Exam 3
MATCHING A nurse is monitoring patients for fluid and electrolyte and acid-base imbalances. Match the body's regulators to the function it provides. a. Increases excretion of sodium and water. b. Reduces excretion of sodium and water. c. Reduces excretion of water. d. Major buffer in the extracellular fluid. e. Vasoconstricts and stimulates aldosterone release. 1. Antidiuretic hormone 2. Angiotensin II 3. Aldosterone 4. Atrial natriuretic peptide 5. Bicarbonate
1. ANS: C 2. ANS: E 3. ANS: B 4. ANS: A 5. ANS: D
MATCHING A nurse is assessing results of vital signs for a group of patients. Match the condition to the assessment findings the nurse is reviewing. a. Patient's temperature is 113 F (45 C) with hot, dry skin. b. Patient's blood pressure sitting is 130/60 and 110/40 standing. c. Patient's pulse is 110 beats/min. d. Patient's temperature is 93.2 F (34 C). e. Patient's blood pressure went from 126/76 to 90/50. 1. Hypothermia 2. Shock/hypotension 3. Heatstroke 4. Orthostatic hypotension 5. Tachycardia
1. ANS: D DIF:Understand (comprehension) 2. ANS: E DIF:Understand (comprehension) 3. ANS: A DIF:Understand (comprehension) 4. ANS: B DIF:Understand (comprehension) 5. ANS: C DIF:Understand (comprehension)
COMPLETION 1. A patient has 250 mL of a jejunostomy feeding with 30 mL of water before and after feeding and 200 mL of urine. Thirty minutes later the patient has 100 mL of diarrhea. At 1300 the patient receives 150 mL of blood and voids another 200 mL. Calculate the patient's intake. Record your answer as a whole number. _________mL
ANS: 460 The patient's fluid intake is 250 mL of feeding, 60 mL of water (30 mL before and after), and 150 blood: 250 + 60 + 150 = 460 mL. Fluid intake includes all liquids that a person eats (e.g., gelatin, ice cream, soup), drinks (e.g., water, coffee, juice), or receives through nasogastric or jejunostomy feeding tubes. IV fluids (continuous infusions and intermittent IV piggybacks) and blood components also are sources of intake. Fluid output includes urine, diarrhea, vomitus, gastric suction, and drainage from postsurgical wounds or other tubes.
14. A patient asks about treatment for stress urinary incontinence. Which is the nurse's best response? a. Perform pelvic floor exercises. b. Avoid voiding frequently. c. Drink cranberry juice. d. Wear an adult diaper.
ANS: A
A nurse assessing a patient who is receiving a blood transfusion finds that the patient is anxiously fidgeting in bed. The patient is afebrile but dyspneic. The nurse auscultates crackles in both lung bases and sees jugular vein distention. On which transfusion complication will the nurse focus interventions? a. Fluid volume excess b. Hemolytic reaction c. Anaphylactic shock d. Septicemia
ANS: A
A nurse caring for a diabetic patient with a bowel obstruction has orders to ensure that the volume of intake matches the output. In the past 4 hours, the patient received dextrose 5% with 0.9% sodium chloride through a 22-gauge catheter infusing at 150 mL/hr and has eaten 200 mL of ice chips. The patient also has an NG suction tube set to low continuous suction that had 300-mL output. The patient has voided 400 mL of urine. After reporting these values to the health care provider, which order does the nurse anticipate? a. Add a potassium supplement to replace loss from output. b. Decrease the rate of intravenous fluids to 100 mL/hr. c. Administer a diuretic to prevent fluid volume excess. d. Discontinue the nasogastric suctioning.
ANS: A
A nurse is caring for a hospitalized patient with a urinary catheter. Which nursing action best prevents the patient from acquiring an infection? a. Maintaining a closed urinary drainage system b. Inserting the catheter using strict clean technique c. Disconnecting and replacing the catheter drainage bag once per shift d. Fully inflating the catheter's balloon according to the manufacturer's recommendation
ANS: A
A nurse is caring for a patient diagnosed with chronic obstructive pulmonary disease (COPD) who is receiving 2 L/min of oxygen. Which oxygen delivery device is most appropriate for the nurse to administer the oxygen? a. Nasal cannula b. Simple face mask c. Non-rebreather mask d. Partial non-rebreather mask
ANS: A
A nurse is caring for a patient prescribed continuous cardiac monitoring for heart dysrhythmias. Which rhythm will cause the nurse to intervene immediately? a. Ventricular tachycardia b. Atrial fibrillation c. Sinus rhythm d. Paroxysmal supraventricular tachycardia
ANS: A
A nurse is caring for a patient prescribed peripheral intravenous (IV) therapy. Which task will the nurse assign to the nursing assistive personnel? a. Recording intake and output b. Regulating intravenous flow rate c. Starting peripheral intravenous therapy d. Changing a peripheral intravenous dressing
ANS: A
A nurse is caring for a patient with a continent urinary reservoir. Which action will the nurse teach the patient? a. Catheterizing the pouch b. Preforming Kegel exercises c. Changing the collection pouch d. To avoid using the Valsalva technique
ANS: A
A nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel (AP)? a. Obtaining a midstream urine specimen b. Interpreting a bladder scan result c. Inserting a straight catheter d. Irrigating a catheter
ANS: A
A nurse is providing care to a patient with an indwelling catheter. Which practice indicates the nurse is following guidelines for avoiding catheter-associated urinary tract infection (CAUTI)? a. Drapes the urinary drainage tubing with no dependent loops. b. Washes the drainage tube toward the meatus with soap and water. c. Places the urinary drainage bag gently on the floor below the patient. d. Allows the spigot to touch the receptacle when emptying the drainage bag.
ANS: A
A nurse is teaching a nutrition class about the different daily values. When teaching about the referenced daily intakes (RDIs), which information should the nurse include? a. Have values for protein, vitamins, and minerals. b. Are based on percentages of fat, cholesterol, and fiber. c. Have replaced recommended daily allowances (RDAs). d. Are used to develop diets for chronic illnesses requiring 1800 cal/day.
ANS: A
A patient diagnosed with chronic obstructive pulmonary disease (COPD) asks the nurse why clubbing occurs. Which response by the nurse is most therapeutic? a. ―Your disease doesn't send enough oxygen to your fingers.‖ b. ―Your disease affects both your lungs and your heart, and not enough blood is being pumped.‖ c. ―Your disease will be helped if you pursed-lip breathe.‖ d. ―Your disease often makes patients lose mental status.‖
ANS: A
A patient has fallen several times in the past week when attempting to get to the bathroom. The patient gets up 3 or 4 times a night to urinate. Which recommendation by the nurse is most appropriate in correcting this urinary problem? a. Limit fluid and caffeine intake before bed. b. Leave the bathroom light on to illuminate a pathway. c. Practice Kegel exercises to strengthen bladder muscles. d. Clear the path to the bathroom of all obstacles before bedtime.
ANS: A
A patient is experiencing oliguria. Which action should the nurse perform first? a. Assess for bladder distention. b. Request an order for diuretics. c. Increase the patient's intravenous fluid rate. d. Encourage the patient to drink caffeinated beverages.
ANS: A
A patient is experiencing respiratory acidosis. Which organ system is responsible for compensation in this patient? a. Renal b. Endocrine c. Respiratory d. Gastrointestinal
ANS: A
A patient reports severe flank pain. The urinalysis reveals presence of calcium phosphate crystals. The nurse will anticipate an order for which diagnostic test? a. Intravenous pyelogram b. Mid-stream urinalysis c. Bladder scan d. Cystoscopy
ANS: A
A patient requests the nurse's help to the bedside commode and becomes frustrated when unable to void in front of the nurse. How should the nurse interpret the patient's inability to void? a. The patient can be anxious, making it difficult for abdominal and perineal muscles to relax enough to void. b. The patient does not recognize the physiological signals that indicate a need to void. c. The patient is lonely and calling the nurse in under false pretenses is a way to get attention. d. The patient is not drinking enough fluids to produce adequate urine output.
ANS: A
A small-bore feeding tube is placed. Which technique will the nurse use to best verify tube placement? a. X-ray b. pH testing c. Auscultation d. Aspiration of contents
ANS: A
Chapter 42 1. A patient is experiencing dehydration. While planning care, the nurse considers that the majority of the patient's total water volume exists in with compartment? a. Intracellular b. Extracellular c. Intravascular d. Transcellular
ANS: A
During preoperative assessment for a 7:30 AM (0730) surgery, the nurse finds the patient drank a cup of coffee this morning. The nurse reports this information to the anesthesia provider. Which action does the nurse anticipate next? a. A delay in or cancellation of surgery b. Questions regarding components of the coffee c. Additional questions about why the patient had coffee d. Instructions to determine what education was provided in the preoperative visit
ANS: A
Four patients arrive at the emergency department at the same time. Which patient will the nurse see first? a. An infant with temperature of 102.2 F and diarrhea for 3 days b. A teenager with a sprained ankle and excessive edema c. A middle-aged adult with abdominal pain who is moaning and holding her stomach d. An older adult with nausea and vomiting for 3 days with blood pressure 112/60
ANS: A
The health care provider has ordered a hypotonic intravenous (IV) solution to be administered. Which IV bag will the nurse prepare? a. 0.45% sodium chloride (1/2 NS) b. 0.9% sodium chloride (NS) c. Lactated Ringer's (LR) d. Dextrose 5% in Lactated Ringer's (D5LR)
ANS: A
The nurse administers an intravenous (IV) hypertonic solution to a patient expects the fluid shift to occur in what direction? a. From intracellular to extracellular b. From extracellular to intracellular c. From intravascular to intracellular d. From intravascular to interstitial
ANS: A
The nurse has completed a preoperative assessment for a patient going to surgery and gathers assessment data. Which will be the most important next step for the nurse to take? a. Notify the operating suite that the patient has a latex allergy. b. Document that the patient had a bath at home this morning. c. Administer the ordered preoperative intravenous antibiotic. d. Ask the nursing assistive personnel to obtain vital signs.
ANS: A
The nurse is assessing a postoperative patient with a history of obstructive sleep apnea for airway obstruction. Which assessment finding will best alert the nurse to this complication? a. Drop in pulse oximetry readings b. Moaning with reports of pain c. Shallow respirations d. Disorientation
ANS: A
The nurse is calculating intake and output on a patient. The patient drinks 150 mL of orange juice at breakfast, voids 125 mL after breakfast, vomits 250 mL of greenish fluid, sucks on 60 mL of ice chips, and for lunch consumes 75 mL of chicken broth. Which totals for intake and output will the nurse document in the patient's medical record? a. Intake 255; output 375 b. Intake 285; output 375 c. Intake 505; output 125 d. Intake 535; output 125
ANS: A
The nurse is caring for a diabetic patient in renal failure who is in metabolic acidosis. Which laboratory findings are consistent with metabolic acidosis? a. pH 7.3, PaCO2 36 mm Hg, HCO3 - 19 mEq/L b. pH 7.5, PaCO2 35 mm Hg, HCO3 - 35 mEq/L c. pH 7.32, PaCO2 47 mm Hg, HCO3- 23 mEq/L d. pH 7.35, PaCO2 40 mm Hg, HCO3- 25 mEq/L
ANS: A
The nurse is caring for a group of patients. Which patient will the nurse see first? a. A patient who had cataract surgery is coughing. b. A patient who had vascular repair of the right leg is not doing right leg exercises. c. A patient after knee surgery is wearing intermittent pneumatic compression devices and receiving heparin. d. A patient after surgery has vital signs taken every 15 minutes twice, every 30 minutes twice, hourly for 2 hours then every 4 hours.
ANS: A
The nurse is caring for a group of patients. Which patient will the nurse see first? a. A patient with D5W hanging with the blood b. A patient with type A blood receiving type O blood c. A patient with intravenous potassium chloride that is diluted d. A patient with a right mastectomy and an intravenous site in the left arm
ANS: A
The nurse is caring for a patient experiencing fluid volume overload. Which physiological effect does the nurse most likely expect? a. Increased preload b. Increased heart rate c. Decreased afterload d. Decreased tissue perfusion
ANS: A
The nurse is caring for a patient in the operating suite who is experiencing hypercarbia, tachypnea, tachycardia, premature ventricular contractions, and muscle rigidity. Which condition does the nurse suspect the patient is experiencing? a. Malignant hyperthermia b. Fluid imbalance c. Hemorrhage d. Hypoxia
ANS: A
The nurse is caring for a patient in the operating suite. Which outcome will be most appropriate for this patient at the end of the intraoperative phase? a. The patient will be free of burns at the grounding pad. b. The patient will be free of nausea and vomiting. c. The patient will be free of infection. d. The patient will be free of pain.
ANS: A
The nurse is caring for a patient in the post-anesthesia care unit. The patient asks for a bedpan and states to the nurse, ―I feel like I need to go to the bathroom, but I can't.‖ Which nursing intervention will be most appropriate initially? a. Assess the patient for bladder distention. b. Encourage the patient to wait a minute and try again. c. Inform the patient that everyone feels this way after surgery. d. Call the health care provider to obtain an order for catheterization.
ANS: A
The nurse is caring for a patient who is prescribed oxygen via a nasal cannula. Which task can the nurse delegate to the nursing assistive personnel? a. Applying the nasal cannula b. Adjusting the oxygen flow c. Assessing lung sounds d. Setting up the oxygen
ANS: A
The nurse is caring for a postoperative patient who has had a minimally invasive carpel tunnel repair. The patient has a temperature of 97 F and is shivering. Which reason will the nurse most likely consider as the primary cause when planning care? a. Anesthesia lowers metabolism. b. Surgical suites have air currents. c. The patient is dressed only in a gown. d. The large open body cavity contributed to heat loss.
ANS: A
The nurse is completing a medication history for the surgical patient in preadmission testing. Which medication should the nurse instruct the patient to hold (discontinue) in preparation for surgery according to protocol? a. Warfarin b. Vitamin C c. Prednisone d. Acetaminophen
ANS: A
The nurse is creating a plan of care for an obese patient who is experiencing fatigue related to ineffective breathing. Which intervention best addresses a short-term goal the patient could achieve? a. Sleeping on two to three pillows at night b. Sensibly reducing daily calorie intake c. Running 30 minutes every morning d. Stopping smoking immediately
ANS: A
The nurse is describing the My Plate program to a patient. Which statement from the patient indicates successful learning? a. ―I can use this to make healthy lifestyle food choices.‖ b. ―I can use this to count specific calories of food.‖ c. ―I can use this for my baby girl.‖ d. ―I can use this when I am sick.‖
ANS: A
The nurse is laboratory blood results will expect to observe which cation in the most abundance? a. Sodium b. Chloride c. Potassium d. Magnesium
ANS: A
The nurse is planning care for a group of stable patients receiving enteral nutrition. Which task will the nurse assign to the nursing assistive personnel? a. Measuring capillary blood glucose level b. Measuring nasoenteric tube for insertion c. Measuring pH in gastrointestinal aspirate d. Measuring the patient's risk for aspiration
ANS: A
The nurse is preparing to apply an external catheter. Which action will the nurse take? a. Allow 1 to 2 inches of space between the tip of the penis and the end of the catheter. b. Spiral wrap the penile shaft using adhesive tape to secure the catheter. c. Twist the catheter before applying drainage tubing to the end of the catheter. d. Shave the pubic area before applying the catheter.
ANS: A
The nurse is preparing to assist the patient in using the incentive spirometer. Which nursing intervention should the nurse provide first? a. Perform hand hygiene. b. Explain use of the mouthpiece. c. Instruct the patient to inhale slowly. d. Place in the reverse Trendelenburg's position.
ANS: A
The nurse is providing home care for a patient diagnosed with acquired immunodeficiency syndrome (AIDS). Which dietary intervention will the nurse add to the care plan? a. Provide small, frequent nutrient-dense meals for maximizing kilocalories. b. Prepare hot meals because they are more easily tolerated by the patient. c. Avoid salty foods and limit liquids to preserve electrolytes. d. Encourage intake of fatty foods to increase caloric intake.
ANS: A
The nurse is providing preoperative teaching for the ambulatory surgery patient who will be having a cyst removed from the right arm. Which will be the best explanation for diet progression after surgery? a. ―Start with clear liquids, soup, and crackers. Advance to a normal diet as tolerated.‖ b. ―Stay with ice chips for several hours. After that, you can have whatever you want.‖ c. ―Stay on clear liquids for 24 hours. Then you can progress to a normal diet.‖ d. ―Start with clear liquids for 2 hours and then full liquids for 2 hours. Then progress to a normal diet.‖
ANS: A
The nurse is reviewing the surgical consent with the patient during preoperative education and finds the patient does not understand what procedure will be performed. What is the nurse's best next step? a. Notify the health care provider about the patient's question. b. Explain the procedure that will be completed. c. Continue with preoperative education. d. Ask the patient to sign the form.
ANS: A
The nurse is teaching about the process of passively moving water from an area of lower particle concentration to an area of higher particle concentration. Which process is the nurse describing? a. Osmosis b. Filtration c. Diffusion d. Active transport
ANS: A
The patient has an intravenous (IV) line and the nurse needs to remove the gown. In which order will the nurse perform the steps, starting with the first one? 1. Remove the sleeve of the gown from the arm without the IV. 2. Remove the sleeve of the gown from the arm with the IV. 3. Remove the IV solution container from its stand. 4. Pass the IV bag and tubing through the sleeve. a. 1, 2, 3, 4 b. 2, 3, 4, 1 c. 3, 4, 1, 2 d. 4, 1, 2, 3
ANS: A
The patient has just started on enteral feedings and is now reporting abdominal cramping. Which action will the nurse take next? a. Slow the rate of tube feeding. b. Instill cold formula to ―numb‖ the stomach. c. Change the tube feeding to a high-fat formula. d. Consult with the health care provider about prokinetic medication.
ANS: A
The patient is an 80-year-old male who is visiting the clinic today for a routine physical examination. The patient's skin turgor is fair, but the patient reports fatigue and weakness. The skin is warm and dry, pulse rate is 116 beats/min, and urinary sodium level is slightly elevated. Which instruction should the nurse provide? a. Drink more water to prevent further dehydration. b. Drink more calorie-dense fluids to increase caloric intake. c. Drink more milk and dairy products to decrease the risk of osteoporosis. d. Drink more grapefruit juice to enhance vitamin C intake and medication absorption.
ANS: A
The patient is experiencing angina pectoris. Which assessment finding does the nurse expect when conducting a history and physical examination? a. Experiences chest pain after eating a heavy meal. b. Experiences adequate oxygen saturation during exercise. c. Experiences crushing chest pain for more than 20 minutes. d. Experiences tingling in the left arm that lasts throughout the morning.
ANS: A
The patient is on parenteral nutrition is lethargic while reporting thirst and headache and has had increased urination. Which problem does the nurse prepare to address? a. Hyperglycemia b. Hypoglycemia c. Hypercapnia d. Hypocapnia
ANS: A
To reduce patient discomfort during a closed intermittent catheter irrigation, what should the nurse do? a. Use room temperature irrigation solution. b. Administer the solution as quickly as possible. c. Allow the solution to sit in the bladder for at least 1 hour. d. Raise the bag of the irrigation solution at least 12 inches above the bladder.
ANS: A
When planning care for an adolescent who plays sports, which modification should the nurse include in the care plan? a. Increasing carbohydrates to 55% to 60% of total intake b. Providing vitamin and mineral supplements c. Decreasing protein intake to 0.75 g/kg/day d. Limiting water before and after exercise
ANS: A
Which coughing technique will the nurse use to help a patient clear central airways? a. Huff b. Quad c. Cascade d. Incentive spirometry
ANS: A
Which nursing assessment will indicate the patient is performing diaphragmatic breathing correctly? a. Hands placed on the border of the rib cage with fingers extended will touch as the chest wall contracts. b. Hands placed on the chest wall with fingers extended will separate as the chest wall contracts. c. The patient will feel upward movement of the diaphragm during inspiration. d. The patient will feel downward movement of the diaphragm during expiration.
ANS: A
Which risk factor for cardiopulmonary disease should the nurse describe as modifiable? a. Stress b. Allergies c. Family history d. Gender
ANS: A
Which determination is the nurse trying to achieve by monitoring a patient's cardiac output? a. Peripheral extremity circulation b. Oxygenation requirements c. Presence of cardiac dysrhythmias d. Ventilation status
ANS: A Cardiac output indicates how much blood is being circulated systemically throughout the body to the periphery. The amount of blood ejected from the left ventricle each minute is the cardiac output. Oxygen status would be determined by pulse oximetry and the presence of cyanosis. Cardiac dysrhythmias are an electrical impulse monitored through ECG results. Ventilation status is measured by respiratory rate, pulse oximetry, and capnography. Capnography provides instant information about the patient's ventilation. Ventilation status does not depend solely on cardiac output.
The nurse is caring for a patient in the postanesthesia care unit who has undergone a left total knee arthroplasty. The anesthesia provider has indicated that the patient received regional anesthesia in the form of a left femoral peripheral nerve block. Which assessment will be an expected finding for this patient? a. Sensation decreased in the left leg b. Patient report of pain in the left foot c. Pulse decreased at the left posterior tibia d. Left toes cool to touch and slightly cyanotic
ANS: A Induction of regional anesthesia results in loss of sensation in an area of the body—in this case, the left leg. The peripheral nerve block influences the portions of sensory pathways that are anesthetized in the targeted area of the body. Decreased pulse, toes cool to touch, and cyanosis are indications of decreased blood flow and are not expected findings. Reports of pain in the left foot may indicate that the block is not working or is subsiding and is not an expected finding in the immediate postoperative period.
The patient is breathing normally. Which process does the nurse consider is working properly when the patient inspires? a. Stimulation of chemical receptors in the aorta b. Reduction of arterial oxygen saturation levels c. Requirement of elastic recoil lung properties d. Enhancement of accessory muscle usage
ANS: A Inspiration is an active process, stimulated by chemical receptors in the aorta. Reduced arterial oxygen saturation levels indicate hypoxemia, an abnormal finding. Expiration is a passive process that depends on the elastic recoil properties of the lungs, requiring little or no muscle work. Prolonged use of the accessory muscles does not promote effective ventilation and causes fatigue.
After taking the patient's temperature, the nurse documents the value and the route used to obtain the reading. What is the reason for the nurse's action? a. Temperatures vary depending on the route used. b. Temperatures are readings of core measurements. c. Rectal temperatures are cooler than when taken orally. d. Axillary temperatures are higher than oral temperatures.
ANS: A Temperatures obtained vary depending on the site used. Rectal temperatures are usually 0.5 C (0.9 F) higher than oral temperatures, and axillary temperatures are usually 0.5 C (0.9 F) lower than oral temperatures. There are core temperature readings and body surface readings.
A nurse explains the function of the alveoli to a patient with respiratory problems. Which information about the alveoli's function will the nurse share with the patient? a. Carries out gas exchange. b. Regulates tidal volume. c. Produces hemoglobin. d. Stores oxygen.
ANS: A The alveolus is a capillary membrane that allows gas exchange of oxygen and carbon dioxide during respiration. The alveoli do not store oxygen, regulate tidal volume, or produce hemoglobin.
A nurse is caring for a group of patients. Which patient should the nurse see first? a. A patient with hypercapnia wearing an oxygen mask b. A patient with a chest tube ambulating with the chest tube unclamped c. A patient with thick secretions being tracheal suctioned first and then orally d. A patient with a new tracheostomy and tracheostomy obturator at bedside
ANS: A The mask is contraindicated for patients with carbon dioxide retention (hypercapnia) because retention can be worsened; the nurse must see this patient first to correct the problem. All the rest are using correct procedures and do not need to be seen first. A chest tube should not be clamped when ambulating. Clamping a chest tube is contraindicated when ambulating or transporting a patient. Clamping can result in a tension pneumothorax. Use nasotracheal suctioning before pharyngeal suctioning whenever possible. The mouth and pharynx contain more bacteria than the trachea. Keep tracheostomy obturator at bedside with a fresh (new) tracheostomy to facilitate reinsertion of the outer cannula if dislodged.
The health care provider prescription reads ―Metoprolol 50 mg PO daily. Do not give if blood pressure is less than 100 mm Hg systolic.‖ The patient's blood pressure is 92/66. The nurse does not give the medication. Which action should the nurse take? a. Documents that the medication was not given because of low blood pressure. b. Does not inform the health care provider that the medication was held. c. Does not tell the patient what the blood pressure is. d. Documents only what the blood pressure was.
ANS: A The nurse must document any interventions initiated as a result of vital sign measurement such as holding an antihypertensive drug. The nurse should inform the patient of the blood pressure value and the need for periodic reassessment of the blood pressure. Documenting the blood pressure only is not sufficient. Any intervention must be documented as well. Abnormal findings must be reported to the nurse in charge or to the health care provider.
A nurse is caring for a patient whose tissue perfusion is poor as the result of hypertension. When the patient asks what to eat for breakfast, which meal should the nurse suggest? a. A cup of nonfat yogurt with granola and a handful of dried apricots b. Whole wheat toast with butter and a side of bacon c. A bowl of cereal with whole milk and a banana d. Omelet with sausage, cheese, and onions
ANS: A A 2000-calorie diet of fruits, vegetables, and low-fat dairy foods that are high in fiber, potassium, calcium, and magnesium and low in saturated and total fat helps prevent and reduce the effects of hypertension. Nonfat yogurt with granola is a good source of calcium, fiber, and potassium; dried apricots add a second source of potassium. Although cereal and a banana provide fiber and potassium, skim milk should be substituted for whole milk to decrease fat. An omelet with sausage and cheese is high in fat. Butter and bacon are high in fat.
A patient is experiencing carbon dioxide retention from lung problems. Which type of diet will the nurse most likely suggest for this patient? a. Moderate-carbohydrate b. Low-caffeine c. High-caffeine d. High-carbohydrate
ANS: A A moderate-carbohydrate diet is best. Diets high in carbohydrates play a role in increasing the carbon dioxide load for patients with carbon dioxide retention. As carbohydrates are metabolized, an increased load of carbon dioxide is created and excreted via the lungs. A low- or high-caffeine diet is not as important as the carbohydrate load.
The patient is experiencing right-sided heart failure. Which finding will the nurse expect when performing an assessment? a. Peripheral edema b. Basilar crackles c. Chest pain d. Cyanosis
ANS: A Right-sided heart failure results from inability of the right side of the heart to pump effectively, leading to a systemic backup. Peripheral edema, distended neck veins, and weight gain are signs of right-sided failure. Basilar crackles can indicate pulmonary congestion from left-sided heart failure. Cyanosis and chest pain result from inadequate tissue perfusion.
A nurse is reviewing the electrocardiogram (ECG) results. Which portion of the conduction system does the nurse consider when evaluating the P wave? a. SA node b. AV node c. Bundle of His d. Purkinje fibers
ANS: A The P wave represents the electrical conduction through both atria; the SA node initiates electrical conduction through the atria. The AV node conducts down through the bundle of His and the Purkinje fibers to cause ventricular contraction.
The nurse demonstrates postoperative exercises for a patient. In which order will the nurse instruct the patient to perform the exercises? 1. Turning 2. Breathing 3. Coughing 4. Leg exercises a. 4, 1, 2, 3 b. 1, 2, 3, 4 c. 2, 3, 4, 1 d. 3, 1, 4, 2
ANS: A The sequence of exercises is leg exercises, turning, breathing, and coughing.
A nurse is teaching the staff about alterations in breathing patterns. Which information will the nurse include in the teaching session? (Select all that apply.) a. Apnea—no respirations b. Tachypnea—regular, rapid respirations c. Kussmaul's—abnormally deep, regular, fast respirations d. Hyperventilation—labored, increased in depth and rate respirations e. Cheyne-Stokes—abnormally slow and depressed ventilation respirations f. Biot's—irregular with alternating periods of apnea and hyperventilation respirations
ANS: A, B, C
MULTIPLE RESPONSE 1. The nurse is participating in a ―time-out.‖ In which activities will the nurse be involved? (Select all that apply.) a. Verify the correct site. b. Verify the correct patient. c. Verify the correct procedure. d. Perform ―time-out‖ after surgery. e. Perform the actual marking of the operative site.
ANS: A, B, C
The nurse is assessing the patient and family for probable familial causes of the patient's hypertension. The nurse begins by analyzing the patient's personal history, as well as family history and current lifestyle situation. Which findings will the nurse consider to be risk factors? (Select all that apply.) a. Obesity b. Cigarette smoking c. Recent weight loss d. Heavy alcohol intake e. Regular exercise sessions
ANS: A, B, D
MULTIPLE RESPONSE 1. A nurse is teaching a health class about the nutritional requirements throughout the life span. Which information should the nurse include in the teaching session? (Select all that apply.) a. Infants triple weight at 1 year. b. Toddlers become picky eaters. c. School-age children need to avoid hot dogs and grapes. d. Breastfeeding women need an additional 750 kcal/day. e. Older adults have altered food flavor from a decrease in taste cells.
ANS: A, B, E
The patient is being encouraged to purchase a portable automatic blood pressure device to monitor blood pressure at home. Which information will the nurse present as benefits for this type of treatment? (Select all that apply.) a. Patients can actively participate in their treatment. b. Self-monitoring helps with compliance and treatment. c. The risk of obtaining an inaccurate reading is decreased. d. Blood pressures can be obtained if pulse rates become irregular. e. Patients can provide information about patterns to health care providers.
ANS: A, B, E
The operating room nurse is providing a hand-off report to the post-anesthesia care unit (PACU) nurse. Which components will the operating room nurse include? (Select all that apply.) a. IV fluids b. Vital signs c. Insurance data d. Family location e. Anesthesia provided f. Estimated blood loss
ANS: A, B, E, F
The nurse is using different toileting schedules. Which principles will the nurse keep in mind when planning care? (Select all that apply.) a. Habit training uses a bladder diary. b. Timed voiding is based upon the patient's urge to void. c. Prompted voiding includes asking patients if they are wet or dry. d. Elevation of feet in patients with edema can decrease nighttime voiding. e. Bladder retraining teaches patients to follow the urge to void as quickly as possible.
ANS: A, C
3. When assessing patient with nutritional needs, which patients will require follow-up from the nurse? (Select all that apply.) a. A patient with infection taking tetracycline with milk b. A patient with irritable bowel syndrome increasing fiber c. A patient with diverticulitis following a high-fiber diet daily d. A patient with an enteral feeding and 500 mL of gastric residual e. A patient with dysphagia being referred to a speech-language pathologist
ANS: A, C, D
The nurse is preparing for a patient who will be going to surgery. The nurse screens for risk factors that can increase a person's risks in surgery. What risk factors are included in the nurse's screening? (Select all that apply.) a. Age b. Race c. Obesity d. Nutrition e. Pregnancy f. Ambulatory surgery
ANS: A, C, D, E
CHAPTER 42 / MULTIPLE RESPONSE 1. A nurse is selecting a site to insert an intravenous (IV) catheter on an adult. Which actions will the nurse take? (Select all that apply.) a. Check for contraindications to the extremity. b. Start proximally and move distally on the arm. c. Choose a vein with minimal curvature. d. Choose the patient's dominant arm. e. Select a vein that is rigid. f. Avoid areas of flexion.
ANS: A, C, F
Which assessments will alert the nurse that a patient's IV has infiltrated? (Select all that apply.) a. Edema of the extremity near the insertion site b. Reddish streak proximal to the insertion site c. Skin discolored or pale in appearance d. Pain and warmth at the insertion site e. Palpable venous cord f. Skin cool to the touch
ANS: A, C, F
The nurse is caring for a postoperative patient with an incision. Which actions will the nurse take to decrease wound infections? (Select all that apply.) a. Maintain normoglycemia. b. Use a straight razor to remove hair. c. Provide bath and linen change daily. d. Perform first dressing change 2 days postoperatively. e. Perform hand hygiene before and after contact with the patient. f. Administer antibiotics within 60 minutes before surgical incision.
ANS: A, E
The nurse is obtaining a 24-hour urine specimen collection from the patient. Which actions should the nurse take? (Select all that apply.) a. Keeping the urine collection container on ice when indicated b. Withholding all patient medications for the day c. Irrigating the sample as needed with sterile solution d. Testing the urine sample with a reagent strip by dipping it in the urine e. Asking the patient to void and discarding that urine to start the collection
ANS: A, E
A nurse is teaching a community health promotion class and discusses the flu vaccine. Which information will the nurse include in the teaching session? (Select all that apply.) a. It is given yearly. b. It is given in a series of four doses. c. It is safe for children allergic to eggs. d. It is safe for adults with acute febrile illnesses. e. The live, attenuated nasal spray is given to people over 50. f. The vaccines are recommended for all people 6 months and older
ANS: A, F
The patient is asking the nurse about the best way to stay healthy. The nurse explains to the patient which teaching points? (Select all that apply.) a. Increase physical activity. b. Keep total fat intake to 10% or less. c. Maintain body weight in a healthy range. d. Choose and prepare foods with little salt. e. Increase intake of meat and other high-protein foods.
ANS: A,C,D
24. The patient is admitted with facial trauma, including a broken nose, and has a history of esophageal reflux and of aspiration pneumonia. With which tube will the nurse most likely administer the feeding? a. Nasogastric tube b. Jejunostomy tube c. Nasointestinal tube d. Percutaneous endoscopic gastrostomy (PEG) tube
ANS: B
A 2-year-old child has ingested a quantity of a medication that causes respiratory depression. For which acid-base imbalance will the nurse most closely monitor this child? a. Respiratory alkalosis b. Respiratory acidosis c. Metabolic acidosis d. Metabolic alkalosis
ANS: B
A female patient is having difficulty voiding in a bedpan but states that her bladder feels full. To stimulate micturition, which nursing intervention should the nurse try first? a. Exiting the room and informing the patient that the nurse will return in 30 minutes to check on the patient's progress b. Utilizing the power of suggestion by turning on the faucet and letting the water run c. Obtaining an order for a Foley catheter d. Administering diuretic medication
ANS: B
A nurse administering a diuretic to a patient is teaching about foods to increase in the diet. Which food choices by the patient will best indicate successful teaching? a. Milk and cheese b. Potatoes and fresh fruit c. Canned soups and vegetables d. Whole grains and dark green leafy vegetables
ANS: B
A nurse is caring for a group of patients. Which patient will the nurse see first? a. Patient receiving total parenteral nutrition of 2-in-1 for 50 hours b. Patient receiving total parenteral nutrition infusing with same tubing for 26 hours c. Patient receiving continuous enteral feeding with same feeding bag for 12 hours d. Patient receiving continuous enteral feeding with same tubing for 24 hours
ANS: B
A nurse is caring for a patient whose electrocardiogram (ECG) presents with changes characteristic of hypokalemia. Which assessment finding will the nurse expect? a. Dry mucous membranes b. Abdominal distention c. Distended neck veins d. Flushed skin
ANS: B
A nurse is providing care to a group of patients. Which patient will the nurse see first? a. A patient who is dribbling urine and has a diagnosis of urge incontinence b. A patient with reflex incontinence with elevated blood pressure and pulse rate c. A patient with an indwelling catheter that has stool on the catheter tubing d. A patient who has just voided and needs a postvoid residual test
ANS: B
A patient develops a foodborne disease from Escherichia coli. When taking a health history, which food item will the nurse most likely find the patient Ingested? a. Improperly home-canned food b. Undercooked ground beef c. Soft cheese d. Custard
ANS: B
A patient experiencing left-sided hemiparesis has developed bronchitis and has a heart rate of 105 beats/min, blood pressure of 156/90 mm Hg, and respiration rate of 30 breaths/min. Which nursing diagnosis is a priority? a. Risk for skin breakdown b. Impaired gas exchange c. Activity intolerance d. Risk for infection
ANS: B
A patient has a decreased gag reflex, left-sided weakness, and drooling. Which action will the nurse take when feeding this patient? a. Position in semi-Fowler's. b. Flex head with chin down. c. Place food on left side. d. Offer fruit juice.
ANS: B
A patient is admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent suction for the past 3 days. Which arterial blood gas values will the nurse expect to observe? a. Respiratory alkalosis b. Metabolic alkalosis c. Metabolic acidosis d. Respiratory acidosis
ANS: B
An 86-year-old patient is experiencing uncontrollable leakage of urine with a strong desire to void and even leaks on the way to the toilet. Which priority nursing diagnosis will the nurse include in the patient's plan of care? a. Functional urinary incontinence b. Urge urinary incontinence c. Impaired skin integrity d. Urinary retention
ANS: B
CHAPTER 46 1. A nurse is teaching a patient about the urinary system. In which order will the nurse present the structures, following the flow of urine? a. Kidney, urethra, bladder, ureters b. Kidney, ureters, bladder, urethra c. Bladder, kidney, ureters, urethra d. Bladder, kidney, urethra, ureters
ANS: B
Chapter 45: Nutrition 1. A nurse is teaching about the energy needed at rest to maintain life-sustaining activities for a specific period of time. What form of energy is the nurse discussing? a. Resting energy expenditure (REE) b. Basal metabolic rate (BMR) c. Nutrient density d. Nutrients
ANS: B
In providing diabetic teaching for a patient diagnosed with type 1 diabetes mellitus, which instructions will the nurse provide to the patient? a. Insulin is the only consideration that must be taken into account. b. Saturated fat should be limited to less than 7% of total calories. c. Nonnutritive sweeteners can be used without restriction. d. Cholesterol intake should be greater than 200 mg/day.
ANS: B
In which patient will the nurse expect to see a positive Chvostek's sign? a. A 7-year-old child admitted for severe burns b. A 24-year-old adult admitted for chronic alcohol abuse c. A 50-year-old patient admitted for an acute exacerbation of hyperparathyroidism d. A 75-year-old patient admitted for a broken hip related to osteoporosis
ANS: B
The circulating nurse is caring for a patient intraoperatively. Which primary role of the circulating nurse will be implemented? a. Suturing the surgical incision in the OR suite b. Managing patient care activities in the OR suite c. Assisting with applying sterile drapes in the OR suite d. Handing sterile instruments and supplies to the surgeon in the OR suite
ANS: B
The nurse anticipates a suprapubic catheter for which patient? a. A patient with recent prostatectomy b. A patient with a urethral stricture c. A patient with an appendectomy d. A patient with menopause
ANS: B
The nurse caring for a preoperative patient teaches the principles and demonstrates leg exercises for the patient. The patient is unable to perform leg exercises correctly. What is the nurse's best next step? a. Encourage the patient to practice at a later date. b. Assess for the presence of anxiety, pain, or fatigue. c. Ask the patient why exercises are not being done. d. Evaluate the educational methods used to educate the patient.
ANS: B
The nurse determines that an older-adult patient is at risk for infection due to decreased immunity. Which plan of care best addresses the prevention of infection for the patient? a. Inform the patient of the importance of finishing the entire dose of antibiotics. b. Encourage the patient to stay up to date on all vaccinations. c. Schedule patient to get annual tuberculosis skin testing. d. Create an exercise routine to run 45 minutes every day.
ANS: B
The nurse explains the pain-relief measures available after surgery during preoperative teaching for a surgical patient. Which comment from the patient indicates the need for additional education on this topic? a. ―I will be asked to rate my pain on a pain scale.‖ b. ―I will have minimal pain because of the anesthesia.‖ c. ―I will take the pain medication as the provider prescribes it.‖ d. ―I will take my pain medications before doing postoperative exercises.‖
ANS: B
The nurse has administered a preoperative medication to the patient going to surgery. Which action will the nurse take next? a. Notify the operating suite that the medication has been given. b. Instruct the patient to call for help to go to the restroom. c. Waste any unused medication according to policy. d. Ask the patient to sign the consent for surgery.
ANS: B
The nurse is caring for a patient who has had a tracheostomy tube inserted. Which nursing intervention is most effective in promoting effective airway clearance? a. Suctioning respiratory secretions several times every hour b. Administering humidified oxygen through a tracheostomy collar c. Instilling normal saline into the tracheostomy to thin secretions before suctioning d. Deflating the tracheostomy cuff before allowing the patient to cough up secretions
ANS: B
The nurse is caring for a patient who will undergo a removal of a lung lobe. Which level of care will the patient require immediately post procedure? a. Acute care—medical-surgical unit b. Acute care—intensive care unit c. Ambulatory surgery d. Ambulatory surgery—extended stay
ANS: B
The nurse is caring for a postoperative patient with an abdominal incision. When the nurse provides a pillow to use during coughing, which activity is the nurse promoting? a. Pain relief b. Splinting c. Distraction d. Anxiety reduction
ANS: B
The nurse is concerned about pulmonary aspiration when providing care to the patient with an intermittent tube feeding. Which action is the priority? a. Observe the color of gastric contents. b. Verify tube placement before feeding. c. Add blue food coloring to the enteral formula. d. Run the formula over 12 hours to decrease overload.
ANS: B
The nurse is concerned about the skin integrity of the patient in the intraoperative phase of surgery. Which action will the nurse take to minimize skin breakdown? a. Encouraging the patient to bathe before surgery b. Securing attachments to the operating table with foam padding c. Periodically adjusting the patient during the surgical procedure d. Measuring the time, a patient is in one position during surgery
ANS: B
The nurse is educating a student nurse on caring for a patient with a chest tube. Which statement from the student nurse indicates successful learning? a. ―I should clamp the chest tube when giving the patient a bed bath.‖ b. ―I should report if I see continuous bubbling in the water-seal chamber.‖ c. ―I should strip the drains on the chest tube every hour to promote drainage.‖ d. ―I should notify the health care provider first, if the chest tube becomes dislodged.‖
ANS: B
The nurse is encouraging the postoperative patient to utilize diaphragmatic breathing. Which priority goal is the nurse trying to achieve? a. Manage pain. b. Prevent atelectasis. c. Reduce healing time. d. Decrease thrombus formation.
ANS: B
The nurse is preparing to check the gastric aspirate for pH. Which equipment will the nurse obtain? a. 10-mL Luer-Lok syringe b. ENFit syringe c. Sterile gloves d. Double gloves
ANS: B
The nurse is preparing to test a patient for postvoid residual with a bladder scan. Which action will the nurse take? a. Measure bladder before the patient voids. b. Measure bladder within 15 minutes after the patient voids. c. Measure bladder with head of bed raised to 60 degrees. d. Measure bladder with head of bed raised to 90 degrees.
ANS: B
The nurse is prescreening a surgical patient in the preadmission testing unit. The medication history indicates that the patient is currently taking an anticoagulant. Which action should the nurse request when consulting with the health care provider? a. A radiological examination of the chest b. An international normalized ratio (INR) c. A blood urea nitrogen (BUN) d. A serum sodium (Na)
ANS: B
The nurse is suctioning a patient with a tracheostomy tube. Which action will the nurse take? a. Set suction regulator at 150 to 200 mm Hg. b. Limit the length of suctioning to 10 seconds. c. Apply suction while gently rotating and inserting the catheter. d. Liberally lubricate the end of the suction catheter with a water-soluble solution.
ANS: B
The nurse observes that the patient's calcium is elevated. When checking the phosphate level, what does the nurse expect to see? a. An increase b. A decrease c. Equal to calcium d. No change in phosphate
ANS: B
The nurse plans to closely monitor the oxygen status of an older-adult patient undergoing anesthesia because of which age-related change? a. Thinner heart valves cause lipid accumulation and fibrosis. b. Diminished respiratory muscle strength may cause poor chest expansion. c. Alterations in mental status prevent patients' awareness of ineffective breathing. d. An increased number of pacemaker cells make proper anesthesia induction more difficult.
ANS: B
The nurse receives the patient's most recent blood work results. Which laboratory value is of greatest concern? a. Sodium of 145 mEq/L b. Calcium of 15.5 mg/dL c. Potassium of 3.5 mEq/L d. Chloride of 100 mEq/L
ANS: B
The nurse, upon reviewing the history, discovers the patient has dysuria. Which assessment finding is consistent with dysuria? a. Blood in the urine b. Burning upon urination c. Immediate, strong desire to void d. Awakes from sleep due to urge to void
ANS: B
The patient is prescribed phenazopyridine. When assessing the urine, what will the nurse expect? a. Red color b. Orange color c. Dark amber color d. Intense yellow color
ANS: B
The post-anesthesia care unit (PACU) nurse transports the inpatient surgical patient to the medical-surgical floor. Before leaving the floor, the medical-surgical nurse obtains a complete set of vital signs. What is the rationale for this nursing action? a. This is done to complete the first action in a head-to-toe assessment. b. This is done to compare and monitor for vital sign variation during transport. c. This is done to ensure that the medical-surgical nurse checks on the postoperative patient. d. This is done to follow hospital policy and procedure for care of the surgical patient.
ANS: B
Which assessment finding should cause a nurse to further assess for extracellular fluid volume deficit? a. Moist mucous membranes b. Postural hypotension c. Supple skin turgor d. Pitting edema
ANS: B
Which blood gas result will the nurse expect to observe in a patient with respiratory alkalosis? a. pH 7.60, PaCO2 40 mm Hg, HCO3 - 30 mEq/L b. pH 7.53, PaCO2 30 mm Hg, HCO3 - 24 mEq/L c. pH 7.35, PaCO2 35 mm Hg, HCO3 - 26 mEq/L d. pH 7.25, PaCO2 48 mm Hg, HCO3 - 23 mEq/L
ANS: B
Which nursing goal is a priority for assessing the patient before surgery? a. Plan for care after the procedure. b. Establish a patient's baseline of normal function. c. Educate the patient and family about the procedure. d. Gather appropriate equipment for the patient's needs.
ANS: B
Which statement by the patient about an upcoming contrast computed tomography (CT) scan indicates a need for further teaching? a. ―I will follow the food and drink restrictions as directed before the test is scheduled.‖ b. ―I will be anesthetized so that I lie perfectly still during the procedure.‖ c. ―I will complete my bowel prep program the night before the scan.‖ d. ―I will be drinking a lot of fluid after the test is over.‖
ANS: B
While receiving a shift report on a female patient, the nurse is informed that the patient has been experiencing urinary incontinence. Upon assessment, which finding will the nurse expect? a. An indwelling Foley catheter b. Reddened irritated skin on buttocks c. Tiny blood clots in the patient's urine d. Foul-smelling discharge indicative of infection
ANS: B
A nurse begins infusing a 250-mL bag of IV fluid at 1845 on Monday and programs the pump to infuse at 50 mL/hr. At what time should the infusion be completed? a. 2300 Monday b. 2345 Monday c. 0015 Tuesday d. 0045 Tuesday
ANS: B 250 mL ÷ 50 mL/hr = 5 hr 1845 + 5 hr = 2345, which would be 2345 on Monday.
The home health nurse recommends that a patient with respiratory problems install a carbon monoxide detector in the home. What is the rationale for the nurse's action? a.Carbon monoxide detectors are required by law in the home. b. Carbon monoxide tightly binds to hemoglobin, causing hypoxia. c. Carbon monoxide signals the cerebral cortex to cease ventilations. d. Carbon monoxide combines with oxygen in the body and produces a deadly toxin.
ANS: B Carbon monoxide binds tightly to hemoglobin; therefore, oxygen is not able to bind to hemoglobin and be transported to tissues, causing hypoxia. A carbon monoxide detector is not required by law, does not signal the cerebral cortex to cease ventilations, and does not combine with oxygen but with hemoglobin to produce a toxin.
The nurse is caring for a patient who is being discharged from the hospital after being treated for hypertension. The patient is instructed to take blood pressure 3 times a day and to keep a record of the readings. The nurse recommends that the patient purchase a portable electronic blood pressure device. Which other information will the nurse share with the patient? a. You can apply the cuff in any manner. b. You will need to recalibrate the machine. c. You can move your arm during the reading. d. You will need to use a stethoscope properly.
ANS: B Electronic devices are easier to manipulate but require frequent recalibration—more than once a year. Because of their sensitivity, improper cuff placement or movement of the arm causes electronic devices to give incorrect readings. The portable home devices include the aneroid sphygmomanometer and electronic digital readout devices that do not require the use of a stethoscope. The cuff will need to be applied correctly, and the patient's arm needs to be still during the reading.
The nurse is caring for a patient who reports feeling light-headed and ―woozy.‖ The nurse checks the patient's pulse and finds that it is irregular. The patient's blood pressure is 100/72. It was 113/80 an hour earlier. What should the nurse do? a. Apply more pressure to the radial artery to feel pulse. b. Perform an apical/radial pulse assessment. c. Call the health care provider immediately. d. Obtain arterial blood gases.
ANS: B If the pulse is irregular, do an apical/radial pulse assessment to detect a pulse deficit. If pulse count differs by more than 2, a pulse deficit exists, which sometimes indicates alterations in cardiac output. The nurse needs to gather as much information as possible before calling the health care provider. The radial pulse is more accurately assessed with moderate pressure. Too much pressure occludes the pulse and impairs blood flow. Arterial blood gases is a laboratory test that measures blood pH and oxygenation status. Arterial blood gases would be appropriate if respirations were abnormal or if pulse oximetry results were severely low.
A nurse is caring for a patient who was in a motor vehicle accident that resulted in cervical trauma to C4. Which assessment is the priority? a. Pulse b. Respirations c. Temperature d. Blood pressure
ANS: B Respirations and oxygen saturation are the priorities. Cervical trauma at C3 to C5 usually results in paralysis of the phrenic nerve. When the phrenic nerve is damaged, the diaphragm does not descend properly, thus reducing inspiratory lung volumes and causing hypoxemia. While pulse and blood pressure are important, respirations are the priority. Temperature is not a high priority in this situation.
The nurse is caring for a patient who is scheduled to undergo a surgical procedure. The nurse is completing an assessment and reviews the patient's laboratory tests and allergies and prepares the patient for surgery. In which perioperative nursing phase is the nurse working? a. Perioperative b. Preoperative c. Intraoperative d. Postoperative
ANS: B Reviewing the patient's laboratory tests and allergies is done before surgery in the preoperative phase. Perioperative means before, during, and after surgery. Intraoperative means during the surgical procedure in the operating suite; postoperative means after the surgery and could occur in the postanesthesia care unit, in the ambulatory surgical area, or on the hospital unit.
CHAPTER 41 OXYGENATION 1. A nurse is teaching staff about the conduction of the heart. In which order will the nurse present the conduction cycle, starting with the first structure? 1. Bundle of His 2. Purkinje network 3. Intraatrial pathways 4. Sinoatrial (SA) node 5. Atrioventricular (AV) node a. 5, 4, 3, 2, 1 b. 4, 3, 5, 1, 2 c. 4, 5, 3, 1, 2 d. 5, 3, 4, 2, 1
ANS: B The conduction system originates with the SA node, the ―pacemaker‖ of the heart. The electrical impulses are transmitted through the atria along intraatrial pathways to the AV node. It assists atrial emptying by delaying the impulse before transmitting it through the Bundle of His and the ventricular Purkinje network.
The nurse is preparing to obtain an oxygen saturation reading on a toddler. Which action will the nurse take? a. Secure the sensor to the toddler's earlobe. b. Determine whether the toddler has a latex allergy. c. Place the sensor on the bridge of the toddler's nose. d. Overlook variations between an oximeter pulse rate and the toddler's pulse rate.
ANS: B The nurse should determine whether the patient has latex allergy because disposable adhesive probes should not be used on patients with latex allergies. Earlobe and bridge of the nose sensors should not be used on infants and toddlers because of skin fragility. Oximeter pulse rate and the patient's apical pulse rate should be the same. Any difference requires re- evaluation of oximeter sensor probe placement and reassessment of pulse rates.
A nurse is caring for a group of patients. Which patient will the nurse see first? a. A 17-year-old male who has just returned from outside ―for a smoke‖ who needs a temperature taken. b. A 20-year-old male postoperative patient whose blood pressure went from 128/70 to 100/60. c. A 27-year-old male patient reporting pain whose blood pressure went from 124/70 to 130/74. d. An 87-year-old male suspected of hypothermia whose temperature is below normal.
ANS: B When a blood pressure drops in a postoperative patient, bleeding may be occurring and lead to shock. The nurse should assess this patient first. Pain will cause the blood pressure to elevate so this is an expected finding, and while it does need to be assessed, it is not the first one to assess. A teenager who has returned from smoking will have to wait at least 20 minutes before a temperature can be taken, so this is not the first one to see. A patient with hypothermia is expected to have a temperature below normal, so this is not the first one to see.
A nurse is administering a blood transfusion. Which assessment finding will the nurse report immediately? a. Blood pressure 110/60 b. Temperature 101.3 F c. Poor skin turgor and pallor d. Heart rate of 100 beats/min
ANS: B A fever should be reported immediately, and the blood transfusion stopped. All other assessment findings are expected. Blood is given to elevate blood pressure, improve pallor, and decrease tachycardia.
A nurse teaches a patient about atelectasis. Which statement by the patient indicates an understanding of atelectasis? a. ―Atelectasis affects only those with chronic conditions such as emphysema.‖ b. ―It is important to do breathing exercises every hour to prevent atelectasis.‖ c. ―If I develop atelectasis, I will need a chest tube to drain excess fluid.‖ d. ―Hyperventilation will open up my alveoli, preventing atelectasis.‖
ANS: B Atelectasis develops when alveoli do not expand. Breathing exercises, especially deep breathing and incentive spirometry, increase lung volume and open the airways, preventing atelectasis. Deep breathing also opens the pores of Kohn between alveoli to allow sharing of oxygen between alveoli. Atelectasis can affect anyone who does not deep breathe. A chest tube is for pneumothorax or hemothorax. It is deep breathing, not hyperventilation, that prevents atelectasis.
The patient presented to the ambulatory surgery center to have a colonoscopy is scheduled to receive moderate sedation (conscious sedation) during the procedure. How will the nurse interpret this information? a. The procedure results in loss of sensation in an area of the body. b. The procedure requires a depressed level of consciousness. c. The procedure will be performed on an outpatient basis. d. The procedure necessitates the patient to be immobile.
ANS: B Moderate sedation (conscious sedation) is used routinely for procedures that do not require complete anesthesia but rather a depressed level of consciousness. Not all patients who are treated on an outpatient basis receive moderate sedation. Regional anesthesia such as local anesthesia provides loss of sensation in an area of the body. General anesthesia is used for patients who need to be immobile and to not remember the surgical procedure.
Upon auscultation of the patient's chest, the nurse hears a whooshing sound at the fifth intercostal space. What does this finding indicate to the nurse? a. The beginning of the systolic phase b. Regurgitation of the mitral valve c. The opening of the aortic valve d. Presence of orthopnea
ANS: B When regurgitation occurs, there is a backflow of blood into an adjacent chamber. For example, in mitral regurgitation, the mitral leaflets do not close completely. When the ventricles contract, blood escapes back into the atria, causing a murmur, or ―whooshing‖ sound. The systolic phase begins with ventricular filling and closing of the aortic valve, which is heard as the first heart sound, S1. Orthopnea is an abnormal condition in which a patient uses multiple pillows when reclining to breathe easier or sits leaning forward with arms elevated.
A nurse administers an antimuscarinic to a patient. A decrease in which findings indicate the patient is having therapeutic effects from this medication? (Select all that apply.) a. Dysuria b. Urgency c. Frequency d. Prostate size e. Bladder infection
ANS: B, C
Which findings should the nurse follow up on after removal of a catheter from a patient? (Select all that apply.) a. Increasing fluid intake b. Dribbling of urine c. Voiding in small amounts d. Voiding within 6 hours of catheter removal e. Burning with the first couple of times voiding
ANS: B, C
The patient has new-onset restlessness and confusion. Pulse rate is elevated, as is respiratory rate. Oxygen saturation is 94%. The nurse ignores the pulse oximeter reading and calls the health care provider for orders because the pulse oximetry reading is inaccurate. Which factors can cause inaccurate pulse oximetry readings? (Select all that apply.) a. O2 saturations (SaO2) >70% b. Carbon monoxide inhalation c. Outside light sources d. Intravascular dyes e. Nail polish f. Jaundice
ANS: B, C, D, E, F
MULTIPLE RESPONSE 1. A nurse is working in the intensive care unit and must obtain core temperatures on patients. Which sites can be used to obtain a core temperature? (Select all that apply.) a. Rectal b. Urinary bladder c. Esophagus d. Temporal artery e. Pulmonary artery
ANS: B, C, E
MULTIPLE RESPONSE 1. A nurse is following the How-to Guide to prevent ventilator-associated pneumonia. Which strategies is the nurse using? (Select all that apply.) a. Head of bed elevation to 90 degrees at all times b. Daily oral care with chlorhexidine c. Delirium monitoring d. Clean technique when suctioning e. Daily ―sedation vacations‖ f. Heart failure prophylaxis
ANS: B, C, E
Which nursing actions will the nurse implement when collecting a urine specimen from a patient? (Select all that apply.) a. Growing urine cultures for up to 12 hours b. Labeling all specimens with date, time, and initials c. Allowing the patient adequate time and privacy to void d. Wearing gown, gloves, and mask for all specimen handling e. Transporting specimens to the laboratory in a timely manner f. Collecting the specimen from the drainage bag of an indwelling catheter
ANS: B, C, E
The nurse is providing preoperative education and reviews with the patient what it will be like to be in the surgical environment. Which points should the nurse include in the teaching session? (Select all that apply.) a. The operative suite will be very dark. b. The family is not allowed in the operating suite. c. The operating table or bed will be comfortable and soft. d. The nurses will be there to assist you through this process. e. The surgical staff will be dressed in special clothing with hats and masks.
ANS: B, D, E
The nurse is using a forced air warmer for a surgical patient preoperatively. Which goals is the nurse trying to achieve? (Select all that apply.) a. Induce shivering. b. Reduce blood loss. c. Induce pressure ulcers. d. Reduce cardiac arrests. e. Reduce surgical site infection.
ANS: B, D, E
A nurse is discontinuing a patient's peripheral IV access. Which actions should the nurse take? (Select all that apply.) a. Wear sterile gloves and a mask. b. Stop the infusion before removing the IV catheter. c. Use scissors to remove the IV site dressing and tape. d. Apply firm pressure with sterile gauze during removal. e. Keep the catheter parallel to the skin while removing it. f. Apply pressure to the site for 2 to 3 minutes after removal.
ANS: B, E, F
42. While the nurse is taking a patient history, the nurse discovers the patient has a type of diabetes that results from a head injury and does not require insulin. Which dietary change should the nurse share with the patient? a. Reduce the quantity of carbohydrates ingested to lower blood sugar. b. Include a serving of dairy in each meal to elevate calcium levels. c. Drink plenty of fluids throughout the day to stay hydrated. d. Avoid foods high in acid to avoid metabolic acidosis.
ANS: C
A nurse has just received a bag of packed red blood cells (RBCs) for a patient. What is the longest time the nurse can let the blood infuse? a. 30 minutes b. 2 hours c. 4 hours d. 6 hours
ANS: C
A nurse is caring for a male patient experiencing urinary retention. Which action should the nurse take first? a. Limit fluid intake. b. Insert a urinary catheter. c. Assist to a standing position. d. Ask for a diuretic medication.
ANS: C
A nurse is caring for a patient diagnosed with cancer who presents with anorexia, blood pressure 100/60, and elevated white blood cell count. Which primary purpose for starting total parenteral nutrition (TPN) will the nurse add to the care plan? a.Stimulate the patient's appetite to eat. b. Deliver antibiotics to fight off infection. c. Replace fluid, electrolytes, and nutrients. d. Provide medication to raise blood pressure.
ANS: C
A nurse is caring for a patient who just underwent an intravenous pyelography that revealed a renal calculus obstructing the left ureter. What is the nurse's first priority in caring for this patient? a. Turn the patient on the right side to alleviate pressure on the left kidney. b. Encourage the patient to increase fluid intake to flush the obstruction. c. Monitor the patient for fever, rash, and difficulty breathing. d. Administer narcotic medications to the patient for pain.
ANS: C
A nurse is caring for a patient with a postsurgical wound. When planning care, which goal will be the priority? a. Reduce dependent nitrogen balance. b. Maintain negative nitrogen balance. c. Promote positive nitrogen balance. d. Facilitate neutral nitrogen balance.
ANS: C
A nurse is caring for an 8-year-old patient who is embarrassed about urinating in bed at night. Which intervention should the nurse suggest to reduce the frequency of this occurrence? a. ―Set your alarm clock to wake you every 2 hours, so you can get up to void.‖ b. ―Line your bedding with plastic sheets to protect your mattress.‖ c. ―Drink your nightly glass of milk earlier in the evening.‖ d. ―Empty your bladder completely before going to bed.‖
ANS: C
A nurse is evaluating a nursing assistive personnel's (AP) care for a patient with an indwelling catheter. Which action by the AP will cause the nurse to intervene? a. Emptying the drainage bag when half full b. Kinking the catheter tubing to obtain a urine specimen c. Placing the drainage bag on the side rail of the patient's bed d. Securing the catheter tubing to the patient's thigh
ANS: C
A nurse is preparing to administer an enteral feeding. In which order will the nurse implement the steps, starting with the first one? 1. Elevate head of bed to at least 30 degrees. 2. Check for gastric residual volume. 3. Flush tubing with 30 mL of water. 4. Verify tube placement. 5. Initiate feeding. a. 4, 2, 1, 5, 3 b. 2, 4, 1, 3, 5 c. 1, 4, 2, 3, 5 d. 2, 1, 4, 5, 3
ANS: C
A nurse is reviewing urinary laboratory results. Which finding will cause the nurse to follow up? a. Protein level of 2 mg/100 mL b. Urine output of 80 mL/hr c. Specific gravity of 1.036 d. pH of 6.4
ANS: C
A nurse preparing to start a blood transfusion will use which type of tubing? a. Two-way valves to allow the patient's blood to mix and warm the blood transfusing b. An injection port to mix additional electrolytes into the blood c. One with a filter to ensure that clots do not enter the patient d. An air vent to let bubbles into the blood
ANS: C
A patient experiencing a pneumothorax has a chest tube inserted and is placed on low constant suction. Which finding requires immediate action by the nurse? a. The patient reports pain at the chest tube insertion site that increases with movement. b. Fifty milliliters of blood gushes into the drainage device after the patient coughs. c. No bubbling is present in the suction control chamber of the drainage device. d. Yellow purulent discharge is seen leaking out from around the dressing site.
ANS: C
A patient is to receive 1000 mL of 0.9% sodium chloride intravenously at a rate of 125 mL/hr. The nurse is using microdrip gravity drip tubing. Which rate will the nurse calculate for the minute flow rate (drops/min)? a. 12 drops/min b. 24 drops/min c. 125 drops/min d. 150 drops/min
ANS: C
A patient presents to the emergency department with reports of vomiting and diarrhea for the past 48 hours. The health care provider orders isotonic intravenous (IV) therapy. Which IV will the nurse prepare? a. 0.225% sodium chloride (1/4 NS) b. 0.45% sodium chloride (1/2 NS) c. 0.9% sodium chloride (NS) d. 3% sodium chloride (3% NaCl)
ANS: C
Before giving the patient an intermittent gastric tube feeding, what should the nurse do? a. Make sure that the tube is secured to the gown with a safety pin. b. Inject air into the stomach via the tube and auscultate. c. Have the tube feeding at room temperature. d. Check to make sure pH is at least 5.
ANS: C
In general, when a patient's energy requirements are completely met by kilocalorie (kcal) intake in food, which assessment finding will the nurse observe? a. Weight increases. b. Weight decreases. c. Weight does not change. d. Weight fluctuates daily.
ANS: C
In providing prenatal care to a pregnant patient, what does the nurse teach the expectant mother? a. Calcium intake is especially important in the first trimester. b. Protein intake needs to decrease to preserve kidney function. c. Folic acid is needed to help prevent birth defects and anemia. d. Extra vitamins and minerals should be taken as much as possible.
ANS: C
The health care provider asks the nurse to monitor the fluid volume status of a heart failure patient and a patient at risk for clinical dehydration. Which is the most effective nursing intervention for monitoring both of these patients? a. Assess the patients for edema in extremities. b. Ask the patients to record their intake and output. c. Weigh the patients every morning before breakfast. d. Measure the patients' blood pressures every 4 hours.
ANS: C
The nurse caring for a postoperative patient will encourage what activity to prevent venous stasis and the formation of thrombus? a. Diaphragmatic breathing b. Incentive spirometry c. Leg exercises d. Coughing
ANS: C
The nurse is assessing a patient and notes crackles in the lung bases and neck vein distention. Which action will the nurse take first? a. Offer calcium-rich foods. b. Administer diuretic. c. Raise head of bed. d. Increase fluids.
ANS: C
The nurse is evaluating the effectiveness of the intravenous fluid therapy in a patient with hypernatremia. Which finding indicates goal achievement? a. Urine output increases to 150 mL/hr. b. Systolic and diastolic blood pressure decreases. c. Serum sodium concentration returns to normal. d. Large amounts of emesis and diarrhea decrease.
ANS: C
The nurse is making a preoperative education appointment with a patient. The patient asks if a family member should come to the appointment. Which is the best response by the nurse? a.―There is no need for an additional person at the appointment.‖ b. ―Your family can come and wait with you in the waiting room.‖ c. ―We recommend including family members at this appointment.‖ d. ―It is required that you have a family member at this appointment.‖
ANS: C
The nurse is monitoring a patient in the post-anesthesia care unit (PACU) for postoperative fluid and electrolyte imbalance. Which action will be most appropriate for the nurse to take? a. Encourage copious amounts of water. b. Start an additional intravenous (IV) line. c. Measure and record all intake and output. d. Weigh the patient and compare with preoperative weight.
ANS: C
The nurse is preparing a patient for a surgical procedure on the right great toe. Which action will be most important to include in this patient's preparation? a. Place the patient in a clean surgical gown. b. Ask the patient to remove all hairpins and cosmetics. c. Ascertain that the surgical site has been correctly marked. d. Determine where the family will be located during the procedure.
ANS: C
The nurse is providing nutrition education to a newly immigrated Korean patient using the five food groups. In doing so, what should be the focus of the teaching? a. Discouraging the patient's ethnic food choices b. Changing the patient's diet to a more conventional American diet c. Including racial and ethnic practices with food preferences of the patient d. Comparing the patient's ethnic preferences with American dietary choices
ANS: C
The nurse observes edema in a patient who is experiencing venous congestion as a result of right heart failure. Which type of pressure facilitated the formation of the patient's edema? a.Osmotic b. Oncotic c. Hydrostatic d. Concentration
ANS: C
The nurse suspects cystitis related to a lower urinary tract infection. Which clinical manifestation does the nurse expect the patient to report? a. Dysuria b. Flank pain c. Frequency d. Fever
ANS: C
The nurse will anticipate inserting a Coudé catheter for which patient? a. An 8-year-old male undergoing anesthesia for a tonsillectomy b. A 24-year-old female who is going into labor c. A 56-year-old male admitted for bladder irrigation d. An 86-year-old female admitted for a urinary tract infection
ANS: C
The patient diagnosed with cardiovascular disease is receiving dietary instructions from the nurse. Which information from the patient indicates teaching is successful? a. Maintain a prescribed carbohydrate intake. b. Eat fish at least 5 times/week. c. Limit cholesterol to less than 300 mg/daily. d. Avoid high-fiber foods.
ANS: C
The patient has been diagnosed with Helicobacter pylori. The nurse should encourage which action initially? a. Avoidance of wheat and oats b. Milkshakes as a nutritious snack c. Completion of antibiotic therapy d. Nonsteroidal anti-inflammatory drugs
ANS: C
The patient has just been started on an enteral feeding and has developed diarrhea after being on the feeding for 2 hours. What does the nurse suspect is the most likely cause of the diarrhea? a. Antibiotic therapy b. Clostridium difficile c. Formula intolerance d. Bacterial contamination
ANS: C
The patient is having at least 75% of nutritional needs met by enteral feeding, so the health care provider has ordered the parenteral nutrition (PN) to be discontinued. However, the nurse notices that the PN infusion has fallen behind. What should the nurse do? a. Increase the rate to get the volume caught up before discontinuing. b. Stop the infusion as ordered. c. Taper infusion gradually. d. Hang 5% dextrose.
ANS: C
The patient is having lower abdominal surgery and the nurse inserts an indwelling catheter. What is the rationale for the nurse's action? a. The patient may void uncontrollably during the procedure. b. Local trauma sometimes promotes excessive urine incontinence. c. Anesthetics can decrease bladder contractility and cause urinary retention. d. The patient will not interrupt the procedure by asking to go to the bathroom.
ANS: C
Upon palpation, the nurse notices that the bladder is firm and distended; the patient expresses an urge to urinate. Which question is most appropriate? a. ―Does your urinary problem interfere with any activities?‖ b. ―Do you lose urine when you cough or sneeze?‖ c. ―When was the last time you voided?‖ d. ―Are you experiencing a fever or chills?‖
ANS: C
Which assessment finding is consistent with the diagnosis of malnutrition? a. Moist lips b. Pink conjunctivae c. Spoon-shaped nails d. Not easily plucked hair
ANS: C
Which assessment question should the nurse ask if stress incontinence is suspected? a. ―Do you think your bladder feels distended?‖ b. ―Do you empty your bladder completely when you void?‖ c. ―Do you experience urine leakage when you cough or sneeze?‖ d. ―Do your symptoms increase with consumption of alcohol or caffeine?‖
ANS: C
Which nursing intervention is most effective in preventing hospital-acquired pneumonia in an older-adult patient? a. Discontinue the humidification delivery device to keep excess fluid from lungs. b. Monitor oxygen saturation, and frequently auscultate lung bases. c. Assist the patient to cough, turn, and deep breathe every 2 hours. d. Decrease fluid intake to 300 mL a shift.
ANS: C
Which observation by the nurse best indicates that a continuous bladder irrigation for a patient following genitourinary surgery is effective? a. Output that is smaller than the amount instilled b. Blood clots or sediment in the drainage bag c. Bright red urine turns pink in the tubing d. Bladder distention with tenderness
ANS: C
When taking an adult blood pressure, the onset of the sound the nurse hears is at 138, the muffled sound the nurse hears is at 70, and the disappearance of the sound the nurse hears is at 62. How should the nurse record this finding? a. 68 b. 76 c. 138/62 d. 138/70
ANS: C 138/62 is the correct reading. The fifth sound marks the disappearance of sound. In adolescents and adults, the fifth sound corresponds with the diastolic pressure. The fourth sound becomes muffled and low pitched as the cuff is further deflated. At this point the cuff pressure has fallen below the pressure within the vessel walls; this sound is the diastolic pressure in infants and children. 68 is the pulse pressure of 138/70; 76 is the pulse pressure for 138/62.
The nurse suspects the patient has increased cardiac afterload. Which piece of equipment should the nurse obtain to determine the presence of this condition? a. Pulse oximeter b. Oxygen cannula c. Blood pressure cuff d. Yankauer suction tip catheter
ANS: C A blood pressure cuff is needed. The diastolic aortic pressure is a good clinical measure of afterload. Afterload is the resistance to left ventricular ejection. In hypertension the afterload increases, making cardiac workload also increase. A pulse oximeter is used to monitor the level of arterial oxygen saturation; it will not help determine increased afterload. While an oxygen cannula may be needed to help decrease the effects of increased afterload, it will not help determine the presence of afterload. A Yankauer suction tip catheter is used to suction the oral cavity.
A patient has experienced a myocardial infarction. On which primary blood vessel will the nurse focus care to reduce ischemia? a. Superior vena cava b. Pulmonary artery c. Coronary artery d. Carotid artery
ANS: C A myocardial infarction is the lack of blood flow due to obstruction to the coronary artery, which supplies the heart with blood. The superior vena cava returns blood back to the heart. The pulmonary artery supplies deoxygenated blood to the lungs. The carotid artery supplies blood to the brain.
A nurse auscultates heart sounds. When the nurse hears S2, which valves is the nurse hearing close? a. Aortic and mitral b. Mitral and tricuspid c. Aortic and pulmonic d. Mitral and pulmonic
ANS: C As the ventricles empty, the ventricular pressures decrease, allowing closure of the aortic and pulmonic valves, producing the second heart sound, S2. The mitral and tricuspid produce the first heart sound, S1. The aortic and mitral do not close at the same time. The mitral and pulmonic do not close at the same time.
While performing an assessment, the nurse hears crackles in the patient's lung fields. The nurse also learns that the patient is sleeping on three pillows to help with the difficulty breathing during the night. Which condition will the nurse most likely observe written in the patient's medical record? a. Atrial fibrillation b. Myocardial ischemia c. Left-sided heart failure d. Right-sided heart failure
ANS: C Left-sided heart failure results in pulmonary congestion, the signs and symptoms of which include shortness of breath, cough, crackles, and paroxysmal nocturnal dyspnea (difficulty breathing when lying flat). Right-sided heart failure is systemic and results in peripheral edema, weight gain, and distended neck veins. Atrial fibrillation is often described as an irregularly irregular rhythm; rhythm is irregular because of the multiple pacemaker sites. Myocardial ischemia results when the supply of blood to the myocardium from the coronary arteries is insufficient to meet myocardial oxygen demands, producing angina or myocardial infarction.
Chapter 50: Perioperative Nursing Care The nurse is caring for a surgical patient, when the family member asks what perioperative nursing means. How should the nurse respond? a. Perioperative nursing occurs in preadmission testing. b. Perioperative nursing occurs primarily in the postanesthesia care unit. c. Perioperative nursing includes activities before, during, and after surgery. d. Perioperative nursing includes activities only during the surgical procedure.
ANS: C Perioperative nursing care occurs before, during, and after surgery. Preadmission testing occurs before surgery and is considered preoperative. Nursing care provided during the surgical procedure is considered intraoperative, and in the postanesthesia care unit, it is considered postoperative. All of these are parts of the perioperative phase, but each individual phase does not explain the term completely.
A nurse is teaching the patient with mitral valve problems about the valves in the heart. Starting on the right side of the heart, describe the sequence of the blood flow through these valves. 1. Mitral 2. Aortic 3. Tricuspid 4. Pulmonic a. 1, 3, 2, 4 b. 4, 3, 2, 1 c. 3, 4, 1, 2 d. 2, 4, 1, 3
ANS: C The blood flows through the valves in the following direction: tricuspid, pulmonic, mitral, and aortic.
A nurse is teaching a health class about the heart. Which information from the class members indicates teaching by the nurse is successful for the flow of blood through the heart, starting in the right atrium? a. Right ventricle, left ventricle, left atrium b. Left atrium, right ventricle, left ventricle c. Right ventricle, left atrium, left ventricle d. Left atrium, left ventricle, right ventricle
ANS: C Unoxygenated blood flows through the venae cavae into the right atrium, where it is pumped down to the right ventricle; the blood is then pumped out the pulmonary artery and is returned oxygenated via the pulmonary vein to the left atrium, where it flows to the left ventricle and is pumped out to the rest of the body via the aorta.
A patient's heart rate increased from 94 to 164 beats/min. What will the nurse expect as a result? a. Increase in diastolic filling time b. Decrease in hemoglobin level c. Decrease in cardiac output d. Increase in stroke volume
ANS: C With a sustained heart rate greater than 160 beats/min, diastolic filling time decreases, decreasing stroke volume, and cardiac output. The hemoglobin level would not be affected.
A nurse is caring for a group of patients. Which patient will the nurse see first? a. A crying infant with P-165 and R-54 b. A sleeping toddler with P-88 and R-23 c. A calm adolescent with P-95 and R-26 d. An exercising adult with P-108 and R-24
ANS: C A calm adolescent should have the following findings: P—60 to 90 and R—16 to 20. Since both findings are elevated, the nurse should see this patient first. An infant should have the following findings: P—120 to 160 and R—30 to 50; however, since the infant is crying these values will be elevated and this is normal. A toddler should have the following findings: P— 90 to 140 and R—25 to 32; however, since the toddler is sleeping these values can be slightly decreased and this is normal. An adult should have the following findings: P—60 to 100 and R—12 to 20; however, since the adult is exercising these values will be elevated and this is normal.
The nurse is caring for a patient in preadmission testing. The patient has been assigned a physical status classification by the American Society of Anesthesiologists of ASA III. Which assessment will support this classification? a. Normal, healthy patient b. Denial of any major illnesses or conditions c. Poorly controlled hypertension with implanted pacemaker d. Moribund patient not expected to survive without the operation
ANS: C An ASA III rating is a patient with a severe systemic disease, such as poorly controlled hypertension with an implanted pacemaker. ASA I is a normal healthy patient with no major illnesses or conditions. ASA II is a patient with mild systemic disease. ASA V is a moribund patient who is not expected to survive without the operation and includes patients with ruptured abdominal/thoracic aneurysm or massive trauma.
A patient has been diagnosed with heart failure and cardiac output is decreased. Which formula can the nurse use to calculate cardiac output? a. Myocardial contractility/ myocardial blood flow b. Ventricular filling time/diastolic filling time c. Stroke volume heart rate d. Preload/afterload
ANS: C Cardiac output can be calculated by multiplying the stroke volume and the heart rate. The other options are not measures of cardiac output.
A nurse is caring for a 5-year-old patient whose temperature is 101.2 F. The nurse expects this patient to hyperventilate. Which factor does the nurse remember when planning care for this type of hyperventilation? a. Anxiety over illness b. Decreased drive to breathe c. Increased metabolic demands d. Infection destroying lung tissues
ANS: C Increased body temperature (fever) increases the metabolic rate, thereby increasing carbon dioxide production. The increased carbon dioxide level stimulates an increase in the patient's rate and depth of respiration, causing hyperventilation. Anxiety can cause hyperventilation, but this is not the direct cause from a fever. Sleep causes a decreased respiratory drive; hyperventilation speeds up breathing. The cause of the fever in this question is unknown.
A nurse caring for a patient prescribed warfarin discovers that the patient is taking garlic to help with hypertension. Which condition will the nurse assess for in this patient? a. Increased cholesterol level b. Distended jugular vein c. Bleeding d. Angina
ANS: C Patients taking warfarin for anticoagulation prolong the prothrombin time (PT)/international normalized ratio (INR) results if they are taking Gingko biloba, garlic, or ginseng with the anticoagulant. The drug interaction can precipitate a life-threatening bleed. Increased cholesterol levels are associated with saturated fat dietary intake. A distended jugular vein and peripheral edema are associated with damage to the right side of the heart. Angina is temporary ischemia of the heart muscle.
A nurse is preparing a patient for nasotracheal suctioning. In which order will the nurse perform the steps, beginning with the first step? 1. Insert catheter. 2. Apply suction and remove. 3. Have patient deep breathe. 4. Encourage patient to cough. 5. Attach catheter to suction system. 6. Rinse catheter and connecting tubing. a. 1, 2, 3, 4, 5, 6 b. 4, 5, 1, 2, 3, 6 c. 5, 3, 1, 2, 4, 6 d. 3, 1, 2, 5, 4, 6
ANS: C The steps for nasotracheal suctioning are as follows: verify that catheter is attached to suction; have patient deep breathe; insert catheter; apply intermittent suction for no more than 10 seconds and remove; encourage patient to cough; and rinse catheter and connecting tubing with normal saline.
A nurse is caring for a patient being treated for sleep apnea. Which types of ventilator support should the nurse be prepared to administer for this patient? (Select all that apply.) a. Assist-control (AC) b. Pressure support ventilation (PSV) c. Bilevel positive airway pressure (BiPAP) d. Continuous positive airway pressure (CPAP) e. Synchronized intermittent mandatory ventilation (SIMV)
ANS: C, D
A nurse is asked how many kcal/g are provided by fats. How should the nurse answer? a. 3 b. 4 c. 6 d. 9
ANS: D
A nurse is assisting the health care provider in inserting a central line. Which action indicates the nurse is following the recommended bundle protocol to reduce central line-associated bloodstream infections (CLABSI)? a. Preps skin with povidone-iodine solution. b. Suggests the femoral vein for insertion site. c. Applies double gloving without hand hygiene. d. Uses chlorhexidine skin antisepsis prior to insertion.
ANS: D
A nurse is caring for a patient who is receiving peripheral intravenous (IV) therapy. When the nurse is flushing the patient's peripheral IV, the patient reports pain. Upon assessment, the nurse notices a red streak that is warm to the touch. What is the nurse's initial action? a. Record a phlebitis grade of 4. b. Assign an infiltration grade. c. Apply moist compress. d. Discontinue the IV.
ANS: D
A nurse is inserting a catheter into a female patient. When the nurse inserts the catheter, no urine is obtained. The nurse suspects the catheter is not in the urethra. What should the nurse do? a. Throw the catheter way and begin again. b. Fill the balloon with the recommended sterile water. c. Remove the catheter, wipe with alcohol, and reinsert after lubrication. d. Leave the catheter in the vagina as a landmark for insertion of a new, sterile catheter.
ANS: D
A nurse is inserting an indwelling urinary catheter for a male patient. Which action will the nurse take? a. Hold the shaft of the penis at a 60-degree angle. b. Hold the shaft of the penis with the dominant hand. c. Cleanse the meatus 3 times with the same cotton ball from clean to dirty. d. Cleanse the meatus with circular strokes beginning at the meatus and working outward.
ANS: D
A nurse is preparing to start peripheral intravenous (IV) therapy. In which order will the nurse perform the steps starting with the first one? 1. Clean site. 2. Select vein. 3. Apply tourniquet. 4. Release tourniquet. 5. Reapply tourniquet. 6. Advance and secure. 7. Insert vascular access device. a. 1, 3, 2, 7, 5, 4, 6 b. 1, 3, 2, 5, 7, 6, 4 c. 3, 2, 1, 5, 7, 6, 4 d. 3, 2, 4, 1, 5, 7, 6
ANS: D
A nurse is reviewing results from a urine specimen. What will the nurse expect to see in a patient with a urinary tract infection? a. Casts b. Protein c. Crystals d. Bacteria
ANS: D
A nurse is teaching a patient about proteins that must be obtained through the diet since they cannot be synthesized in the body. Which term used by the patient indicates teaching is successful? a. Amino acids b. Triglycerides c. Dispensable amino acids d. Indispensable amino acids
ANS: D
A nurse is watching a nursing assistive personnel (AP) perform a postvoid bladder scan on a female with a previous hysterectomy. Which action will require the nurse to follow up? a.Palpates the patient's symphysis pubis. b. Wipes scanner head with alcohol pad. c. Applies a generous amount of gel. d. Sets the scanner to female.
ANS: D
A patient has an acute intravascular hemolytic reaction to a blood transfusion. After discontinuing the blood transfusion, which is the nurse's next action? a. Discontinue the IV catheter. b. Return the blood to the blood bank. c. Run normal saline through the existing tubing. d. Start normal saline at rate to keep vein open using new tubing.
ANS: D
A patient is on a full liquid diet. Which food item choice by the patient will cause the nurse to intervene? a. Custard b. Frozen yogurt c. Pureed vegetables d. Mashed potatoes and gravy
ANS: D
A patient receiving chemotherapy has gained 5 pounds in 2 days. Which assessment question by the nurse is most appropriate? a. ―Are you following any weight loss program?‖ b. ―How many calories a day do you consume?‖ c. ―Do you have dry mouth or feel thirsty?‖ d. ―How many times a day do you urinate?‖
ANS: D
In providing diet education for a patient on a low-fat diet, which information is important for the nurse to share? a. Polyunsaturated fats should be less than 7% of the total calories. b. Trans fat should be less than 7% of the total calories. c. Unsaturated fats are found mostly in animal sources. d. Saturated fats are found mostly in animal sources.
ANS: D
In teaching mothers-to-be about infant nutrition, which instruction should the nurse provide? a. Supplement breast milk with corn syrup. b. Give cow's milk during the first year of life. c. Add honey to infant formulas for increased energy. d. Provide breast milk or formula for the first 4 to 6 months.
ANS: D
The nurse and the nursing assistive personnel (NAP) are caring for a group of postoperative patients who need turning, coughing, deep breathing, incentive spirometer, and leg exercises. Which task will the nurse assign to the NAP? a. Teaching postoperative exercises b. Doing nothing associated with postoperative exercises c. Documenting in the medical record when exercises are completed d. Informing the nurse if the patient is unwilling to perform exercises
ANS: D
The nurse and the nursing assistive personnel are assisting a postoperative patient to turn in bed. To assist in minimizing discomfort, which instruction should the nurse provide to the patient? a. ―Close your eyes and think about something pleasant.‖ b. ―Hold your breath and count to three.‖ c. ―Grab my shoulders with your hands.‖ d. ―Use your hand to support your incision.‖
ANS: D
The nurse is assessing a patient diagnosed with emphysema. Which assessment finding requires further follow-up with the health care provider? a. Increased anterior-posterior diameter of the chest b. Accessory muscle used for breathing c. Clubbing of the fingers d. Hemoptysis
ANS: D
The nurse is assessing a patient for nutritional status. Which action will the nurse take? a. Forego the assessment in the presence of chronic disease. b. Use the Mini Nutritional Assessment for pediatric patients. c. Choose a single objective tool that fits the patient's condition. d. Combine multiple objective measures with subjective measures.
ANS: D
The nurse is caring for a patient in the preoperative holding area of an ambulatory surgery center. Which nursing action will be most appropriate for this area? a. Counting the sterile surgical instruments b. Emptying the urinary drainage bag c. Checking the surgical dressing d. Appling a warm blanket
ANS: D
The nurse is caring for a patient receiving total parenteral nutrition (TPN). Which action will the nurse take? a. Run lipids for no longer than 24 hours. b. Take down a running bag of TPN after 36 hours. c. Clean injection port with alcohol 5 seconds before and after use. d. Wear a sterile mask when changing the central venous catheter dressing.
ANS: D
The nurse is caring for a patient with hyperkalemia. Which body system assessment is the priority? a. Gastrointestinal b. Neurological c. Respiratory d. Cardiac
ANS: D
The nurse is encouraging a reluctant postoperative patient to deep breathe and cough. Which explanation can the nurse provide that may encourage the patient to comply? a. ―If you don't deep breathe and cough, you will get pneumonia.‖ b. ―You will need to cough only a few times during this shift.‖ c. ―Let's try clearing the throat because that will work just as well.‖ d. ―Deep breathing and coughing will clear your lungs of the anesthesia.‖
ANS: D
The nurse is preparing to insert a nasogastric tube. To determine the length of the tube needed to be inserted, how should the nurse measure the tube? a. From the tip of the nose to the earlobe b. From the tip of the earlobe to the xiphoid process c. From the tip of the earlobe to the nose to the xiphoid process d. From the tip of the nose to the earlobe to the xiphoid process
ANS: D
The nurse is teaching a health class about the My Plate program. Which guidelines will the nurse include in the teaching session? a. Balancing sodium and potassium b. Decreasing water consumption c. Increasing portion size d. Balancing calories
ANS: D
The nurse is using a closed suction device. Which patient will be most appropriate for this suctioning method? a. A 5-year-old with excessive drooling from epiglottitis b. A 5-year-old with an asthma attack following severe allergies c. A 24-year-old with a right pneumothorax following a motor vehicle accident d. A 24-year-old with acute respiratory distress syndrome requiring mechanical ventilation
ANS: D
The patient has a calculated body mass index (BMI) of 34. How will the nurse classify this finding? a. Normal weight b. Underweight c. Overweight d. Obese
ANS: D
The patient has a catheter that must be irrigated. The nurse is using a needleless closed irrigation technique. In which order will the nurse perform the steps, starting with the first one? 1. Clean injection port. 2. Inject prescribed solution. 3. Twist needleless syringe into port. 4. Remove clamp and allow to drain. 5. Clamp catheter just below specimen port. 6. Draw up prescribed amount of sterile solution ordered. a. 3, 2, 6, 1, 5, 4 b. 5, 6, 1, 2, 3, 4 c. 1, 5, 6, 3, 2, 4 d. 6, 5, 1, 3, 2, 4
ANS: D
The patient is to receive multiple medications via the nasogastric tube. The nurse is concerned that the tube may become clogged. Which action is best for the nurse to take? a. Instill nonliquid medications without diluting. b. Irrigate the tube with 60 mL of water after all medications are given. c. Mix all medications together to decrease the number of administrations. d. Check with the pharmacy for availability of the liquid forms of medications.
ANS: D
The patient who has been diagnosed with cardiovascular disease and placed on a low-fat diet, asks the nurse, ―How much fat should I have? I guess the less fat, the better.‖ Which information will the nurse include in the teaching session? a. Cholesterol intake needs to be less than 300 mg/day. b. Fats have no significance in health and the incidence of disease. c. All fats come from external sources, so this can be easily controlled. d. Deficiencies occur when fat intake falls below 10% of daily nutrition.
ANS: D
To obtain a clean-voided urine specimen from a female patient, what should the nurse teach the patient to do? a. Cleanse the urethral meatus from the area of most contamination to least. b. Initiate the first part of the urine stream directly into the collection cup. c. Drink fluids 5 minutes before collecting the urine specimen. d. Hold the labia apart while voiding into the specimen cup.
ANS: D
Which assessment finding will the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL? a. Weak quadriceps muscles b. Decreased deep tendon reflexes c. Light-headedness when standing up d. Tingling of extremities with possible tetany
ANS: D
Which clinical manifestation will the nurse expect to observe in a patient with excessive white blood cells present in the urine? a. Reduced urine specific gravity b. Increased blood pressure c. Abnormal blood sugar d. Fever with chills
ANS: D
Which patient diagnosis increases the risk for developing neurogenic dysphagia? a. Benign peptic stricture b. Muscular dystrophy c. Myasthenia gravis d. Stroke
ANS: D
The nurse is teaching about the process of exchanging gases through the alveolar capillary membrane. Which term will the nurse use to describe this process? a. Ventilation b. Surfactant c. Perfusion d. Diffusion
ANS: D Diffusion is the process of gases exchanging across the alveoli and capillaries of body tissues. Ventilation is the process of moving gases into and out of the lungs. Surfactant is a chemical produced in the lungs to maintain the surface tension of the alveoli and keep them from collapsing. Perfusion is the ability of the cardiovascular system to carry oxygenated blood to tissues and return deoxygenated blood to the heart.
The nurse is preparing to assess the blood pressure of a 3-year-old. How should the nurse proceed? a. Use the diaphragm portion of the stethoscope to detect Korotkoff sounds. b. Obtain the reading before the child has a chance to ―settle down.‖ c. Choose the cuff that says ―Child‖ instead of ―Infant.‖ d. Explain the procedure to the child.
ANS: D The child's cooperation is increased when you or the parent have prepared the child for the unusual sensation of the BP cuff. Most children understand the analogy of a ―tight hug on your arm.‖ Different arm sizes require careful and appropriate cuff size selection. Do not choose a cuff based on the name of the cuff. An ―Infant‖ cuff is too small for some infants. Readings are difficult to obtain in restless or anxious infants and children. Allow at least 15 minutes for children to recover from recent activities and become less apprehensive. Korotkoff sounds are difficult to hear in children because of low frequency and amplitude. A pediatric stethoscope bell is often helpful.
The nursing assistive personnel (NAP) is taking vital signs and reports that a patient's blood pressure is abnormally low. What should the nurse do next? a. Ask the NAP to retake the blood pressure. b. Instruct the NAP to assess the patient's other vital signs. c. Disregard the report and have it rechecked at the next scheduled time. d. Retake the blood pressure personally and assess the patient's condition.
ANS: D The nursing assistive personnel should report abnormalities to the nurse, who should further assess the patient. The nursing assistive personnel should not retake the blood pressure or other vital signs because the nurse needs to assess the patient. The report cannot be disregarded. Assessment must be done by the nurse.
The nurse is caring for a patient in the postanesthesia care unit. The patient has developed profuse bleeding from the surgical site, and the surgeon has determined the need to return to the operative area. How will the nurse classify this procedure? a. Major b. Urgent c. Elective d. Emergency
ANS: D An emergency procedure must be done immediately to save a life or preserve the function of a body part. An example would be repair of a perforated appendix, repair of a traumatic amputation, or control of internal hemorrhaging. An urgent procedure is necessary for a patient's health and often prevents additional problems from developing. An example would be excision of a cancerous tumor, removal of a gallbladder for stones, or vascular repair for an obstructed artery. An elective procedure is performed on the basis of the patient's choice; it is not essential and is not always necessary for health. An example would be a bunionectomy, plastic surgery, or hernia reconstruction. A major procedure involves extensive reconstruction or alteration in body parts; it poses great risks to well-being. An example would be a coronary artery bypass or colon resection.
The nurse is caring for a patient with respiratory problems. Which assessment finding indicates a late sign of hypoxia? a. Elevated blood pressure b. Increased pulse rate c. Restlessness d. Cyanosis
ANS: D Cyanosis, blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries, is a late sign of hypoxia. Elevated blood pressure, increased pulse rate, and restlessness are early signs of hypoxia.
A patient has inadequate stroke volume related to decreased preload. Which treatment does the nurse prepare to administer? a. Diuretics b. Vasodilators c. Chest physiotherapy d. Intravenous (IV) fluids
ANS: D Preload is affected by the circulating volume; if the patient has decreased fluid volume, it will need to be replaced with fluid or blood therapy. Preload is the amount of blood in the left ventricle at the end of diastole, often referred to as end-diastolic volume. Giving diuretics and vasodilators will make the situation worse. Diuretics cause fluid loss; the patient is already low on fluids or the preload would not be decreased. Vasodilators reduced blood return to the heart, making the situation worse; the patient does not have enough blood and fluid to the heart or the preload would not be decreased. Chest physiotherapy is a group of therapies for mobilizing pulmonary secretions. Chest physiotherapy will not help this cardiovascular problem.
A nurse is preparing to suction a patient. The pulse is 65 and pulse oximetry is 94%. Which finding will cause the nurse to stop suctioning? a. Pulse 75 b. Pulse 80 c. Oxygen saturation 91% d. Oxygen saturation 88%
ANS: D Stop when oxygen saturation is 88%. Monitor patient's vital signs and oxygen saturation during procedure; note whether there is a change of 20 beats/min (either increase or decrease) or if pulse oximetry falls below 90% or 5% from baseline. If this occurs, stop suctioning. A pulse rate of 75 is only 10 beats different from the start of the procedure. A pulse rate of 80 is 15 beats different from the start of suctioning. Oxygen saturation of 91% is not 5% from baseline or below 90%.
The nurse is caring for a group of postoperative patients on the surgical unit. Which patient assessments indicate the nurse needs to follow up? (Select all that apply.) a. Patient with abdominal surgery has patent airway. b. Patient with knee surgery has approximated incision. c. Patient with femoral artery surgery has strong pedal pulse. d. Patient with lung surgery has 20 mL/hr of urine output via catheter. e. Patient with bladder surgery has bloody urine within the first 12 hours. f. Patient with appendix surgery has thready pulse and blood pressure is 90/60.
ANS: D, F
The nurse is caring for a newborn infant in the hospital nursery and notices that the infant is breathing rapidly but is pink, warm, and dry. Which normal respiratory rate will the nurse consider when planning care for this newborn? a. 30 to 60 b. 22 to 28 c. 16 to 20 d. 10 to 15
a. 30 to 60 The acceptable respiratory rate range for a newborn is 30 to 60 breaths/min. An infant (6 months) is expected to have a rate between 30 and 50 breaths/min. A toddler's respiratory range is 25 to 32 breaths/min. A child should breathe 20 to 30 times a minute. An adolescent should breathe 16 to 20 times a minute. An adult should breathe 12 to 20 times a minute. DIF:Understand (comprehension) OBJ:Demonstrate accurate recording and reporting of vital sign measurements. TOP:Planning MSC: Health Promotion and Maintenance
The patient with heart failure is restless with a temperature of 102.2 F (39 C). Which action will the nurse take? a. Place the patient on oxygen. b. Encourage the patient to cough. c. Restrict the patient's fluid intake. d. Increase the patient's metabolic rate.
a. Place the patient on oxygen. Interventions during a fever include oxygen therapy. During a fever, cellular metabolism increases, and oxygen consumption rises. Myocardial hypoxia produces angina. Cerebral hypoxia produces confusion. Dehydration is a serious problem through increased respiration and diaphoresis. The patient is at risk for fluid volume deficit. Fluids should not be restricted, even though the patient has heart failure; the patient needs fluids at this time due to the fever. Increasing the metabolic rate further would not be advisable. Coughing will increase muscular activity, which will increase fever. DIF:Apply (application) OBJ:Summarize physiological changes associated with fever. TOP:Implementation MSC: Reduction of Risk Potential
The nurse needs to obtain a radial pulse from a patient. What must the nurse do to obtain a correct measurement? a. Place the tips of the first two fingers over the groove along the thumb side of the patient's wrist. b. Place the tips of the first two fingers over the groove along the little finger side of the patient's wrist. c. Place the thumb over the groove along the little finger side of the patient's wrist. d. Place the thumb over the groove along the thumb side of the patient's wrist.
a. Place the tips of the first two fingers over the groove along the thumb side of the patient's Place the tips of the first two or middle three fingers of the hand over the groove along the radial or thumb side of the patient's inner wrist. Fingertips are the most sensitive parts of the hand to palpate arterial pulsation. The thumb has a pulsation that interferes with accuracy. The groove along the little finger is the ulnar pulse. DIF:Apply (application) OBJ:Evaluate patient's disease process, cognition, age, and other factors when selecting sights for temperature, pulse, blood pressure assessments. TOP:Implementation MSC: Health Promotion and Maintenance
The nurse is caring for a patient who has a temperature reading of 100.4 F (38 C). The patient's last two temperature readings were 98.6 F (37 C) and 96.8 F (36 C). Which action will the nurse take? a. Wait 30 minutes and recheck the patient's temperature. b. Assume that the patient has an infection and order blood cultures. c. Encourage the patient to move around to increase muscular activity. d. Be aware that temperatures this high are harmful and affect patient safety.
a. Wait 30 minutes and recheck the patient's temperature. Waiting 30 minutes and rechecking the patient's temperature would be the most appropriate action in this case. A fever is usually not harmful if it stays below 102.2 F (39 C), and a single temperature reading does not always indicate a fever. In addition to physical signs and symptoms of infection, a fever determination is based on several temperature readings at different times of the day compared with the usual value for that person at that time. Nurses should base actions on knowledge, not on assumptions. Encouraging the patient to increase muscular activity will cause heat production to increase up to 50 times normal. The temperature has decreased and a symptom of infection would be an increase in temperature. DIF:Apply (application) OBJ:Select nursing measures that promote heat loss and heat conservation. TOP:Implementation MSC: Reduction of Risk Potential
The patient's blood pressure is 140/60. Which value will the nurse record for the pulse pressure? a. 60 b. 80 c. 140 d. 200
b. 80 The difference between the systolic pressure and the diastolic pressure is the pulse pressure. For a blood pressure of 140/60, the pulse pressure is 80 (140 - 60 = 80). 140 is the systolic pressure. 60 is the diastolic pressure. 200 is the systolic (140) added to the diastolic (60), but this has no clinical significance. DIF:Apply (application) OBJ:Analyze a patient's radial and apical pulses. TOP:Implementation MSC: Health Promotion and Maintenance
The patient requires temperatures to be taken every 2 hours. Which task will be the responsibility of an RN? a. Using appropriate route and device b. Assessing changes in body temperature c. Being aware of the usual values for the patient d. Obtaining temperature measurement at ordered frequency
b. Assessing changes in body temperature The nurse is responsible for assessing changes in body temperature. The nursing assistive personnel can use the appropriate route and device to measure temperature, obtain temperature measurement at ordered frequency, and be aware of the usual values for the patient. DIF:Apply (application) OBJ:Determine when it is appropriate to delegate of vital sign measurements to nursing assistive personnel. TOP:Implementation MSC: Management of Care
The nurse is caring for an infant and is obtaining the patient's vital signs. Which artery will the nurse use to best obtain the infant's pulse? a. Radial b. Brachial c. Femoral d. Popliteal
b. Brachial The brachial or apical pulse is the best site for assessing an infant's or a young child's pulse because other peripheral pulses such as the radial, femoral, and popliteal arteries are deep and difficult to palpate accurately. DIF:Understand (comprehension) OBJ:Evaluate patient's disease process, cognition, age, and other factors when selecting sights for temperature, pulse, blood pressure assessments. TOP:Implementation MSC: Health Promotion and Maintenance
3. The patient has a temperature of 105.2 F. The nurse is attempting to lower temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. Which technique is the nurse using to lower the patient's temperature? a. Radiation b. Conduction c. Convection d. Evaporation
b. Conduction Applying an ice pack or bathing a patient with a cool cloth increases conductive heat loss because of the direct contact. Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between the two. Evaporation is the transfer of heat energy when a liquid is changed to a gas. Convection is the transfer of heat away from the body by air movement. DIF:Understand (comprehension) OBJ:Analyze a patient's body temperature. TOP:Implementation MSC: Basic Care and Comfort
The patient is admitted with shortness of breath and chest discomfort. Which laboratory value could account for the patient's symptoms? a. Red blood cell count of 5.0 million/mm3 b. Hemoglobin level of 8.0 g/100 mL c. Hematocrit level of 45% d. Pulse oximetry of 95%
b. Hemoglobin level of 8.0 g/100 mL The concentration of hemoglobin reflects the patient's capacity to carry oxygen, which if low can lead to shortness of breath and chest discomfort. Normal hemoglobin levels range from 14 to 18 g/100 mL in males and from 12 to 16 g/100 mL in females. Hemoglobin of 8.0 is low and indicates a decreased ability to deliver oxygen to meet bodily needs. All other values in the selection are considered normal. DIF:Analyze (analysis) OBJ:Summarize factors that cause variations in body temperature, pulse, oxygen saturation (SpO2), capnography, respirations, and blood pressure measurement. TOP:Assessment MSC: Reduction of Risk Potential
When assessing the temperature of newborns and children, the nurse decides to utilize a temporal artery thermometer. What is the rationale for the nurse's action? a. It is not affected by skin moisture. b. It has no risk of injury to patient or nurse. c. It reflects rapid changes in radiant temperature. d. It is accurate even when the forehead is covered with hair.
b. It has no risk of injury to patient or nurse. The temporal artery thermometer is especially beneficial when used in premature infants, newborns, and children because there is no risk of injury to the patient or nurse. Temporal artery temperature is a reliable noninvasive measure of core temperature. However, it is inaccurate with head covering or hair on the forehead and is affected by skin moisture such as diaphoresis or sweating. It provides very rapid measurement and reflects rapid changes in core temperature, not radiant temperature. DIF:Understand (comprehension) OBJ:Demonstrate accurate recording and reporting of vital sign measurements. TOP:Assessment MSC: Health Promotion and Maintenance
The patient was found unresponsive in an apartment and is being brought to the emergency department. The patient has arm, hand, and leg edema, the temperature is 95.6 F, and hands are cold secondary to a history of peripheral vascular disease. It is reported that the patient has a latex allergy. What should the nurse do to quickly measure the patient's oxygen saturation? a. Attach a finger probe to the patient's index finger. b. Place a non-adhesive sensor on the patient's earlobe. c. Attach a disposable adhesive sensor to the bridge of the patient's nose. d. Place the sensor on the same arm that the electronic blood pressure cuff is on.
b. Place a non-adhesive sensor on the patient's earlobe. A non-adhesive sensor is best for latex allergy, and the earlobe site is the best choice for this patient with peripheral vascular disease and edema. Select forehead, ear or bridge of nose if an adult patient has a history of peripheral vascular disease. Do not attach probe to finger, ear, forehead, or bridge of nose if area is edematous or skin integrity is compromised. Do not use disposable adhesive probes if the patient has latex allergy. Do not attach probe to fingers that are hypothermic. Do not place the sensor on the same extremity as the electronic blood pressure cuff because blood flow to the finger will be temporarily interrupted when the cuff inflates. DIF:Apply (application) OBJ:Summarize factors that cause variations in body temperature, pulse, oxygen saturation (SpO2), capnography, respirations, and blood pressure measurement. TOP:Implementation MSC: Physiological Adaptation
The nurse is caring for an older-adult patient and notes that the temperature is 96.8 F (36 C). How will the nurse interpret this finding? a. The patient has hyperthermia. b. The patient has a normal temperature. c. The patient is suffering from hypothermia. d. The patient is demonstrating increased metabolism.
b. The patient has a normal temperature. The average body temperature of older adults is approximately 35 to 36.1 C (95 to 97 F). This is not hypothermia or hyperthermia. Older adults have poor vasomotor control, reduced amounts of subcutaneous tissue, reduced sweat gland activity, and reduced metabolism. The end result is lowered body temperature. DIF:Understand (comprehension) OBJ:Summarize factors that cause variations in body temperature, pulse, oxygen saturation (SpO2), capnography, respirations, and blood pressure measurement. TOP:Assessment MSC: Health Promotion and Maintenance
A patient is experiencing pyrexia. Which piece of equipment will the nurse obtain to monitor this condition? a. Stethoscope b. Thermometer c. Blood pressure cuff d. Sphygmomanometer
b. Thermometer Pyrexia, or fever, occurs because heat loss mechanisms are unable to keep pace with excess heat production, resulting in an abnormal rise in body temperature; therefore, a thermometer is needed. A stethoscope is not used to take a temperature but can be used for apical pulse and blood pressure. A pulse oximeter is used to determine oxygen content in the blood. A sphygmomanometer and blood pressure cuff is used to determine blood pressure and will be used for blood pressure problems. DIF:Apply (application) OBJ:Summarize physiological changes associated with fever. TOP:Assessment MSC: Health Promotion and Maintenance
When taking the pulse of an infant, the nurse notices that the rate is 145 beats/min and the rhythm is regular. How should the nurse interpret this finding? a. This is normal for an infant. b. This is too fast for an infant. c. This is too slow for an infant. d. This is not a rate for an infant but for a toddler.
b. This is too fast for an infant. The normal rate for an infant is 120 to 140 beats/min. The rate obtained (145 beats/min) is higher than the normal range for an infant. The normal rate for a toddler is between 90 and 140 beats/min; 145 is too high for a toddler. DIF:Understand (comprehension) OBJ:Summarize factors that cause variations in body temperature, pulse, oxygen saturation (SpO2), capnography, respirations, and blood pressure measurement. TOP:Assessment MSC: Health Promotion and Maintenance
The patient is being admitted to the emergency department with reports of shortness of breath. The patient has had chronic lung disease for many years but still smokes. What will the nurse do? a. Allow the patient to breathe into a paper bag. b. Use oxygen cautiously in this patient. c. Administer high levels of oxygen. d. Give CO2 via mask.
b. Use oxygen cautiously in this patient. Oxygen must be used cautiously in these types of patients. Hypoxemia helps to control ventilation in patients with chronic lung disease. Because low levels of arterial O2 provide the stimulus that allows a patient to breathe, administration of high oxygen levels may be fatal for patients with chronic lung disease. Patients with chronic lung disease have ongoing hypercarbia (elevated CO2 levels) and do not need to have CO2 administered or ―rebreathed‖ with a paper bag. DIF:Apply (application) OBJ:Summarize factors that cause variations in body temperature, pulse, oxygen saturation (SpO2), capnography, respirations, and blood pressure measurement. TOP:Implementation MSC: Physiological Adaptation
A nurse reviews blood pressures of several patients. Which finding will the nurse report as prehypertension? a. 98/50 in a 7-year-old child b. 115/70 in an infant c. 120/80 in a middle-aged adult d. 146/90 in an older adult
c. 120/80 in a middle-aged adult An adult's blood pressure tends to rise with advancing age. The optimal blood pressure for a healthy, middle-aged adult is less than 120/80. Values of 120 to 139/80 to 89 mm Hg are considered prehypertension. Blood pressure greater than 140/90 is defined as hypertension. Blood pressure of 98/50 is normal for a child, whereas 115/70 can be normal for an infant. DIF:Analyze (analysis) OBJ:Analyze a patient's blood pressure. TOP:Assessment MSC: Health Promotion and Maintenance
The nurse is providing a blood pressure clinic for the community. Which group will the nurse most likely address? a. Non-Hispanic Caucasians b. European Americans c. African Americans d. Asian Americans
c. African Americans The incidence of hypertension is greater in diabetic patients, older adults, and African Americans. The incidence of hypertension (high BP) is higher in African Americans than in European Americans. DIF:Understand (comprehension) OBJ:Evaluate patient's disease process, cognition, age, and other factors when selecting sights for temperature, pulse, blood pressure assessments. TOP:Planning MSC: Health Promotion and Maintenance
The nurse is caring for a small child and needs to obtain vital signs. Which site choice from the nursing assistive personnel (NAP) will cause the nurse to have confidence in the NAP? a. Ulnar site b. Radial site c. Brachial site d. Femoral site
c. Brachial site The nurse will praise the NAP when obtaining the pulse from the brachial site. The brachial or apical pulse is the best site for assessing an infant's or a young child's pulse because other peripheral pulses are deep and difficult to palpate accurately. DIF:Understand (comprehension) OBJ:Demonstrate accurate recording and reporting of vital sign measurements. TOP:Assessment MSC: Management of Care
The patient is found to be unresponsive and not breathing. Which pulse site will the nurse use? a. Radial b. Apical c. Carotid d. Brachial
c. Carotid The heart continues to deliver blood through the carotid artery to the brain as long as possible. The carotid pulse is easily accessible during physiological shock or cardiac arrest. The radial pulse is used to assess peripheral circulation or to assess the status of circulation to the hand. The brachial site is used to assess the status of circulation to the lower arm. The apical pulse is used to auscultate the apical area. DIF:Apply (application) OBJ:Evaluate patient's disease process, cognition, age, and other factors when selecting sights for temperature, pulse, blood pressure assessments. TOP:Implementation MSC: Physiological Adaptation
A patient presents with heatstroke. The nurse uses cool packs, cooling blanket, and a fan. Which technique is the nurse using when the fan produces heat loss? a. Radiation b. Conduction c. Convection d. Evaporation
c. Convection Convection is the transfer of heat away from the body by air movement. Conduction is the transfer of heat from one object to another with direct contact. Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between the two. Evaporation is the transfer of heat energy when a liquid is changed to a gas. DIF:Understand (comprehension) OBJ:Select nursing measures that promote heat loss and heat conservation. TOP:Implementation MSC: Basic Care and Comfort
The nurse reviews the laboratory results for a patient and determines the viscosity of the blood is thick. Which laboratory result did the nurse check? a. Arterial blood gas b. Blood culture c. Hematocrit d. Potassium
c. Hematocrit The hematocrit, or the percentage of red blood cells in the blood, determines blood viscosity. Blood cultures determine the causative agent of an infection. Abnormal potassium levels can cause dysrhythmias. Arterial blood gases determine acid-base balance or the pH levels of the blood.
The nurse is caring for a patient who has an elevated temperature. Which principle will the nurse consider when planning care for this patient? a. Hyperthermia and fever are the samething. b. Hyperthermia is an upward shift in the set point. c. Hyperthermia occurs when the body cannot reduce heat production. d. Hyperthermia results from a reduction in thermoregulatory mechanisms.
c. Hyperthermia occurs when the body cannot reduce heat production. An elevated body temperature related to the inability of the body to promote heat loss or reduce heat production is hyperthermia. Whereas fever is an upward shift in the set point, hyperthermia results from an overload of the thermoregulatory mechanisms of the body. DIF:Understand (comprehension) OBJ:Summarize physiological changes associated with fever. TOP:Planning MSC: Physiological Adaptation
The nurse is assessing the patient's respirations. Which action by the nurse is most appropriate? a. Inform the patient that she is counting respirations. b. Do not touch the patient until completed. c. Obtain without the patient knowing. d. Estimate respirations.
c. Obtain without the patient knowing Do not let a patient know that you are assessing respirations. A patient aware of the assessment can alter the rate and depth of breathing. Assess respirations immediately after measuring pulse rate, with your hand still on the patient's wrist as it rests over the chest or abdomen. Respirations are the easiest of all vital signs to assess, but they are often the most haphazardly measured. Do not estimate respirations. DIF:Apply (application) OBJ:Evaluate patient's disease process, cognition, age, and other factors when selecting sights for temperature, pulse, blood pressure assessments. TOP:Implementation MSC: Health Promotion and Maintenance
A nurse is focusing on temperature regulation of newborns and infants. Which action will the nurse take? a. Apply just a diaper. b. Double the clothing. c. Place a cap on their heads. d. Increase room temperature to 90 degrees.
c. Place a cap on their heads. A newborn loses up to 30% of body heat through the head and therefore needs to wear a cap to prevent heat loss. Temperature control mechanisms in newborns are immature and respond drastically to changes in the environment; do not increase the room temperature to 90 degrees. Take extra care to protect newborns from environmental temperatures. Provide adequate clothing; do not double the clothing or apply just a diaper. DIF:Apply (application) OBJ:Select nursing measures that promote heat loss and heat conservation. TOP:Implementation MSC: Health Promotion and Maintenance
A nurse is caring for a patient who smokes and drinks caffeine. Which point is important for the nurse to understand before assessing the patient's blood pressure (BP)? a. Smoking increases BP for up to 3 hours. b. Caffeine increases BP for up to 15 minutes. c. Smoking result in vasoconstriction, falsely elevating BP. d. Caffeine intake should not have occurred 30 to 40 minutes before BP measurement.
c. Smoking result in vasoconstriction, falsely elevating BP. Smoking results in vasoconstriction, a narrowing of blood vessels. BP rises when a person smokes and returns to baseline about 15 to 20 minutes after stopping smoking. Caffeine increases BP for up to 3 hours. Be sure that patient has not ingested caffeine or smoked 20 to 30 minutes before BP measurement. DIF:Apply (application) OBJ:Summarize factors that cause variations in body temperature, pulse, oxygen saturation (SpO2), capnography, respirations, and blood pressure measurement. TOP:Assessment MSC: Health Promotion and Maintenance
A patient has a head injury and damages the hypothalamus. Which vital sign will the nurse monitor most closely? a. Pulse b. Respirations c. Temperature d. Blood pressure
c. Temperature Disease or trauma to the hypothalamus or the spinal cord, which carries hypothalamic messages, causes serious alterations in temperature control. The hypothalamus does not control pulse, respirations, or blood pressure. DIF:Understand (comprehension) OBJ:Select nursing measures that promote heat loss and heat conservation. TOP:Assessment MSC: Physiological Adaptation
The patient is being admitted to the emergency department following a motor vehicle accident. The patient's jaw is broken with several broken teeth. The patient is ashen, has cool skin, and is diaphoretic. Which route will the nurse use to obtain an accurate temperature reading? a. Oral b. Axillary c. Tympanic d. Temporal
c. Tympanic The tympanic route is the best choice in this situation. Oral temperatures are not used for patients who have had oral surgery, trauma, history of epilepsy, or shaking chills. Axillary temperature is affected by exposure to the environment, including time to place the thermometer. It also requires a long measurement time. Temporal artery temperature is affected by skin moisture such as diaphoresis or sweating. DIF:Apply (application) OBJ:Evaluate patient's disease process, cognition, age, and other factors when selecting sights for temperature, pulse, blood pressure assessments. TOP:Implementation MSC: Health Promotion and Maintenance
A nurse is reviewing capnography results for adult patients. Which value will cause the nurse to follow up? a. 35 mm Hg b. 40 mm Hg c. 45 mm Hg d. 50 mm Hg
d. 50 mm Hg 50 mm Hg is abnormal, so the nurse will follow up. Normal capnography results are 35 to 45 mm Hg. DIF:Understand (comprehension) OBJ:Capnography. TOP:Assessment MSC: Management of Care
The nurse is working the night shift on a surgical unit and is making 4:00 AM rounds. The nurse notices that the patient's temperature is 96.8 F (36 C), whereas at 4:00 PM the preceding day, it was 98.6 F (37 C). What should the nurse do? a. Call the health care provider immediately to report a possible infection. b. Administer medication to lower the temperature further. c. Provide another blanket to conserve body temperature. d. Realize that this is a normal temperature variation.
d. Realize that this is a normal temperature variation. Body temperature normally changes 0.5 to 1 C (0.9 to 1.8 F) during a 24-hour period and is usually lowest between 1:00 and 4:00 AM, with a maximum temperature at 4:00 PM, making this variation normal for the time of day. Unless the patient reports being cold, there is no physiological need for providing an extra blanket or medication to lower the body temperature further. There is also no need to call a health care provider to report a normal temperature variation. DIF:Apply (application) OBJ:Select nursing measures that promote heat loss and heat conservation. TOP:Implementation MSC: Health Promotion and Maintenance
The nurse is caring for a patient who has a pulse rate of 48. His blood pressure is within normal limits. Which finding will help the nurse determine the cause of the patient's low heart rate? a. The patient has a fever. b. The patient has possible hemorrhage or bleeding. c. The patient has chronic obstructive pulmonary disease (COPD). d. The patient has calcium channel blockers or digitalis medication prescriptions.
d. The patient has calcium channel blockers or digitalis medication prescriptions. Negative chronotropic drugs such as digitalis, beta-adrenergic agents, and calcium channel blockers can slow down pulse rate. Fever, bleeding, hemorrhage, and COPD all increase the body's need for oxygen, leading to an increased heart rate. DIF:Apply (application) OBJ:Summarize factors that cause variations in body temperature, pulse, oxygen saturation (SpO2), capnography, respirations, and blood pressure measurement. TOP:Assessment MSC: Physiological Adaptation
The patient requires routine temperature assessment but is confused, easily agitated, and has a history of seizures. Which route will the nurse use to obtain the patient's temperature? a. Oral b. Rectal c. Axillary d. Tympanic
d. Tympanic The tympanic route is easily accessible, requires minimal patient repositioning, and often can be used without disturbing the patient. It also has a very rapid measurement time. Oral temperatures require patient cooperation and are not recommended for patients with a history of seizures. Rectal temperatures require positioning and may increase patient agitation. Axillary temperatures need long measurement times and continuous positioning. The patient's agitation state may not allow for long periods of attention. DIF:Apply (application) OBJ:Evaluate patient's disease process, cognition, age, and other factors when selecting sights for temperature, pulse, blood pressure assessments. TOP:Implementation MSC: Health Promotion and Maintenance
