acute gastritis. To determine possible risk factors for gastritis, the nurse will ask the patient about a. the amount of fat in the diet. b. history of recent weight gain or loss. c. any family history of gastric problems. d. use of nonsteroidal anti-inflammatory drugs (NSAIDs).

ANS: D Use of an NSAID is associated with damage to the gastric mucosa, which can result in acute gastritis. Family history, recent weight gain or loss, and fatty foods are not risk factors for acute gastritis.

What are the possible causes for L.C.'s acute abdominal pain?

Abdominal compartment syndrome, acute pancreatitis, appendicitis, bowel obstruction, cholecystitis, diverticulitis, gastroenteritis, perforated gastric or duodenal ulcer, peritonitis, ruptured abdominal aneurysm

All the following medications are included in the admission orders for an 86-year-old patient with moderate degenerative arthritis in both hips. Which medication will the nurse use as an initial therapy? a. Aspirin (Bayer) 650 mg orally b. Oxycodone (Roxicodone) 5 mg orally c. Acetaminophen (Tylenol) 650 mg orally d. Naproxen (Aleve) 200 mg orally

Acetaminophen

4.In planning postoperative interventions to promote repositioning, ambulation, coughing, and deep breathing, which action should the nurse recognize will best enable the patient to achieve the desired outcomes? Administering adequate analgesics to promote relief or control of pain Asking the patient to demonstrate the postoperative exercises every 1 hour Giving the patient positive feedback when the activities are performed correctly Warning the patient about possible complications if the activities are not performed

Administering adequate analgesics to promote relief or control of pain

A home health patient has a prescription for pentazocine (Talwin,) a mixed opioid agonist-antagonist. When teaching the patient and family about adverse effects, the nurse will plan to focus on how to monitor for a. agitation. b. respiratory depression. c. hypotension. d. physical dependence.

agitation

Which action should the nurse take when preparing patient-controlled analgesia for a postoperative patient? a. Caution the patient to limit the number of times he presses the dosing button. b. Ask another nurse to double-check the setup before patient use. c. Instruct the patient to administer a dose only when experiencing pain. d. Provide clear, simple instructions for dosing if the patient is cognitively impaired.

Ask another nurse to double-check the setup before patient use

Which of these nursing actions should the nurse delegate to a nursing assistant working on the medical unit? a. Determine the usual alcohol intake for a client with cardiomyopathy. b. Monitor the pain level for a client with acute pericarditis. c. Obtain daily weights for several clients with class IV heart failure. d. Check for peripheral edema in a client with endocarditis.

C: Daily weight assessment is included in the role of the nursing assistant, who will report the weights to the RN. The role of the professional nurse is to perform assessments; do not delegate this activity.

Colon cancer is most closely associated with which of the following conditions? A. Appendicitis B. Hemorrhoids C. Hiatal hernia D. Ulcerative colitis

D. Chronic ulcerative colitis, granulomas, and familial polposis seem to increase a person's chance of developing colon cancer. The other conditions listed have no known effect on colon cancer risk.

13. A patient arrives at the emergency department experiencing a headache and rates the pain as 7 on a 0 to 10 pain scale. What nonpharmacological intervention does the nurse implement for this patient while awaiting orders for pain medication from the health care provider? • Frequently reassesses the patient's pain scores • Reassures the patient that the provider will come to the emergency department soon • Softly plays music that the patient finds relaxing • Teaches the patient how to do yoga

Softly plays music that the patient finds relaxing

What makes a person most susceptible to infective endocarditis?

Untreated group A Streptococcus

Which dysrhythmia will definitely result in death without cardiopulmonary resuscitation (CPR)?

Ventricular fibrillation

Varicose veins can cause changes in what component of Virchow's triad? a. Blood coagulability b. Vessel walls c. Blood flow d. Blood viscosity

c. Blood flow

9. Which of the following statements made by the patient indicates to the nurse that teaching on a patient-controlled analgesia (PCA) device has been effective? • "This is the only pain medication I will need to be on." • "I can administer the pain medication as frequently as I need to" • "I feel less anxiety about the possibility of overdosing." • "I will need the nurse to notify me when it is time for another dose."

"I feel less anxiety about the possibility of overdosing."

24. A nurse is supervising a student who is caring for a patient with chronic pain. Which statement by the student indicates an understanding of pain management? • "This patient says her pain is a 5, but she is not acting like it. I am not going to give her any pain medication." • "The patient is sleeping, so I pushed her PCA button for her." • "I need to reassess the patient's pain 1 hour after administering oral pain medication." • "It wasn't time for the patient's medication, so when she requested it, I gave her a placebo."

"I need to reassess the patient's pain 1 hour after administering oral pain medication." Correct

4.The nurse is providing discharge teaching to a 51-year-old female patient who has had a laparoscopic cholecystectomy at an ambulatory surgery center. Which statement, if made by the patient, indicates an understanding of the discharge instructions? "I will have someone stay with me for 24 hours in case I feel dizzy." "I should wait for the pain to be severe before taking the medication." "Because I did not have general anesthesia, I will be able to drive home." "It is expected after this surgery to have a temperature up to 102.4o F."

"I will have someone stay with me for 24 hours in case I feel dizzy." The nurse must assess understanding of discharge instructions and the ability of the patient and caregiver to provide for home care needs. The patient must be accompanied by a responsible adult caregiver. The patient may not drive after receiving anesthetics or sedatives. The patient should understand how to manage pain, and pain medication should be taken before the pain becomes severe. The patient should understand symptoms to be reported, such as a fever.

19. A nurse is providing medication education to a patient who just started taking ibuprofen, a nonselective nonsteroidal anti-inflammatory drug (NSAID). Which statement made by the nurse best indicates how ibuprofen works? • "Ibuprofen helps to remove factors that cause or stimulate pain." • "Ibuprofen reduces anxiety, which will help you better cope with your pain." • "Ibuprofen helps to decrease the production of prostaglandins." • "Ibuprofen binds with opiate receptors to reduce your pain."

"Ibuprofen helps to decrease the production of prostaglandins."

3. Which of the following statements made by a patient reflects that the patient understands the relationship between the gate control theory of pain and the use of meditation to relieve pain? • "Meditation controls pain by blocking pain impulses from coming through the gate." • "Meditation will help me sleep through the pain because it opens the gate." • "Meditation stops the occurrence of pain stimuli." • "Meditation alters the chemical composition of pain neuroregulators, which closes the gate."

"Meditation controls pain by blocking pain impulses from coming through the gate."

23. Which statement made by a nursing educator best explains why it is important for nurses to determine a patient's medical history and recent drug use? • "Health care providers have a responsibility to prevent drug seekers from gaining access to drugs." • "This information is useful in determining what type of pain interventions will most likely be effective in providing pain relief." • "Some recreational drugs have pharmaceutical counterparts that may be more effective in managing pain." • "Getting this information gives the nurse an opportunity to provide patient teaching about drug abstinence."

"This information is useful in determining what type of pain interventions will most likely be effective in providing pain relief." Correct

10. A nurse is caring for a patient who is experiencing pain following abdominal surgery. What information is important for the nurse to tell the patient when providing patient education about effective pain management? • "To prevent overdose, you need to wait to ask for pain medication until you begin to experience pain." • "You should take your medication after you walk to make sure you do not fall while you are walking." • "We should work together to create a regular schedule of medications that does not allow for breakthrough pain." • "You need to take oral pain medications when you experience severe pain."

"We should work together to create a regular schedule of medications that does not allow for breakthrough pain." Correct

2. A nurse is caring for a patient who recently had an abdominal hysterectomy and states that she is experiencing severe pain. The patient's blood pressure is 110/60, and her heart rate is 60. Additionally, the patient does not appear to be in any distress. Which response by the nurse is most therapeutic? • "Your vitals do not show that you are having pain; can you describe your pain?" • "You do not look like you are in pain." • "OK, I will go get you some narcotic pain relievers immediately." • "What would you like to try to alleviate your pain?"

"What would you like to try to alleviate your pain?"

20. A nurse has brought the patient his scheduled pain medication. The patient asks the nurse to wait to give pain medication until the time for the dressing change, which is 2 hours away. Which response by the nurse is most therapeutic? • "This medication will still be providing you relief at the time of your dressing change." • "OK, swallow this pain pill, and I will return in a minute to fill your wound." • "Would you like medication to be given for dressing changes on top of your regularly scheduled medication?" • "Your medication is scheduled for this time, and I can't adjust the time for you. I'm sorry, but you must take your pill right now."

"Would you like medication to be given for dressing changes on top of your regularly scheduled medication?"

14. A patient who has had type 2 diabetes for 26 years is beginning to experience peripheral neuropathy in the feet and lower legs, which is causing the patient to have a decreased ability to feel pain in the lower extremities. The nurse is providing education to the patient to prevent injury to the feet. The nurse tells the patient to always wear shoes or slippers when walking. Which of the following statements made by the nurse best explains the rationale for this instruction? • "Wearing shoes blocks pain perception and helps you adapt to pain, which ends up protecting your feet." • "Shoes provide nonpharmacological pain relief to people with diabetes and peripheral neuropathy." • "Since you cannot feel pain as much in your feet, you need to open your neurological gates to allow pain sensations to come through. Wearing shoes helps to open those gates, which protects your feet." • "You have lost the ability to withdraw from pain because of your peripheral neuropathy. If you step on something and are not wearing shoes, you will not feel it; this could possibly cause injury to your foot."

"You have lost the ability to withdraw from pain because of your peripheral neuropathy. If you step on something and are not wearing shoes, you will not feel it; this could possibly cause injury to your foot."

12. A nurse is providing discharge teaching for a patient with a fractured humerus. The patient is going home with Vicodin (5/325). What important patient education does the nurse provide? • "Be sure to eat a meal high in fat before taking the medication, to avoid a stomach ulcer." • "Narcotics can be addictive, so do not take them unless you are in severe pain." • "You need to drink plenty of fluids and eat a diet high in fiber." • "As your pain severity lessens, you will begin to give yourself once-daily intramuscular injections."

"You need to drink plenty of fluids and eat a diet high in fiber."

What is true about HF in America?

*Cardiac dysrhythmias can contribute to HF. *Approximately 1 in 100 people will develop HF. *African Americans have a higher incidence of HF.

a nurse is planning care for a client who has postrenal acute kidney injury due to metastatic cancer. The client has serum creatinine of 5mg/dL. which of the following are appropriate actions by the nurse? select all the apply 1. provide a high protein die 2. assess the urine for blood 3. monitor for intermittent anuria 4. administer diuretic medication 5. provide NSAIDS for pain

1, 2, 3, the nurse should provide the client with a high protein diet because of a high rate of protein breakdown that occurs with acute kidney injury. The nurse should assess the client's urine for blood, stones, and praticles indicating an abstruction of the urinary structues that leave the kidney. the nurse should assess the clietn for intermittent anuria because of possible bilateral destruction of the remaining nephrons on the kidney.

A client with diverticulitis has developed peritonitis following diverticular rupture. The nurse should assess the client to determine which of the following? Select all that apply. 1. Percuss the abdomen to note resonance and tympany. 2. Percuss the liver to note lack of dullness. 3. Monitor the vital signs for fever, tachypnea, and bradycardia. 4. Assess presence of polyphagia and polydipsia. 5. Auscultate bowel sounds to note frequency

1, 2, 5. Assessment during peritonitis will reveal fever, tachypnea, and tachycardia. The abdomen becomes rigid with rebound tenderness and there will be absent bowel sounds. Percussion will show resonance and tympany indicating paralytic ileus; loss of liver dullness may indicate free air in the abdomen. There is anorexia, nausea, and vomiting as peristalsis decreases.

The nurse is aware that the diagnostic tests typically ordered for acute diverticulitis do not include a barium enema. The reason for this is that a barium enema: 1. Can perforate an intestinal abscess. 2. Would greatly increase the client's pain. 3. Is of minimal diagnostic value in diverticulitis. 4. Is too lengthy a procedure for the client to tolerate

1. Barium enemas and colonoscopies are contraindicated in clients with acute diverticulitis because they can lead to perforation of the colon and peritonitis. A barium enema may be ordered after the client has been treated with antibiotic therapy and the inflammation has subsided. A barium enema is diagnostic in diverticulitis. A barium enema could increase the client's pain; however, that is not a reason for excluding this test. The client may be able to tolerate the procedure but the concern is the potential for perforation of the intestine.

A client with diverticular disease is receiving psyllium hydrophilic mucilloid (Metamucil). The drug has been effective when the client tells the nurse that he: 1. Passes stool without cramping. 2. Does not have diarrhea any longer. 3. Is not as anxious as he was. 4. Does not expel gas like he used to.

1. Diverticular disease is treated with a high-fiber diet and bulk laxatives such as psyllium hydrophilic mucilloid (Metamucil). Fiber decreases the intraluminal pressure and makes it easier for stool to pass through the colon. Bulk laxatives do not manage diarrhea, anxiety or relieve gas formation

A nurse receives a telephone call from the postanesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to do which of the following first on arrival of the client? 1. Assess the patency of the airway? 2. Check tubes or trains for patency. 3. Check the dressing to assess for bleeding. 4. Assess the vital signs to compare with preoperative measurements.

1. Assess the patency of the airway? Rationale: The first action of the nurse is to assess the patency of the airway and respiratory function. If the airway is not patent, the nurse must take immediate measures for the survival of the client. The nurse then takes vital signs followed by checking the dressing and the tubes or drains. The other nursing actions should be performed after a patent airway has been established. Test-Taking Strategy: Note the strategic word first. Use the principles of prioritization when answering this question. Use the ABCs—airway , breathing , and circulation . Ensuring airway patency is the first action to be taken, directing you to the correct option. Review the initial care of the post-operative client if you had difficulty with this question.

A nurse is preparing a preoperative client for transfer to the operating room. The nurse should take which action in the care of this client at this time? 1. Ensure the client has voided. 2. Administer all the daily medication. 3. Practice postoperative breathing exercises. 4. Verify that the client has not eaten for the last 24 hours.

1. Ensure the client has voided. The nurse should ensure that the client has voided if a Foley catheter is not in place. The nurse does not administer all daily medication just before sending a client to the operating room. Rather, the physician writes a specific order outlining which medications may be given with a sip of water. The time of transfer to the operating room is nnot the time to practice breathing exercises. This should have been doned earlier. The client has nothing by mouth for 6 to 8 hours before surgery, not 24 hours. Test-Taking Strategy: Note that the question contains the strategic words "at this time". This tells you that you must prioritize your answer according to a time line. With this in mind, eliminate options 2 and 4 first because they are incorrect. Choos correctly between the remaining options by knowing that the client must empty his or her bladder or by knowing that the client is likely to be anxious at this time, making it inappropriate to practice breathing exercises. Revie preoperative nursing intervetiions if you had difficulty with this question.

The client has an eviscerated abdominal wound. Which intervention should the nurse implement? 1. Apply sterile normal saline dressing. 2. Use sterile gloves to replace protruding parts. 3. Place the client in reverse Trendelenburg position. 4. Administer intravenous antibiotic STAT

1. Evisceration is a life-threatening condition in which the abdominal contents protrude through the ruptured incision. The nurse must protect the bowel from the environment by placing a sterile normal saline gauze on it, which prevents the intestines from drying out and necrosing. (2. the nurse should not attempt to replace the protruding bowel.) (3. this position places the client with the head of bed elevated, which will make the situation worse.) (4. Antibiotics will not protect the protruding bowels, which must be priority. Antibiotics will be administed at a later time to prevention infection, but this is not urgent. MedSurg Success pg 269

A nurse is monitoring the status of a postoperative client. The nurse would become most concerned with which of the following signs that could indicate an evolving complication? 1. Increasing restlessness 2. A negative Homans' sign 3. Hypoactive bowel sounds in all four quadrants 4. Blood pressure of 110/70 mm Hg and a pulse of 86 beats/min

1. Increasing restlessness Rationale: Increasing restlessness is a sign that requires continuous and close monitoring because it could indicate a potential complication, such as hemorrhage, shock, or pulmonary embolism. A blood pressure of 110/70 mm Hg with a pulse of 86 beats/minute is within normal limits. Hypoactive bowel sounds heard in all four quadrants are a normal occurrence, as is a negative Homans' sign (A positive Homans' sign may indicate thrombophlebitis). Test-Taking Strategy: Use the process of elimination and note the strategic word, "most". Focus on the subject , "a manifestation of an evolving complication". Eliminate each of the incorrect options because they are comparable or alike and are normal expected findings. If you had difficulty with this question, review the normal expected postoperative findings and the signs and symptoms of postoperative complications.

A postoperative client asks a nurse why it is so important to deep-breathe and cough after surgery. In formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative can lead to: 1. Pneumonia 2. Fluid imbalance 3. Pulmonary edema 4. Carbon dioxide retention

1. Pneumonia Rationale: Postoperative respiratory problems are atelectasis, pneumonia, and pulmonary emboli. Pneumonia is the inflammation of lung tissue that causes productive cough, dyspnea, and lung crackles and can be caused by retained pulmonary secretions. Fluid imbalance can be a deficit or excess related to fluid loss or overload. Pulmonary edema usually results from failure of the left side of the heart and can be caused by medications or fluid overload. Carbon dioxide retention results from an inability to exhale carbon dioxide in conditions such as chronic obstructive pulmonary disease. Test-Taking Strategy: Focus on the relationship between the words "deep-breathe and cough" in the question and "pneumonia" is the correct option. Review the common postoperative complications if you had difficulty with this question.

A nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which of the following parameters most carefully during the next hour? 1. Urinary output of 20 mL/hr 2. Temperature of 37.6 C (99.6 F) 3. Blood pressure of 100/70 mm Hg 4. Serous drainage on the surgical drainage

1. Urinary output of 20 mL/hr Rationale: Urine output should be maintained at a minimum of 30 mL/hour for an adult. An output of less than 30 mL for each of 2 consecutive hours should be reported to the health care provider. A temperature higher than 37.7° C (100° F) or lower than 36.1° C (97° F) and a falling systolic blood pressure, lower than 90 mm Hg, are usually considered reportable immediately. The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal. Test-Taking Strategy: To answer this question correctly, you must know the normal ranges for temperature, blood pressure, urinary output, and wound drainage. Through the process of elimination, you then can determine that the urinary output is the only observation that is not within the normal range. Review these basic postoperative assessment findings if you had difficulty with this question.

A patient diagnosed with Crohn's disease has a new colostomy. When assessing the patient's stoma, which of these will alert the healthcare provider that the stoma has retracted? 1. Concave and bowl-shaped 2. Narrowed and flattened 3. Pinkish-red and moist 4. Dry and reddish-purple

1. concave and bowel-shaped

Postoperative nursing care for a client after an appendectomy should include which of the following? 1. Administering sitz baths four times a day. 2. Noting the first bowel movement after surgery. 3. Limiting the client's activity to bathroom privileges. 4. Measuring abdominal girth every 2 hours.

2. Noting the client's first bowel movement after surgery is important because this indicates that normal peristalsis has returned. Sitz baths are used after rectal surgery, not appendectomy. Ambulation is started the day of surgery and is not confined to bathroom privileges. The abdomen should be auscultated for bowel sounds and palpated for softness, but there is no need to measure the girth every 2 hours.

A patient diagnosed with ulcerative colitis is prescribed the aminosalicylate sulfasalazine. When teaching the patient about this medication, which of the following statements is a priority for the healthcare provider include? 1. "Be sure to limit your intake of fluids during therapy." 2. "Avoid exposure to sunlight while taking this medication." 3. "Call our office immediately if your urine turns an orangish color." 4. "You may crush the enteric-coated tablet and mix it with applesauce."

2. "Avoid exposure to sunlight while taking this medication"

10. The nurse in charge is evaluating the infection control procedures on the unit. Which finding indicates a break in technique and the need for education of staff? a. The nurse aide is not wearing gloves when feeding an elderly client. b. A client with active tuberculosis is asked to wear a mask when he leaves his room to go to another department for testing. c. A nurse with open, weeping lesions of the hands puts on gloves before giving direct client care. d. The nurse puts on a mask, a gown, and gloves before entering the room of a client on strict isolation.

10. Answer C. There is no need to wear gloves when feeding a client. However, universal precautions (treating all blood and body fluids as if they are infectious) should be observed in all situations. A client with active tuberculosis should be on respiratory precautions. Having the client wear a mask when leaving his private room is appropriate. Persons with exudative lesions or weeping dermatitis should not give direct client care or handle client-care equipment until the condition resolves. Strict isolation requires the use of mask, gown, and gloves.

11. The charge nurse observes a new staff nurse who is changing a dressing on a surgical wound. After carefully washing her hands the nurse dons sterile gloves to remove the old dressing. After removing the dirty dressing, the nurse removes the gloves and dons a new pair of sterile gloves in preparation for cleaning and redressing the wound. The most appropriate action for the charge nurse is to: a. interrupt the procedure to inform the staff nurse that sterile gloves are not needed to remove the old dressing. b. congratulate the nurse on the use of good technique. c. discuss dressing change technique with the nurse at a later date. d. interrupt the procedure to inform the nurse of the need to wash her hands after removal of the dirty dressing and gloves.

11. Answer D. Nonsterile gloves are adequate to remove the old dressing. However, the use of sterile gloves does not put the client in danger so discussion of this can wait until later. The staff nurse is doing two things incorrectly. Nonsterile gloves are adequate to remove the old dressing. The nurse should wash her hands after removing the soiled dressing and before donning sterile gloves to clean and dress the wound. The nurse should wash her hands after removing the soiled dressing and before donning the sterile gloves to clean and dress the wound. Not doing this compromises client safety and should be brought to the immediate attention of the nurse. The staff nurse is doing two things incorrectly. Nonsterile gloves are adequate to remove the old dressing. However, the use of sterile gloves does not put the client in danger so discussion of this can wait until later. However, the nurse should wash her hands after removing the soiled dressing and before donning sterile gloves to clean and dress the wound. Not doing this compromises client safety and should be brought to the immediate attention of the nurse.

12. Nurse Jane is visiting a client at home and is assessing him for risk of a fall. The most important factor to consider in this assessment is: a. Correct illumination of the environment. b. amount of regular exercise. c. the resting pulse rate. d. status of salt intake.

12. Answer A. To prevent falls, the environment should be well lighted. Night lights should be used if necessary. Other factors to assess include removing loose scatter rugs, removing spills, and installing handrails and grab bars as appropriate. The amount of regular exercise is not the most important factor to assess. It is only indirectly related. The resting pulse rate is not related to preventing falls. The salt intake is not directly related to preventing falls.

13. Mrs. Jones will have to change the dressing on her injured right leg twice a day. The dressing will be a sterile dressing, using 4 X 4s, normal saline irrigant, and abdominal pads. Which statement best indicates that Mrs. Jones understands the importance of maintaining asepsis? a. "If I drop the 4 X 4s on the floor, I can use them as long as they are not soiled." b. "If I drop the 4 X 4s on the floor, I can use them if I rinse them with sterile normal saline." c. "If I question the sterility of any dressing material, I should not use it." d. "I should put on my sterile gloves, then open the bottle of saline to soak the 4 X 4s."

13. Answer C. Anything dropped on the floor is no longer sterile and should not be used. The statement indicates lack of understanding. Anything dropped on the floor is no longer sterile and should not be used. The statement indicates lack of understanding. If there is ever any doubt about the sterility of an instrument or dressing, it should not be used. The 4 X 4s should be soaked prior to donning the sterile gloves. Once the sterile gloves touch the bottle of normal saline they are no longer sterile. This statement indicates a need for further instruction.

14. A client has been placed in blood and body fluid isolation. The nurse is instructing auxiliary personnel in the correct procedures. Which statement by the nursing assistant indicates the best understanding of the correct protocol for blood and body fluid isolation? a. Masks should be worn with all client contact. b. Gloves should be worn for contact with nonintact skin, mucous membranes, or soiled items. c. Isolation gowns are not needed. d. A private room is always indicated.

14. Answer B. Masks should only be worn during procedures that are likely to cause splashes of blood or body fluid. Gloves should be worn for all contact with blood and body fluids, nonintact skin and mucous membranes; for handling soiled items; and for performing venipuncture. Gowns should be worn during procedures that are likely to cause splashes of blood or body fluids. A private room is only indicated if the client's hygiene is poor.

15. A client has been placed in blood and body fluid isolation. The nurse is instructing auxiliary personnel in the correct procedures. Which statement by the nursing assistant indicates the best understanding of the correct protocol for blood and body fluid isolation? a. Masks should be worn with all client contact. b. Gloves should be worn for contact with nonintact skin, mucous membranes, or soiled items. c. Isolation gowns are not needed. d. A private room is always indicated.

15. Answer B. Masks should only be worn during procedures that are likely to cause splashes of blood or body fluid. Gloves should be worn for all contact with blood and body fluids, nonintact skin and mucous membranes; for handling soiled items; and for performing venipuncture. Gowns should be worn during procedures that are likely to cause splashes of blood or body fluids. A private room is only indicated if the client's hygiene is poor.

16. The nurse is evaluating whether nonprofessional staff understand how to prevent transmission of HIV. Which of the following behaviors indicates correct application of universal precautions? a. A lab technician rests his hand on the desk to steady it while recapping the needle after drawing blood. b. An aide wears gloves to feed a helpless client. c. An assistant puts on a mask and protective eye wear before assisting the nurse to suction a tracheostomy. d. A pregnant worker refuses to care for a client known to have AIDS.

16. Answer C. Needles that have been used to draw blood should not be recapped. If it is necessary to recap them, an instrument such as a hemostat should be used to recap. The hand should never be used. Gloves are not necessary when feeding, since there is no contact with mucus membranes. Although saliva may have small amounts of HIV in it, the virus does not invade through unbroken skin. There is no evidence in the question to indicate broken skin. Masks and protective eye wear are indicated anytime there is great potential for splashing of body fluids that may be contaminated with blood. Suctioning of a tracheostomy almost always stimulates coughing, which is likely to generate droplets that may splash the health care worker. Clients who are suctioned frequently or have had an invasive procedure like a tracheostomy are likely to have blood in the sputum. There is no reason to restrict pregnant workers from caring for persons with AIDS as long as they utilize universal precautions.

17. Jayson, 1 year old child has a staph skin infection. Her brother has also developed the same infection. Which behavior by the children is most likely to have caused the transmission of the organism? a. Bathing together. b. Coughing on each other. c. Sharing pacifiers. d. Eating off the same plate.

17. Answer A. Direct contact is the mode of transmission for staphylococcus. Staph is not spread by coughing. Staph is not spread through oral secretions. Direct contact is required. Staph is not spread through oral secretions.

18. Jessie, a young man with newly diagnosed acquired immune deficiency syndrome (AIDS) is being discharged from the hospital. The nurse knows that teaching regarding prevention of AIDS transmission has been effective when the client: a. verbalizes the role of sexual activity in spread of the disorder. b. states he will make arrangements to drop his college classes. c. acknowledges the need to avoid all contact sports. d. says he will avoid close contact with his three-year-old niece.

18. Answer A. The AIDS virus is spread through direct contact with body fluids such as blood and through sexual intercourse. Casual contact with other people does not pose a risk of transmission of AIDS. Unless the client is feeling very ill, there is no need for him to drop his college classes. Contact sports are not contraindicated unless there is a significant chance of bleeding and direct contact with others. Casual contact with other people does not pose a risk of transmission of AIDS. There is no need to limit casual contact with children.

A client who had an appendectomy for a perforated appendix returns from surgery with a drain inserted in the incisional site. The purpose of the drain is to: 1. Provide access for wound irrigation. 2. Promote drainage of wound exudates. 3. Minimize development of scar tissue. 4. Decrease postoperative discomfort.

2. Drains are inserted postoperatively in appendectomies when an abscess was present or the appendix was perforated. The purpose is to promote drainage of exudate from the wound and facilitate healing. A drain is not used for irrigation of the wound. The drain will not minimize scar tissue development or decrease postoperative discomfort.

Client is one day post op major abdominal surgery. Which problem is priority? 1. Impaired skin integrity 2. Fluid and Electrolyte imbalance 3. Altered bowel elimination 4. Altered body image

2. After abdominal surgery, the body distributes fluids to the affected area as part of the healing process. These fluids are shifted from the intravascular compartment to the interstitial space, which causes potential fluid & electrolyte imbalance. (1 the client has a surgical incision, which impairs the skin integrity, but it is not the priority bc it is sutured undered sterile conditions.) (3. Bowel elimination is a problem, but after general anesthesia wears off, the bowel sounds will return and this is not a life threatening problem.) (4. Psychosocial problems are not priority over actual physiological problems.) from MedSurg Success pg 269

A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which of the following laboratory results should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed? 1. Sodium, 141 mEq/L 2. Hemoglobin, 8.0 g/dL 3. Platelets, 210,000/mm3 4. Serum creatinine, 0.8 mg/dL

2. Hemoglobin, 8.0 g/dL Rationale: Routine screening tests include a complete blood count, serum electrolyte analysis, coagulation studies, and a serum creatinine test. The complete blood count includes the hemoglobin analysis. All these values are within normal range except for hemoglobin. If a client has a low hemoglobin level, the surgery likely could be postponed by the surgeon. Test-Taking Strategy: Focus on the subject , an abnormal laboratory result that needs to be reported. Use knowledge of the normal laboratory values to assist in answering correctly. The hemoglobin value is the only incorrect laboratory finding. Review these laboratory values if you had difficulty answering this question.

A nurse is reviewing a physician's order sheet for a preoperative client that states that the client must be NPO after midnight. The nurse would telephone the physician to clarify whether which of the following medications should be given to the client and not withheld? 1. Ferrous sulfate 2. Prednisone (Deltasone) 3. Cycloenzaprine (Flexeril) 4. Conjugated estrogen (Premarin)

2. Prednisone (Deltasone) Rationale: Prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which reduces the ability of the body to withstand stress. When stress is severe, corticosteroids are essential to life. Before and during surgery, dosages may be increased temporarily. Ferrous sulfate is an oral iron preparation used to treat iron deficiency anemia. Cyclobenzaprine (Flexeril) is a skeletal muscle relaxant. Conjugated estrogen (Premarin) is an estrogen used for hormone replacement therapy in postmenopausal women. These last three medications may be withheld before surgery without undue effects on the client. Test-Taking Strategy: Use the process of elimination and knowledge about medications that may have special implications for the surgical client. Focus on the subject, the medication that should be administered in the preoperative period. Remember that when stress is severe, corticosteroids are essential to life. Review the effects of corticosteroids if you had difficulty with this question.

A nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? 1. Red, hard skin 2. Serous drainage 3. Purulent drainage 4. Warm, tender skin

2. Serous drainage Rationale: Serous drainage is an expected finding at a surgical site. The other options indicate signs of wound infection. Signs and symptoms of infection include warm, red, and tender skin around the incision. Wound infection usually appears 3 to 6 days after surgery. The client also may have a fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a contaminated wound before surgical exploration; existing client conditions such as diabetes mellitus or immunocompromise may place the client at risk. Test-taking strategy: Use the process of elimination, noting the strategy words normal finding. Recalling the signs of a wound infection and noting these strategy words will direct you to option 2. Review the signs of a wound infection if you had difficulty with this question.

A patient diagnosed with inflammatory bowel disease experiences an obstruction in the small bowel. When assessing the patient, which of the following will the healthcare provider anticipate? 1. Scaphoid abdomen 2. Hypovolemia 3. Increased flatus 4. Passage of melena

2. hypovolemia

A client with abdominal surgery tells the nurse, "I felt something give way in my stomach." Which intervention should the nurse implement first? 1. Notify the surgeon immediately. 2. Instruct the client to splint the incision. 3. Assess the abdominal wound incision. 4. Administer pain medication intravenously.

3. Assessing the surgical incision is the first intervention because this may indicate the wound has dehiscence. (1. the nurse may notify the surgeon, but this is not the first intervention) (2. the nurse should instruct the client to splint the incision when coughing, then take further action) (4. the nurse should never admin pain meds without assessing for potential complications) MedSurg Success pg 268

20. Mrs. Parker, a 70-year-old woman with severe macular degeneration, is admitted to the hospital the day before scheduled surgery. The nurse's preoperative goals for Mrs. M. would include: a. independently ambulating around the unit. b. reading the routine preoperative education materials. c. maneuvering safely after orientation to the room. d. using a bedpan for elimination needs.

20. Answer C. Independently ambulating around the unit is not appropriate because the unit environment can change and injury could result. Assistance is necessary because of the client's visual deficit. It is unlikely the client can see well enough to read the materials. Maneuvering safely after orientation to the room is a realistic goal for a person with impaired vision. Orienting the client to the room should help the client to move safely. Using the bedpan is an unnecessary restriction on the client as she can be oriented to the bathroom or to call for assistance.

Which of the following laboratory findings would the nurse expect to find in a client with diverticulitis? 1. Elevated red blood cell count. 2. Decreased platelet count. 3. Elevated white blood cell count. 4. Elevated serum blood urea nitrogen concentration.

3. Because of the inflammatory nature of diverticulitis, the nurse would anticipate an elevated white blood cell count. The remaining laboratory findings are not associated with diverticulitis. Elevated red blood cell counts occur in clients with polycythemia vera or fluid volume deficit. Decreased platelet counts can occur as a result of aplastic anemias or malignant blood disorders, as an adverse effect of some drugs, and as a result of some heritable conditions. Elevated serum blood urea nitrogen concentration is usually associated with renal conditions.

The nurse is admitting a client with acute appendicitis to the emergency department. The client has abdominal pain of 10 on a pain scale of 1 to 10. The client will be going to surgery as soon as possible. The nurse should: 1. Contact the surgeon to request an order for a narcotic for the pain. 2. Maintain the client in a recumbent position. 3. Place the client on nothing-by-mouth (NPO) status. 4. Apply heat to the abdomen in the area of the pain.

3. The nurse should place the client on NPO status in anticipation of surgery. The nurse can initiate pain relief strategies, such as relaxation techniques, but the surgeon will likely not order narcotic medication prior to surgery. The nurse can place the client in a position that is most comfortable for the client. Heat is contraindicated because it may lead to perforation of the appendix.

A preoperative client expresses anxiety to a nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? 1. "If it's any help, everyone is nervous before surgery." 2. "I will be happy to explain the entire surgical procedure to you." 3. "Can you share with me what you've been told about your surgery?" 4. "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate."

3. "Can you share with me what you've been told about your surgery?" Rationale: Explanations should begin with the information that the client knows. By providing the client with individualized explanations of care and procedures, the nurse can assist the client in handling anxiety and fear for a smooth preoperative experience. Clients who are calm and emotionally prepared for surgery withstand anesthesia better and experience fewer postoperative complications. Option 1 does not focus on the client's anxiety. Explaining the entire surgical procedure may increase the client's anxiety (option 2). Option 4 avoids the client's anxiety and is focuses on postoperative care. Test-Taking Strategy: Note that the client expresses anxiety. Use knowledge of therapeutic communication techniques . Note that the question contains the strategic words "most likely" and also note the words "stimulate further discussion". Also use the steps of the nursing process . The correct option addresses assessment and is the only therapeutic response. If this question was difficult, review the fundamental principles of therapeutic communication.

When performing a surgical dressing change of a client's abdominal dressing, a nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. The nurse should do which of the following in the initial care of this wound? 1. Leave the incision open to the air to dry the area. 2. Irrigate the wound and apply a sterile dry dressing. 3. Apply a sterile dressing soaked with normal saline. 4. Apply a sterile dressing soaked in providone-iodine (Betadine).

3. Apply a sterile dressing soaked with normal saline. Rationale: Wound dehiscence is the separation of wound edges at the suture line. Signs and symptoms include increased drainage and the appearance of underlying tissues. Dehiscence usually occurs 6 to 8 days after surgery. The client should be instructed to remain quiet and avoid coughing or straining. The client should be positioned to prevent further stress on the wound (semi-Fowler's). Sterile dressings soaked with sterile normal saline should be used to cover the wound. The nurse must notify the physician after applying the initial dressing to the wound. Options 1, 2, and 4 are incorrect. Test-taking strategy: Use the process of elimination. Eliminate option 1 first because this action would dry the wound and also present a risk of infection to the underlying tissues. Eliminate options 2 and 4 next because a dry dressing and a dressing soaked with providone-iodine will irritate the exposed body tissues. Review initial nursing care when dehiscence or evisceration occurs if you had difficulty with this question.

The client is diagnosed with peritonitis. Which assessment data indicate to the nurse the client's condition is improving? 1. The client is using more pain medication on a daily basis. 2. The client's nasogastric tube is draining coffee-ground material. 3. The client has a decrease in temperature and a soft abdomen. 4. The client has had two soft, formed bowel movements.

3. Because the signs of peritonitis are elevated temp & rigid abdomen, a reversal of these signs indicates the client is getting better. (1. more pain meds means he is getting worse) (2. Coffee ground material indicates od blood from the GI system) (4. Two soft formed bowel movements are normal; but this does not have anything to do with peritonitis) MedSurg Success pg 269

A client is admitted to a surgical unit postoperatively with a wound drain in place. Which actions should the nurse avoid in the care of the drain? 1. Check the drain for patency. 2. Observe for bright red bloody drainage. 3. Curl the drain tightly and tape it firmly to the body. 4. Maintain aseptic technique when emptying the drain.

3. Curl the drain tightly and tape it firmly to the body. Rationale: A postoperative drain should not be curled tightly or obstructed in any way. This could prevent the drain from functioning properly. The nurse should check the tube or drain for patency to provide an exit for the fluid or blood to promote healing. The nurse must use aseptic technique for emptying the drainage container or changing the dressing to avoid contamination of the wound. The nurse should monitor the drainage characteristics. Usually, the drainage from the wound is pale, red, and watery. Active bleeding will be bright red. Test-Taking Strategy: Note the strategy word "avoid". Remember that surgical drains need to remain patent so that accumulated secretions can escape from the wound bed. If you had difficulty with this question, review nursing care for the client with a surgical drain.

A nurse in a surgical unit receives a postoperative client from the postanesthesia care unit. After the initial assessment of the client, the nurse plans to continue with postoperative assessment activities: 1. Every hour for 2 hours, and then every 4 hours as needed. 2. Every 30 minutes for the first hour, every hour for 2 hours, and then every 4 hours as needed. 3. Every 15 minutes for the first hour, every 30 minutes for 2 hours, every hour for 4 hours, and then every 4 hours as needed. 4. Every 5 minutes for the first half-hour, every 15 minutes for 2 hours, every 30 minutes for 4 hours, and then every hour as needed.

3. Every 15 minutes for the first hour, every 30 minutes for 2 hours, every hour for 4 hours, and then every 4 hours as needed. Rationale: When the postoperative client arrives from the postanesthesia care unit, the nurse performs an initial assessment. Common time frames for continuing postoperative assessment activities are every 15 minutes the first hour, every 30 minutes for 2 hours, every hour for 4 hours, and then every 4 hours as needed. However, agency policies should always be followed. Options 1 and 2 identify time frames that are too infrequent and that will not provide adequate assessment of the postoperative client. Option 4 identifies close time frames that are unnecessary. Test-Taking Strategy: Eliminate option 4 first because the time frames are so close. By the time that the nurse completed the assessment, the 5 minutes would have lapsed and the nurse would immediately have to perform the assessment again. This is unnecessary and unreasonable. Eliminate options 1 and 2 because they identify time frames that are too infrequent and will not provide adequate assessment of the postoperative client. Review postoperative assessment procedures if you had difficulty with this question.

An operating room nurse is positioning a client on the operating room table to prevent the client's extremities from dangling over the sides of the table. A nursing student who is observing for the day asks the nurse why this is so important. The nurse responds that this is done primarily to prevent: 1. An increase in pulse rate. 2. A drop in blood pressure. 3. Nerve and muscle damage. 4. Muscle fatigue in the extremities.

3. Nerve and muscle damage. Rationale: The client's extremities should not be allowed to dangle over the sides of the table because this may impair circulation to the local area or cause nerve and muscle damage. Part of the operating room nurse's role is to ensure that the safety needs of the client are met, which includes proper positioning. Test-Taking Strategy: Use knowledge regarding the basic principles related to positioning. Recall the client is anesthetized will direct you to option 3. Review the nurse's role during surgery if you had difficulty with this question.

A nurse is monitoring a postoperative client after abdominal surgery for signs of complications. The nurse assesses the client for the presence of Homans' sign and determines that this sign is positive if which of the following is noted? 1. Incisional pain 2. Absent bowel sounds 3. Pain with dorsiflexion of the foot 4. Crackles on auscultation of the lungs

3. Pain with dorsiflexion of the foot Rationale: To elicit Homans' sign, the nurse would dorsiflex the client's foot and assess the client for pain in the calf area. If pain is present, a positive Homans' sign is present, which is an indication of thrombophlebitis. Incisional pain is an expected occurrence after abdominal surgery. Absent bowel sounds may occur in the immediate postoperative period. Crackles on auscultation of the lungs may indicate a respiratory complication. Test-Taking Strategy: Use knowledge of the significance of a positive Homans' sign. Recalling that a positive Homans' sign indicates thrombophlebitis will direct you to option 3. Review this assessment technique if you had difficulty with this question.

The healthcare provider is assessing a patient diagnosed with ulcerative colitis. The patient has an altered level of consciousness, fever, and lower abdominal distension. Which of these additional findings would confirm a diagnosis of toxic megacolon? 1. Bradycardia 2. Splenomegaly 3. Leukocytosis 4. Constipation

3. leukocytosis

a nurse is planning care for a client who has prerenal acute kidney injury. The client's urinary output is 80mL in the past 4 hr. and blood pressure is 92/58mm Hg. which of the following should be included in the plan of care? 1. prepare the client for a CAT scan with contrast die 2. anticipate urine specific gravity to be 1.010 3. plan to administer a fluid challenge 4. place client in trendelenburg position

3. plan to administer a fluid challenge for hypovolemia, which is indicated by the clients low urinary output and BP.

A client with chronic renal failure has an internal venous access site for hemodialysis on her left forearm. What action will the nurse take to protect this access site? 1) Irrigate with heparin and NS q8 hrs 2) Apply warm moist packs to the area after hemodialysis 3) Do not use the left arm to take blood pressure readings. 4) Keep the arm elevated above the level of the heart.

3: Protect the arm with the functioning shunt. No blood pressure readings should be taken from that arm, and there should be no needle sticks. The access is not irrigated with Heparin.

The nurse should teach the client with diverticulitis to integrate which of the following into a daily routine at home? 1. Using enemas to relieve constipation. 2. Decreasing fluid intake to increase the formed consistency of the stool. 3. Eating a high-fiber diet when symptomatic with diverticulitis. 4. Refraining from straining and lifting activities.

4. Clients with diverticular disease should refrain from any activities, such as lifting, straining, or coughing, that increase intra-abdominal pressure and may precipitate an attack. Enemas are contraindicated because they increase intestinal pressure. Fluid intake should be increased, rather than decreased, to promote soft, formed stools. A low-fiber diet is used when inflammation is present.

A client with acute appendicitis develops a fever, tachycardia, and hypotension. Based on these assessment findings, the nurse should further assess the client for which of the following complications? 1. Deficient fluid volume. 2. Intestinal obstruction. 3. Bowel ischemia. 4. Peritonitis.

4. Complications of acute appendicitis are perforation, peritonitis, and abscess development. Signs of the development of peritonitis include abdominal pain and distention, tachycardia, tachypnea, nausea, vomiting, and fever. Because peritonitis can cause hypovolemic shock, hypotension can develop. Deficient fluid volume would not cause a fever. Intestinal obstruction would cause abdominal distention, diminished or absent bowel sounds, and abdominal pain. Bowel ischemia has signs and symptoms similar to those found with intestinal obstruction.

A nurse is providing wound care to a client 1 day after the client underwent an appendectomy. A drain was inserted into the incisional site during surgery. Which action should the nurse perform when providing wound care? 1. Remove the dressing and leave the incision open to air. 2. Remove the drain if wound drainage is minimal. 3. Gently irrigate the drain to remove exudate. 4. Clean the area around the drain moving away from the drain.

4. The nurse should gently clean the area around the drain by moving in a circular motion away from the drain. Doing so prevents the introduction of microorganisms to the wound and drain site. The incision cannot be left open to air as long as the drain is intact. The nurse should note the amount and character of wound drainage, but the surgeon will determine when the drain should be removed. Surgical wound drains are not irrigated.

A nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsaliclic acid (aspirin). Then nurse determines that the client needs additional teaching if the client states: 1. "Aspirin can cause bleeding after surgery." 2. "Aspirin can cause my ability to clot blood to be abnormal." 3. "I need to discontinue the aspirin 48 hours before the scheduled surgery." 4. "I need to continue to take the aspirin until the day of surgery."

4. "I need to continue to take the aspirin until the day of surgery." Rationale: Anticoagulants alter normal clotting factors and increase the risk of bleeding after surgery. Aspirin has properties that can alter the clotting mechanism and should be discontinued at least 48 hours before surgery. However, the client should always check with his or her health care provider regarding when to stop taking the aspirin when a surgical procedure is scheduled. Options 1, 2, and 4 are accurate client statements. Test-Taking Strategy: Note the strategic words "needs additional teaching". These words indicate a negative event query and that you need to select the incorrect client statement. Eliminate options 1 and 2 first because they are comparable or alike . From the remaining options, recalling that aspirin has properties that can alter the clotting mechanism will direct you to the correct option. If you had difficulty with this question, review medications that affect the client preparing for surgery.

The client developed a paralytic ileus after abdominal surgery. Which intervention should the nurse include in the plan of care? 1. Administer a laxative of choice. 2. Encourage client to increase oral fluids. 3. Encourage client to take deep breaths. 4. Maintain a patent nasogastric tube.

4. A paralytic ileus is the absence of peristalsis; therefore the bowel will be unable to process any oral intake. A nasogastric tube is inserted to decompress the bowel until surgical intervention or until bowel sounds return spontaneously. (1. the client is NPO - no medication will be administered) (2. The client is NPO- no food or fluids are allowed) (3. Deep breathing will help prevent pulmonary complications but does not address the client's paralytic ileus) MedSurg Success pg 269

A nurse is developing a plan of care for a preoperative client who has a latex allergy. Which intervention should be included in the plan? 1. Avoid using medications from glass ampules. 2. Avoid using IV tubing that is made of polyvinyl chloride.. 3. Use medications that are from ampules with rubber stoppers. 4. Apply a cloth barrier to the client's arm under a blood pressure cuff when taking the blood pressure.

4. Apply a cloth barrier to the client's arm under a blood pressure cuff when taking the blood pressure. Rationale: If a client has a latex allergy, a cloth barrier should be applied to his or her arm under a blood pressure cuff to prevent skin contact with the cuff. Medications from glass ampules are safe to use, and medications from ampules with rubber stoppers are unsafe to use. Latex-safe intravenous tubing made of polyvinyl chloride should be used for a client with a latex allergy. Additionally, agency procedures should be followed for a client with a latex allergy; usually, a latex allergy cart containing latex-free supplies is kept in the client's room. Test-Taking Strategy: Focus on the subject of the question, the latex allergy. Recalling the causes of a latex allergy will direct you easily to option 4. Review nursing interventions for the client with a latex allergy if you had difficulty with this question.

A 35-year-old man with a family history of adenomatous polyposis had a colonoscopy with removal of multiple polyps. Which signs and symptoms should the nurse teach the patient to report immediately? A Fever and abdominal pain B Flatulence and liquid stool C Loudly audible bowel sounds D Sleepiness and abdominal cramps

A Fever and abdominal pain The patient should be taught to observe for signs of rectal bleeding and peritonitis. Fever, malaise, and abdominal pain and distention could indicate a perforated bowel with peritonitis.

The nurse caring for a client who has had abdominal aortic aneurysm (AAA) repair would be most alarmed by which finding? A. Urine output of 20 mL over 2 hours B. Blood pressure of 106/58 mm Hg C. Absent bowel sounds D. +3 pedal pulses

A Complications post AAA stent repair include bleeding, which may manifest as signs of hypovolemia and oliguria

The nurse is assigned to all of these clients. Which client should be assessed first? A. The client who had percutaneous transluminal angioplasty (PTA) of the right femoral artery 30 minutes ago B. The client admitted with hypertensive crisis who has a nitroprusside (Nipride) drip and blood pressure of 149/80 mm Hg C. The client with peripheral vascular disease who has a left leg ulcer draining purulent yellow fluid D. The client who had a right femoral-popliteal bypass 3 days ago and has ongoing edema of the foot

A The client who had PTA should have checks of vascular status and vital signs every 15 minutes in the first hour after the procedure.

6. The nurse anticipates administering an opioid fentanyl patch to which patient? • A 15-year-old adolescent with a broken femur • A 30-year-old adult with cellulitis • A 50-year-old patient with prostate cancer • An 80-year-old patient with a broken hip

A 50-year-old patient with prostate cancer Correct

The nurse is instructing a client with heart failure about energy conservation. Which is the best instruction? a. "Walk until you become short of breath and then walk back home." b. "Gather everything you need for a chore before you begin." c. "Pull rather than push or carry items heavier than 5 pounds." d. "Take a walk after dinner every day to build up your strength."

ANS: B Gathering all supplies needed for a chore at one time decreases the amount of energy needed.

19. A patient is hospitalized with vomiting of "coffee-ground" emesis. The nurse will anticipate preparing the patient for a. endoscopy. b. angiography. c. gastric analysis testing. d. barium contrast studies.

ANS: A Endoscopy is the primary tool for visualization and diagnosis of upper gastrointestinal (GI) bleeding. Angiography is used only when endoscopy cannot be done because it is more invasive and has more possible complications. Gastric analysis testing may help with determining the cause of gastric irritation, but it is not used for acute GI bleeding. Barium studies are helpful in determining the presence of gastric lesions, but not whether the lesions are actively bleeding.

A patient had a stomach resection for stomach cancer. The nurse should teach the patient about the loss of the hormone that stimulates gastric acid secretion and motility and maintains lower esophageal sphincter tone. Which hormone will be decreased with a gastric resection? A Gastrin B Secretin C Cholecystokinin D Gastric inhibitory peptide

A Gastrin Gastrin is the hormone activated in the stomach (and duodenal mucosa) by stomach distention that stimulates gastric acid secretion and motility and maintains lower esophageal sphincter tone. Secretin inhibits gastric motility and acid secretion and stimulates pancreatic bicarbonate secretion. Cholecystokinin allows increased flow of bile into the duodenum and release of pancreatic digestive enzymes. Gastric inhibitory peptide inhibits gastric acid secretion and motility.

A 90-year-old healthy man is suffering from dysphagia. The nurse explains what age-related change of the GI tract is the most likely cause of his difficulty? A Xerostomia B Esophageal cancer C Decreased taste buds D Thinner abdominal wall

A Xerostomia Xerostomia, decreased volume of saliva, leads to dry oral mucosa and dysphagia. Esophageal cancer is not an age-related change. Decreased taste buds and a thinner abdominal wall do not contribute to difficulty swallowing.

A nurse is developing a list of home care instructions for a client being discharged after a laparoscopic cholecystectomy. Which of the following instructions would be least appropriate to include in the postoperative discharge plan of care? 1. Wound care 2. Follow-up care 3. Activity restrictions 4. Deep-breathing exercises

4. Deep-breathing exercises Rationale: The type of planning and instruction required varies with each individual and type of surgery. Specific instructions that the client needs to receive before discharge should include wound care, activity restrictions, dietary instructions, postoperative medication instructions, personal hygiene, and follow-up appointments. Deep-breathing exercises are taught in the postoperative period. Test-Taking Strategy: Note the strategy words "least appropriate". Options 1, 2, and 3 are comparative or alike and refer to information that needs to be taught postoperatively. Option 4 refers to information that should be taught preoperatively. Review the client education points related to discharge teaching preoperatively and postoperatively if you had difficulty with this question.

A client with a perforated gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which appropriate action in the care of this client? 1. Obtain a court order for the surgery. 2. Send the client to surgery without the consent form being signed. 3. Have the hospital chaplain sign the informed consent immediately. 4. Obtain a telephone consent from a family member, following agency policy.

4. Obtain a telephone consent from a family member, following agency policy. Rationale: Every effort should be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. A telephone consent must be witnessed by two persons who hear the family member's oral consent. The two witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under the influence of sedatives. In an emergency, a client may be unable to sign and family members may not be available. In this situation, a health care provider is permitted legally to perform surgery without consent, but in this case it is not an emergency. Options 1 and 3 are not appropriate in this situation. Also, agency policies regarding informed consent should always be followed. Test-Taking Strategy: Note the strategic words "most appropriate". Focus on the data in the question. Eliminate 1 and 3 first. Option 1 will delay necessary surgery and option 3 is inappropriate. Select the correct option over option 2 because it is the most appropriate of the options presented and it is legally acceptable to obtain a telephone permission from a family member if it is witnessed by two persons. Review the implications surrounding informed consent if you had difficulty with this question.

A nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussion with the client? 1. Inhale as rapidly as possible. 2. Keep a loose seal between the lips and the mouthpiece. 3. After maximum inspiration, hold the breath for 15 seconds and exhale. 4. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.

4. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees. Rationale: For optimal lung expansion with the incentive spirometer, the client should assume the semi-Fowler's or high Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. The breath should be held for 5 seconds before exhaling slowly. Test-Taking Strategy: Visualize the procedure for using the incentive spirometer. Options 1, 2, and 3 are incorrect steps regarding incentive spirometer use. The breath should be held for five seconds before exhaling slowly.

During an acute exacerbation of inflammatory bowel disease, a patient is to receive total parenteral nutrition (TPN) and lipids. Which of these interventions is the priority when caring for this patient? . 1. Monitor urine specific gravity every shift 2. Change the administration set every 72 hours 3. Infuse the solution in a large peripheral vein 4. Monitor the patient's blood glucose per protocol

4. monitor the patients blood glucose per protocol

5. An adult woman is admitted to an isolation unit in the hospital after tuberculosis was detected during a pre-employment physical. Although frightened about her diagnosis, she is anxious to cooperate with the therapeutic regimen. The teaching plan includes information regarding the most common means of transmitting the tubercle bacillus from one individual to another. Which contamination is usually responsible? a. Hands. b. Droplet nuclei. c. Milk products. d. Eating utensils.

5. Answer B. Hands are the primary method of transmission of the common cold. The most frequent means of transmission of the tubercle bacillus is by droplet nuclei. The bacillus is present in the air as a result of coughing, sneezing, and expectoration of sputum by an infected person. The tubercle bacillus is not transmitted by means of contaminated food. Contact with contaminated food or water could cause outbreaks of salmonella, infectious hepatitis, typhoid, or cholera. The tubercle bacillus is not transmitted by eating utensils. Some exogenous microbes can be transmitted via reservoirs such as linens or eating utensils.

6. A 2 year old is to be admitted in the pediatric unit. He is diagnosed with febrile seizures. In preparing for his admission, which of the following is the most important nursing action? a. Order a stat admission CBC. b. Place a urine collection bag and specimen cup at the bedside. c. Place a cooling mattress on his bed. d. Pad the side rails of his bed.

6. Answer D. Preparing for routine laboratory studies is not as high a priority as preventing injury and promoting safety. Preparing for routine laboratory studies is not as high a priority as preventing injury and promoting safety. A cooling blanket must be ordered by the physician and is usually not used unless other methods for the reduction of fever have not been successful. The child has a diagnosis of febrile seizures. Precautions to prevent injury and promote safety should take precedence.

When preparing a patient for a capsule endoscopy study, what should the nurse do? A Ensure the patient understands the required bowel preparation. B Have the patient return to the procedure room for removal of the capsule. C Teach the patient to maintain a clear liquid diet throughout the procedure. D Explain to the patient that conscious sedation will be used during placement of the capsule.

A Ensure the patient understands the required bowel preparation. A capsule endoscopy study involves the patient performing a bowel prep to cleanse the bowel before swallowing the capsule. The patient will be on a clear liquid diet for 1 to 2 days before the procedure and will remain NPO for 4 to 6 hours after swallowing the capsule. The capsule is disposable and will pass naturally with the bowel movement, although the monitoring device will need to be removed.

7. A young adult is being treated for second and third degree burns over 25% of his body and is now ready for discharge. The nurse evaluates his understanding of discharge instructions relating to wound care and is satisfied that he is prepared for home care when he makes which statement? a. "I will need to take sponge baths at home to avoid exposing the wounds to unsterile bath water." b. "If any healed areas break open I should first cover them with a sterile dressing and then report it." c. "I must wear my Jobst elastic garment all day and can only remove it when I'm going to bed." d. "I can expect occasional periods of low-grade fever and can take Tylenol every 4 hours."

7. Answer B. Bathing or showering in the usual manner is permitted, using a mild detergent soap such as Ivory Snow. This cleanses the wounds, especially those that are still open, and removes dead tissue. The client is taught to report changes in wound healing such as blister formation, signs of infection, and opening of a previously healed area. Sterile dressings are applied until the wound is assessed and a plan of care developed. The Jobs garment is designed to place constant pressure on the new healthy tissue that is forming to promote adherence to the underlying structure in order to prevent hypertrophic scarring. In order to be effective, the garment must be worn for 23 hours daily. It is removed for wound assessment and wound care and to permit bathing. The client must be aware that infection of the wound may occur; signs of infection, including fever, redness, pain, warmth in and around the wound and increased or foul smelling drainage must be reported immediately.

8. An eighty five year old man was admitted for surgery for benign prostatic hypertrophy. Preoperatively he was alert, oriented, cooperative, and knowledgeable about his surgery. Several hours after surgery, the evening nurse found him acutely confused, agitated, and trying to climb over the protective side rails on his bed. The most appropriate nursing intervention that will calm an agitated client is a. limit visits by staff. b. encourage family phone calls. c. position in a bright, busy area. d. speak soothingly and provide quiet music.

8. Answer D. The client needs frequent visits by the staff to orient him and to assess his safety. Phone calls from his family will not help a client who is trying to climb over the side rails and may even add to his danger. Putting the client in a bright, busy area would probably add to his confusion. The environment is an important factor in the prevention of injuries. Talking softly and providing quiet music have a calming effect on the agitated client.

9. Ms. Smith is admitted for internal radiation for cancer of the cervix. The nurse knows the client understands the procedure when she makes which of the following remarks the night before the procedure? a. She says to her husband, "Please bring me a hamburger and french fries tomorrow when you come. I hate hospital food." b. "I told my daughter who is pregnant to either come to see me tonight or wait until I go home from the hospital." c. "I understand it will be several weeks before all the radiation leaves my body." d. "I brought several craft projects to do while the radium is inserted."

9. Answer B. The client will be on a clear liquid or very low residue diet. Hamburgers and french fries are not allowed. People who are pregnant should not come in close contact with someone who has internal radiation therapy. The radioactivity could possibly damage the fetus. This statement is not true. As soon as the radiation source is removed (probably 36 to 72 hours after insertion), the client is no longer contaminated with radioactivity. Craft projects usually require the client to sit. The client must remain flat with very little head elevation during the time the rods are in place.

During an assessment of a patient's abdomen, a pulsating abdominal mass is noted by the healthcare provider. Which of the following should be the healthcare provider's next action? A. Assess femoral pulses B. Obtain a bladder scan C. Measure the abdominal circumference D. Ask the patient to perform a Valsalva maneuver

A

The nurse is caring for a client with peripheral arterial disease (PAD). For which symptoms does the nurse assess? A. Reproducible leg pain with exercise B. Unilateral swelling of affected leg C. Decreased pain when legs are elevated D. Pulse oximetry reading of 90%

A Claudication (leg pain with ambulation due to ischemia) is reproducible in similar circumstances. Unilateral swelling is typical of venous problems such as deep vein thrombosis. With PAD, pain decreases with legs in the dependent position. Pulse oximetry readings reflect the amount of oxygen bound to hemoglobin; PAD results from atherosclerotic occlusion of peripheral arteries.

The nurse educates a primary HTN patient on lifestyle changes. Which ones should be included in her teaching? A. consume more fruits/veggies B. Monitor/lose weight C. Limit alchoholic drinks to 3 per day or less D. Regular exercise (walking) E. Limit sodium intake to 3200 mg per day

A, B, D

Which are risk factors that are known to contribute to atherosclerosis-related diseases? (Select all that apply.) A. Low-density lipoprotein cholesterol (LDL-C) of 160 mg/dL B. Smoking C. Aspirin (acetylsalicylic acid [ASA]) consumption D. Type 2 diabetes E. Vegetarian diet

A, B, D Having an LDL-C value of less than 100 mg/dL is optimal; 100 to 129 mg/dL is near or less than optimal; with LDL-C 130 to 159 mg/dL (borderline high), the client is advised to modify diet and exercise. Smoking is a modifiable risk factor and should be avoided or terminated, and diabetes is a risk factor for atherosclerotic disease.

The nurse is caring for a client with heart failure. For which symptoms should the nurse assess? Select all that apply. a. Chest discomfort or pain b. Tachycardia c. Expectorates thick, yellow sputum d. Sleeps on back without a pillow e. Shortness of breath with exertion

A, B, E: Decreased tissue perfusion may cause chest pain or discomfort. Tachycardia may occur as compensation for or as a result of decreased cardiac output. Dyspnea results as pulmonary venous congestion ensues. C - Incorrect: Thick, yellow sputum is indicative of infection; clients with acute heart failure have dry cough and, when severe, pink, frothy sputum. D - Incorrect: Orthopnea, the inability to lie flat, occurs in clients with heart failure.

The nurse assists the client with acute kidney injury (AKI) to modify the diet in which way? Select all that apply: A. Restricted protein B. Liberal sodium C. Fluid restriction D. Low potassium E. Low fat

A, C, and D: Restricted protein (Breakdown of protein leads to azotemia and increased blood urea nitrogen (BUN). Fluid is restricted during the oliguric phase of acute renal failure. Potassium intoxication may occur; dietary potassium is restricted.

The nurse is concerned that an older adult client with heart failure is developing pulmonary edema. What manifestation alerts the nurse to further assess the client for this complication? a. Confusion b. Dysphagia c. Sacral edema d. Irregular heart rate

ANS: A Impending pulmonary edema is characterized by a change in mental status, disorientation, and confusion, along with dyspnea and increasing fluid levels in the lungs. Dysphagia, sacral edema, and an irregular heart rate are not related to pulmonary edema.

Which of the following diets is most commonly associated with colon cancer? A. Low-fiber, high fat B. Low-fat, high-fiber C. Low-protein, high-carbohydrate D. Low carbohydrate, high protein

A. A low-fiber, high-fat diet reduced motility and increases the chance of constipation. The metabolic end products of this type of diet are carcinogenic. A low-fat, high-fiber diet is recommended to prevent colon cancer.

Mike, a 43-year old construction worker, has a history of hypertension. He smokes two packs of cigarettes a day, is nervous about the possibility of being unemployed, and has difficulty coping with stress. His current concern is calf pain during minimal exercise that decreased with rest. The nurse assesses Mike's symptoms as being associated with peripheral arterial occlusive disease. The nursing diagnosis is probably: a. Alteration in tissue perfusion related to compromised circulation b. Dysfunctional use of extremities related to muscle spasms c. Impaired mobility related to stress associated with pain d. Impairment in muscle use associated with pain on exertion.

A. Alteration in tissue perfusion related to compromised circulation

A patient with osteoarthritis has been taking ibuprofen (Advil) 400 mg every 8 hours. The patient states that the drug does not seem to work as well as it used to in controlling the pain. The most appropriate response to the patient is based on what knowledge? A. Another NSAID may be indicated because of individual variations in response to drug therapy. B. It may take several months for NSAIDs to reach therapeutic levels in the blood and thus be effective. C. If NSAIDs are not effective in controlling symptoms, systemic corticosteroids are the next line of therapy. D. The patient is probably not compliant with the drug therapy, and therefore the nurse must initially assess the patient's knowledge base and initiate appropriate teaching.

A. Another NSAID may be indicated because of individual variations in response to drug therapy. Patients vary in their response to medications so when one NSAID does not provide relief, another should be tried. There is no evidence to ascertain any noncompliance to drug therapy.

Before administering celecoxib (Celebrex), the nurse will assess the patient's medical record for which medication that would increase the risk of adverse effects? A. Aspirin B. Scopolamine C. Theophylline D. Acetaminophen

A. Aspirin Celecoxib is a nonsteroidal antiinflammatory drug (NSAID) of the cyclooxygenase-2 (COX-2) inhibitor type. Although celecoxib does not inhibit COX-1 and thus has a decreased risk of bleeding, bleeding is still of concern as an adverse effect. For this reason, the drug should not be taken with other drugs that increase risk of bleeding, such as aspirin.

The nurse should teach a patient to avoid which medication while taking ibuprofen? A. Aspirin B. Furosemide (Lasix) C. Nitroglycerin (Nitro-Bid) D. Morphine sulfate (generic)

A. Aspirin The patient should not take aspirin while taking ibuprofen because the combination could increase the risk of GI bleeding.

The client with chronic kidney disease reports chest pain. The nurse notes tachycardia and low-grade fever. Which additional assessment is warranted? A. Auscultate for pericardial friction rub B. Assess for crackles C. Monitor for decreased peripheral pulses D. Determine whether the client is able to ambulate

A. Auscultate for pericardial friction rub The client with uremia is prone to pericarditis; symptoms include inspiratory chest pain, low-grade fever, and ST segment elevation. Crackles and tachycardia are symptomatic of fluid overload; fever is not present.

A stroke patient who primarily uses a wheelchair for mobility has diarrhea with fecal incontinence. What should the nurse assess first? A. Fecal impaction B. Perineal hygiene C. Dietary fiber intake D. Antidiarrheal agent use

A. Fecal impaction Patients with limited mobility are at risk for fecal impactions due to constipation that may lead to liquid stool leaking around the hardened impacted feces, so assessing for fecal impaction is the priority. Perineal hygiene can be assessed at the same time. Assessing the dietary fiber and fluid intake and antidiarrheal agent use will be assessed and considered next.

The patient has hypokalemia, and the nurse obtains the following measurements on the rhythm strip: Heart rate of 86 with a regular rhythm; the P wave is 0.06 seconds (sec) and normal shape; the PR interval is 0.24 sec; the QRS is 0.09 sec. How should the nurse document this rhythm? A. First-degree AV block B. Second-degree AV block C. Premature atrial contraction (PAC) D. Premature ventricular contraction (PVC)

A. First-degree AV block In first-degree AV block there is prolonged duration of AV conduction that lengthens the PR interval above 0.20 sec. In type I second-degree AV block the PR interval continues to increase in duration until a QRS complex is blocked. In Type II the PR interval may be normal or prolonged, the ventricular rhythm may be irregular, and the QRS is usually greater than 0.12 sec. PACs cause an irregular rhythm with a different-shaped P wave than the rest of the beats, and the PR interval may be shorter or longer. PVCs cause an irregular rhythm, and the QRS complex is wide and distorted in shape.

A client in severe heart failure has a heparin drip infusing. The health care provider prescribes nesiritide (Natrecor) to be given intravenously. Which intervention is essential before administration of this medication? a. Insert a separate IV access. b. Prepare a test bolus dose. c. Prepare the piggyback line. d. Administer furosemide (Lasix) first.

ANS: A Natrecor should be given through a separate IV access because it is incompatible with many medications, especially heparin. A test bolus is not needed, nor is Lasix. Because the medication should be given through a separate IV, it is not necessary to prepare a piggyback line.

A patient has sought care following a syncopal episode of unknown etiology. Which nursing action should the nurse prioritize in the patient's subsequent diagnostic workup? A. Preparing to assist with a head-up tilt-test B. Preparing an IV dose of a β-adrenergic blocker C. Assessing the patient's knowledge of pacemakers D. Teaching the patient about the role of antiplatelet aggregators

A. Preparing to assist with a head-up tilt-test In patients without structural heart disease, the head-up tilt-test is a common component of the diagnostic workup following episodes of syncope. IV β-blockers are not indicated although an IV infusion of low-dose isoproterenol may be started in an attempt to provoke a response if the head-up tilt-test did not have a response. Addressing pacemakers is premature and inappropriate at this stage of diagnosis. Patient teaching surrounding antiplatelet aggregators is not directly relevant to the patient's syncope at this time.

A patient with a history of peptic ulcer disease has presented to the emergency department reporting severe abdominal pain and has a rigid, boardlike abdomen that prompts the health care team to suspect a perforated ulcer. What intervention should the nurse anticipate? A. Providing IV fluids and inserting a nasogastric (NG) tube B. Administering oral bicarbonate and testing the patient's gastric pH level C. Performing a fecal occult blood test and administering IV calcium gluconate D. Starting parenteral nutrition and placing the patient in a high-Fowler's position

A. Providing IV fluids and inserting a nasogastric (NG) tube A perforated peptic ulcer requires IV replacement of fluid losses and continued gastric aspiration by NG tube. Nothing is given by mouth, and gastric pH testing is not a priority. Calcium gluconate is not a medication directly relevant to the patient's suspected diagnosis, and parenteral nutrition is not a priority in the short term.

The nurse has obtained this rhythm strip from her patient's monitor. Which description of this ECG is correct? ** COULDN'T GET IMAGINE ON THIS SIDE.. FLIP A. Sinus tachycardia B. Sinus bradycardia C. Ventricular fibrillation D. Ventricular tachycardia

A. Sinus tachycardia This rhythm strip shows sinus tachycardia because the rate on this strip is above 101, and it displays normal P wave, PR interval, and QRS complex. Sinus bradycardia would look similar to sinus tachycardia but with a rate less than 60 beats per minute. Ventricular fibrillation does not have a measureable heart rate, PR interval, or QRS, and the P wave is not visible and the rhythm is irregular and chaotic. Ventricular tachycardia has a rate of 150 to 250 beats/minutes, with a regular or irregular rhythm and P waves occurring independently of the QRS complex.

For which dysrhythmia is defibrillation primarily indicated? A. Ventricular fibrillation B. Third-degree AV block C. Uncontrolled atrial fibrillation D. Ventricular tachycardia with a pulse

A. Ventricular fibrillation Defibrillation is always indicated in the treatment of ventricular fibrillation. Drug treatments are normally used in the treatment of uncontrolled atrial fibrillation and for ventricular tachycardia with a pulse (if the patient is stable). Otherwise, synchronized cardioversion is used (as long as the patient has a pulse). Pacemakers are the treatment of choice for third-degree heart block.

Two days following a colectomy for an abdominal mass, a patient reports gas pains and abdominal distention. The nurse plans care for the patient based on the knowledge that the symptoms are occurring as a result of A. impaired peristalsis. B. irritation of the bowel. C. nasogastric suctioning. D. inflammation of the incision site.

A. impaired peristalsis. Until peristalsis returns to normal following anesthesia, the patient may experience slowed gastrointestinal motility leading to gas pains and abdominal distention. Irritation of the bowel, nasogastric suctioning, and inflammation of the surgical site do not cause gas pains or abdominal distention.

The nurse is providing discharge teaching to the client with heart failure, focusing on when to seek medical attention. Which statement by the client indicates understanding of the teaching? a. "I will call the provider if I have a cough lasting 3 or more days." b. "I will report to the provider weight loss of 2 to 3 pounds in a day." c. "I will try walking for 1 hour each day." d. "I should expect occasional chest pain."

A: Cough, a symptom of heart failure, is indicative of intra-alveolar edema; the provider should be notified. The client should call the provider for weight gain of 3 pounds in a week. The client should begin by walking 200 to 400 feet per day. Chest pain is indicative of myocardial ischemia and worsening of heart failure; the provider should be notified.

The nurse caring for a client discusses the importance of restricting sodium in the diet. Which statement made by the client indicates that he needs further teaching? a. "I should avoid grilling hamburgers." b. "I must cut out bacon and canned foods." c. "I shouldn't put the salt shaker on the table anymore." d. "I should avoid lunch meats but may cook my own turkey."

A: Cutting out beef or hamburgers made at home is not necessary; however, fast food hamburgers are to be avoided owing to higher sodium content. Bacon and canned foods are high in sodium, which promotes fluid retention; these are to be avoided. This client does not need further teaching. The client should avoid adding salt to food; he does not need further teaching. This client understands that all lunch meats and processed foods are high in sodium and are to be avoided.

The nurse is caring for an 82-year-old client admitted for exacerbation of heart failure. The nurse questions the client about the use of which medication because it raises an index of suspicion as to the cause of heart failure? a. Ibuprofen (Motrin) b. Hydrochlorothiazide (HydroDIURIL) c. NPH Insulin d. Levothyroxine (Synthroid)

A: Long-term use of NSAIDs, such as ibuprofen (Motrin), causes fluid and sodium retention. A diuretic may be used in the treatment of heart failure and hypertension. Although diabetes may be a risk factor for cardiovascular disease, it does not directly cause heart failure. In proper doses, Synthroid replaces thyroid hormone for those with hypothyroidism; it does not cause heart failure.

25. Twelve hours after undergoing a gastroduodenostomy (Billroth I), a patient complains of increasing abdominal pain. The patient has absent bowel sounds and 200 mL of bright red nasogastric (NG) drainage in the last hour. The most appropriate action by the nurse at this time is to a. notify the surgeon. b. irrigate the NG tube. c. administer the prescribed morphine. d. continue to monitor the NG drainage.

ANS: A Increased pain and 200 mL of bright red NG drainage 12 hours after surgery indicate possible postoperative hemorrhage, and immediate actions such as blood transfusion and/or return to surgery are needed. Because the NG is draining, there is no indication that irrigation is needed. The patient may need morphine, but this is not the highest priority action. Continuing to monitor the NG drainage is not an adequate response.

After receiving change-of-shift report about these four clients, which client should the nurse assess first? a. The 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset, frequent premature ventricular complexes b. The 55-year-old admitted with pulmonary edema who received furosemide (Lasix) and whose current O2 saturation is 94% c. The 68-year-old with pericarditis who is reporting sharp, stabbing chest pain when taking deep breaths d. The 79-year-old admitted for possible rejection of a heart transplant who has sinus tachycardia, rate 104

A: This client's premature ventricular complexes may be indicative of digoxin toxicity. Further assessment for clinical manifestations of digoxin toxicity should be done and the physician notified about the dysrhythmia. Option B: This client is stable. Option C: This type of pain is expected in pericarditis. Option D: Tachycardia is expected in this client because rejection will cause signs of decreased cardiac output, including tachycardia.

The nurse is assessing clients on a cardiac unit. Which client does the nurse assess most carefully for developing left-sided heart failure? a. Middle-aged woman with aortic stenosis b. Middle-aged man with pulmonary hypertension c. Older woman who smokes cigarettes daily d. Older man who has had a myocardial infarction

ANS: A Although most people with heart failure will have failure that progresses from left to right, it is possible to have left-sided failure alone for a short period. It is also possible to have heart failure that progresses from right to left. Causes of left ventricular failure include mitral or aortic valve disease, coronary artery disease (CAD), and hypertension.

A client with heart failure is prescribed enalapril (Vasotec). What is the nurse's priority teaching for this client? a. "Avoid using salt substitutes." b. "Take your medication with food." c. "Avoid using aspirin-containing products." d. "Check your pulse daily."

ANS: A Angiotensin-converting enzyme (ACE) inhibitors inhibit the excretion of potassium. Hyperkalemia can be a life-threatening side effect, and clients should be taught to limit potassium intake. Salt substitutes are composed of potassium chloride.

A client has been admitted to the acute care unit for an exacerbation of heart failure. Which is the nurse's priority intervention? a. Assess respiratory status. b. Monitor electrolyte levels. c. Administer intravenous fluids. d. Insert a Foley catheter.

ANS: A Assessment of respiratory and oxygenation status is the priority nursing intervention for the prevention of complications. Monitoring electrolytes and inserting a catheter are important but do not take priority over assessing respiratory status. The client needs IV access, but fluids may need to be administered judiciously.

36. The health care provider prescribes the following therapies for a patient who has been admitted with dehydration and hypotension after 3 days of nausea and vomiting. Which order will the nurse implement first? a. Infuse normal saline at 250 mL/hr. b. Administer IV ondansetron (Zofran). c. Provide oral care with moistened swabs. d. Insert a 16-gauge nasogastric (NG) tube.

ANS: A Because the patient has severe dehydration, rehydration with IV fluids is the priority. The other orders should be accomplished as quickly as possible after the IV fluids are initiated.

16. Cobalamin injections have been prescribed for a patient with chronic atrophic gastritis. The nurse determines that teaching regarding the injections has been effective when the patient states, a. "The cobalamin injections will prevent me from becoming anemic." b. "These injections will increase the hydrochloric acid in my stomach." c. "These injections will decrease my risk for developing stomach cancer." d. "The cobalamin injections need to be taken until my inflamed stomach heals."

ANS: A Cobalamin supplementation prevents the development of pernicious anemia. The incidence of stomach cancer is higher in patients with chronic gastritis, but cobalamin does not reduce the risk for stomach cancer. Chronic gastritis may cause achlorhydria, but cobalamin does not correct this. The loss of intrinsic factor secretion with chronic gastritis is permanent, and the patient will need lifelong supplementation with cobalamin.

A client asks the nurse why it is important to be weighed every day if he has right-sided heart failure. What is the nurse's best response? a. "Weight is the best indication that you are gaining or losing fluid." b. "Daily weights will help us make sure that you're eating properly." c. "The hospital requires that all inpatients be weighed daily." d. "You need to lose weight to decrease the incidence of heart failure."

ANS: A Daily weights are needed to document fluid retention or fluid loss. One liter of fluid equals 2.2 pounds.

An older adult client with heart failure states, "I don't know what to do. I don't want to be a burden to my daughter, but I can't do it alone. Maybe I should die." What is the nurse's best response? a. "Would you like to talk about this more?" b. "You're lucky to have such a devoted daughter." c. "You must feel as though you are a burden." d. "Would you like an antidepressant medication?"

ANS: A Depression can occur in clients with heart failure, especially older adults. Having the client talk about his or her feelings will help the nurse focus on the actual problem. Open-ended statements allow the client to respond safely and honestly.

An older adult client is admitted with fluid volume excess. Which diagnostic study does the nurse facilitate as a priority? a. Echocardiography b. Chest x-ray c. T4 and thyroid-stimulating hormone (TSH) d. Arterial blood gas

ANS: A Echocardiography is considered the best tool for the diagnosis of heart failure. A chest x-ray probably will be done, and if the client has dyspnea, an arterial blood gas will be drawn, but the echocardiogram is the priority. T4 and TSH might be ordered to assess for a contributing cause of heart failure.

13. A patient has just arrived on the postoperative unit after having a laparoscopic esophagectomy for treatment of esophageal cancer. Which nursing action should be included in the postoperative plan of care? a. Elevate the head of the bed to at least 30 degrees. b. Reposition the nasogastric (NG) tube if drainage stops or decreases. c. Notify the doctor immediately about bloody NG drainage. d. Start oral fluids when the patient has active bowel sounds.

ANS: A Elevation of the head of the bed decreases the risk for reflux and aspiration of gastric secretions. The NG tube should not be repositioned without consulting with the health care provider. Bloody NG drainage is expected for the first 8 to 12 hours. A swallowing study is needed before oral fluids are started.

18. A patient who has had several episodes of bloody diarrhea is admitted to the emergency department. Which action should the nurse anticipate taking? a. Obtain a stool specimen for culture. b. Administer antidiarrheal medications. c. Teach about adverse effects of nonsteroidal anti-inflammatory drugs (NSAIDs). d. Provide education about antibiotic therapy.

ANS: A Patients with bloody diarrhea should have a stool culture for E. coli O157:H7. NSAIDs may cause occult blood in the stools, but not diarrhea. Antidiarrheal medications usually are avoided for possible infectious diarrhea to avoid prolonging the infection. Antibiotic therapy in the treatment of infectious diarrhea is controversial because it may precipitate kidney complications.

A client with heart failure is experiencing acute shortness of breath. What is the nurse's priority action? a. Place the client in a high Fowler's position. b. Perform nasotracheal suctioning of the client. c. Auscultate the client's heart and lung sounds. d. Place the client on a 1000 mL fluid restriction.

ANS: A Placing a client in a high Fowler's position, especially with pillows under each arm, can maximize chest expansion and improve oxygenation. The nurse next should auscultate the client's heart and lungs. The client may or may not need fluid restriction to help manage heart failure, and suctioning is not needed.

The nurse is caring for a client with severe heart failure. What is the best position in which to place this client? a. High Fowler's, pillows under arms b. Semi-Fowler's, with legs elevated c. High Fowler's, with legs elevated d. Semi-Fowler's, on the left side

ANS: A Placing the client in high Fowler's position, with pillows under the arms, allows for maximum chest expansion.

21. The health care provider orders intravenous (IV) ranitidine (Zantac) for a patient with gastrointestinal (GI) bleeding caused by peptic ulcer disease. When teaching the patient about the effect of the medication, which information will the nurse include? a. "Ranitidine decreases secretion of gastric acid." b. "Ranitidine neutralizes the acid in the stomach." c. "Ranitidine constricts the blood vessels in the stomach and decreases bleeding." d. "Ranitidine covers the ulcer with a protective material that promotes healing."

ANS: A Ranitidine is a histamine-2 (H2) receptor blocker, which decreases the secretion of gastric acid. The response beginning, "Ranitidine constricts the blood vessels" describes the effect of vasopressin. The response beginning "Ranitidine neutralizes the acid" describes the effect of antacids. And the response beginning "Ranitidine covers the ulcer" describes the action of sucralfate (Carafate).

32. When counseling a patient with a family history of stomach cancer about ways to decrease risk for developing stomach cancer, the nurse will teach the patient to avoid a. smoked foods such as bacon and ham. b. foods that cause abdominal distention. c. chronic use of H2 blocking medications. d. emotionally or physically stressful situations.

ANS: A Smoked foods such as bacon, ham, and smoked sausage increase the risk for stomach cancer. Use of H2 blockers, stressful situations, and abdominal distention are not associated with an increased incidence of stomach cancer.

30. Which information will be best for the nurse to include when teaching a patient with peptic ulcer disease (PUD) about dietary management of the disease? a. "Avoid foods that cause pain after you eat them." b. "High-protein foods are least likely to cause pain." c. "You will need to remain on a bland diet indefinitely." d. "You should avoid eating many raw fruits and vegetables."

ANS: A The best information is that each individual should choose foods that are not associated with postprandial discomfort. Raw fruits and vegetables may irritate the gastric mucosa, but chewing well seems to decrease this and some patients may tolerate these well. High-protein foods help to neutralize acid, but they also stimulate hydrochloric (HCl) acid secretion and may increase discomfort for some patients. Bland diets may be recommended during an acute exacerbation of PUD, but there is little scientific evidence to support their use.

A client with a history of myocardial infarction calls the clinic to report the onset of a cough that is troublesome only at night. What direction does the nurse give to the client? a. "Please come into the clinic for an evaluation." b. "Increase your fluid intake during waking hours." c. "Use an over-the-counter cough suppressant." d. "Sleep on two pillows to facilitate postnasal drainage."

ANS: A The client with a history of myocardial infarction is at risk for developing heart failure. The onset of nocturnal cough is an early manifestation of heart failure, and the client needs to be evaluated as soon as possible.

The nurse is providing care to a client with infective endocarditis. What infection control precautions does the nurse use? a. Standard Precautions b. Bleeding Precautions c. Reverse isolation d. Contact isolation

ANS: A The client with infective endocarditis does not pose any specific threat of transmitting the causative organism.

A client with heart failure is due to receive enalapril (Vasotec) and has a blood pressure of 98/50 mm Hg. What is the nurse's best action? a. Administer the Vasotec. b. Recheck the blood pressure. c. Hold the Vasotec. d. Notify the health care provider.

ANS: A The nurse should administer the medication. Generally, the health care provider will maintain the client's blood pressure between 90 and 110 mm Hg.

27. A patient recovering from a gastrojejunostomy (Billroth II) for treatment of a duodenal ulcer develops dizziness, weakness, and palpitations about 20 minutes after eating. To avoid recurrence of these symptoms, the nurse teaches the patient to a. lie down for about 30 minutes after eating. b. choose foods that are high in carbohydrates. c. increase the amount of fluid intake with meals. d. drink sugared fluids or eat candy after each meal.

ANS: A The patient is experiencing symptoms of dumping syndrome, which may be reduced by lying down after eating. Increasing fluid intake and choosing high carbohydrate foods will increase the risk for dumping syndrome. Having a sweet drink or hard candy will correct the hypoglycemia that is associated with dumping syndrome but will not prevent dumping syndrome.

The nurse assesses a client and notes the presence of an S3 gallop. What is the nurse's best intervention? a. Assess for symptoms of left-sided heart failure. b. Document this as a normal finding. c. Call the health care provider immediately. d. Transfer the client to the intensive care unit.

ANS: A The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left ventricular pressure and left ventricular failure. The other actions are not warranted.

23. A patient with a bleeding duodenal ulcer has a nasogastric (NG) tube in place, and the health care provider orders 30 mL of aluminum hydroxide/magnesium hydroxide (Maalox) to be instilled through the tube every hour. To evaluate the effectiveness of this treatment, the nurse a. periodically aspirates and tests gastric pH. b. monitors arterial blood gas values on a daily basis. c. checks each stool for the presence of occult blood. d. measures the amount of residual stomach contents hourly.

ANS: A The purpose for antacids is to increase gastric pH. Checking gastric pH is the most direct way of evaluating the effectiveness of the medication. Arterial blood gases may change slightly, but this does not directly reflect the effect of antacids on gastric pH. Because the patient has upper gastrointestinal (GI) bleeding, occult blood in the stools will appear even after the acute bleeding has stopped. The amount of residual stomach contents is not a reflection of resolution of bleeding or of gastric pH.

The nurse is assessing a client with left-sided heart failure. What conditions does the nurse assess for? (Select all that apply.) a. Pulmonary crackles b. Confusion, restlessness c. Pulmonary hypertension d. Dependent edema e. S3/S4 summation gallop f. Cough worsens at night

ANS: A, B, E, F Left-sided failure occurs with a decrease in contractility of the heart or an increase in afterload. Most of the signs will be noted in the respiratory system. Right-sided failure occurs with problems from the pulmonary vasculature onward. Signs will be noted before the right atrium or ventricle.

The nurse is evaluating the laboratory results for a client with heart failure. What results does the nurse expect? (Select all that apply.) a. Hematocrit (Hct), 32.8% b. Serum sodium, 130 mEq/L c. Serum potassium, 4.0 mEq/L d. Serum creatinine, 1.0 mg/dL e. Proteinuria f. Microalbuminuria

ANS: A, B, E, F The hematocrit is low (should be 42.6%), indicating a dilutional ratio of red blood cells (RBCs) to fluid. The serum sodium is low because of hemodilution. Microalbuminuria and proteinuria are present, indicating a decrease in renal filtration. This is an early warning sign of decreased compliance of the heart.

34. Which information about a patient who has just been admitted to the hospital with nausea and vomiting will require the most rapid intervention by the nurse? a. The patient has taken only sips of water. b. The patient is lethargic and difficult to arouse. c. The patient's chart indicates a recent resection of the small intestine. d. The patient has been vomiting several times a day for the last 4 days.

ANS: B A lethargic patient is at risk for aspiration, and the nurse will need to position the patient to decrease aspiration risk. The other information also is important to collect, but it does not require as quick action as the risk for aspiration.

The nurse is administering captopril (Capoten) to a client with heart failure. What is the priority intervention for this client? a. Administer this medication before meals to aid absorption. b. Instruct the client to ask for assistance when arising from bed. c. Give the medication with milk to prevent stomach upset. d. Monitor the potassium level and check for symptoms of hypokalemia.

ANS: B Administration of the first dose of angiotensin-converting enzyme (ACE) inhibitors is often associated with hypotension, usually termed first-dose effect. The nurse should instruct the client to seek assistance before arising from bed to prevent injury from postural hypotension.

2. A patient who has been NPO during treatment for nausea and vomiting caused by gastric irritation is to start oral intake. Which of these should the nurse offer to the patient? a. A glass of orange juice b. A dish of lemon gelatin c. A cup of coffee with cream d. A bowl of hot chicken broth

ANS: B Clear liquids are usually the first foods started after a patient has been nauseated. Acidic foods such as orange juice, very hot foods, and coffee are poorly tolerated when patients have been nauseated.

The nurse is discharging a client home following mitral valve replacement. What statement indicates that the client requires further education? a. "I will be able to carry heavy loads after 6 months of rest." b. "I will have my teeth cleaned by the dentist in 2 weeks." c. "I will avoid eating foods high in vitamin K, like spinach." d. "I will use an electric razor instead of a straight razor to shave."

ANS: B Clients who have defective or repaired valves are at high risk for endocarditis. The client who has had valve surgery should avoid dental procedures for 6 months because of the risk for endocarditis. When undergoing any invasive procedure, the client needs to be placed on prophylactic antibiotics.

The nurse is assessing a client with a history of heart failure. What priority question assists the nurse to assess the client's activity level? a. "Do you have trouble breathing or chest pain?" b. "Are you able to walk upstairs without fatigue?" c. "Do you awake with breathlessness during the night?" d. "Do you have new-onset heaviness in your legs?"

ANS: B Clients with a history of heart failure generally have negative findings, such as shortness of breath. The nurse needs to determine whether the client's activity is the same or worse, or whether the client identifies a decrease in activity level.

38. Which of these assessment findings in a patient with a hiatal hernia who returned from a laparoscopic Nissen fundoplication 4 hours ago is most important for the nurse to address immediately? a. The patient is experiencing intermittent waves of nausea. b. The patient has absent breath sounds throughout the left lung. c. The patient has decreased bowel sounds in all four quadrants. d. The patient complains of 6/10 (0 to 10 scale) abdominal pain.

ANS: B Decreased breath sounds on one side may indicate a pneumothorax, which requires rapid diagnosis and treatment. The abdominal pain and nausea also should be addressed but they are not as high priority as the patient's respiratory status. The patient's decreased bowel sounds are expected after surgery and require ongoing monitoring but no other action.

22. The family member of a patient who has suffered massive abdominal trauma in an automobile accident asks the nurse why the patient is receiving famotidine (Pepcid). The nurse will explain that the medication will a. prevent aspiration of gastric contents. b. inhibit the development of stress ulcers. c. lower the chance for H. pylori infection. d. decrease the risk for nausea and vomiting.

ANS: B Famotidine is administered to prevent the development of physiologic stress ulcers, which are associated with a major physiologic insult such as massive trauma. Famotidine does not decrease nausea or vomiting, prevent aspiration, or prevent H. pylori infection.

A client with systolic dysfunction has an ejection fraction of 38%. The nurse assesses for which physiologic change? a. Increase in stroke volume b. Decrease in tissue perfusion c. Increase in oxygen saturation d. Decrease in arterial vasoconstriction

ANS: B In systolic dysfunction, the ventricle is unable to contract with enough force to eject blood effectively during systole. As the ejection fraction decreases (50% to 70% is normal), tissue perfusion decreases and the client develops activity intolerance. Stroke volume and oxygen saturation do not increase with a low ejection fraction.

The client with heart failure has been prescribed intravenous nitroglycerin and furosemide (Lasix) for pulmonary edema. Which is the priority nursing intervention? a. Insert an indwelling urinary catheter. b. Monitor the client's blood pressure. c. Place the nitroglycerin under the client's tongue. d. Monitor the client's serum glucose level.

ANS: B Intravenous nitroglycerin and morphine will decrease the client's blood pressure, so it is important to monitor closely for hypotension. Intravenous medications are not administered under the tongue. Although the client may need an indwelling urinary catheter to monitor output, it is not the priority. The client's glucose levels should not be affected by these medications.

The nurse is assessing a client admitted to the cardiac unit. What statement made by the client alerts the nurse to the possibility of right-sided heart failure? a. "I sleep with four pillows at night." b. "My shoes fit really tight lately." c. "I wake up coughing every night." d. "I have trouble catching my breath."

ANS: B Signs of systemic congestion occur with right-sided heart failure. Fluid is retained, pressure builds in the venous system, and peripheral edema develops. Left-sided heart failure symptoms include respiratory symptoms. Orthopnea, coughing, and difficulty breathing all could be results of left-sided heart failure.

The nurse notes that the client's apical pulse is displaced to the left. What conclusion can be drawn from this assessment? a. This is a normal finding. b. The heart is hypertrophied. c. The left ventricle is contracted. d. The client has pulsus alternans.

ANS: B The client with heart failure typically has an enlarged heart that displaces the apical pulse to the left.

A client with pericarditis is admitted to the cardiac unit. What assessment finding does the nurse expect in this client? a. Heart rate that speeds up and slows down b. Friction rub at the left lower sternal border c. Presence of a regularly gallop rhythm d. Coarse crackles in bilateral lung bases

ANS: B The client with pericarditis may present with a pericardial friction rub at the left lower sternal border. This sound is the result of friction from inflamed pericardial layers when they rub together. The other assessments are not relate

17. A patient with peptic ulcer disease associated with the presence of Helicobacter pylori is treated with triple drug therapy. The nurse will plan to teach the patient about a. sucralfate (Carafate), nystatin (Mycostatin), and bismuth (Pepto-Bismol). b. amoxicillin (Amoxil), clarithromycin (Biaxin), and omeprazole (Prilosec). c. famotidine (Pepcid), magnesium hydroxide (Mylanta), and pantoprazole (Protonix). d. metoclopramide (Reglan), bethanechol (Urecholine), and promethazine (Phenergan).

ANS: B The drugs used in triple drug therapy include a proton pump inhibitor such as omeprazole and the antibiotics amoxicillin and clarithromycin. The other combinations listed are not included in the protocol for H. pylori infection.

24. A patient with a peptic ulcer who has a nasogastric (NG) tube develops sudden, severe upper abdominal pain, diaphoresis, and a very firm abdomen. Which action should the nurse take next? a. Irrigate the NG tube. b. Obtain the vital signs. c. Listen for bowel sounds. d. Give the ordered antacid.

ANS: B The patient's symptoms suggest acute perforation, and the nurse should assess for signs of hypovolemic shock. Irrigation of the NG tube, administration of antacids, or both would be contraindicated because any material in the stomach will increase the spillage into the peritoneal cavity. The nurse should assess the bowel sounds, but this is not the first action that should be taken.

A client is being discharged home after a heart transplant with a prescription for cyclosporine (Sandimmune). What priority education does the nurse provide with the client's discharge instructions? a. "Use a soft-bristled toothbrush and avoid flossing." b. "Avoid large crowds and people who are sick." c. "Change positions slowly to avoid hypotension." d. "Check your heart rate before taking the medication."

ANS: B These agents cause immune suppression, leaving the client more vulnerable to infection.

The rehabilitation nurse is assisting a client with heart failure to increase activity tolerance. During ambulation of the client, identification of what symptom causes the nurse to stop the client's activity? a. Decrease in oxygen saturation from 98% to 95% b. Respiratory rate change from 22 to 28 breaths/min c. Systolic blood pressure change from 136 to 96 mm Hg d. Increase in heart rate from 86 to 100 beats/min

ANS: C A blood pressure change (increase or decrease) of greater than 20 mm Hg during or after activity indicates poor cardiac tolerance of the activity. A significant decrease (>20%) in blood pressure during or after activity is especially ominous, because it indicates an inability of the left ventricle to maintain sufficient cardiac output.

7. When admitting a patient with a stroke who is unconscious and unresponsive to stimuli, the nurse learns from the patient's family that the patient has a history of gastroesophageal reflux disease (GERD). The nurse will plan to do frequent assessments of the patient's a. apical pulse. b. bowel sounds. c. breath sounds. d. abdominal girth.

ANS: C Because GERD may cause aspiration, the unconscious patient is at risk for developing aspiration pneumonia. Bowel sounds, abdominal girth, and apical pulse will not be affected by the patient's stroke or GERD and do not require more frequent monitoring than the routine.

The nurse reminds the client who has received a heart transplant to change positions slowly. Why is this instruction a priority? a. Rapid position changes can create shear and friction forces, which can tear out internal vascular sutures. b. The new vascular connections are more sensitive to position changes, leading to increased intravascular pressure. c. The new heart is denervated and is unable to respond to decreases in blood pressure caused by position changes. d. The recovering heart diverts blood flow away from the brain when the client stands, increasing the risk for stroke.

ANS: C Because the new heart is denervated, the baroreceptor and other mechanisms that compensate for blood pressure drops caused by position changes do not function. This allows orthostatic hypotension to persist in the postoperative period.

1. A patient with deep partial-thickness burns experiences severe pain associated with nausea during dressing changes. Which action will be most useful in decreasing the patient's nausea? a. The patient NPO for 2 hours before and after dressing changes. b. Avoid performing dressing changes close to the patient's mealtimes. c. Administer the prescribed morphine sulfate before dressing changes. d. Give the ordered prochlorperazine (Compazine) before dressing changes.

ANS: C Because the patient's nausea is associated with severe pain, it is likely that it is precipitated by stress and pain. The best treatment will be to provide adequate pain medication before dressing changes. The nurse should avoid doing painful procedures close to mealtimes, but nausea/vomiting that occur at other times also should be addressed. Keeping the patient NPO does not address the reason for the nausea and vomiting and will have an adverse effect on the patient's nutrition. Administration of antiemetics is not the best choice for a patient with nausea caused by pain.

The nurse is assessing a client in an outpatient clinic. Which client statement alerts the nurse to possible left-sided heart failure? a. "I have been drinking more water than usual." b. "I have been awakened by the need to urinate at night." c. "I have to stop halfway up the stairs to catch my breath." d. "I have experienced blurred vision on several occasions."

ANS: C Clients with left-sided heart failure report weakness or fatigue while performing normal activities of daily living, as well as difficulty breathing, or "catching their breath." This occurs as fluid moves into the alveoli. Nocturia is often seen with right-sided heart failure. Thirst and blurred vision are not related to heart failure.

26. The nurse implements discharge teaching for a patient following a gastroduodenostomy for treatment of a peptic ulcer. Which patient statement indicates that the teaching has been effective? a. "Persistent heartburn is expected after surgery." b. "I will try to drink liquids along with my meals." c. "Vitamin supplements may be needed to prevent problems with anemia." d. "I will need to choose foods that are low in fat and high in carbohydrate."

ANS: C Cobalamin deficiency may occur after partial gastrectomy, and the patient may need to receive cobalamin via injections or nasal spray. Foods that have moderate fat and low carbohydrate should be chosen to prevent dumping syndrome. Ingestion of liquids with meals is avoided to prevent dumping syndrome. Although peptic ulcer disease may recur, persistent heartburn is not expected after surgery and the patient should call the health care provider if this occurs.

A client is admitted with early-stage heart failure. Which assessment finding does the nurse expect? a. A decrease in blood pressure and urine output b. An increase in creatinine and extremity edema c. An increase in heart rate and respiratory rate d. A decrease in respirations and oxygen saturation

ANS: C In heart failure, stimulation of the sympathetic nervous system represents the most immediate response. Adrenergic receptor stimulation causes an increase in heart rate and respiratory rate. Blood pressure will remain the same or will elevate slightly. Changes in creatinine occur when kidney damage has occurred, which is a later manifestation. Other later manifestations may include edema, increased respiratory rate, and lowered oxygen saturation readings.

29. The health care provider prescribes antacids and sucralfate (Carafate) for treatment of a patient's peptic ulcer. The nurse will teach the patient to take a. antacids 30 minutes before the sucralfate. b. sucralfate at bedtime and antacids before meals. c. antacids after eating and sucralfate 30 minutes before eating. d. sucralfate and antacids together 30 minutes before each meal.

ANS: C Sucralfate is most effective when the pH is low and should not be given with or soon after antacid. Antacids are most effective when taken after eating. Administration of sucralfate 30 minutes before eating and antacids just after eating will ensure that both drugs can be most effective. The other regimens will decrease the effectiveness of the medications.

37. After receiving change-of-shift report, which patient should the nurse assess first? a. A patient who was admitted yesterday with gastrointestinal (GI) bleeding and has melena b. A patient who is crying after receiving a diagnosis of esophageal cancer c. A patient with esophageal varices who has a blood pressure of 96/54 mm Hg d. A patient with nausea who has a dose of metoclopramide (Reglan) scheduled

ANS: C The patient's history and blood pressure indicate possible hemodynamic instability caused by GI bleeding. The data about the other patients do not indicate acutely life-threatening complications.

41. A patient with acute gastrointestinal (GI) bleeding is receiving normal saline IV at a rate of 500 mL/hr. Which assessment finding obtained by the nurse is most important to communicate immediately to the health care provider? a. The patient's blood pressure (BP) has increased to 142/94 mm Hg. b. The nasogastric (NG) suction is returning coffee-ground material. c. The patient's lungs have crackles audible to the midline. d. The bowel sounds are very hyperactive in all four quadrants.

ANS: C The patient's lung sounds indicate that pulmonary edema may be developing as a result of the rapid infusion of IV fluid and that the fluid infusion rate should be slowed. The return of coffee-ground material in an NG tube is expected for a patient with upper GI bleeding. The BP is slightly elevated but would not be an indication to contact the health care provider immediately. Hyperactive bowel sounds are common when a patient has GI bleeding.

11. A 62-year-old patient who has been diagnosed with esophageal cancer tells the nurse, "I know that my chances are not very good, but I do not feel ready to die yet." Which response by the nurse is most appropriate? a. "You may have quite a few years still left to live." b. "Thinking about dying will only make you feel worse." c. "Having this new diagnosis must be very hard for you." d. "It is important that you be realistic about your prognosis."

ANS: C This response is open-ended and will encourage the patient to further discuss feelings of anxiety or sadness about the diagnosis. Patients with esophageal cancer have only a low survival rate, so the response "You may have quite a few years still left to live" is misleading. The response beginning, "Thinking about dying" indicates that the nurse is not open to discussing the patient's fears of dying. And the response beginning, "It is important that you be realistic," discourages the patient from feeling hopeful, which is important to patients with any life-threatening diagnosis.

40. All of the following orders are received for a patient who has vomited 1500 mL of bright red blood. Which order will the nurse implement first? a. Insert a nasogastric (NG) tube and connect to suction. b. Administer intravenous (IV) famotidine (Pepcid) 40 mg. c. Draw blood for typing and crossmatching. d. Infuse 1000 mL of lactated Ringer's solution.

ANS: D Because the patient has vomited a large amount of blood, correction of hypovolemia and prevention of hypovolemic shock are the priorities. The other actions also are important to implement quickly but are not the highest priorities.

12. Which information will the nurse include when teaching a patient with newly diagnosed gastroesophageal reflux disease (GERD)? a. "Peppermint tea may be helpful in reducing your symptoms." b. "You should avoid eating between meals to reduce acid secretion." c. "Vigorous physical activities may increase the incidence of reflux." d. "It will be helpful to keep the head of your bed elevated on blocks."

ANS: D Elevating the head of the bed will reduce the incidence of reflux while the patient is sleeping. Peppermint will lower LES pressure and increase the chance for reflux. Small, frequent meals are recommended to avoid abdominal distention. There is no need to make changes in physical activities because of GERD.

9. After the nurse teaches a patient with gastroesophageal reflux disease (GERD) about recommended dietary modifications, which diet choice for a snack 2 hours before bedtime indicates that the teaching has been effective? a. Chocolate pudding b. Glass of low-fat milk c. Peanut butter sandwich d. Cherry gelatin and fruit

ANS: D Gelatin and fruit are low fat and will not decrease lower esophageal sphincter (LES) pressure. Foods like chocolate are avoided because they lower LES pressure. Milk products increase gastric acid secretion. High-fat foods such as peanut butter decrease both gastric emptying and LES pressure.

A client is taking triamterene-hydrochlorothiazide (Dyazide) and furosemide (Lasix). What assessment finding requires action by the nurse? a. Cough b. Headache c. Pulse of 62 beats/min d. Potassium of 2.9 mEq/L

ANS: D Hypokalemia is a side effect of both thiazide and loop diuretics. The client loses electrolytes with fluid. Coughing is not a typical side effect of this medication. Headache may occur with any medication and is not a serious side effect. Bradycardia is not likely to occur with this medication.

28. A patient who requires daily use of a nonsteroidal anti-inflammatory drug (NSAID) for management of severe rheumatoid arthritis has recently developed melena. The nurse will anticipate teaching the patient about a. substitution of acetaminophen (Tylenol) for the NSAID. b. use of enteric-coated NSAIDs to reduce gastric irritation. c. reasons for using corticosteroids to treat the rheumatoid arthritis. d. the benefits of misoprostol (Cytotec) in protecting the gastrointestinal (GI) mucosa.

ANS: D Misoprostol, a prostaglandin analog, reduces acid secretion and incidence of upper GI bleeding associated with NSAID use. Enteric coating of NSAIDs does not reduce the risk for GI bleeding. Corticosteroids increase the risk for ulcer development and will not be substituted for NSAIDs for this patient. Acetaminophen will not be effective in treating the patient's rheumatoid arthritis.

A client with end-stage heart failure is awaiting a transplant. The client appears depressed and states, "I know a transplant is my last chance, but I don't want to become a vegetable." What is the nurse's best response? a. "Would you like to speak with a priest or chaplain?" b. "I will consult a psychiatrist to speak with you." c. "Do you want to come off the transplant list?" d. "Would you like information about advance directives?"

ANS: D The client is verbalizing a real concern or fear about negative outcomes of the surgery. This anxiety itself can have a negative effect on the outcome of the surgery because of sympathetic stimulation. The best action is to allow the client to verbalize the concern and work toward a positive outcome without making the client feel as though he or she is crazy. The client needs to feel that he or she has some control over the future.

A client has been admitted to the intensive care unit with worsening pulmonary manifestations of heart failure. What is the nurse's best action? a. Place the client in a high Fowler's position. b. Begin cardiopulmonary resuscitation (CPR). c. Promote rest and minimize activities. d. Administer loop diuretics as prescribed.

ANS: D The client with worsening heart failure is most at risk for pulmonary edema as a consequence of fluid retention. Administering diuretics will decrease the fluid overload, thereby decreasing the incidence of pulmonary edema. High Fowler's position might help the client breathe easier but will not solve the problem. CPR is not warranted in this situation. Rest is important for clients with heart failure, but this is not the priority.

The nurse is obtaining the admission health history for a young adult who presents with fever, dyspnea, and a murmur. What priority data does the nurse inquire about? a. Family history of coronary artery disease b. Recent travel to Third World countries c. Pet ownership, especially cats with litter boxes d. History of a systemic infection within the past month

ANS: D The clinical manifestations suggest infective endocarditis, which can occur within 2 to 4 weeks after a systemic infection or bacteremia. Assessing for coronary artery disease, recent travel, or pet ownership is not related to endocarditis.

39. A patient who is vomiting bright red blood is admitted to the emergency department. Which assessment should the nurse perform first? a. Checking the level of consciousness b. Measuring the quantity of any emesis c. Auscultating the chest for breath sounds d. Taking the blood pressure (BP) and pulse

ANS: D The nurse is concerned about blood loss and possible hypovolemic shock in a patient with acute gastrointestinal (GI) bleeding; BP and pulse are the best indicators of these complications. The other information also is important to obtain, but BP and pulse rate are the best indicators for hypoperfusion.

31. A patient with a recent 20-pound unintended weight loss is diagnosed with stomach cancer. Which nursing action will be included in the plan of care? a. Refer the patient for hospice services. b. Infuse IV fluids through a central line. c. Teach the patient about antiemetic therapy. d. Offer supplemental feedings between meals.

ANS: D The patient data indicate a poor nutritional state and improvement in nutrition will be helpful in improving response to therapies such as surgery, chemotherapy, or radiation. Nausea and vomiting are not common clinical manifestations of stomach cancer. There is no indication that the patient requires hospice or IV fluid infusions.

8. A patient with recurring heartburn receives a new prescription for esomeprazole (Nexium). In teaching the patient about this medication, the nurse explains that this drug a. neutralizes stomach acid and provides relief of symptoms in a few minutes. b. reduces the reflux of gastric acid by increasing the rate of gastric emptying. c. coats and protects the lining of the stomach and esophagus from gastric acid. d. treats gastroesophageal reflux disease by decreasing stomach acid production.

ANS: D The proton pump inhibitors decrease the rate of gastric acid secretion. Promotility drugs such as metoclopramide (Reglan) increase the rate of gastric emptying. Cryoprotective medications such as sucralfate (Carafate) protect the stomach. Antacids neutralize stomach acid and work rapidly.

3. Several clients are admitted to an adult medical unit. The nurse would ensure airborne precautions for a client with which of the following medical conditions? a. A diagnosis of AIDS and cytomegalovirus b. A positive PPD with an abnormal chest x-ray c. A tentative diagnosis of viral pneumonia d. Advanced carcinoma of the lung

Answer B. The client who must be placed in airborne precautions is the client with a positive PPD (purified protein derivative) who has a positive x-ray for a suspicious tuberculin lesion.

1. A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which of the following nursing measures should the nurse do FIRST? a. Institute seizure precautions b. Assess neurologic status c. Place in respiratory isolation d. Assess vital signs

Answer C. The initial therapeutic management of acute bacterial meningitis includes isolation precautions, initiation of antimicrobial therapy and maintenance of optimum hydration. Nurses should take necessary precautions to protect themselves and others from possible infection.

2. A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is MOST appropriate for this client? a. Reverse isolation b. Respiratory isolation c. Standard precautions d. Contact isolation

Answer D. Contact or Body Substance Isolation (BSI) involves the use of barrier protection (e.g. gloves, mask, gown, or protective eyewear as appropriate) whenever direct contact with any body fluid is expected. When determining the type of isolation to use, one must consider the mode of transmission. The hands of personnel continues to be the principal mode of transmission for methicillin resistant staphylococcus aureus (MRSA). Because the organism is limited to the sputum in this example, precautions are taken if contact with the patient"s sputum is expected. A private room and BSI, along with good hand washing techniques, are the best defense against the spread of MRSA pneumonia

What physical assessment data is necessary to calculate a pt's cardiac index (CI)? 1. weight & height 2. weight only 3. weight & waist measurement 4. waist measurement & height

Answer: 1 Rationale 1: Cardiac index (CI) is the cardiac output adjusted for the pt's body size or body surface area. Body surface area is calculated using height & weight measurements. Rationale 2,3,4: Body surface area is calculated using height & weight measurements.

In the pt w/ hypovolemic shock, the nurse realizes that the heart sounds will change in which of the following ways? 1. diminished S2 & accentuated 2. accentuated S2 & diminished S1 3. S1diminished S1 & S2 4. no change in S1 or S2

Answer: 1 Rationale 1: Diminished S2 occurs due to a fall in blood pressure & accentuated S1 occurs because of the tachycardia. The three earliest signs of hypovolemic shock are tachycardia, delayed capillary refill, & restlessness.

A pt received an implantable cardioverter-defibrillator (ICD). The nurse would include which instruction during discharge teaching for this pt? 1. "If a family member is in direct contact with you when the ICD discharges, he or she may experience a shock or tingling sensation." 2. "You can activate the ICD whenever you feel a change in your heart rhythm." 3. "The batteries of the ICD won't need to be replaced if the ICD never shocks the heart." 4. "There should be no discomfort if the ICD discharges & you probably won't notice it."

Answer: 1 Rationale 1: Family members may receive a shock or tingling sensation when in direct contact with an individual when their ICD discharges. Rationale 2: The ICD is programmed to automatically activate when detecting a potentially lethal cardiac rhythm & cannot be activated by the pt. Rationale 3: Batteries must be surgically replaced every five years or following manufacturer's instructions. Rationale 4: Some pts experience significant discomfort with ICD discharge.

Which is the priority nursing intervention for a pt with a junctional escape rhythm? 1. Assess the pt for symptoms associated with this rhythm. 2. Contact the physician immediately for emergency orders. 3. Eliminate caffeine from the diet. 4. Prepare for a pacemaker insertion.

Answer: 1 Rationale 1: Junctional escape rhythms may be monitored if the pt is not symptomatic. It is most important to assess the pt to see how they are affected by the rhythm. Rationale 2: Then, calling the physician to report the rhythm may be appropriate. Rationale 3: Eliminating caffeine is not an appropriate action for this pt with a junctional escape rhythm. No indication of symptoms relating to the rhythm was given. Rationale 4: Preparing for a pacemaker insertion is not an appropriate action for this pt with a junctional escape rhythm. No indication of symptoms relating to the rhythm was given

Premature ventricular contractions (PVCs) are best characterized by which statement? 1. They are insignificant in people with no history of heart disease. 2. PVCs typically have no pattern. 3. The frequency of PVCs is not associated with specific events. 4. Their incidence & significance has no relevance to the pt having had a myocardial infarction.

Answer: 1 Rationale 1: PVCs often have no significance in people without history of heart disease. Rationale 2: PVCs may be isolated or occur in specific patterns. Rationale 3: They may be triggered by anxiety or stress; tobacco, alcohol or caffeine use; hypoxia, acidosis, & electrolyte imbalances; sympathomimetic drugs; & coronary heart disease. Rationale 4: They may be associated with an increased risk for lethal dysrhythmias & their incidence & significance is greatest after myocardial infarction.

At which location will S1 be heard the loudest? 1. left midclavicular line at the fifth intercostal space 2. left sternal border at the fifth intercostal space 3. right midclavicular line at the fifth intercostal space 4. right sternal border at the third intercostal space

Answer: 1 Rationale 1: S1 is the sound produced by the atrioventricular (AV) valves closing. The apex of the heart is located lower on the left chest wall than the base of the heart. The loudest sounds can be heard over the apex of the heart. Rationale 2: The sound is audible at the left sternal border, but would not be as loud. Rationale 3: This sound would not normally be audible on the right midclavicular line at the5th intercostal space. Rationale 4: This sound would not normally be audible at the sternal border.

When listening to heart sounds, the nurse expects to hear S1 & S2. The presence of an additional sound immediately following S2 is called _____, which can result from _____. 1. S3, ventricular volume overload 2. S4, increased resistance to ventricular filling 3. S4, inflammation of the pericardial sac 4. S3, a stenotic mitral valve

Answer: 1 Rationale 1: S3 is an abnormal (pathologic) heart sound heard immediately following S2 in adults. It is often called a ventricular gallop & results from conditions such as congestive heart failure (CHF), mitral, or tricuspid valve regurgitation. Rationale 2: S4 immediately precedes S1 & can result from conditions such as anemia or a change in ventricular compliance. Rationale 3: S4 immediately precedes S1 & can result from conditions such as anemia or a change in ventricular compliance. Rationale 4: S3 is an abnormal (pathologic) heart sound heard immediately following S2 in adults. It is often called a ventricular gallop & results from conditions such as congestive heart failure (CHF), mitral, or tricuspid valve regurgitation

The nurse is caring for an adult pt who is admitted with chest pain that began four hours ago. Which test will be most specific in identifying acute heart damage? 1. troponin 2. CPK 3. CK-MB 4. cholesterol

Answer: 1 Rationale 1: Troponin is primarily located in cardiac muscle & can indicate myocardial infarction or unstable angina. Troponin elevates at two to four hours after myocardial infarction. Rationale 2,3: CPK & CK-MB will elevate with myocardial damage, but will take longer to rise & are not as specific as troponin. Rationale 4: Cholesterol level is not helpful in diagnosis of myocardial damage.

17. The nurse recognizes that which of the following is a modifiable contributor to a patient's perception of pain? • Age and gender • Anxiety and fear • Culture • Previous pain experience

Anxiety and fear

21. A nurse receives an order from a health care provider to administer Vicodin ES, which contains 750 mg acetaminophen and 7.5 mg hydrocodone, to a patient who is experiencing 8/10 postsurgical pain. The order is to give 2 tablets every 6 hours by mouth as needed for pain. What is the nurse's best next action? • Give the Vicodin ES to the patient immediately because the patient is experiencing severe pain. • Ask the health care provider to verify the dosage and frequency of the medication. • Ask the health care provider for an order for a nonsteroidal anti-inflammatory drug (NSAID). • Ask the health care provider for an order to play music for the patient, in addition to providing the pain medication.

Ask the health care provider to verify the dosage and frequency of the medication.

30. The nurse is caring for a patient who suddenly experiences chest pain. What is the nurse's first priority? • Call the rapid response team. • Ask the patient to rate and describe the pain. • Raise the head of the bed. • Administer pain relief medications.

Ask the patient to rate and describe the pain.

Your patient developed respirator depression after her first dose of intravenous (IV) morphine. After giving 0.2mg of nalozone (Narcan) IV push, the patient's respiratory rate and depth are within normal limits. Which action do you take now? a. Leave the patient alone to sleep now. b. Discontinue all pain medications ordered c. Administer another dose of naloxone in 1 hours d. Assess the patient's vital signs every 15 minutes for 2 hours

Asses the patients vital signs every 15 mins for 2 hours

3. When assessing a patient's surgical dressing on the first postoperative day, the nurse notes new, bright-red drainage about 5 cm in diameter. In response to this finding, what should the nurse do first? Recheck in 1 hour for increased drainage. Notify the surgeon of a potential hemorrhage. Assess the patient's blood pressure and heart rate. Remove the dressing and assess the surgical incision.

Assess the patient's blood pressure and heart rate. The first action by the nurse is to gather additional assessment data to form a more complete clinical picture. The nurse can then report all of the findings. Continued reassessment will be done. Agency policy determines whether the nurse may change the dressing for the first time or simply reinforce it.

For a client with an 8-cm abdominal aortic aneurysm, which problem must be addressed immediately to prevent rupture? A. Heart rate 52 beats/min B. Blood pressure 192/102 mm Hg C. Report of constipation D. Anxiety

B Elevated blood pressure can increase the rate of aneurysmal enlargement and risk for early rupture.

When administering furosemide (Lasix) to a client who does not like bananas or orange juice, the nurse recommends that the client try which intervention to maintain potassium levels? A. Increase red meat in the diet. B. Consume melons and baked potatoes. C. Add several portions of dairy products each day. D. Try replacing your usual breakfast with oatmeal or Cream of Wheat.

B Melons and baked potatoes contain potassium. Red meat is high in saturated fat and is to be consumed sparingly. Dairy products are high in calcium. Cereals are fortified with iron; oatmeal contains fiber but not potassium

When caring for a client with an abdominal aortic aneurysm (AAA), the nurse suspects dissection of the aneurysm when the client makes which statement? A. "I feel my heart beating in my abdominal area." B. "I just started to feel a tearing pain in my belly." C. "I have a headache. May I have some acetaminophen?" D. "I have had hoarseness for a few weeks."

B Severe pain of sudden onset in the back or lower abdomen, which may radiate to the groin, buttocks, or legs, is indicative of impending rupture of AAA.

A 62-year-old woman patient is scheduled for a percutaneous transhepatic cholangiography to restore biliary drainage. The nurse discusses the patient's health history and is most concerned if the patient makes which statement? A "I am allergic to bee stings." B "My tongue swells when I eat shrimp." C "I have had epigastric pain for 2 months." D "I have a pacemaker because my heart rate was slow."

B "My tongue swells when I eat shrimp." The percutaneous transhepatic cholangiography procedure will include the use of radiopaque contrast medium. Patients allergic to shellfish and iodine are also allergic to contrast medium. Having a pacemaker will not affect the patient during this procedure. It would be expected that the patient would have some epigastric pain given the patient's condition.

Inspection of an older patient's mouth reveals the presence of white, curd-like lesions on the patient's tongue. What is the most likely etiology for this abnormal assessment finding? A Herpesvirus B Candida albicans C Vitamin deficiency D Irritation from ill-fitting dentures

B Candida albicans White, curd-like lesions surrounded by erythematous mucosa are associated with oral candidiasis. Herpesvirus causes benign vesicular lesions in the mouth. Vitamin deficiencies may cause a reddened, ulcerated, swollen tongue. Irritation from ill-fitting dentures will cause friable, edematous, painful, bleeding gingivae.

The patient had a car accident and was "scared to death." The patient is now reporting constipation. What affecting the gastrointestinal (GI) tract does the nurse know could be contributing to the constipation? A The patient is too nervous to eat or drink, so there is no stool. B The sympathetic nervous system was activated, so the GI tract was slowed. C The parasympathetic nervous system is now functioning to slow the GI tract. D The circulation in the GI system has been increased, so less waste is removed.

B The sympathetic nervous system was activated, so the GI tract was slowed The constipation is most likely related to the sympathetic nervous system activation from the stress related to the accident. SNS activation can decrease peristalsis. Even without oral intake for a short time, stool will be formed. The parasympathetic system stimulates peristalsis. The circulation to the GI system is decreased with stress.

A 61-year-old patient with suspected bowel obstruction had a nasogastric tube inserted at 4:00 AM. The nurse shares in the morning report that the day shift staff should check the tube for patency at what times? A. 7:00 AM, 10:00 AM, and 1:00 PM B. 8:00 AM, 12:00 PM, and 4:00 PM C. 9:00 AM and 3:00 PM D. 9:00 AM, 12:00 PM, and 3:00 PM

B. 8:00 AM, 12:00 PM, and 4:00 PM A nasogastric tube should be checked for patency routinely at 4-hour intervals. Thus if the tube were inserted at 4:00 AM, it would be due to be checked at 8:00 AM, 12:00 PM, and 4:00 PM.

The postoperative patient is receiving epidural fentanyl for pain relief. For which common side effects should the nurse monitor the patient (select all that apply)? A. Ataxia B. Itching C. Nausea D. Urinary retention E. Gastrointestinal bleeding

B, C, D. Common side effects of intraspinal opioids include nausea, itching, and urinary retention. Ataxia is a common side effect of intraspinal clonidine.

After administering a dose of promethazine (Phenergan) to a patient with nausea and vomiting, what common temporary adverse effect of the medication does the nurse explain may be experienced? A. Tinnitus B. Drowsiness C. Reduced hearing D. Sensation of falling

B. Drowsiness Although being given to this patient as an antiemetic, promethazine also has sedative and amnesic properties. For this reason, the patient is likely to experience drowsiness as an adverse effect of the medication. Tinnitus, reduced hearing, and loss of balance are not side effects of promethazine.

The nurse caring for the client with heart failure is concerned that digoxin toxicity has developed. For which signs and symptoms of digoxin toxicity does the nurse notify the provider? Select all that apply. a. Hypokalemia b. Sinus bradycardia c. Fatigue d. Serum digoxin level of 1.5 e. Anorexia

B, C, E: Digoxin toxicity may be manifested by bradycardia, fatigue, and/or anorexia. A - Incorrect: Hypokalemia causes increased sensitivity to the drug and toxicity, but it is not a symptom of toxicity. D - Incorrect: This represents a therapeutic value that is between 0.8 and 2.0.

The nurse is doing discharge teaching with the patient and spouse of the patient who just received an implantable cardioverter-defibrillator (ICD) in the left side. Which statement by the patient indicates to the nurse that the patient needs more teaching? A. "I will call the cardiologist if my ICD fires." B. "I cannot fly because it will damage the ICD." C. "I cannot move my left arm until it is approved." D. "I cannot drive until my cardiologist says it is okay."

B. "I cannot fly because it will damage the ICD." The patient statement that flying will damage the ICD indicates misunderstanding about flying. The patient should be taught that informing TSA about the ICD can be done because it may set off the metal detector and if a hand-held screening wand is used, it should not be placed directly over the ICD. The other options indicate the patient understands the teaching.

The patient's neuropathic pain is not well controlled with the opioid analgesic prescribed. What medications may be added for a multimodal approach to treat the patient's pain (select all that apply)? A. NSAIDs B. Fentanyl C. Antiseizure drugs D. β-adrenergic agonists E. Tricyclic antidepressants

C, E. Antiseizure drugs, tricyclic antidepressants, SNRIs, transdermal lidocaine, and α2-adrenergic agonists will be used for multimodal treatment when opioid analgesics alone do not control neuropathic pain.

The patient who is admitted with a diagnosis of diverticulitis and a history of irritable bowel disease and gastroesophageal reflux disease (GERD) has received a dose of Mylanta 30 mL PO. The nurse should evaluate its effectiveness by questioning the patient as to whether which symptom has been resolved? A. Diarrhea B. Heartburn C. Constipation D. Lower abdominal pain

B. Heartburn Mylanta is an antacid that contains both aluminum and magnesium. It is indicated for the relief of GI discomfort, such as heartburn associated with GERD. Mylanta can cause both diarrhea and constipation as a side effect. Mylanta does not affect lower abdominal pain.

The nurse is planning care for a 68-year-old patient with an abdominal mass and suspected bowel obstruction. Which factor in the patient's history increases the patient's risk for colorectal cancer? A. Osteoarthritis B. History of colorectal polyps C. History of lactose intolerance D. Use of herbs as dietary supplements

B. History of colorectal polyps A history of colorectal polyps places this patient at risk for colorectal cancer. This tissue can degenerate over time and become malignant. Osteoarthritis, lactose intolerance, and the use of herbs do not pose additional risk to the patient.

What information would have the highest priority to be included in preoperative teaching for a 68-year-old patient scheduled for a colectomy? A. How to care for the wound B. How to deep breathe and cough C. The location and care of drains after surgery D. Which medications will be used during surgery

B. How to deep breathe and cough Because anesthesia, an abdominal incision, and pain can impair the patient's respiratory status in the postoperative period, it is of high priority to teach the patient to cough and deep breathe. Otherwise, the patient could develop atelectasis and pneumonia, which would delay early recovery from surgery and hospital discharge. Care for the wound and location and care of the drains will be briefly discussed preoperatively, but done again with higher priority after surgery. Knowing which drugs will be used during surgery may not be meaningful to the patient and should be reviewed with the patient by the anesthesiologist.

When administering medications to the client with chronic kidney disease, the nurse recognizes that which of these medications is most effective in slowing the progression of kidney failure? A. Diltiazem (Cardizem) B. Lisinopril (Zestril) C. Clonidine (Catapres) D. Doxazosin (Cardura)

B. Lisinopril (Zestril): Angiotensin-converting enzyme (ACE) inhibitors appear to be the most effective drugs to slow the progression of kidney failure. Calcium channel blockers (diltiazem/Cardizem) may indirectly prevent kidney disease by controlling hypertension but are not specific to slowing progression of kidney disease.

With peripheral arterial insufficiency, leg pain during rest can be reduced by: a. Elevating the limb above heart level b. Lowering the limb so it is dependent c. Massaging the limb after application of cold compresses d. Placing the limb in a plane horizontal to the body

B. Lowering the limb so it is dependent

The nurse should administer an as-needed dose of magnesium hydroxide (MOM) after noting what information while reviewing a patient's medical record? A. Abdominal pain and bloating B. No bowel movement for 3 days C. A decrease in appetite by 50% over 24 hours D. Muscle tremors and other signs of hypomagnesemia

B. No bowel movement for 3 days MOM is an osmotic laxative that produces a soft, semisolid stool usually within 15 minutes to 3 hours. This medication would benefit the patient who has not had a bowel movement for 3 days. MOM would not be given for abdominal pain and bloating, decreased appetite, or signs of hypomagnesemia.

The patient has atrial fibrillation with a rapid ventricular response. The nurse knows to prepare for which treatment if an electrical treatment is planned for this patient? A. Defibrillation B. Synchronized cardioversion C. Automatic external defibrillator (AED) D. Implantable cardioverter-defibrillator (ICD)

B. Synchronized cardioversion Synchronized cardioversion is planned for a patient with supraventricular tachydysrhythmias (atrial fibrillation with a rapid ventricular response). Defibrillation or AEDs are the treatment of choice to end ventricular fibrillation and pulseless ventricular tachycardia (VT). An ICD is used with patients who have survived sudden cardiac death (SCD), have spontaneous sustained VT, and are at high risk for future life-threatening dysrhythmias.

To reduce the risk of adverse effects, what should the nurse do when caring for a patient receiving morphine sulfate via patient-controlled analgesia (PCA)? A. Instruct the patient not to push the button too frequently. B. Teach the caregiver not to push the button for the patient. C. Ask the patient to do deep breathing exercises every hour. D. Administer medications to prevent the occurrence of diarrhea.

B. Teach the caregiver not to push the button for the patient. It is important to teach the caregiver not to push the button for the patient because it is only the patient who can determine the need for the medication. If the caregiver pushes the button, the patient could receive more of a dose than is actually needed, and this increases the risk of adverse effects.

When caring for the client with acute kidney injury and a temporary subclavian hemodialysis catheter, which of these should the nurse report to the provider? A. Crackles at lung bases B. Temperature of 100.8 F C. +1 ankle edema D. Anorexia

B. Temperature of 100.8 F: Infection is a major complication of temporary catheters. Report all symptoms of infection, including fever, to the provider. The catheter may have to be removed. Some degree of fluid retention is expected. Rising blood urea nitrogen (BUN) may result in anorexia, nausea, and vomiting.

The nurse obtains a 6-second rhythm strip and charts the following analysis: TAB 1 ATRIAL DATA: Rate: 70, regular; Variable PR interval; Independent beats TAB 2 VENTRICULAR DATA: Rate: 40, regular; Isolated escape beats TAB 3 ADDITIONAL DATA: QRS: 0.04 sec; P wave and QRS complexes unrelated What is the correct interpretation of this rhythm strip? A. Sinus arrhythmias B. Third-degree heart block C. Wenckebach phenomenon D. Premature ventricular contractions

B. Third-degree heart block Third-degree heart block represents a loss of communication between the atrium and ventricles from AV node dissociation. This is depicted on the rhythm strip as no relationship between the P waves (representing atrial contraction) and QRS complexes (representing ventricular contraction). The atria are beating totally on their own at 70 beats/min, whereas the ventricles are pacing themselves at 40 beats/min. Sinus dysrhythmia is seen with a slower heart rate with exhalation and an increased heart rate with inhalation. In Wenckebach heart block, there is a gradual lengthening of the PR interval until an atrial impulse is nonconducted and a QRS complex is blocked or missing. Premature ventricular contractions (PVCs) are the early occurrence of a wide, distorted QRS complex.

The home health nurse visits a client with heart failure who has gained 5 pounds in the past 3 days. The client states, "I feel so tired and short of breath." Which action should the nurse take first? a. Assess the client for peripheral edema. b. Listen to the client's posterior breath sounds. c. Notify the physician about the client's weight gain. d. Remind the client about dietary sodium restrictions.

B: Because the client is at risk for pulmonary edema and hypoxemia, the first action should be to assess breath sounds. Assessment of edema may be delayed while the nurse focuses on breathing and breath sounds. After a full assessment, the nurse should notify the physician. Defer this action until physiologic stability is attained; then ask the client about behaviors that may have caused the weight gain, such as increased sodium intake or changes in medications.

A client with heart failure has furosemide (Lasix). Which finding would concern the nurse with this new prescription? a. Serum sodium level of 135 mEq/L b. Serum potassium level of 2.8 mEq/L c. Serum creatinine of 1.0 mg/dL d. Serum magnesium level of 1.9 mEq/L

B: Clients taking loop diuretics should be monitored for potassium deficiency from diuretic therapy.

How does the nurse in the cardiac clinic recognize that the client with heart failure has demonstrated a positive outcome related to the addition of metoprolol (Lopressor) to the medication regimen? a. Ejection fraction is 25%. b. Client states that she is able to sleep on one pillow. c. Client was hospitalized five times last year with pulmonary edema. d. Client reports that she experiences palpitations.

B: Improvement in activity tolerance, less orthopnea, and improved symptoms represent a positive response to beta blockers. An ejection fraction of 25% is well below the normal ejection fraction of 50% to 70% and indicates poor cardiac output. Repeated hospitalization for acute exacerbation of left-sided heart failure does not demonstrate a positive outcome. Although metoprolol decreases the heart rate, palpitations are defined as the feeling of the heart beating fast in the chest; this is not a positive outcome.

The client who has been admitted for the third time this year for cardiac failure says, "This isn't worth it anymore. I just want it all to end." What is the nurse's best response? a. Calls the family to lift the client's spirits b. Considers further assessment for depression c. Sedates the client to decrease myocardial oxygen demand d. Tells the client that things will get better

B: This client is at risk for depression because of the diagnosis of heart failure, and further assessment should be done. Calling the family to help distract the client does not address the core issue. Sedation is inappropriate in this situation because it ignores the client's feelings. Telling the client that things will get better may give the client false hope and ignores his feelings.

Which of these clients is best to assign to an LPN/LVN working on the telemetry unit? a. A client with heart failure who is receiving dobutamine (Dobutrex) b. A client with restrictive cardiomyopathy who uses oxygen for exertional dyspnea c. A client with pericarditis who has a paradoxical pulse and distended jugular veins d. A client with rheumatic fever who has a new systolic murmur

B: This client, who needs oxygen only with exertion, is the most stable; administration of oxygen to a stable client is within the scope of LPN/LVN practice. Option A: This client is receiving an intravenous inotropic agent, which requires monitoring by the professional nurse. Option C: This client is displaying signs of cardiac tamponade and requires immediate life-saving intervention. Option D: A new-onset murmur requires assessment and notification of the provider, which is within the scope of practice of the professional nurse.

A patient who uses a fentanyl (Duragesic) patch for chronic cancer pain complains to the nurse of the rapid onset of pain at a level 9 (of a 0-10 scale) and requests "something for pain that will work quickly." The best way for the nurse to document this information is as a. breakthrough pain. b. neuropathic pain. c. somatic pain. d. referred pain

Breakthrough pain

Essential hypertension would be diagnosed in a 40-year-old male whose blood pressure readings were consistently at or above which of the following? A. 120/ 90 mm Hg. B. 130/ 85 mm Hg. C. 140/ 90 mm Hg. D. 160/ 80 mm Hg.

C American Heart Association standards define hypertension as a consistent systolic blood pressure level greater than 140 mm Hg and a consistent diastolic blood pressure level greater than 90 mm Hg.

Which teaching point does the nurse include for a client with peripheral arterial disease (PAD)? A. "Elevate your legs above heart level to prevent swelling." B. "Inspect your legs daily for brownish discoloration around the ankles." C. "Walk to the point of leg pain, then rest, resuming when pain stops." D. "Apply a heating pad to the legs if they feel cold."

C Exercise may improve arterial blood flow by building collateral circulation; instruct the client to walk until the point of claudication, stop and rest, and then walk a little farther.

The client undergoing femoral popliteal bypass states that he is fearful he will lose the limb in the near future. Which response by the nurse is most therapeutic? A. "Are you afraid you will not be able to work?" B. "If you control your diabetes, you can avoid amputation." C. "Your concerns are valid; we can review some steps to limit disease progression." D. "What about the situation concerns you most?"

C It is important to validate the client's concern and offer needed information. Asking the client if he is afraid may identify fear but does not allow the client to discuss his specific concern.

A client with peripheral arterial disease (PAD) has undergone percutaneous transluminal angioplasty (PTA) of the lower extremity. What is essential for the nurse to assess after the procedure? A. Ankle-brachial index B. Dye allergy C. Pedal pulses D. Gag reflex

C Priority nursing care focuses on assessment for bleeding at the arterial puncture site and monitoring for distal pulses. Pulse checks must be assessed postprocedure to detect improvement (stronger pulses) or complications (diminished or absent pulses).

When caring for the patient with heart failure, the nurse knows that which gastrointestinal process is most dependent on cardiac output and may affect the patient's nutritional status? A Ingestion B Digestion C Absorption D Elimination

C Absorption Substances that interface with the absorptive surfaces of the GI tract (primarily in the small intestine) diffuse across the intestinal membranes into intestinal capillaries and are then carried to other parts of the body for use in energy production. The cardiac output provides the blood flow for this absorption of nutrients to occur.

When assessing a patient's abdomen, what would be most appropriate for the nurse to do? A Palpate the abdomen before auscultation. B Percuss the abdomen before auscultation. C Auscultate the abdomen before palpation. D Perform deep palpation before light palpation.

C Auscultate the abdomen before palpation. During examination of the abdomen, auscultation is done before percussion and palpation because these latter procedures may alter the bowel sounds.

A patient who is scheduled for surgery with general anesthesia in 1 hour is observed with a moist, but empty water glass in his hand. Which assessment finding may indicate that the patient drank a glass of water? A Flat abdomen without movement upon inspection B Tenderness at left upper quadrant upon palpation C Easily heard, loud gurgling in the right upper quadrant D High-pitched, hollow sounds in the left upper quadrant

C Easily heard, loud gurgling in the right upper quadrant If the patient drank water on an empty stomach, gurgling can be assessed without a stethoscope or assessed with auscultation. High-pitched, hollow sounds are tympanic and indicate an empty cavity. A flat abdomen and tenderness do not indicate that the patient drank a glass of water.

The nurse is assessing a 50-year-old woman admitted with a possible bowel obstruction. Which assessment finding would be expected in this patient? A Tympany to abdominal percussion B Aortic pulsation visible in epigastric region C High-pitched sounds on abdominal auscultation D Liver border palpable 1 cm below the right costal margin

C High-pitched sounds on abdominal auscultation The bowel sounds are more high pitched (rushes and tinkling) when the intestines are under tension, as in intestinal obstruction. Bowel sounds may also be diminished or absent with an intestinal obstruction. Normal findings include aortic pulsations on inspection and tympany with percussion, and the liver may be palpable 1 to 2 cm along the right costal margin.

The health care team is assessing a male patient for acute pancreatitis after he presented to the emergency department with severe abdominal pain. Which laboratory value is the best diagnostic indicator of acute pancreatitis? A Gastric pH B Blood glucose C Serum amylase D Serum potassium

C Serum amylase Elevated serum amylase levels indicate early pancreatic dysfunction and are used to diagnose acute pancreatitis. Serum lipase levels stay elevated longer than serum amylase in acute pancreatitis. Blood glucose, gastric pH, and potassium levels are not direct indicators of acute pancreatic dysfunction.

The patient tells the nurse she had a history of abdominal pain, so she had a surgery to make an opening into the common bile duct to remove stones. The nurse knows that this surgery is called a A colectomy B cholecystectomy C choledocholithotomy D choledochojejunostomy

C choledocholithotomy A choledocholithotomy is an opening into the common bile duct for the removal of stones. A colectomy is the removal of the colon. The cholecystectomy is the removal of the gallbladder. The choledochojejunostomy is an opening between the common bile duct and the jejunum.

Which clinical manifestations of inflammatory bowel disease are common to both patients with ulcerative colitis (UC) and Crohn's disease (select all that apply)? A. Restricted to rectum B. Strictures are common. C. Bloody, diarrhea stools D. Cramping abdominal pain E. Lesions penetrate intestine.

C, D. Clinical manifestations of UC and Crohn's disease include bloody diarrhea, cramping abdominal pain, and nutritional disorders. Intestinal lesions associated with UC are usually restricted to the rectum before moving into the colon. Lesions that penetrate the intestine or cause strictures are characteristic of Crohn's disease.

A nurse is assessing a patient for essential hypertension. She will expect him to report which symptom? A. Chest tightness B. Shortness of Breath C. No symptoms to report D. Anxious

C. Primary (essential) HTN is the silent killer and s/s are not obvious

After the nurse teaches a patient with gastroesophageal reflux disease (GERD) about recommended dietary modifications, which statement by the patient indicates that the teaching has been effective? A. "I can have a glass of low-fat milk at bedtime." B. "I will have to eliminate all spicy foods from my diet." C. "I will have to use herbal teas instead of caffeinated drinks." D. "I should keep something in my stomach all the time to neutralize the excess acids."

C. "I will have to use herbal teas instead of caffeinated drinks." Rationale: Patients with gastroesophageal reflux disease should avoid foods (such as tea and coffee) that decrease lower esophageal pressure. Patients should also avoid milk, especially at bedtime, as it increases gastric acid secretion. Patients may eat spicy foods, unless these foods cause reflux. Small, frequent meals help prevent overdistention of the stomach, but patients should avoid late evening meals and nocturnal snacking.

A patient asks the nurse why a dose of hydromorphone (Dilaudid) by IV push is given before starting the medication via PCA. Which response is most appropriate? A. "PCA will never be effective unless a loading dose is given first." B. "The IV push dose will enhance the effects of the PCA for the next 8 hours." C. "The IV push dose will provide for immediate pain relief, which can be maintained by using the PCA." D. "PCA takes at least 2 hours to begin working, so the IV push dose will provide pain relief in the interim."

C. "The IV push dose will provide for immediate pain relief, which can be maintained by using the PCA." An IV push loading dose of an opioid analgesic provides an effective opioid level in the body, which results in immediate pain control. The PCA medication doses may be smaller and can be used more frequently to maintain pain control when the loading dose begins to wear off.

When computing a heart rate from the ECG tracing, the nurse counts 15 of the small blocks between the R waves of a patient whose rhythm is regular. From these data, the nurse calculates the patient's heart rate to be A. 60 beats/min. B. 75 beats/min. C. 100 beats/min. D. 150 beats/min.

C. 100 beats/min. Since each small block on the ECG paper represents 0.04 seconds, 1500 of these blocks represents 1 minute. By dividing the number of small blocks (15, in this case) into 1500, the nurse can calculate the heart rate in a patient whose rhythm is regular (in this case, 100).

The nurse carefully observes for toxicity of drugs excreted through the kidney. Which of these represents a sign or symptom of digoxin toxicity? A. Serum digoxin level of 1.2 ng/mL B. Polyphagia C. Anorexia D. Serum potassium of 5.0 mEq/L

C. Anorexia: Anorexia, nausea, and vomiting are symptoms of digoxin toxicity

The patient with chronic gastritis is being put on a combination of medications to eradicate H. pylori. Which drugs does the nurse know will probably be used for this patient? A. Antibiotic(s), antacid, and corticosteroid B. Antibiotic(s), aspirin, and antiulcer/protectant C. Antibiotic(s), proton pump inhibitor, and bismuth D. Antibiotic(s) and nonsteroidal antiinflammatory drugs (NSAIDs)

C. Antibiotic(s), proton pump inhibitor, and bismuth To eradicate H. pylori, a combination of antibiotics, a proton pump inhibitor, and possibly bismuth (for quadruple therapy) will be used. Corticosteroids, aspirin, and NSAIDs are drugs that can cause gastritis and do not affect H. pylori.

The nurse is caring for a patient who is 24 hours postpacemaker insertion. Which nursing intervention is most appropriate at this time? A. Reinforcing the pressure dressing as needed B. Encouraging range-of-motion exercises of the involved arm C. Assessing the incision for any redness, swelling, or discharge D. Applying wet-to-dry dressings every 4 hours to the insertion site

C. Assessing the incision for any redness, swelling, or discharge After pacemaker insertion, it is important for the nurse to observe signs of infection by assessing for any redness, swelling, or discharge from the incision site. The nonpressure dressing is kept dry until removed, usually 24 hours postoperatively. It is important for the patient to limit activity of the involved arm to minimize pacemaker lead displacement.

A patient admitted with metastatic lung cancer is ordered to receive morphine sulfate for pain. Which side effect of this medication should the nurse try to prevent with oral intake and medication? A. Diarrhea B. Agitation C. Constipation D. Urinary incontinence

C. Constipation Morphine sulfate is an opioid analgesic that can lead to constipation as a side effect, and tolerance to opioid-induced constipation does not develop. It is very important to use measures, such as increased fiber and fluids in the diet, and exercise when possible, to prevent this side effect. A gentle stimulant laxative plus a stool softener are also frequently needed to prevent constipation in a patient who is likely to develop this side effect.

The nurse recognizes that the client with end-stage kidney disease has difficulty adhering to the fluid restriction when which of these is found? A. Blood pressure 118/78 B. Weight loss of 3 lbs during hospitalization C. Dyspnea and anxiety at rest D. Central venous pressure (CVP) of 6 mm Hg

C. Dyspnea and anxiety at rest: Dyspnea is a sign of fluid overload and possible pulmonary edema; the nurse assists the client in correlating symptoms of fluid overload with nonadherence to fluid restriction. Excess fluid intake and fluid retention are manifested by elevated CVP (>8 mm Hg). Excess fluid intake and fluid retention are manifested by weight gain, not loss. Nonadherence to fluid restriction results in fluid volume excess and higher blood pressures; 118/78 is a normal blood pressure.

The nurse determines that a patient has experienced the beneficial effects of therapy with famotidine (Pepcid) when which symptom is relieved? A. Nausea B. Belching C. Epigastric pain D. Difficulty swallowing

C. Epigastric pain Famotidine is an H2-receptor antagonist that inhibits parietal cell output of HCl acid and minimizes damage to gastric mucosa related to hyperacidity, thus relieving epigastric pain. Famotidine is not indicated for nausea, belching, and dysphagia.

A female patient has a sliding hiatal hernia. What nursing interventions will prevent the symptoms of heartburn and dyspepsia that she is experiencing? A. Keep the patient NPO. B. Put the bed in the Trendelenberg position. C. Have the patient eat 4 to 6 smaller meals each day. D. Give various antacids to determine which one works for the patient.

C. Have the patient eat 4 to 6 smaller meals each day. Eating smaller meals during the day will decrease the gastric pressure and the symptoms of hiatal hernia. Keeping the patient NPO or in a Trendelenberg position are not safe or realistic for a long period of time for any patient. Varying antacids will only be done with the care provider's prescription, so this is not a nursing intervention.

The nurse is caring for a patient receiving morphine sulfate 10 mg IV push when necessary for pain. Upon assessment, the nurse finds the patient obtunded with a respiratory rate of 8/minute. Which medication would the nurse prepare to administer to treat these symptoms? A. Atropine sulfate B. Protamine sulfate C. Naloxone (Narcan) D. Neostigmine bromide (Prostigmin)

C. Naloxone (Narcan) Naloxone is the antidote or reversal agent for opioid analgesics, such as morphine. Excessive sedation and respiratory depression are symptoms of overdose and/or severe adverse effects that must be reversed for patient safety.

Which clinical manifestation should the nurse attribute to adverse effects of morphine sulfate administered via PCA? A. Diarrhea B. Urinary incontinence C. Nausea and vomiting D. Increased blood pressure

C. Nausea and vomiting Morphine sulfate promotes nausea and vomiting by directly stimulating the chemoreceptor trigger zone in the medulla. Other common side effects include constipation, sedation, respiratory depression, decreased blood pressure, and pruritus.

Which ECG characteristic is consistent with a diagnosis of ventricular tachycardia (VT)? A. Unmeasurable rate and rhythm B. Rate 150 beats/min; inverted P wave C. Rate 200 beats/min; P wave not visible D. Rate 125 beats/min; normal QRS complex

C. Rate 200 beats/min; P wave not visible VT is associated with a rate of 150 to 250 beats/min; the P wave is not normally visible. Rate and rhythm are not measurable in ventricular fibrillation. P wave inversion and a normal QRS complex are not associated with VT.

Following administration of a dose of metoclopramide (Reglan) to the patient, the nurse determines that the medication has been effective when what is noted? A. Decreased blood pressure B. Absence of muscle tremors C. Relief of nausea and vomiting D. No further episodes of diarrhea

C. Relief of nausea and vomiting Metoclopramide is classified as a prokinetic and antiemetic medication. If it is effective, the patient's nausea and vomiting should resolve. Metoclopramide does not affect blood pressure, muscle tremors, or diarrhea.

Following bowel resection, a patient has a nasogastric (NG) tube to suction, but complains of nausea and abdominal distention. The nurse irrigates the tube as necessary as ordered, but the irrigating fluid does not return. What should be the priority action by the nurse? A. Notify the physician. B. Auscultate for bowel sounds. C. Reposition the tube and check for placement. D. Remove the tube and replace it with a new one.

C. Reposition the tube and check for placement. The tube may be resting against the stomach wall. The first action by the nurse (since this is intestinal surgery and not gastric surgery) is to reposition the tube and check it again for placement. The physician does not need to be notified unless the tube function cannot be restored by the nurse. The patient does not have bowel sounds, which is why the NG tube is in place. The NG tube would not be removed and replaced unless it was no longer in the stomach or the obstruction of the tube could not be relieved.

Which assessment is of highest priority for the nurse to complete before administration of morphine? A. Pain rating B. Blood pressure C. Respiratory rate D. Level of consciousness

C. Respiratory rate A decreased respiratory rate below 12/min is a sign of opioid toxicity. Using the ABC approach in prioritization of care, a patent airway is always the first priority and is important to assess as a baseline before and during the administration of morphine.

Which statement best describes the electrical activity of the heart represented by measuring the PR interval on the ECG? A. The length of time it takes to depolarize the atrium B. The length of time it takes for the atria to depolarize and repolarize C. The length of time for the electrical impulse to travel from the SA node to the Purkinje fibers D. The length of time it takes for the electrical impulse to travel from the SA node to the AV node

C. The length of time for the electrical impulse to travel from the SA node to the Purkinje fibers The electrical impulse in the heart must travel from the SA node through the AV node and into the Purkinje fibers in order for synchronous atrial and ventricular contraction to occur. When measuring the PR interval (the time from the beginning of the P wave to the beginning of the QRS), the nurse is identifying the length of time it takes for the electrical impulse to travel from the SA node to the Purkinje fibers. The P wave represents the length of time it takes for the impulse to travel from the SA node through the atrium causing depolarization of the atria (atrial contraction). Atrial repolarization occurs during ventricular depolarization and is hidden by the QRS complex. The length of time it takes for the electrical impulse to travel from the SA node to the AV node is the flat line between the end of the P wave and the beginning of the Q wave on the ECG and is not usually measured.

The nurse is seeing artifact on the telemetry monitor. Which factors could contribute to this artifact? A. Disabled automaticity B. Electrodes in the wrong lead C. Too much hair under the electrodes D. Stimulation of the vagus nerve fibers

C. Too much hair under the electrodes Artifact is caused by muscle activity, electrical interference, or insecure leads and electrodes that could be caused by excessive chest wall hair. Disabled automaticity would cause an atrial dysrhythmia. Electrodes in the wrong lead will measure electricity in a different plane of the heart and may have a different wave form than expected. Stimulation of the vagus nerve fibers causes a decrease in heart rate, not artifact.

In monitoring the diagnostic test of a client admitted with heart failure (HF), which finding is consistent with this diagnosis? a. Serum potassium level of 3.2 mEq/L b. Ejection fraction of 60% c. B-type natriuretic peptide (BNP) of 760 ng/dL d. Chest x-ray report showing right middle lobe consolidation

C: BNP is produced and released by the ventricles when the client has fluid overload as a result of HF; a normal value is less than 100 pg/mL. Hypokalemia may occur in response to diuretic therapy for heart failure but may also occur with other conditions; it is not specific to heart failure. Consolidation on chest x-ray may indicate pneumonia.

Which intervention will best assist the client with acute pulmonary edema in reducing anxiety and dyspnea? a. Monitor pulse oximetry and cardiac rate and rhythm. b. Reassure the client that his distress can be relieved with proper intervention. c. Place the client in high Fowler's position with the legs down. d. Ask a family member to remain with the client.

C: High Fowler's position and placing the legs in a dependent position will decrease venous return to the heart, thus decreasing pulmonary venous congestion. Monitoring of vital signs will detect abnormalities but will not prevent them. Option B may help to alleviate anxiety, but dyspnea and anxiety result from hypoxemia secondary to intra-alveolar edema, which must be relieved. Option D may help to alleviate anxiety, but dyspnea and anxiety result from hypoxemia secondary to intra-alveolar edema, which must be relieved.

The client, a college athlete who has collapsed during soccer practice, has been diagnosed with hypertrophic cardiomyopathy. The client says, "This can't be. I am in great shape. I eat right and exercise." What is the nurse's best response? a. "How does this make you feel?" b. "This can be caused by taking performance-enhancing drugs." c. "This may be caused by a genetic trait." d. "Just imagine how bad it would be if you weren't in good shape."

C: Hypertrophic cardiomyopathy is often transmitted as a single-gene autosomal dominant trait.

Which nursing intervention for a client admitted today with heart failure will assist the client to conserve energy? a. Client ambulates around the nursing unit with a walker. b. The nurse monitors the client's pulse and blood pressure frequently. c. The nurse obtains a bedside commode before administering furosemide. d. The nurse returns the client to bed when he becomes tachycardic.

C: Limiting the need for ambulation on the first day of admission to sitting in a chair or performing basic leg exercises promotes physical rest and reduced oxygen demand. On the day of admission, the client is experiencing dyspnea, fatigue, and weakness; this activity will increase oxygen demand. Monitoring of vital signs will alert the nurse to increased energy expenditures but will not prevent them. Waiting until tachycardia occurs permits increased oxygen demand; the nurse should prevent this situation.

When caring for a client who has undergone a partial left ventriculectomy, which of these new-onset clinical manifestations indicates the need for immediate action by the nurse? a. Chest pain with movement b. Fatigue after ambulation c. Muffled heart sounds d. Bi-basilar fine crackles

C: Muffled heart sounds may be a clinical manifestation of bleeding into the pericardial space; the nurse should assess the client for possible decreased cardiac output and should notify the surgeon. Surgery will result in pain with mobility; pain should be treated but not until physiologic stability is ensured. This procedure was performed for heart failure; this client has had surgery as well and will need some time to recover his energy. Although the nurse should strive to prevent atelectasis or dependent crackles, this common after chest surgery. This client should be gotten out of bed and shown how to use an incentive spirometer.

The nurse is assessing the client with a cardiac infection. Which symptoms support the diagnosis of infective endocarditis instead of pericarditis or rheumatic carditis? a. Friction rub auscultated at the left lower sternal border b. Pain aggravated by breathing, coughing, and swallowing c. Splinter hemorrhages d. Thickening of the endocardium

C: Splinter hemorrhages are indicative of infective endocarditis. Friction rub in the left lower sternal border is a sign of chronic constrictive pericarditis. Pain aggravated by breathing, coughing, and swallowing is indicative of signs and symptoms of chronic constrictive pericarditis. Thickening of the endocardium is indicative of rheumatic carditis.

The nurse in the emergency department is caring for a client with acute heart failure who is experiencing severe dyspnea, pink, frothy sputum, and crackles throughout the lung fields. Which prescription should the nurse carry out first? a. Enalapril b. Heparin c. Furosemide d. I & O

C: The client is displaying typical signs of acute pulmonary edema, secondary to fluid-filled alveoli and pulmonary congestion; a diuretic will promote fluid loss. Although enalapril will promote vasodilation and decrease cardiac workload, the client is demonstrating signs of acute pulmonary edema secondary to intra-alveolar fluid. Heparin will prevent deep vein thrombosis (DVT) secondary to immobility but will not reduce fluid excess. Although all clients with congestive heart failure (CHF) should have I & O maintained, this is not a priority; removing fluid volume and treating dyspnea are matters of priority.

9.An older patient who had surgery is displaying manifestations of delirium. What should the nurse do first to provide the best care for this new patient? Check his chart for intraoperative complications. Check which medications were used for anesthesia. Check the effectiveness of the analgesics he has received. Check his preoperative assessment for previous delirium or dementia.

Check his preoperative assessment for previous delirium or dementia. If the patient's ABCs are okay, it is important to first know if the patient was mentally alert without cognitive impairments before surgery. Then intraoperative complications, anesthesia medications, and pain will be assessed as these can all contribute to delirium.

The term pacemaker noncapture requires which nursing action(s)? Select all that apply. 1. Contact the physician & describe what is noted on the ECG strip. 2. Assess the pt to determine response to the pacemaker noncapture. 3. Document the event by printing the ECG strip & placing it on the pt's record. 4. Ask the pt to ambulate to increase cardiac output. 5. Administer nitroglycerin sublingual one dose stat according to physician prescription.

Correct Answer: 1,2,3 Rationale 1: Actions the nurse should take when noncapture occurs include contacting the physician & describing the ECG strip. Rationale 2: Actions the nurse should take when noncapture occurs include assessing the pt to determine the response to the noncapture event. Rationale 3: Actions the nurse should take when noncapture occurs include documenting the event by printing an ECG strip & placing it on the pt's record. Rationale 4: Having the pt ambulate would not be indicated for pacemaker malfunction. Rationale 5: Administering nitroglycerin would not be indicated for pacemaker malfunction. Nitrogycerin is administered for chest pain.

The nurse realizes that the pt in the critical care area with ventricular tachycardia will require which action? Select all that apply. 1. immediate assessment & probable emergency intervention by the nurse 2. cardioversion, if sustained & symptomatic 3. probable administration of a potassium channel blocker 4. close observation for one hour prior to calling the physician 5. defibrillation to convert the rhythm in the awake pt

Correct Answer: 1,2,3 Rationale 1: The nurse should immediately assess the pt to see how the potentially life-threatening rhythm is being tolerated. Rationale 2: The nurse should be prepared to cardiovert the pt in ventricular tachycardia with a pulse according to standing prescriptions. The nurse in critical care needs to be aware of standing prescriptions for each pt prior to an emergent event & needs to have the necessary emergency equipment & meds ready. Rationale 3: Class III antidysrhythmic meds (potassium channel blockers) are typically administered. Rationale 4: Observation prior to calling a physician is not an appropriate action when a potentially life-threatening rhythm is identified. Rationale 5: Defibrillation is only conducted in ventricular tachycardia when the pt is pulseless; otherwise, time is taken to synchronize for cardioversion.

A pt is in sinus tachycardia. Which nursing interventions are appropriate? Select all that apply. 1. Observe the pt for effects on cardiac function. 2. Administer two tablets of acetaminophen (Tylenol) per physician prescription if an elevated temperature is present. 3. Administer normal saline 0.9% IV at the prescribed rate of 200 mL per hour if hypovolemia is suspected as the cause. 4. Give pain meds as prescribed if pain is present. 5. Give atropine per physician prescription to slow the heart rate

Correct Answer: 1,2,3,4 Rationale 1: Appropriate nursing interventions for the pt in sinus tachycardia are to observe the pt for effects on cardiac function; treat fever, hypovolemia, & pain if present. The focus is on determining the pt response to the elevated heart rate & treating the underlying causes, which are often fever, pain, & hypovolemia. Rationale 2: Appropriate nursing intervention for the pt in sinus tachycardia is to treat fever Rationale 3: Appropriate nursing intervention for the pt in sinus tachycardia is to treat hypovolemia. Rationale 4: Appropriate nursing intervention for the pt in sinus tachycardia is to treat pain if present. Rationale 5: Atropine acts to increase heart rate & may be a cause of sinus tachycardia.

Which person should the nurse identify as having the highest risk for abdominal aortic aneurysm? a A 70-year-old male, with high cholesterol and hypertension b A 40-year-old female with obesity and metabolic syndrome c A 60-year-old male with renal insufficiency who is physically inactive d A 65-year-old female with hyperhomocysteinemia and substance abuse

Correct Answer: A The most common etiology of descending abdominal aortic aneurysm (AAA) is atherosclerosis. Male gender, age 65 years or older, and tobacco use are the major risk factors for AAAs of atherosclerotic origin. Other risk factors include the presence of coronary or peripheral artery disease, high blood pressure, and high cholesterol.

A 67-year-old man with peripheral artery disease is seen in the primary care clinic. Which symptom reported by the patient would indicate to the nurse that the patient is experiencing intermittent claudication? a Patient complains of chest pain with strenuous activity. b Patient says muscle leg pain occurs with continued exercise. c Patient has numbness and tingling of all his toes and both feet. d Patient states the feet become red if he puts them in a dependent position.

Correct Answer: B Intermittent claudication is an ischemic muscle ache or pain that is precipitated by a consistent level of exercise, resolves within 10 minutes or less with rest, and is reproducible. Angina is the term used to describe chest pain with exertion. Paresthesia is the term used to describe numbness or tingling in the toes or feet. Reactive hyperemia is the term used to describe redness of the foot; if the limb is in a dependent position the term is dependent rubor.

The patient had aortic aneurysm repair. What priority nursing action will the nurse use to maintain graft patency? a Assess output for renal dysfunction. b Use IV fluids to maintain adequate BP. c Use oral antihypertensives to maintain cardiac output. d Maintain a low BP to prevent pressure on surgical site

Correct Answer: B Rationale: The priority is to maintain an adequate BP (determined by the surgeon) to maintain graft patency. A prolonged low BP may result in graft thrombosis, and hypertension may cause undue stress on arterial anastomoses resulting in leakage of blood or rupture at the suture lines, which is when IV antihypertensives may be used. Renal output will be assessed when the aneurysm repair is above the renal arteries to assess graft patency, not maintain it.

A male patient was admitted for a possible ruptured aortic aneurysm, but had no back pain. Ten minutes later his assessment includes the following: sinus tachycardia at 138, BP palpable at 65 mm Hg, increasing waist circumference, and no urine output. How should the nurse interpret this assessment about the patient's aneurysm? a Tamponade will soon occur. b The renal arteries are involved. c Perfusion to the legs is impaired. d He is bleeding into the abdomen.

Correct Answer: D Rationale: The lack of back pain indicates the patient is most likely exsanguinating into the abdominal space, and the bleeding is likely to continue without surgical repair. A blockade of the blood flow will not occur in the abdominal space as it would in the retroperitoneal space where surrounding anatomic structures may control the bleeding. The lack of urine output does not indicate renal artery involvement, but that the bleeding is occurring above the renal arteries, which decreases the blood flow to the kidneys. There is no assessment data indicating decreased perfusion to the legs.

The nurse is caring for a patient who complains of abdominal pain and hematemesis. Which new assessment finding(s) would indicate the patient is experiencing a decline in condition? a. Pallor and diaphoresis b. Ecchymotic peripheral IV site c. Guaiac-positive diarrhea stools d. Heart rate 90, respiratory rate 20, BP 110/60

Correct Answer: a A patient with hematemesis has some degree of bleeding from an unknown source. Guaiac-positive diarrhea stools would be an expected finding. When monitoring the patient for stability, the nurse observes for signs of hypovolemic shock such as tachycardia, tachypnea, hypotension, altered level of consciousness, pallor, and cool and clammy skin. An ecchymotic peripheral IV site will require assessment to determine the need for reinsertion. Access would be critical in the immediate treatment of shock, but the ecchymotic site does not represent a decline in condition.

Which patient would be at highest risk for developing oral candidiasis? a. A 74-yr-old patient who has vitamin B and C deficiencies b. A 22-yr-old patient who smokes 2 packs of cigarettes per day c. A 32-yr-old patient who is receiving ciprofloxacin for 3 weeks d. A 58-yr-old patient who is receiving amphotericin B for 2 days

Correct answer: C Oral candidiasis is caused by prolonged antibiotic treatment (e.g., ciprofloxacin) or high doses of corticosteroids. Amphotericin B is used to treat candidiasis. Vitamin B and C deficiencies may lead to Vincent's infection. Use of tobacco products leads to stomatitis, not candidiasis.

A patient with a history of peptic ulcer disease has presented to the emergency department with severe abdominal pain and a rigid, boardlike abdomen. The health care provider suspects a perforated ulcer. Which interventions should the nurse anticipate? a. Providing IV fluids and inserting a nasogastric (NG) tube Correct b. Administering oral bicarbonate and testing the patient's gastric pH level c. Performing a fecal occult blood test and administering IV calcium gluconate d. Starting parenteral nutrition and placing the patient in a high-Fowler's position Incorrect

Correct answer: a A perforated peptic ulcer requires IV replacement of fluid losses and continued gastric aspiration by NG tube. Nothing is given by mouth, and gastric pH testing is not a priority. Calcium gluconate is not a medication directly relevant to the patient's suspected diagnosis, and parenteral nutrition is not a priority in the short term

The results of a patient's recent endoscopy indicate the presence of peptic ulcer disease (PUD). Which teaching point should the nurse provide to the patient based on this new diagnosis? a "It would be beneficial for you to eliminate drinking alcohol." Correct b "You'll need to drink at least two to three glasses of milk daily." c "Many people find that a minced or pureed diet eases their symptoms of PUD." d "Taking medication will allow you to keep your present diet while minimizing symptoms."

Correct answer: a Alcohol increases the amount of stomach acid produced. so it should be avoided. Although there is no specific recommended dietary modification for PUD, most patients find it necessary to make some sort of dietary modifications to minimize symptoms. Milk may exacerbate PUD.

The nurse teaches senior citizens at a community center how to prevent food poisoning at social events. Which community member statement reflects accurate understanding? a. "Pasteurized juices and milk are safe to drink." b. "Alfalfa sprouts are safe if rinsed before eating." c. "Fresh fruits do not need to be washed before eating." d. "Ground beef is safe to eat if cooked until it is brown."

Correct answer: a Drink only pasteurized milk, juice, or cider. Ground beef should be cooked thoroughly. Browned meat can still harbor live bacteria. Cook ground beef until a thermometer reads at least 160° F. If a thermometer is unavailable, decrease the risk of illness by cooking the ground beef until there is no pink color in the middle. Fruits and vegetables should be washed thoroughly, especially those that will not be cooked. Persons who are immunocompromised or older should avoid eating alfalfa sprouts until the safety of the sprouts can be ensured.

The patient at highest risk for venous thromboembolism (VTE) is a. a 62-year-old man with spider veins who is having arthroscopic knee surgery. b. a 32-year-old woman who smokes, takes oral contraceptives, and is planning a trip to Europe. c. a 26-year-old woman who is 3 days postpartum and received maintenance IV fluids for 12 hours during her labor. d. an active 72-year-old man at home recovering from transurethral resection of the prostate for benign prostatic hyperplasia.

Correct answer: b Rationale: Three important factors (called Virchow's triad) in the etiology of venous thrombosis are (1) venous stasis, (2) damage of the endothelium (inner lining of the vein), and (3) hypercoagulability of the blood. Patients at risk for venous thrombosis usually have predisposing conditions for these three disorders (see Table 38-8). The 32-year-old woman has the highest risk: long trips without adequate exercise (venous stasis), tobacco use, and use of oral contraceptives. Note: The likelihood of hypercoagulability of blood is increased in women older than 35 years who use tobacco.

The nurse is caring for a postoperative patient who has just vomited yellow green liquid and reports nausea. Which action would be an appropriate nursing intervention? a. Offer the patient an herbal supplement such as ginseng. b. Apply a cool washcloth to the forehead and provide mouth care. c, Take the patient for a walk in the hallway to promote peristalsis. d. Discontinue any medications that may cause nausea or vomiting. TERM

Correct answer: b Cleansing the face and hands with a cool washcloth and providing mouth care are appropriate comfort interventions for nausea and vomiting. Ginseng is not used to treat postoperative nausea and vomiting. Unnecessary activity should be avoided. The patient should rest in a quiet environment. Medications may be temporarily withheld until the acute phase is over, but the medications should not be discontinued without consultation with the health care provider.

The patient receiving chemotherapy rings the call bell and reports the onset of nausea. The nurse should prepare an as-needed dose of which medication? a. Zolpidem b. Ondansetron c. Dexamethasone d. Morphine sulfate

Correct answer: b Ondansetron is a 5-HT3 receptor antagonist antiemetic that is especially effective in reducing cancer chemotherapy-induced nausea and vomiting. Morphine sulfate may cause nausea and vomiting. Zolpidem does not relieve nausea and vomiting. Dexamethasone is usually used in combination with ondansetron for acute and chemotherapy-induced emesis.

A patient with infective endocarditis develops sudden left leg pain with pallor, paresthesia, and a loss of peripheral pulses. The nurse's initial action should be to a. elevate the leg to promote venous return. b. start anticoagulant therapy with IV heparin. c. notify the physician of the change in peripheral perfusion. d. place the bed in reverse Trendelenburg to promote perfusion.

Correct answer: c Rationale: The patient has potentially developed acute arterial ischemia (sudden interruption in the arterial blood supply to the extremity), caused by an embolism from a cardiac thrombus that occurred as a complication of infective endocarditis. Clinical manifestations of acute arterial ischemia include any or all of the six Ps : pain, pallor, paralysis, pulselessness, paresthesia, and poikilothermia. Without immediate intervention, ischemia may progress quickly to tissue necrosis and gangrene within a few hours. If the nurse detects these signs, the physician should be notified immediately

The nurse is caring for a patient treated with IV fluid therapy for severe vomiting. As the patient recovers and begins to tolerate oral intake, which food choice would be most appropriate? Iced tea Dry toast Hot coffee Plain yogurt

Correct answer:b Dry toast or crackers may alleviate the feeling of nausea and prevent further vomiting. Water is the initial fluid of choice. Extremely hot or cold liquids and fatty foods are generally not well tolerated.

Which client who has just arrived in the emergency department does the nurse classify as emergent and needing immediate medical evaluation? A. A 60-year-old with venous insufficiency who has new-onset right calf pain and tenderness B. A 64-year-old with chronic venous ulcers who has a temperature of 100.1° F (37.8° C) C. A 69-year-old with a 40-pack-year cigarette history who is reporting foot numbness D. A 70-year-old with a history of diabetes who has "tearing" back pain and is diaphoretic

D The 70-year-old's history and clinical manifestations suggest possible aortic dissection. The nurse will immediately assess the client's blood pressure and plan for IV antihypertensive therapy, rapid diagnostic testing, and possible transfer to surgery

The nurse is reviewing the home medication list for a 44-year-old man admitted with suspected hepatic failure. Which medication could cause hepatotoxicity? A Nitroglycerin B Digoxin (Lanoxin) C Ciprofloxacin (Cipro) D Acetaminophen (Tylenol)

D Acetaminophen (Tylenol) Many chemicals and drugs are potentially hepatotoxic (see Table 39-6) and result in significant patient harm unless monitored closely. For example, chronic high doses of acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs) may be hepatotoxic.

The ED nurse has inspected, auscultated, and palpated the abdomen with no obvious abnormalities, except pain. When the nurse palpates the abdomen for rebound tenderness, there is severe pain. The nurse should know that this could indicate what problem? A Hepatic cirrhosis B Hypersplenomegaly C Gall bladder distention D Peritoneal inflammation

D Peritoneal inflammation When palpating for rebound tenderness, the problem area of the abdomen will produce pain and severe muscle spasm when there is peritoneal inflammation. Hepatic cirrhosis, hypersplenomegaly, and gall bladder distention do not manifest with rebound tenderness.

The nurse is performing a focused abdominal assessment of a patient who has been recently admitted. In order to palpate the patient's liver, where should the nurse palpate the patient's abdomen? A Left lower quadrant B Left upper quadrant C Right lower quadrant D Right upper quadrant

D Right upper quadrant Although the left lobe of the liver is located in the left upper quadrant of the abdomen, the bulk of the liver is located in the right upper quadrant.

Which effect should the nurse instruct a patient receiving NSAIDs to report? A. Blurred vision B. Nasal stuffiness C. Urinary retention D. Black or tarry stools

D. Black or tarry stools Black, tarry stools could indicate GI bleeding, which is a risk associated with NSAIDs. For this reason, the patient should be taught to report this sign and other signs of bleeding immediately.

The nurse is caring for a 68-year-old patient admitted with abdominal pain, nausea, and vomiting. The patient has an abdominal mass, and a bowel obstruction is suspected. The nurse auscultating the abdomen listens for which type of bowel sounds that are consistent with the patient's clinical picture? A. Low-pitched and rumbling above the area of obstruction B. High-pitched and hypoactive below the area of obstruction C. Low-pitched and hyperactive below the area of obstruction D. High-pitched and hyperactive above the area of obstruction

D. High-pitched and hyperactive above the area of obstruction Early in intestinal obstruction, the patient's bowel sounds are hyperactive and high-pitched, sometimes referred to as "tinkling" above the level of the obstruction. This occurs because peristaltic action increases to "push past" the area of obstruction. As the obstruction becomes complete, bowel sounds decrease and finally become absent.

A patient reports having a dry mouth and asks for something to drink. The nurse recognizes that this symptom can most likely be attributed to a common adverse effect of which medication that the patient is taking? A. Digoxin (Lanoxin) B. Cefotetan (Cefotan) C. Famotidine (Pepcid) D. Promethazine (Phenergan)

D. Promethazine (Phenergan) A common adverse effect of promethazine, an antihistamine/antiemetic agent, is dry mouth; another is blurred vision. Common side effects of digoxin are yellow halos and bradycardia. Common side effects of cefotetan are nausea, vomiting, stomach pain, and diarrhea. Common side effects of famotidine are headache, abdominal pain, constipation, or diarrhea.

A 72-year-old patient was admitted with epigastric pain due to a gastric ulcer. Which patient assessment warrants an urgent change in the nursing plan of care? A. Chest pain relieved with eating or drinking water B. Back pain 3 or 4 hours after eating a meal C. Burning epigastric pain 90 minutes after breakfast D. Rigid abdomen and vomiting following indigestion

D. Rigid abdomen and vomiting following indigestion A rigid abdomen with vomiting in a patient who has a gastric ulcer indicates a perforation of the ulcer, especially if the manifestations of perforation appear suddenly. Midepigastric pain is relieved by eating, drinking water, or antacids with duodenal ulcers, not gastric ulcers. Back pain 3-4 hours after a meal is more likely to occur with a duodenal ulcer. Burning epigastric pain 1-2 hours after a meal is an expected manifestation of a gastric ulcer related to increased gastric secretions and does not cause an urgent change in the nursing plan of care.

When caring for a client who receives peritoneal dialysis (PD), which of these findings must the nurse report to the provider immediately? A. Pulse oximetry reading of 95% B. Sinus bradycardia, rate of 58 C. Blood pressure of 148/90 D. Temperature of 101.2 F

D. Temperature of 101.2 F: Peritonitis is the major complication of PD caused by intra-abdominal catheter site contamination; use meticulous aseptic technique when caring for PD equipment.

The nurse prepares to administer digoxin to a client with heart failure and notes the following information: Temperature: 99.8 Pulse: 48 and irregular Respirations: 20 Potassium level: 3.2 mEq/L What action does the nurse take? a. Give digoxin; reassess the heart rate in 30 minutes. b. Give the digoxin; document assessment findings in the medical record. c. Hold the digoxin, and obtain a prescription for an additional dose of furosemide. d. Hold the digoxin, and obtain a prescription for a potassium supplement.

D: Digoxin causes bradycardia; hypokalemia potentiates digitalis. The nurse seeks to correct this situation through collaboration with the provider. Digoxin causes bradycardia, so should be held. Digoxin is given to treat heart failure and atrial fibrillation, an irregular heart rate. Regardless of mental status, the drug should be held. Hypokalemia potentiates digitalis toxicity. Lasix decreases circulating blood volume and depletes potassium; no indication suggests that the client has fluid excess at this time.

The nurse is caring for the client with congestive heart failure (CHF) in the coronary care unit (CCU). The client is now exhibiting signs of air hunger and anxiety. Which nursing intervention does the nurse perform first for this client? a. Determines the client's physical limitations b. Encourages alternate rest and activity periods c. Monitors and documents heart rate, rhythm, and pulses d. Positions the client to alleviate dyspnea

D: Positioning the client to alleviate dyspnea will help ease air hunger and anxiety. Determining the client's physical limitations and encouraging alternate rest and activity periods are not priorities in this situation. Monitoring of heart rate, rhythm, and pulses is important but is not the priority for this client.

A client admitted for heart failure has a priority problem of Excess Fluid Volume related to compromised regulatory mechanisms. Which of these assessment data obtained the day after admission is the best indicator that the treatment has been effective? a. The client has a diuresis of 400 mL in 24 hours. b. The client's blood pressure is 122/84 mm Hg. c. The client has an apical pulse of 82 beats/min. d. The client's weight decreases by 2.5 kg.

D: The best indicator of fluid volume loss is daily weight; because each kilogram represents approximately 1 L, this client has lost approximately 2500 mL of fluid. Option A: This volume of urine represents oliguria, not the needed response of diuresis. Option B: Although this is a normal finding, alone it is not significant for relief of fluid volume excess. Option C: Although this is a normal finding, alone it is not significant to determine whether fluid excess is relieved.

A 73-year-old patient who sustained a right hip fracture in a fall requests pain medication from the nurse. Based on his injury, which type of pain is this patient most likely experiencing? a. Phantom b. Visceral c. Deep somatic d. Referred

Deep somatic

A 45-year-old patient has breast cancer that has spread to the liver and spine. The patient has been taking oxycodone (OxyContin) and amitriptyline (Elavil) for pain control at home but now has constant severe pain and is hospitalized for pain control and development of a pain-management program. When doing the initial assessment, which question will be most appropriate to ask first? a. How would you describe your pain? b. How much medication do you take for the pain? c. How long have you had this pain? d. How many times a day do you medicate for pain?

How would you describe your pain?

Following surgery, a client has great difficulty getting out of bed, walking, and coughing and deep breathing. Although patient-controlled analgesia (PCA) is in place, it is rarely used, even when suggested by the nurse. This concerns the nurse. Which statement is the best way to address this concern with the client? a. "I noticed you use very little pain medication. You must be very brave and strong. But without pain medication, you will get weaker, not stronger." b. "I noticed you don't use much pain medication. If you don't push that button, I will. You need that medicine. Don't worry about getting addicted. It won't happen." c. "I noticed you haven't used your pain medication as often as you could, even though it is painful for you to get out of bed and to walk. Many people are reluctant to take pain medication. Tell me what makes you reluctant." d. "I can understand why you are reluctant to use pain medication. Many people feel the same way. Yet without pain relief, you can get atelectasis, pneumonia, and blood clots, and maybe even develop an ileus."

I noticed you haven't used your pain meds as often as you could, even though it is painful for you to get out of bed and walk. many people are reluctant to take pain meds. Tell me what makes you reluctant

5.The nurse cares for a 72-year-old Native American male patient 2 days after a thoracotomy for tumor resection. What would be the most appropriate action if the patient does not report any pain? Contact the health care provider. Identify possible reasons for denial of pain. Administer the prescribed pain medication. Assess the renal and liver function test results.

Identify possible reasons for denial of pain.

The hospice RN obtains the following information about a 72-year-old terminally ill patient with cancer of the colon. The patient takes oxycodone (OxyContin) 100 mg twice daily for level 6 abdomen pain on a 10-point scale. The pain has made it difficult to continue with favorite activities such as playing cards with friends twice a week. The patient's children are supportive of the patient's wish to stop chemotherapy but express sadness that the patient does not have long to live. Based on this information, which nursing diagnosis has priority in planning the patient's care? a. Impaired social interaction related to disabling pain b. Anxiety related to poor patient coping skills c. Disabled family coping related to patient-family conflict d. Risk for aspiration related to opioid use

Impaired social interaction related to disabling pain

The nurse administers codeine sulfate 30 mg orally to a patient who underwent craniotomy 3 days ago for a brain tumor. How soon after administration should the nurse reassess the patient's pain? a. Immediately b. In 10 minutes c. In 15 minutes d. In 60 minutes

In 60 mins

1.A 67-year-old male patient is admitted to the postanesthesia care unit (PACU) after abdominal surgery. Which assessment, if made by the nurse, is the best indicator of respiratory depression? Increased respiratory rate Decreased oxygen saturation Increased carbon dioxide pressure Frequent premature ventricular contractions (PVCs)

Increased carbon dioxide pressure Transcutaneous carbon dioxide pressure (PtcCO2) monitoring is a sensitive indicator of respiratory depression. Increased CO2 pressures would indicate respiratory depression. Clinical manifestations of inadequate oxygenation include increased respiratory rate, dysrhythmias (e.g., premature ventricular contractions), and decreased oxygen saturation.

28. The nurse is assessing a patient for opioid tolerance. Which finding supports the nurse's assessment? • Increasingly higher doses of opioid are needed to control pain. • The patient needed a substantial dose of naloxone (Narcan). • The patient asks for pain medication close to the time it is due around the clock. • The patient no longer experiences sedation from the usual dose of opioid.

Increasingly higher doses of opioid are needed to control pain. Correct

34. The nurse is caring for an infant in the intensive care unit. Which of the following is the most accurate description of factors that will influence the perception and management of pain for this patient? • Infants cannot tolerate analgesics owing to an underdeveloped metabolism. • Infants have an increased sensitivity to pain when compared with older children. • Pain cannot be accurately assessed in infants. • Infants respond behaviorally and physiologically to painful stimuli.

Infants respond behaviorally and physiologically to painful stimuli. Correct

4. A nursing student is planning care for an elderly patient who is experiencing pain. Which of the following statements made by the nursing student indicates the need for the nursing professor to clarify the nursing student's knowledge? • "Older patients often have difficulty determining what is causing their pain." • "It is safe to administer opioids to older adults as long as you start with small doses and frequently assess the patient's response to the medication." • "As adults age, their ability to perceive pain decreases." • "Patients who have dementia probably experience pain, and their pain is not always well controlled."

It is safe to administer opioids to older adults as long as you start with small doses and frequently assess the patient's response to the medication." Correct

7. What nursing intervention is most effective in preventing injury to a patient following administration of epidural anesthesia? • Keeping the reversal agent in a syringe in the patient's bedside table • Applying a gauze dressing to the epidural catheter insertion site • Labeling the tubing that leads to the epidural catheter • Asking the nursing assistive personnel to check on the patient at least once every 2 hours

Labeling the tubing that leads to the epidural catheter Correct

2.The nurse is caring for a 54-year-old unconscious female patient who has just been admitted to the postanesthesia care unit after abdominal hysterectomy. How should the nurse position the patient? Left lateral position with head supported on a pillow Prone position with a pillow supporting the abdomen Supine position with head of bed elevated 30 degrees Semi-Fowler's position with the head turned to the right

Left lateral position with head supported on a pillow The unconscious patient should be placed in the lateral "recovery" position to keep the airway open and reduce the risk of aspiration. Once conscious, the patient is usually returned to a supine position with the head of the bed elevated to maximize expansion of the thorax by decreasing the pressure of the abdominal contents on the diaphragm.

11.A patient is having elective cosmetic surgery performed on her face. The surgeon will keep her at the surgery center for 24 hours after surgery. What is the nurse's postoperative priority for this patient? Manage patient pain. Control the bleeding. Maintain fluid balance. Manage oxygenation status.

Manage oxygenation status. The nurse's priority is to manage the patient's oxygenation status by maintaining an airway and ventilation. With surgery on the face, there may be swelling that could compromise her ability to breathe. Pain, bleeding, and fluid imbalance from the surgery may increase her risk for upper airway edema causing airway obstruction and respiratory suppression, which also indicate managing oxygenation status as the priority.

5. The nurse is caring for two patients; both are having a hysterectomy. The first patient is having the hysterectomy after a complicated birth. The second patient has uterine cancer. What will most likely influence the experience of pain for these two patients? • Neurological factors • Competency of the surgeon • Meaning of pain • Postoperative support personnel

Meaning of pain Correct

The patient receiving chemotherapy rings the call bell and reports the onset of nausea. The nurse should prepare an as-needed dose of which medication? A. Morphine sulfate B. Zolpidem (Ambien) C. Ondansetron (Zofran) D. Dexamethasone (Decadron)

Ondansetron is a 5-HT3 receptor antagonist antiemetic that is especially effective in reducing cancer chemotherapy-induced nausea and vomiting. Morphine sulfate may cause nausea and vomiting. Zolpidem does not relieve nausea and vomiting. Dexamethasone is usually used in combination with ondansetron for acute and chemotherapy-induced emesis.

29. A nurse is caring for a patient with rheumatoid arthritis who is now going to be taking 2 acetaminophen (Tylenol) tablets every 6 hours to control pain. Which part of the patient's social history is the nurse most concerned about? • Patient drinks 1 to 2 glasses of wine every night. • Patient smokes 2 packs of cigarettes a day. • Patient occasionally smokes marijuana. • Patient takes antianxiety medications.

Patient drinks 1 to 2 glasses of wine every night. Correct

8. A 24-year-old Asian woman is in labor and refuses to receive any sort of anesthesia medication. Which alternative treatment is best for this patient? • Relaxation and guided imagery • Transcutaneous electrical nerve stimulation (TENS) • Herbal supplements with analgesic effects • Pudendal block

Relaxation and guided imagery Correct

One hour after administering the first dose of an intravenous opioid to your postoperative patient, about which of the following assessments should you be most concerned? a. Respiratory rate of 6 breaths per minute b. Oxygen saturation of 95% on room air c. Heart rate of 70 regular d. Blood pressure of 140/72

Resp rate 6 breaths per min

7. The patient had abdominal surgery. The estimated blood loss was 400 mL. The patient received 300 mL of 0.9% saline during surgery. Postoperatively, the patient is hypotensive. What should the nurse anticipate for this patient? Blood administration Restoring circulating volume An ECG to check circulatory status Return to surgery to check for internal bleeding

Restoring circulating volume The nurse should anticipate restoring circulating volume with IV infusion. Although blood could be used to restore circulating volume, there are no manifestations in this patient indicating a need for blood administration. An ECG may be done if there is no response to the fluid administration, or there is a past history of cardiac disease, or cardiac problems were noted during surgery. Returning to surgery to check for internal bleeding would only be done if patient's level of consciousness changes or the abdomen becomes firm and distended.

35. The nurse is administering ibuprofen (Advil) to an older patient. Which of the following assessment data causes the nurse to hold the medication? (Select all that apply.) • Past medical history of gastric ulcer Correct • Patient states last bowel movement was 4 days ago • Stated allergy to aspirin • Patient states has 2/10 intermittent joint pain • Patient experienced respiratory depression after administration of an opioid medication

Stated allergy to aspirin Correct

The LPN/LVN is evaluating the patient's electrocardiogram (ECG) rhythm strip and notes the distance between the P waves are the same. Which interpretation by the nurse of this ECG is correct?

The heart rate is regular.

A patient who has heart failure (HF) has been prescribed a digitalis preparation. The patient asks the nurse how this medication will help his HF. Which response by the nurse is correct?

The medication increases the force of the heart contraction.

When caring for a patient who is receiving epidural morphine, which information obtained by the nurse indicates that the patient may be experiencing a side effect of the medication? a. The patient complains of a "pounding" headache. b. The patient becomes restless and agitated. c. The patient has not voided for over 10 hours. d. The patient has cramping abdominal pain.

The patient has not voided for over 10 hours

A 7-year old pediatric patient tells you that he is in pain. The patient rates the pain as 4 on the Faces Pain Scale of 0-10. His mother, who is in the room, states that her son is having pain at a level of 8 on the 0-10 scale. Which is the most accurate assessment of the patient's pain? a. The patient is the best resource for assessing the pain and should receive the appropriate pain medication b. The patient is the best resource for assessing the pain, but should not receive any pain medication because his level is only 4 out of 10. c. The nurse is the best resource for assessing the pediatric patient's pain level and gives the dose of pain medication that matches the nurses' judgment. d. The mother is the best resource for assessing the pain in this case, and the patient should receive the maximum dose of pain medication ordered.

The patient is the best resource for assessing the pain and should receive the appropriate pain medication

16. A patient who had a motor vehicle accident 2 days ago is experiencing pain and is receiving patient-controlled analgesia (PCA). How does the nurse know that the patient is experiencing effective pain management with the PCA? • The patient is sleeping and is difficult to arouse. • The patient rates pain at an acceptable level of 3 on a 0 to 10 scale. • Sufficient medication is left in the PCA syringe. • The patient presses the control button to deliver pain medication.

The patient rates pain at an acceptable level of 3 on a 0 to 10 scale. Correct

The nurse is assessing the patient who has been taking digoxin for the past 2 months. Which assessment finding would alert the nurse that the patient may be experiencing digitalis toxicity?

The patient reports frequent nausea and diarrhea.

26. The nurse is teaching a student nurse about pain assessment scales. Which statement by the student indicates correct understanding? • "You cannot use a pain scale to compare the pain of my patient with the pain of your patient." • "When patients say they don't need pain medication, they aren't in pain." • "The patient who is experiencing 8/10 pain and has a STAT order for pain medication • "A patient's behavior is more reliable than the patient's report of pain."

The patient who is experiencing 8/10 pain and has a STAT order for pain medication Correct

27. The nurse is administering pain medication for several patients. Which patient does the nurse administer medication to first? • The patient who needs to take a scheduled dose of maintenance pain medication • The patient who needs to be premedicated before walking • The patient with a PCA running who needs to have the syringe replaced • The patient who is experiencing 8/10 pain and has a STAT order for pain medication

The patient who is experiencing 8/10 pain and has a STAT order for pain medication Correct

11. A nurse is caring for a patient who recently had spinal surgery. The nurse knows that patients usually experience acute pain following this type of surgery. The patient refuses to get up and walk and is not moving around in the bed. However, the patient is stoic and denies experiencing pain at this time. What most likely explains this patient's behavior and response to surgery? • The surgery successfully cured the patient's pain. • The patient's culture is possibly influencing the patient's experience of pain. • The patient is experiencing urinary retention because of manipulation of the spine during surgery; this is preventing the patient from experiencing pain. • The nurse is allowing personal beliefs about pain to influence pain management at this time.

The patient's culture is possibly influencing the patient's experience of pain. Correct

A nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is: a. Normal because of the increased blood flow through the leg b. Slightly deteriorating and should be monitored for another hour c. Moderately impaired, and the surgeon should be called. d. Adequate from the arterial approach, but venous complications are arising.

a. An expected outcome of surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow. Options 2, 3, and 4 are incorrect interpretations.

22. The nurse knows that which technique is best for assessing pain in a child who is 4 years of age? • Ask the parents if they think their child is in pain. • Use the FACES scale. • Ask the child to rate the level of pain on a 0 to 10 pain scale. • Check to see what previous nurses have charted.

Use the FACES scale.

10.The patient had surgery at an ambulatory surgery center. Which criteria support that this patient is ready for discharge (select all that apply)? Vital signs baseline or stable Minimal nausea and vomiting Wants to go to the bathroom at home Responsible adult taking patient home Comfortable after IV opioid 15 minutes ago

Vital signs baseline or stable Minimal nausea and vomiting Responsible adult taking patient home Ambulatory surgery discharge criteria includes meeting Phase I PACU discharge criteria that includes vital signs baseline or stable and minimal nausea and vomiting. Phase II criteria includes a responsible adult driving patient, no IV opioid drugs for last 30 minutes, able to void, able to ambulate if not contraindicated, and received written discharge instruction with patient understanding confirmed.

25. The nurse is assessing how a patient's pain is affecting mobility. Which assessment question is most appropriate? • "Have you considered working with a physical therapist?" • "What activities, if any, has your pain prevented you from doing?" • "Would you please rate your pain on a scale from 1 to 10 for me?" • "What effect does your pain medication typically have on your pain?"

What activities, if any, has your pain prevented you from doing?"

After teaching about ways to decrease risk factors for CAD, the nurse recognizes that additional instruction is needed when the patient says a. "I would like to add weight lifting to my exercise program." b. "I can only keep my blood pressure normal with medication" c. "I can change my diet to decrease my intake of saturated fats." d. "I will change my lifestyle to reduce activities that increase my stress."

a. "I would like to add weight lifting to my exercise program." Rationale: Risk factors for coronary artery disease include elevated serum levels of lipids, elevated BP, tobacco use, physical inactivity, obesity, diabetes, metabolic syndrome, certain psychologic states, and elevated homocysteine levels. Weight lifting is not a cardioprotective exercise. An example of health-promoting regular physical activity is brisk walking (3 to 4 miles/hr) for at least 30 minutes five or more times each week.

A patient is admitted to the ICU with a diagnosis of unstable angina. Which drug(s) would the nurse expect the patient to receive (select all that apply)? a. ACE inhibitor b. Antiplatelet therapy c. Thrombolytic therapy d. Prophylactic antibiotics e. Intravenous nitroglycerin

a. ACE inhibitor b. Antiplatelet therapy e. Intravenous nitroglycerin Rationale: In addition to oxygen, several drugs may be used to treat unstable angina (UA): IV nitroglycerin, aspirin (chewable), and morphine. For patients with UA with negative cardiac biomarkers and ongoing angina, a combination of aspirin, heparin, and a glycoprotein IIb/IIIa inhibitor (e.g., eptifibatide [Integrilin]) is recommended. Angiotensin-converting enzyme (ACE) inhibitors decrease myocardial oxygen demand by producing vasodilation, reducing blood volume, and slowing or reversing cardiac remodeling.

The nurse recognizes that primary manifestations of systolic failure include a. Decreased EF and increased PAWP b. Decreased PAWP and increased EF c. Decreased pulmonary hypertension associated with normal EF d. Decreased afterload and decreased left ventricular end-diastolic pressure

a. Decreased EF and increased PAWP Rationale: Systolic heart failure results in systolic failure in the left ventricle (LV). The LV loses its ability to generate enough pressure to eject blood forward through the aorta. This results in increased pulmonary artery wedge pressure (PAWP). The hallmark of systolic failure is a decrease in the left ventricular ejection fraction (EF).

A patient with chronic HF and atrial fibrillation is treated with a digitalis glycoside and a loop diuretic. To prevent possible complications of this combination of drugs, what does the nurse need to do (select all that apply)? a. Monitor serum potassium levels b. Teach the patient how to take a pulse rate c. Keep an accurate measure of intake and output d. Teach the patient about dietary restriction of potassium e. Withhold digitalis and notify health care provider if pulse is irregular

a. Monitor serum potassium levels b. Teach the patient how to take a pulse rate Rationale: Hypokalemia, which can be caused by the use of potassium-depleting diuretics (e.g., thiazides, loop diuretics), is one of the most common causes of digitalis toxicity. Low serum levels of potassium enhance the action of digitalis, causing a therapeutic dose to achieve toxic levels. Hypokalemia can also precipitate dysrhythmias. Monitoring the serum potassium levels of patients receiving digitalis preparations and potassium-depleting diuretics is essential. Patients taking digitalis preparations should be taught how to measure their pulse rate because bradycardia and atrioventricular blocks are late signs of digitalis toxicity. In addition, patients should know what pulse rate would require a call to the HCP. Patients should not independently decide to skip a dose of digitalis.

Morphine 10 mg IV every 4 to 6 hours prn is ordered for a patient with a pancreatic tumor who has a distant history of opioid abuse. After 3 days of receiving the morphine every 6 hours, the patient tells the nurse that the medication is needed more frequently to control the pain. The best initial action by the nurse is to a. administer the morphine every 4 hours as needed. b. consult with the doctor about initiating an appropriate weaning protocol for the morphine c. remind the patient that the previous substance abuse increases the risk for addiction. d. use alternative therapies such as heat or cold.

administer the morphine every 4 hours as needed Response Feedback: Rationale: These patient data indicate that tolerance for the morphine is developing and more frequent administration is needed to maintain pain control. A weaning protocol is not indicated, since the patient still has the pancreatic tumor and there is no indication that the physiologic basis of the pain has changed. Although the patient may be at risk for addiction, adequate pain management is the priority at present. Alternative therapies may be a useful adjuvant to the morphine but should not be the first nursing action.

A patient who has just started taking sustained-release morphine sulfate (MS Contin) for chronic pain complains of nausea and abdominal fullness. The most appropriate initial action by the nurse is to a. consult with the health care provider about using a different opioid. b. administer the ordered metoclopramide (Reglan) 10 mg IV. c. tell the patient that the nausea will subside in about a week. d. order the patient a clear liquid diet until the nausea decreases.

administer the ordered metoclopramide (Reglan) 10 mg IV

A 24-year old patient is admitted to the trauma unit with a diagnosis of a fractured femur after a motor vehicle accident. He states that he has pain in the injured leg. What should be the first action taken by the nurse? a. Administer the lowest dose of pain medication b. Assess the characteristics of the pain c. Call the orthopedic surgeon d. Complete the admission assessment

assess the characteristics of the pain

A nurse is caring for a client who had a percutaneous insertion of an inferior vena cava filter and was on heparin therapy before surgery. The nurse would inspect the surgical site most closely for signs of: a. Thrombosis and infection b. Bleeding and infection c. Bleeding and wound dehiscence. d. Wound dehiscence and evisceration.

b. After inferior vena cava insertion, the nurse inspects the surgical site for bleeding and signs and symptoms of infection. Otherwise, care is the same as for any post-op client

Patients with a heart transplantation are at risk for which complications in the first year after transplantation (select all that apply)? a. Cancer b. Infection c. Rejection d. Vasculopathy e. Sudden cardiac death

b. Infection c. Rejection e. Sudden cardiac death Rationale: A variety of complications can occur after heart transplantation. In the first year after transplantation, the major causes of death are acute rejection and infection. Heart transplant recipients also are at risk for sudden cardiac death. Later, malignancy (especially lymphoma) and cardiac vasculopathy (accelerated CAD) are major causes of death.

A client comes to the outpatient clinic and tells the nurse that he has had legs pains that begin when he walks but cease when he stops walking. Which of the following conditions would the nurse assess for? a. An acute obstruction in the vessels of the legs b. Peripheral vascular problems in both legs c. Diabetes d. Calcium deficiency

b. Intermittent claudication is a condition that indicates vascular deficiencies in the peripheral vascular system. If an obstruction were present, the leg pain would persist when the client stops walking. Low calcium levels may cause leg cramps but would not necessarily be related to walking.

A nurse is assessing a client with an abdominal aortic aneurysm. Which of the following assessment findings by the nurse is probably unrelated to the aneurysm? a. Pulsatile abdominal mass b. Hyperactive bowel sounds in that area c. Systolic bruit over the area of the mass d. Subjective sensation of "heart beating" in the abdomen.

b. Not all clients with abdominal aortic aneurysms exhibit symptoms. Those who do describe a feeling of the "heart beating" in the abdomen when supine or be able to feel the mass throbbing. A pulsatile mass may be palpated in the middle and upper abdomen. A systolic bruit may be auscultated over the mass. Hyperactive bowel sounds are not related specifically to an abdominal aortic aneurysm.

The nurse is caring for a patient who is 2 days post MI. The patient reports that she is experiencing chest pain. She states, "It hurts when I take a deep breath." Which action would be a priority? a. Notify the physician STAT and obtain a 12-lead ECG b. Obtain vital signs and auscultate for a pericardial friction rub c. Apply high-flow O2 by face mask and auscultate breath sounds d. Medicate the patient with PRN analgesic and reevaluate in 30 minutes

b. Obtain vital signs and auscultate for a pericardial friction rub Rationale: Acute pericarditis is inflammation of the visceral and/or parietal pericardium. It often occurs 2 to 3 days after an acute myocardial infarction. Chest pain may vary from mild to severe and is aggravated by inspiration, coughing, and movement of the upper body. Sitting in a forward position often relieves the pain. The pain is usually different from pain associated with a myocardial infarction. Assessment of the patient with pericarditis may reveal a friction rub over the pericardium.

In preparation for discharge of a client with arterial insufficiency and Raynaud's disease, client teaching instructions should include: a. Walking several times each day as an exercise program. b. Keeping the heat up so that the environment is warm c. Wearing TED hose during the day d. Using hydrotherapy for increasing oxygenation

b. The client's instructions should include keeping the environment warm to prevent vasoconstriction. Wearing gloves, warm clothes, and socks will also be useful when preventing vasoconstriction, but TED hose would not be therapeutic. Walking would most likely increase pain.

A 24-year old man seeks medical attention for complaints of claudication in the arch of the foot. A nurse also notes superficial thrombophlebitis of the lower leg. The nurse would next assess the client for: a. Familial tendency toward peripheral vascular disease b. Smoking history c. Recent exposures to allergens d. History of insect bites

b. The mixture of arterial and venous manifestations (claudication and phlebitis, respectively) in the young male client suggests Buerger's disease. This is an uncommon disorder characterized by inflammation and thrombosis of smaller arteries and veins. This disorder typically is found in young adult males who smoke. The cause is not known precisely but is suspected to have an autoimmune component.

Which technique is considered the gold standard for diagnosing DVT? a. Ultrasound imaging b. Venography c. MRI d. Doppler flow study

b. Venography

In teaching a patient about coronary artery disease, the nurse explains that the changes that occur in this disorder include (select all that apply) a. diffuse involvement of plaque formation in coronary veins b. abnormal levels of cholesterol, especially low-density lipoproteins c. accumulation of lipid and fibrous tissue within the coronary arteries d. development of angina due to a decreased blood supply to the heart muscle e. chronic vasoconstriction of coronary arteries leading to permanent vasospasm

b. abnormal levels of cholesterol, especially low-density lipoproteins c. accumulation of lipid and fibrous tissue within the coronary arteries d. development of angina due to a decreased blood supply to the heart muscle Rationale: Atherosclerosis is the major cause of coronary artery disease (CAD) and is characterized by a focal deposit of cholesterol and lipids, primarily within the intimal wall of the artery. The endothelial lining of the coronary arteries becomes inflamed from the presence of unstable plaques and the oxidation of low-density lipoprotein (LDL) cholesterol. Fibrous plaque causes progressive changes in the endothelium of the arterial wall. The result is a narrowing of the vessel lumen and a reduction in blood flow to the myocardial tissue.

A hospitalized patient with a history of chronic stable angina tells the nurse that she is having chest pain. The nurse bases his actions on the knowledge that ischemia a. will always progress to myocardial infarction b. will be relieved by rest, nitroglycerin, or both c. indicates that irreversible myocardial damage is occurring d. is frequently associated with vomiting and extreme fatigue

b. will be relieved by rest, nitroglycerin, or both Rationale: Chronic stable angina is chest pain that occurs intermittently over a long period with the same pattern of onset, duration, and intensity of symptoms. The chest pain is relieved by rest or by rest and medication (e.g., nitroglycerin). The ischemia is transient and does not cause myocardial damage.

Which are probable clinical findings in a person with an acute lower extremity VTE (select all that apply)? a.Pallor and coolness of foot and calf b.Mild to moderate calf pain and tenderness c.Grossly diminished or absent pedal pulses d.Unilateral edema and induration of the thigh e.Palpable cord along a superficial varicose vein

b.Mild to moderate calf pain and tenderness d.Unilateral edema and induration of the thigh The patient with lower extremity venous thromboembolism (VTE) may or may not have unilateral leg edema, extremity pain, a sense of fullness in the thigh or calf, paresthesias, warm skin, erythema, or a systemic temperature greater than 100.4 F (38 C). If the calf is involved, it may be tender to palpation.

A patient is admitted to the hospital with a diagnosis of abdominal aortic aneurysm. Which signs and symptoms would suggest that his aneurysm has ruptured? a.Sudden shortness of breath and hemoptysis b.Sudden, severe low back pain and bruising along his flank c.Gradually increasing substernal chest pain and diaphoresis d.Sudden, patchy blue mottling on feet and toes and rest pain

b.Sudden, severe low back pain and bruising along his flank The clinical manifestations of a ruptured abdominal aortic aneurysm include severe back pain, back or flank ecchymosis (Grey Turner's sign), and hypovolemic shock (tachycardia, hypotension, pale clammy skin, decreased urine output, altered level of consciousness, and abdominal tenderness).

The patient at highest risk for venous thromboembolism (VTE) is a.a 62-year-old man with spider veins who is having arthroscopic knee surgery. b.a 32-year-old woman who smokes, takes oral contraceptives, and is planning a trip to Europe. c.a 26-year-old woman who is 3 days postpartum and received maintenance IV fluids for 12 hours during her labor. d.an active 72-year-old man at home recovering from transurethral resection of the prostate for benign prostatic hyperplasia.

b.a 32-year-old woman who smokes, takes oral contraceptives, and is planning a trip to Europe. Three important factors (called Virchow's triad) in the etiology of venous thrombosis are (1) venous stasis, (2) damage of the endothelium (inner lining of the vein), and (3) hypercoagulability of the blood. Patients at risk for venous thrombosis usually have predisposing conditions for these three disorders (see Table 38-8). The 32-year-old woman has the highest risk: long trips without adequate exercise (venous stasis), tobacco use, and use of oral contraceptives. Note: The likelihood of hypercoagulability of blood is increased in women older than 35 years who use tobacco.

a patient who had a gastroduodenostomy (Billroth I operation) for stomach cancer reports generalized weakness, sweating, palpitations, and dizziness 15 to 30 minutes after eating. What long-term complication does the nurse suspect is occurring? Malnutrition Bile reflux gastritis Dumping syndrome Postprandial hypoglycemia

c After a Billroth I operation, dumping syndrome may occur 15 to 30 minutes after eating because of the hypertonic fluid going to the intestine and additional fluid being drawn into the bowel. Malnutrition may occur but does not cause these symptoms. Bile reflux gastritis cannot happen when the stomach has been removed. Postprandial hypoglycemia occurs with similar symptoms, but 2 hours after eating.

The patient is having an esophagoenterostomy with anastomosis of a segment of the colon to replace the resected portion. What initial postoperative care should the nurse expect when this patient returns to the nursing unit? a Turn, deep breathe, cough, and use spirometer every 4 hours. b Maintain an upright position for at least 2 hours after eating. c NG will have bloody drainage and it should not be repositioned. d Keep in a supine position to prevent movement of the anastomosis.

c The patient will have bloody drainage from the nasogastric (NG) tube for 8 to 12 hours, and it should not be repositioned or reinserted without contacting the surgeon. Turning and deep breathing will be done every 2 hours, and the spirometer will be used more often than every 4 hours. Coughing would put too much pressure in the area and should not be done. Because the patient will have the NG tube, the patient will not be eating yet. The patient should be kept in a semi-Fowler's or Fowler's position, not supine, to prevent reflux and aspiration of secretions.

The patient with chronic gastritis is being put on a combination of medications to eradicate Helicobacter pylori. Which drugs does the nurse know will probably be used? a Antibiotic(s), antacid, and corticosteroid b Antibiotic(s), aspirin, and antiulcer/protectant c Antibiotic(s), proton pump inhibitor, and bismuth d Antibiotic(s) and nonsteroidal antiinflammatory drugs (NSAIDs)

c To eradicate H. pylori, a combination of antibiotics, a proton pump inhibitor, and possibly bismuth (for quadruple therapy) will be used. Corticosteroids, aspirin, and NSAIDs are drugs that can cause gastritis and do not affect H. pylori.

A patient is recovering from an uncomplicated MI. Which rehabilitation guideline is a priority to include in the teaching plan? a. Refrain from sexual activity for a minimum of 3 weeks b. Plan a diet program that aims for a 1- to 2-pound weight loss per week c. Begin an exercise program that aims for at least five 30-minute sessions per week d. Consider the use of erectile agents and prophylactic NTG before engaging in sexual activity

c. Begin an exercise program that aims for at least five 30-minute sessions per week Rationale: Physical activity should be regular, rhythmic, and repetitive, with the use of large muscles to build up endurance (e.g., walking, cycling, swimming, rowing). Physical activity sessions should be at least 30 minutes long. Instruct the patient to begin slowly at personal tolerance (perhaps only 5 to 10 minutes) and build up to 30 minutes.

Which of the following characteristics is typical of the pain associated with DVT? a. Dull ache b. No pain c. Sudden onset d. Tingling

c. DVT is associated with deep leg pain of sudden onset, which occurs secondary to the occlusion. A dull ache is more commonly associated with varicose veins. A tingling sensation is associated with an alteration in arterial blood flow. If the thrombus is large enough, it will cause pain.

You are caring for a patient with ADHF who is receiving IV dobutamine (Dobutrex). You know that this drug is ordered because it (select all that apply) a. increases SVR b. produces diuresis c. improves contractility d. dilates renal blood vessels e. works on the B1-receptors in the heart

c. improves contractility e. works on the B1-receptors in the heart Rationale: Dobutamine (Dobutrex) has a positive chronotropic effect and increases heart rate and improves contractility. It is a selective β-adrenergic agonist and works primarily on the β1-adrenergic receptors in the heart. It is frequently used in the short-term management of acute decompensated heart failure (ADHF).

A 50-year-old woman weighs 95 kg and has a history of tobacco use, high blood pressure, high sodium intake, and sedentary lifestyle. When developing an individualized care plan for her, the nurse determines that the most important risk factors for peripheral artery disease (PAD) that need to be modified are a.weight and diet. b.activity level and diet. c.tobacco use and high blood pressure. d.sedentary lifestyle and high blood pressure.

c. tobacco use and high blood pressure Significant risk factors for peripheral artery disease include tobacco use, hyperlipidemia, elevated levels of high-sensitivity C-reactive protein, diabetes mellitus, and uncontrolled hypertension; the most important is tobacco use. Other risk factors include family history, hypertriglyceridemia, hyperuricemia, increasing age, obesity, sedentary lifestyle, and stress.

A patient complaining of nausea receives a dose of metoclopramide. Which potential adverse effect should the nurse tell the patient to report? a Tremors b Constipation c Double vision d Numbness in fingers and toes

correct answer a Extrapyramidal side effects, including tremors and tardive dyskinesias, may occur with metoclopramide administration. Constipation, double vision, and numbness in fingers and toes are not adverse effects of metoclopramide.

A patient with oral cancer is not eating. A small-bore feeding tube was inserted and the patient started on enteral feedings. Which patient goal would indicate improvement? a Weight gain of 1 kg in 1 week b Administer tube feeding at 25 mL/hr. c Consume 50% of clear liquid tray this shift. d Monitor for tube for placement and gastrointestinal residual

correct answer a The goal for a patient with oral cancer that is not eating would be to note weight gain rather than loss. Consuming 50% of the clear liquid tray is not a realistic goal. Administering feedings, monitoring tube placement, and tolerance are interventions used to achieve the goal.

A patient has a sliding hiatal hernia. What nursing intervention will reduce the symptoms of heartburn and dyspepsia? a Keeping the patient NPO b Putting the bed in the Trendelenburg position c Having the patient eat 4 to 6 smaller meals each day Correct d Giving various antacids to determine which one works for the patient

correct answer c Eating smaller meals during the day will decrease the gastric pressure and symptoms of hiatal hernia. Keeping the patient NPO or in a Trendelenburg position is not safe or realistic for a long period of time for any patient. Varying antacids will only be done with the health care provider's prescription, so this is not a nursing intervention.

A patient was admitted with epigastric pain because of a gastric ulcer. Which patient assessment warrants an urgent change in the nursing plan of care? a Back pain 3 or 4 hours after eating a meal b Chest pain relieved with eating or drinking water c Burning epigastric pain 90 minutes after breakfast d Rigid abdomen and vomiting following indigestion

correct answer d A rigid abdomen with vomiting in a patient who has a gastric ulcer indicates a perforation of the ulcer, especially if the manifestations of perforation appear suddenly. Midepigastric pain is relieved by eating, drinking water, or antacids with duodenal ulcers, not gastric ulcers. Back pain 3 to 4 hours after a meal is more likely to occur with a duodenal ulcer. Burning epigastric pain 1 to 2 hours after a meal is an expected manifestation of a gastric ulcer related to increased gastric secretions and does not cause an urgent change in the nursing plan of care.

A patient is seeking emergency care after choking on a piece of steak. The nursing assessment reveals a history of alcoholism, cigarette smoking, and hemoptysis. Which diagnostic study is most likely to be performed on this patient? a Barium swallow b Endoscopic biopsy c Capsule endoscopy d Endoscopic ultrasonography

correct answer:b Because of this patient's history of excessive alcohol intake, smoking, and hemoptysis and the current choking episode, cancer may be present. A biopsy is necessary to make a definitive diagnosis of carcinoma, so an endoscope will be used to obtain a biopsy and observe other abnormalities as well. A barium swallow may show narrowing of the esophagus, but it is more diagnostic for achalasia. An endoscopic ultrasonography may be used to stage esophageal cancer. Capsule endoscopy can show alterations in the esophagus but is more often used for small intestine problems. A barium swallow, capsule endoscopy, and endoscopic ultrasonography cannot provide a definitive diagnosis for

The patient who is admitted with a diagnosis of diverticulitis and a history of irritable bowel disease and gastroesophageal reflux disease (GERD) has received a dose of Mylanta 30 mL PO. The nurse will determine the medication was effective when which symptom has been resolved? a Diarrhea b Heartburn c Constipation d Lower abdominal pain

correct answer:b Mylanta is an antacid that contains both aluminum and magnesium. It is indicated for the relief of gastrointestinal discomfort, such as heartburn associated with GERD. Mylanta can cause both diarrhea and constipation as a side effect. Mylanta does not affect lower abdominal pain.

The nurse is teaching a group of college students how to prevent food poisoning. Which comment shows an understanding of foodborne illness protection? a "Eating raw cookie dough from the package is a great snack when you do not have time to bake." b "Since we only have one cutting board, we can cut up chicken and salad vegetables at the same time." c "To save refrigerator space, leftover food can be kept on the counter if it is in sealed containers." d "When the cafeteria gave me a pink hamburger, I sent it back and asked for a new bun and clean plate."

d The student who did not accept the pink hamburger and asked for a new bun and clean plate understood that the pink meat may not have reached 160°F and could be contaminated with bacteria. Improperly storing cooked foods, eating raw cookie dough from a refrigerated package, and only using one cutting board without washing it with hot soapy water between the chicken and salad vegetables could all lead to food poisoning from contamination.

A client is admitted with a venous stasis leg ulcer. A nurse assesses the ulcer, expecting to note that the ulcer: a. Has a pale colored base b. Is deep, with even edges c. Has little granulation tissue d. Has brown pigmentation around it.

d. Venous leg ulcers, also called stasis ulcers, tend to be more superficial than arterial ulcers, and the ulcer bed is pink. The edges of the ulcer are uneven, and granulation tissue is evident. The skin has a brown pigmentation from accumulation of metabolic waste products resulting from venous stasis. The client also exhibits peripheral edema. (options 1, 2, and 3 is due to tissue malnutrition; and thus us an arterial problem)

The health care provider plans to titrate a patient-controlled opioid infusion (PCA) to provide pain relief for a patient with acute surgical pain who has never received opioids in the past. Which of the following nursing actions regarding opioid administration are appropriate at this time? (Select all that apply.) a. Monitoring for therapeutic and adverse effects of opioid administration b. Teaching about the need to decrease opioid doses by the second postoperative day c. Assessing for signs that the patient is becoming addicted to the opioid d. Educating the patient about how analgesics improve postoperative activity level e. Emphasizing that the risk of opioid side effects increases over time

monitoring for therapeutic and adverse effects of opioid admin educating the patient about how analgesics improve postoperative activity level

Which of the following instructions for use of a patient-controlled analgesia (PCA) pump is most important when educating the patient and family before implementation? a. Notify the nurse when you need to push the button on the pump. b. Only the patient should push the button for more medication. c. A spouse can push the button when the patient is asleep. d. Wait for the pain to become at least a 7 on the pain scale before pushing the button.

only the patient should push the button for more medication

The health care provider tells a patient to use ibuprofen (Motrin, Advil) to relieve pain after treating a laceration on the patient's forearm from a dog bite. The patient asks the nurse how ibuprofen will control the pain. The nurse will teach the patient that ibuprofen interferes with the pain process by decreasing the a. production of pain-sensitizing chemicals. b. spinal cord transmission of pain impulses. c. sensitivity of the brain to painful stimuli. d. modulating effect of descending nerves.

production of pain-sensitizing chemicals

Both clients and nurses have misconceptions about pain. Which statement reflects a misconception? a. People can adapt to severe pain. b. Minor injuries can cause intense pain. c. The client is the authority about pain. d. Regular administration of analgesics leads to addiction.

regular administration of analgesics leads to addiction

A hospice patient is in continuous pain, and the health care provider has left orders to administer morphine at a rate that controls the pain. When the nurse visits the patient, the patient is awake but moaning with severe pain and asks for an increase in the morphine dosage. The respiratory rate is 10 breaths per minute. The most appropriate action by the nurse is to a. titrate the morphine dose upward until the patient states there is adequate pain relief. b. administer a nonopioid analgesic, such as ibuprofen, to improve patient pain control. c. tell the patient that additional morphine can be administered when the respirations are 12. d. inform the patient that increasing the morphine will cause the respiratory drive to fail

titrate the morphine dose upward until the patient states there is adequate pain relief. Response Feedback: Rationale: The goal of opioid use in terminally ill patients is effective pain relief regardless of adverse effects such as respiratory depression. A nonopioid analgesic like ibuprofen would not provide adequate analgesia or be absorbed quickly. The rule of double effect provides ethical justification for administering an increased morphine dose to provide effective pain control even though the morphine may further decrease the patient's respiratory rate.

A postoperative patient who has undergone extensive bowel surgery moves as little as possible and does not use the incentive spirometer unless specifically reminded. The patient rates the pain severity as an 8 on a 10-point scale but tells the nurse, "I can tough it out." In encouraging the patient to use pain medication, the best explanation by the nurse is that a. very few patients become addicted to opioids when using them for acute pain control. b. there is little need to worry about side effects because these problems decrease over time. c. there are many pain medications and if one drug is ineffective, other drugs may be tried. d. unrelieved pain can be harmful due to the effect on respiratory function and

unrelieved pain can be harmful due to the effect on respiratory function.