exam 3 textbook questions
An 86 year old woman is admitted to the unit with chills and a fever of 104 degrees F. What physiological process explains why she is at risk for dyspnea?
Fever increases metabolic demands requiring increased oxygen need. Correct
Which instruction about clopidogrel [Plavix] should the nurse include in the discharge teaching for a patient who has received a drug-eluting coronary stent?
"Check with your healthcare provider before taking any over-the-counter medications for gastric acidity." Correct
Which instruction should be included in the teaching for a patient for whom fluticasone propionate [Flovent] MDI has been ordered?
"Gargle after using your inhaler." Correct
Which statement should the nurse include in the teaching for a patient who is to be started on zileuton [Zyflo]?
"Have your blood drawn once a month for the next 3 months so that your liver function can be checked." Correct
A patient with nonvalvular atrial fibrillation is to be discharged on dabigatran etexilate [Pradaxa]. Which statement should the nurse include in the discharge teaching?
"The medication must be stored in the manufacturer-supplied bottle." Correct
The patient's heparin is infusing at 28 mL/hr. The bag of fluid is mixed 20,000 units of heparin in 500 mL D5W. What hourly dose is the patient receiving? (Fill in the blank and record your answer.)
1120 units/hr
The health care provider's order is 500 mL 0.9% NaCl intravenously over 4 hours. Which rate do you program into the infusion pump?
125 mL/hr Correct
A patient with an acute myocardial infarction is prescribed an intravenous (IV) bolus of tenecteplase [TNKase]. The patient weighs 160 pounds. The nurse will administer what dosage?
40 mg Correct
The nurse is ready to begin a heparin infusion for a patient with evolving stroke. The baseline activated partial thromboplastin time (aPTT) is 40 seconds. Which aPTT value indicates that a therapeutic dose has been achieved?
70
Which patient do you plan to teach regarding water restriction?
A 34-year-old with hyponatremia Correct
You assess four patients. Which patient has greatest risk for hypomagnesemia?
A 72-year-old with chronic alcoholism Correct
The nurse is caring for a group of patients taking warfarin [Coumadin]. Which patients are at moderate to high risk for harm as a result of warfarin therapy? (Select all that apply.)
A patient with variant genes that code for VKORC1 and CYP2CP Correct A woman with a new onset of symptoms of a pulmonary embolus Correct A patient with a prosthetic heart valve, for whom an interacting drug is being deleted from the regimen Correct
What best describes measurement of post-void residual (PVR)?
Bladder scan the patient immediately after voiding. Correct
Which assessment do you interpret as a transfusion reaction?
Chills, tachycardia, and flushing Correct
The nurse is monitoring a patient receiving a heparin infusion for the treatment of pulmonary embolism. Which assessment finding most likely relates to an adverse effect of heparin?
Discolored urine Correct
Your older-adult patient is receiving intravenous (IV) 0.9% NaCl. You detect new onset of crackles in the lung bases. What is your priority action?
Decrease the IV flow rate Correct
A patient is admitted with severe lobar pneumonia. Which of the following assessment findings would indicate that the patient needs airway suctioning?
Decreased ability to clear airway through couching Correct
A patient has been diagnosed with severe iron deficiency anemia. During physical assessment, which of the following symptoms are associated with decreased oxygenation?
Decreased activity tolerance and increased breathlessness Correct
A patient presents to the emergency department with symptoms of acute myocardial infarction. After a diagnostic workup, the healthcare provider prescribes a 15-mg IV bolus of alteplase (tPA), followed by 50 mg infused over 30 minutes. In monitoring this patient, which finding by the nurse most likely indicates an adverse reaction to this drug?
Decreasing level of consciousness Correct
A patient with a deep vein thrombosis receiving an intravenous (IV) heparin infusion asks the nurse how this medication works. What is the nurse's best response?
Heparin suppresses coagulation by helping antithrombin perform its natural functions. Correct
A patient admitted with deep vein thrombosis (DVT) and subsequent pulmonary embolism (PE) requires immediate anticoagulation. What medication would be appropriate for this patient who has a history of heparin-induced thrombocytopenia (HIT)?
Lepirudin [Refludan] Correct
The laboratory calls to report a drop in the platelet count to 90,000/mm3 for a patient receiving heparin for the treatment of postoperative deep vein thrombosis. Which action by the nurse is the most appropriate?
Notify the healthcare provider to discuss the reduction or withdrawal of heparin. Correct
What statement made by a 4-year-old patient's mother indicates that she understands how to administer her son's eardrops?
"I need to straighten his ear canal before administering the medication by pulling his ear upward and outward." Correct
A patient has been newly diagnosed with chronic lung disease. In discussing his condition with the nurse, which of his statements would indicate a need for further education? "I'll make sure that I rest between activities so I don't get so short of breath." "I'll practice the pursed-lip breathing technique to improve my exercise tolerance." "If I have trouble breathing at night, I'll use two to three pillows to prop up." "If I get short of breath, I'll turn up my oxygen level to 6 L/min.
"If I get short of breath, I'll turn up my oxygen level to 6 L/min." Correct
A patient with asthma is scheduled to start taking a glucocorticoid medication with a metered-dose inhaler (MDI). The nurse should give the patient which instruction about correct use of the inhaler?
"Use a spacer with the inhaler and rinse your mouth after each dose administration." Correct
A nurse is teaching a patient about montelukast [Singulair]. Which statement by the patient would indicate that the nurse's teaching was effective?
"While taking this medicine, I may be able to reduce my steroid medication." Correct
The nurse is administering an intravenous (IV) push medication to a patient who has a compatible IV fluid running through intravenous tubing. Place the following steps in the appropriate order. 1. Release tubing and inject medication within amount of time recommended by agency policy, pharmacist, or medication reference manual. Use watch to time administration. 2. Select injection port of intravenous (IV) tubing closest to patient. Whenever possible, injection port should accept a needleless syringe. Use IV filter if required by medication reference or agency policy. 3. After injecting medication, release tubing, withdraw syringe, and recheck fluid infusion rate 4. Connect syringe to port of intravenous (IV) line. Insert needleless tip or small-gauge needle of syringe containing prepared drug through center of injection port. 5. Clean injection port with antiseptic swab. Allow to dry. 6. Occlude intravenous (IV) line by pinching tubing just above injection port. Pull back gently on syringe plunger to aspirate blood return.
2, 5, 4, 6, 1, 3 Correct
What is the correct sequence for suctioning a patient? 1. Open kit and basin. 2. Apply gloves. 3. Lubricate catheter. 4. Verify functioning of suction device and pressure .5. Connect suctioning tubing to suction catheter. 6. Increase supplemental oxygen. 7. Reapply oxygen. 8. Suction airway.
4, 6, 1, 3, 2, 5, 8, 7 Correct
The healthcare provider prescribes heparin 900 units/hr. The label on the IV bag reads Heparin 10,000 units in 500 mL D5W. How many mL/hr will deliver the correct dose? (Fill in the blank and record your answer.)
45 mL
Which of the following is the correct order for insertion of an indwelling catheter in a female patient? 1. Insert and advance catheter. 2. Lubricate catheter. 3. Inflate catheter balloon. 4. Cleanse urethral meatus. 5. Drape the patient with the sterile square and fenestrated drapes. 6. When urine appears advance another 2.5 to 5 cm. 7. Prepare sterile field and supplies. 8. Gently pull catheter until resistance is felt. 9. Attach drainage tubing.
5, 7, 2, 4, 1, 6, 3, 8, 9 Correct
Which needle length and gauge should the nurse choose to administer subcutaneous heparin?
5/8 inch; 25 gauge Correct
What is the correct order for discontinuing intravenous (IV) access? 1. Perform hand hygiene and apply gloves. 2. Explain procedure to patient. 3. Remove IV site dressing and tape. 4. Use two identifiers to ensure correct patient. 5. Stop the infusion and clamp the tubing. 6. Carefully check the health care provider's order. 7. Clean the site, withdraw the catheter, and apply pressure.
6, 4, 2, 1, 5, 3, 7 Correct
What does the nurse identify as a possible adverse effect of long-term glucocorticoid therapy? (Select all that apply.)
Adrenal insufficiency Correct Osteoporosis Cataracts
What is a critical step when inserting an indwelling catheter into a male patient?
Advance the catheter to the bifurcation of the drainage and balloon ports. Correct
A nurse should establish which outcomes on the care plan for a patient taking oral terbutaline? (Select all that apply.)
Absence of tachycardia Correct No reports of chest pain Correct Decrease in bronchospasm Correct
A patient is receiving glucocorticoids for the treatment of rheumatoid arthritis. The patient complains of having a headache. Which ordered medication should the nurse administer?
Acetaminophen [Tylenol] Correct
You are working in a health clinic on a college campus. You need to administer medroxyprogesterone acetate intramuscularly (IM) to a female patient for birth control. You look up this medication in a reference manual and determine that it is viscous and injections can be painful. On the basis of this information, you plan which of the following when administering this medication? (Select all that apply.)
Administer the medication in the ventral gluteal site Correct Use the z-track method when administering the medication Correct Ask the patient questions about her major and which classes she is taking during the injection to provide distraction Correct
Which nursing interventions should the nurse implement when removing an indwelling urinary catheter in an adult patient? (Select all that apply.)
Allow the balloon to drain into the syringe by gravity. Correct Initiate a voiding record/bladder diary Correct
A toddler is to receive 2.5 mL of an antipyretic by mouth. Which equipment is the most appropriate for medication administration for this child?
An oral-dosing syringe Correct
The nurse is reviewing the results of the patient's diagnostic testing. Of the following results, the finding that falls within expected or normal limits is:
Arterial oxygen tension (PaO2) of 95 mmHg Correct
A patient is scheduled to have an intravenous pyelogram (IVP) the next morning. Which nursing measures should be implemented prior to the test? (Select all that apply.)
Ask the patient about any allergies and reactions. Correct Ensure that informed consent has been obtained. Correct
A pediatric nurse takes a medication to a 12-year-old female patient. The patient tells the nurse to take it away because she is not going to take it. What is the nurse's next action?
Ask the patient's reason for refusal Correct
The NAP reports to the nurse that a patient's catheter drainage bag has been empty for 4 hours. What is a priority nursing intervention?
Assess the catheter and drainage tubing for obvious occlusion. Correct
After receiving an intramuscular (IM) injection in the deltoid, a patient states, "My arm really hurts. It's burning and tingling where I got my injection. What should the nurse do next? (Select all that apply.)
Assess the injection site Correct Notify the patient's health care provider of assessment findings Correct Document assessment findings and related interventions in the patient's medical record Correct
A post-operative patient with a three-way indwelling urinary catheter and continuous bladder irrigation (CBI) complains of lower abdominal pain and distention. What should be the nurse's initial intervention?
Assess the intake and output Correct
A nurse accidently gives a patient the medications that were ordered for the patient's roommate. What is the nurse's first priority?
Assess the patient for adverse effects. Correct
The nurse is caring for a patient who takes warfarin [Coumadin] for prevention of deep vein thrombosis. The patient has an international normalized ratio (INR) of 1.2. Which action by the nurse is most appropriate?
Call the healthcare provider to increase the dose. Correct
Which of the following diagnosis is a patient who started smoking in adolescence and continues to smoke for 40 years at this risk for?
Cardiopulmonary disease and lung cancer Correct
A patient is taking oral theophylline for maintenance therapy of stable asthma. A nurse instructs the patient to avoid using which substance to prevent a complication?
Caffeine
You are a new graduate nurse completing your orientation on a very busy intensive care unit. You cannot read a health care provider's order for one of your patient's medications. You have heard from more experienced nurses that this health care provider does not like to be called, and you know that another of the health care provider's patients is very unstable. What is the most appropriate next step for you to take?
Call the health care provider to clarify the order Correct
Your patient has hypokalemia with stable cardiac function. What are your priority nursing interventions? (Select all that apply.)
Fall prevention interventions Correct Monitoring for constipation Correct
The nurse is developing a plan to minimize the risk of adrenal insufficiency for a patient who is receiving long-term glucocorticoid therapy. Which outcome should be included?
Increases or supplements dosage of glucocorticoid at times of stress Correct
Which nursing assessment question would best indicate that an incontinent man with a history of prostate enlargement might not be emptying his bladder adequately?
Do you dribble urine constantly? Correct
When administering prednisone to a patient, the nurse will do what?
Ensure that meals are at bedside so that administration with food reduces gastric irritation. Correct
After seeing a patient, the health care provider starts to give a nursing student a verbal order for a new medication. The nursing student first needs to:
Explain to the health care provider that the order needs to be given to a registered nurse. Correct
Your patient has severe hypercalcemia. What are your priority nursing interventions? (Select all that apply.)
Fall prevention interventions Correct Encouraging increased fluid intake Correct Monitoring for constipation
A patient is admitted to the emergency department with suspected carbon monoxide poisoning. Even though her color is ruddy not cyanotic, the nurse understands the patient is at a risk for decreased oxygen-carrying capacity of blood because carbon Monoxide does which of the following:
Forms a strong bond with hemoglobin thus preventing oxygen binding in the lungs Correct
The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of pulmonary complication?
Frequent change of position Correct
Which assessment do you use as a clinical marker of vascular volume in a patient at high risk of extracellular fluid volume (ECV) deficit?
Fullness of neck veins when supine Correct
What nursing intervention decreases the risk for catheter associated urinary tract infection (CAUTI)?
Hang the urinary drainage bag below the level with the bladder. Correct
A patient is admitted to the emergency department with acute severe exacerbation of asthma. Which drug should the nurse anticipate will be included in the treatment plan?
High-dose albuterol [Proventil] via nebulizer treatment Correct
What does the nurse identify as possible complications of glucocorticoid therapy? (Select all that apply.)
Impaired carbohydrate and glucose tolerance Correct Predisposition to gastrointestinal ulceration Correct
An intravenous (IV) fluid is infusing more slowly than ordered. The infusion pump is set correctly. Which factors could cause this slowing? (Select all that apply.)
Infiltration at vascular access device (VAD) site Correct Patient lying on tubing Tubing kinked in bedrails Correct
A patient is admitted with the diagnosis of severe left-sided heart failure. What adventitious lung sounds are expected on auscultation?
Inspiratory crackles in lung bases Correct
The nurse knows that which statement is accurate for enoxaparin [Lovenox]?
It reduces the activity of factor Xa more than the activity of thrombin. Correct
A patient who takes cromolyn for exercise-induced bronchospasm should follow which approach for maximum therapeutic effectiveness?
It should be administered by inhalation 15 minutes before anticipated exertion. Correct
What should the nurse teach a young woman with a history of urinary tract infections about UTI prevention? (Select all that apply.)
Keep the bowels regular. Correct Wear cotton underwear Correct Cleanse the perineum from front to back.
There is no urine when a catheter is inserted into a female's urethra. What should the nurse do next?
Leave the catheter there and start over with a new catheter. Correct
When assessing a patient's first voided urine of the day, which finding should be reported to the health care provider?
Light pink urine Correct
Which are advantages of a dry-powder inhaler (DPI) over a metered-dose inhaler (MDI)? (Select all that apply.)
More of the drug is delivered to the lungs and less to the oropharynx. Correct Use of a spacer is not necessary. Correct Less hand-lung coordination is required. Correct DPIs pose no environmental risk
The nurse is screening a patient before administering a live virus vaccine. The patient is currently taking a glucocorticoid medication. Which action should the nurse take?
Note the contraindication and clarify the order with the healthcare provider. Correct
The nurse is caring for a patient receiving clopidogrel [Plavix] to prevent blockage of coronary artery stents. Which other drug on the patient's medication administration record may reduce the antiplatelet effects of clopidogrel?
Omeprazole [Prilosec] Correct
To achieve therapeutic effectiveness, a nurse teaches a patient with chronic asthma to use an inhaled glucocorticoid medication according to which schedule?
On a continuing, daily basis Correct
When delegating input and output (I&O) measurement to nursing assistive personnel, you instruct them to record what information for ice chips?
One-half of the volume Correct
Which of the following skills can be delegated to nursing assistive personnel (NAP)? (Select all that apply.)
Oropharyngeal suctioning of a stable patient Correct Permanent tracheostomy tube suctioning Correct
A history of allergy to which substance is a contraindication to the use of ipratropium/albuterol [Combivent]?
Peanuts
A patient is receiving a continuous heparin infusion for venous thromboembolism treatment. Which laboratory results should the nurse monitor? (Select all that apply.)
Platelets Activated partial thromboplastin time (aPTT) Correct
A patient takes glucocorticoids and digoxin [Lanoxin]. It is most important for the nurse to monitor which electrolyte?
Potassium
The nurse goes to assess a new patient and finds him short of breath with a rate of 32 and lying supine in bed. What is the priority nursing action?
Raise the head of the bed to 60 degrees or higher. Correct
Two hours after surgery, the nurse assesses a patient who had a chest tube inserted during surgery. There is 200 ml of dark red drainage in the chest tube at this time. What is the appropriate action for the nurse to perform?
Record the amount and continue to monitor drainage. Correct
What instructions should the nurse give the NAP concerning a patient who has had an indwelling urinary catheter removed that day?
Report the time and amount of first voiding. Correct
A patient is admitted to the hospital with severe dyspnea and wheezing. Arterial blood gas levels on admission are pH 7.26; PaCO2, 55 mm Hg; PaO2, 68 mm Hg; and HCO3-, 24. You interpret these laboratory values to indicate:
Respiratory acidosis. Correct
Your patient is hyperventilating from acute pain and hypoxia. Interventions to manage his pain and oxygenation will decrease his risk of which acid-base imbalance?
Respiratory alkalosis Correct
A nursing student is administering ampicillin PO. The expiration date on the medication wrapper was yesterday. What is the appropriate action for the nursing student to take next?
Return the medication to pharmacy and get another tablet Correct
A nurse admits a 72-year-old patient with a medical history of hypertension, heart failure, renal failure, and depression to a general medical patient care unit. The nurse reviews the patient's medication orders and notes that the patient has three health care providers who have ordered a total of 13 medications. What is the most appropriate action for the nurse to take next?
Review the list of medications with the health care providers to ensure that the patient needs all 13 medications Correct
A patient was admitted following a motor vehicle accident with multiple fractured ribs. Respiratory assessment includes signs/symptoms of secondary pneumothorax. Which are the most common assessment findings associated with a pneumothorax? (Select all that apply).
Sharp pleuritic pain that worsens on inspiration Correct Worsening dyspnea Correct Absent lung sounds to auscultation on affected side Correct
The nurse is caring for a patient who exhibits labored breathing, using accessory muscles, and is coughing up pink frothy sputum. The patient has bilateral lung bases and diminished breath sounds. What are the priority nursing assessments for the nurse to perform prior to notifying the patient's health care provider? (Select all that apply.)
SpO2 levels Correct Amount, color and consistency of sputum production Correct Change in respiratory rate and pattern Correct
An ambulatory elderly woman with dementia is incontinent of urine. She has poor short term memory and has not been seen toileting independently. What is the best nursing intervention for this patient?
Start a scheduled toileting program. Correct
When you assess pain and redness at a vascular access device (VAD) site, which action do you take first?
Stop the infusion and discontinue the intravenous infusion Correct
A nurse teaches a patient with chronic obstructive pulmonary disease (COPD) about the adverse effects of tiotropium [Spiriva]. Which behavior by the patient would indicate that the teaching has been effective?
Sucks on hard candy as needed Correct
Which outcome should a nurse establish as a priority for a patient taking an oral glucocorticoid for long-term treatment of asthma?
Supplements additional doses at times of stress Correct
The nurse should question an order for glucocorticoids in the treatment of a patient with what?
Systemic fungal infection Correct
A nursing student is administering medications to a patient through a gastric tube (G-tube). Which of the following actions taken by the nursing student requires the nursing instructor to intervene?
The nursing student crushes a nifedipine extended-release tablet and mixes it with water before administering it. Correct
A patient with a chronic illness is on daily glucocorticoids. He is brought to the hospital following a severe motor vehicle accident. He is wearing a medical alert bracelet stating his home medications. Noting that the patient takes glucocorticoids daily, the nurse knows which of the following to be true?
The patient will need higher doses of glucocorticoids following a trauma. Correct
What assessment do you make before hanging an intravenous (IV) fluid that contains potassium?
Urine output Correct
Which nursing intervention minimizes the risk for trauma and infection when applying an external/condom catheter?
Wash with soap and water prior to applying the condom type catheter. Correct
Using a stepwise approach to managing asthma, a nurse teaches a patient who is at step 1 to use albuterol MDI [Proventil] at which of these times?
Whenever needed (PRN) as a quick-relief agent Correct
A patient diagnosed with a pulmonary embolism is receiving a continuous heparin infusion at 1000 units/hr. Of which findings should the nurse immediately notify the healthcare provider? (Select all that apply.)
aPTT of 40 seconds Correct Nosebleeds Correct aPTT of 100 seconds
A patient is being discharged from the hospital on warfarin [Coumadin] for deep vein thrombosis prevention. Which instructions should the nurse include in the patient's discharge teaching plan? (Select all that apply.)
wear a medical alert bracelet. Correct Check all urine and stool for discoloration. Correct Do not start any new medication without first talking to your healthcare provider. Correct
